Ethics

When you learn about self care in massage school or read current articles on self care for massage professionals they teach proper body mechanics, proper posture, eat right, exercise, meditate or do some type of movement and of course getting regular massage to help stay grounded.  While these things can help, they are really just the tip of the iceberg – the external components of self care.  But knowing what things to do for self care and doing them are usually two different things.  What leads you to take action or not take action is the underlying unconscious beliefs about whether you are worthy or need self care.

Self care is everything you do to take care of yourself in every way.

• Physical strength, flexibility
• Diet and Nutrition for energy and health
• Mental clearness free from drama and critical mindsets
• Emotional security and self confidence
• Financial self care making more than you spend, saving and having enough money for self care and running your business
• Spiritual or connections with others

Being financially responsible is one such method of self care which usually is not mentioned in self care classes/articles.   Having the money that you need to live and run your business is the highest form of self care possible. The other way to take care of yourself is taking care of your personal needs for appreciation, love and nurturing. When you combine the two things you won’t have to worry about body mechanics or how hard you work on clients or working more than the agreed upon time.

Helping has a way of bringing up our unmet needs. It shows up in counter-transference. The reasons why massage therapists want to help others is usually filled with unconscious unmet needs and old feelings. Counter-transference influences the client interactions and the healing process sometimes hindering it. When you are in a state of counter-transference , projecting your old issues and feelings onto a client it can cause you to lose the objectivity you need to see the client clearly and hear the client clearly.  See also:  Why do you help?

The best thing you can do to take care of yourself is to become more conscious of your unmet needs and repressed/suppressed feelings so that you can be more present in your massage sessions for your clients. That is what they pay you for really. Your unmet needs and old emotions are what get projected onto others and onto clients in the form of counter-transference. I have written about counter-transference before here.

Your unmet needs and old emotions are projected into your practice, your money issues and your personal relationships.  Self  care that addresses these issues and helps you to become more aware of these issues can often reduce the physical stress of doing massage.  The more you take care of yourself in that way, the more confident you become in asking for what you need and creating boundaries to take care of yourself in the client/massage therapist relationship.

In simple terms, projection happens when you are not aware of your feelings or needs so you ‘project’ them onto someone else. Projections can cause reactions such as always giving advice to a client. To become more present means to be able to feel the feeling that is causing the projection (are you following this? It is hard to understand since it is unconscious.)

Remember – this is an unconscious process. Everyone is unconscious most of the time. Since it is unconscious you are not aware of what you are really doing. Becoming more conscious is a very complex process. We live our lives with many blind spots. Some people won’t even believe they are doing something unconsciously because it seems so real. It is real.

The way to track your thoughts and beliefs is through your feelings and becoming more aware of them.

Supervision and peer supervision can help you to become more self aware.  Supervision is not someone telling you what to do in the regular definition of supervision in the workplace.  Supervision is the process of working with a more experienced massage therapist in order to understand your practice issues more and help you become more aware of yourself.

Working with a skilled psychologist can also take you deeper into your old patterns of behaving onto can do wonders for your massage practice and personal life. Since all relationships start in transference and the therapeutic relationship has a way of intensifying that transference it is important to find out more about your unmet needs. For the most part all we can do is grieve the loss of never having had them met as it is too late to get them met. Then it is a matter of taking personal responsibility for yourself and actions.  The more you take care of yourself, your unmet needs and deal with the emotions, the more present you are able to be in your sessions and be there for clients.   The more you take care of your internal self the easier it is to do those external self care things like setting boundaries around your time and financial needs.

Transference is one of the most important concepts to understand for a massage therapist but the least understood and talked about. It is usually covered in a few hour workshop in massage school. Transference is a very complex phenomenon that comes from the psychology profession. The reason that it is so important to understand is the fact that the process of transference is actually what can lead a person to becoming more aware of their thoughts and issues. Transference is what heals.

Ben Benjamin author of the book The Ethics of Touch: The Hands-on Practitioner’s Guide to Creating a Professional, Safe and Enduring Practice
defines transference as this:

Clients defer to the practitioner’s judgment because they desire to be helped by an authority figure that possesses greater knowledge, healing ability and, therefore, power.

Since a power differential exists in any health care relationship, the client may be inclined to respond to the practitioner as he or she would other authority figures, and in doing so, may recreate elements of similar past relationships. This situation is known as transference, a normal, unconscious phenomenon that appears during a therapeutic process. Professional helping relationships usually have a strong transference element in which the parent-child relationship is unconsciously re-established. In transference, unresolved needs, feelings and issues from childhood are transferred onto the helper.

Elliott Greene author of the book “The Psychology of the Body” writes this:

Transference is the displacement or transfer of feeling, thoughts, and behaviors originally related to a significant person, such as a parent, onto someone else, such as the massage therapist. It is a common reaction of clients to their therapists. A bit of transference happens in most relationships in which there is feeling present. Usually, transference-related feelings were formed in the past, so it could be said that these feelings transfer from the past to the present. In transference then, the client relates to the therapist and present moment as if the therapist were the significant person. In this sense, transference is a projection of the internal drama of the client, and the therapist is assigned a particularly important role and script.”

Nina McIntosh in her book “The Educated Heart” says this about Transference.

“Transference may sound complex and unusual, but it’s actually part of our everyday life even outside of our offices. It’s normal for any of us to bring the past into our present relationship. In fact it happens all the time. They are magnified in a manual therapy session because of the intimacy of the setting, the clients altered state and the way that the practitioner/client roles mimic those of the parent/child.””Transference isn’t a rational process.

Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says this:

“The very nature of the therapeutic relationship allows transference to happen easily. Bodywork can trigger a variety of emotions from clients such as anger, frustration, sadness, fear, or joy. These feelings are generally the result of some emotion the client felt in the past towards another person.”

Cidalia Paiva in her book “Keeping the Professional Promise” says this:

“Transference refers to those situations where the patient projects onto the therapist old feelings or attitudes they had about significant people in their past, often parental figures. Transference is often referred to as ‘the unreal relationship in therapy’. The roots of transference are most often found in early childhood, and it constitutes a repetition of past conflicts with significant people in our lives.

So what is transference then?

Simply put, transference happens when there is difference in authority that resembles the parent-child relationship. The client who comes to a massage therapist receives the nurturing that they never received as a child and puts the massage therapist on a pedestal. The nurturing touch brings out the old feelings and emotions that were repressed or suppressed in early childhood. The client unconsciously begins to see the massage therapist as the nurturing parent and it can bring up feelings of attachment that were not resolved growing up. It is when the client unconsciously thinks that the massage therapist is their mother or father or other significant caretaker. Note the word – UNCONSCIOUS.

Attachment is what happens between a mother and child that allows the child to grow and build self esteem. The infant knows learns about themselves through touch. There are various stages of attachment that occur in child development where the infant feels like they are one with the mother. (And of course they once were in eutero.) As a child grows they learn that they are separate from the mother. This is where things often go astray. If a secure attachment is not formed in their early part of life, they will have life long challenges that result from that.

Massage and nurturing touch re-enacts the process of development. I actually think this is also why spa treatments are so popular with the use of healing waters and body wraps. Getting regular massage and developing a relationship with a massage therapist in which the client feels nurtured and cared for as if they were receiving it from their mothers can help heal the grief of not ever getting those early childhood needs met.

Transference is really important yet difficult to understand. The best way to understand it is to experience it. You may or may not have had some of these feelings arise when you were getting a massage from someone:

• Feeling like you don’t want the massage to ever end
• Not wanting to leave the office
• Seeing the massage therapist outside of the office and wanting to follow them where ever they go.

Or from the other aspect seeing it in your clients:

• bringing you flowers or special gifts
• hearing about people’s personal problems
• being asked to make exceptions in scheduling and payment options.
• inviting you out socially as a friend
• asking you out on a date or making other advances on you.

Or if you ever worked with a psychologist or mental health professional in therapy, you can come to learn more about transference from seeing your own. Becoming aware of your projections in a therapy setting can be a painful experience. It is a matter of getting a look at your unconscious thoughts through relationship. It can be a very eye-opening process and really lasts a lifetime.

While some of these things may just seem like normal things, it is difficult to know the difference. You probably won’t know the difference.

What you can do is create a code of ethics and a set of policies and procedures for your practice that will help you make proper decisions in any situation. It is having boundaries that teach people when they are in transference that you are separate from them is what will allow the person to heal and build self esteem.

The other thing about transference is that it not only occurs in these helping types of relationships but almost all relationships. Friendships, significant others, family members and the person who checks you out at the grocery store who seems to ‘look just like your mother”.

Reading and learning everything you can about transference can also help. These are some of my favorite books:

The The Psychology of the Body (Lww Massage Therapy & Bodywork Educational Series)

Ethics for Massage Therapists

The The Educated Heart: Professional Boundaries for Massage Therapists, Bodyworkers, and Movement Teachers (LWW In Touch Series)

Issues and Ethics in the Helping Professions
On Becoming a Person: A Therapist’s View of Psychotherapy

Erections during a professional massage happen there is no doubt about it.  The way the massage therapist responds to it will depend on their level of professionalism and of course the situation.  How the massage therapist responds can influence the therapeutic relationship which is the basis of interaction in a massage room. Getting an erection on the massage table can be as embarrassing to the client as is is to the massage therapist.

What should you do if you notice your client has an erection?

• Run out of the room screaming for help?
• Close your eyes and hope you are seeing things
• Say something?
• Work deeper on another area of the body that is less sensual
• Throw a towel over it
• Say something general like “Oh, That happens”

Erections are a natural occurrence that can not be controlled.  Each situation will have to be evaluated.  First if there is obvious threat to your safety and well being with the male client asking you to do something about it or he is sexually stimulating himself- get out of there right away without saying or doing anything else.  Be ready to call the police if the person does not exit immediately.

That being said most cases are innocent and do not mean anything.  If you respond with disapproval or further embarrass the person it can be damaging to their emotional well being.  Some men will not seek out massage because they worry so much about getting an erection during massages.

For women massage therapists in particular, erections are often associated with thinking that the client is coming on to them and thinking of the massage as something sexual rather than therapeutic.  They can also begin to think that they are giving the wrong message to the client.

Cherie Sohnen Moe in her book “Ethics of Touch” says:

Several realities shape female perceptions of erections.  Many were raised with pervasive myths about erections:  If you are with a man and he has an erection a) you have caused it and b) you are responsible for taking care of it.   Additionally, erections are often associated with rape and sexual violence.

Nina McIntosh in her book “Educated Heart” says this:

Some people wrongly believe that if a man is having an erection the practitioner must immediately end the session. There is the misconception that for a man to have an erection, he must be deliberately sexualizing the situation and either mentally or physically stimulating himself. The truth is that having an erection can be an innocent accident and just as embarrassing to the client as it may be anxiety producing for the practitioner.”

Women often react in fear to a male erection on their massage table because of the many cases of men looking for something more than just a massage. They think that if they don’t stop the massage, it may escalate to something more like an unsafe situation for themselves. Since erections on the massage table are not talked about much dealing from a place of fear can add to the embarrassment and shaming of both parties. You don’t want to add to the situation, yet you want to protect yourself.

If a male is obviously doing things to bring on an erection or relieve an erection it has no place in the massage room.

Each case has to be looked at individually. If the client has a past relationship with you and hasn’t had this issue come up before, it is most likely ok to continue working or talk about it.

If it is a new client and they are making sexual comments or acting inappropriately, a massage therapist has the right to end the massage at any time.
Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says it this way:

A therapist has the right to refuse to treat a client if the therapist determines that the therapeutic relationship cannot be maintained in an ethical manner.

If a massage therapist finds themselves constantly getting clients who are seeking more than just a massage it is often a good idea to have the massage therapist take a deeper look at their intentions and professional image. ( I actually worked with a massage therapist who was having this problem and she couldn’t figure out why. When I looked at her website I saw pictures of her in sexy tank tops showing more than was needed. Another always worked without proper draping and wondered why erections were more common.)

The more we can talk seriously about issues like this, the stronger we can become as a profession setting boundaries that can protect the massage therapist and educate clients. Healing on both sides of the issue can happen.

How to deal with Erections on the massage table.

• Assess the situation – are they asking for something more?  Can you clear the situation up by explaining that you don’t do that or do you have to send them out the door?  It is possible to have a regular client get caught up in the physical aspects of it all and ask for something more and still continue the relationship.  You have to decide but also know that shaming men more for this can be damaging.   Are they laying quietly ignoring the situation?  Don’t do anything.
• You can use thicker sheets or place a thick towel on top of the client’s erection to cover things up more.
• Have a section on your website explaining the situation to tell people it is normal.
• Talk about it if necessary.

So dealing with an erection on the massage table is a matter of evaluating the circumstances and using compassion.

And don’t forget that women also can be stimulated during a professional massage but of course it isn’t as obvious or as much of a threat although I have heard stories of male massage therapists  getting special requests from women clients.

Since erections do happen we need to be able to deal with them in the manner that supports us both professionally and personally. Nina McIntosh in her book “Educated Heart” says this:

Some people wrongly believe that if a man is having an erection the practitioner must immediately end the session. There is the misconception that for a man to have an erection, he must be deliberately sexualizing the situation and either mentally or physically stimulating himself. The truth is that having an erection can be an innocent accident and just as embarrassing to the client as it may be anxiety producing for the practitioner.”

Women often react in fear to a male erection on their massage table because of the many cases of men looking for something more than just a massage. They think that if they don’t stop the massage, it may escalate to something more like an unsafe situation for themselves. Since erections on the massage table are not talked about much dealing from a place of fear can add to the embarrassment and shaming of both parties. You don’t want to add to the situation, yet you want to protect yourself.

If a male is obviously doing things to bring on an erection or relieve an erection it has no place in the massage room.

Each case has to be looked at individually. If the client has a past relationship with you and hasn’t had this issue come up before, it is most likely ok to continue working or talk about it.
If it is a new client and they are making sexual comments or acting inappropriately, a massage therapist has the right to end the massage at any time.
Terrie Yardly-Nohr in her book “Ethics for Massage Therapists” says it this way:

A therapist has the right to refuse to treat a client if the therapist determines that the therapeutic relationship cannot be maintained in an ethical manner.

If a massage therapist finds themselves constantly getting clients who are seeking more than just a massage it is often a good idea to have the massage therapist take a deeper look at their intentions and professional image. ( I actually worked with a massage therapist who was having this problem and she couldn’t figure out why. When I looked at her website I saw pictures of her in sexy tank tops showing more than was needed. Another always worked without proper draping and wondered why erections were more common.)

The more we can talk seriously about issues like this, the stronger we can become as a profession setting boundaries that can protect the massage therapist and educate clients. Healing on both sides of the issue can happen.

And NO – for those who are finding this page by searching for erections during massage and happy endings – NO!  Happy endings are acts of prostitution and are illegal!

One of the least talked about concepts in massage school is the therapeutic relationship that occurs between the massage therapist and the client. Cidalia Paivia in her book “Keeping the Professional Promise” says:

When a massage therapist and a patient come together, the therapist and patient enter into a therapeutic relationship. What distinguishes the therapeutic relationship from other relationships is its very special purpose and goal, which is to serve the needs and interests of our patients.

The Therapeutic relationship’s primary function is to facilitate the health and well-being of our patients, ensuring that we bring our full presence and commitment to this experience.”

When people come to us seeking help with their condition or distress, what happens is that a power differential is created. People come to us thinking we can ‘fix’ or help them. They think that we hold the answers to relief from their symptoms. They are vulnerable because they are in pain or under stress. The act of seeking help recreates an old pattern of relating to someone in power which is based on our early relationship with our parents or major caregiver. Since no caregiver is perfect and able to provide for all of our needs we are left with holes in our essence and we seek to fill these in most relationships especially one where a person is actually seeking help.   (Transference)

On the other hand the “helpers” have their own issues and reasons why they feel compelled to be the helper. (Countertransference) While on the surface many help because it brings more meaning to the helpers lives, helping is also a great way to really learn more about oneself. Rachel Remen in her article “in the Service of Life” talks about helping in this way:

Serving is different from helping. Helping is based on inequality; it is not a relationship between equals. When you help you use your own strength to help those of lesser strength. If I’m attentive to what’s going on inside of me when I’m helping, I find that I’m always helping someone who’s not as strong as I am, who is needier than I am. People feel this inequality. When we help we may inadvertently take away from people more than we could ever give them; we may diminish their self-esteem, their sense of worth, integrity and wholeness.

Because the nature of touch can bring up so many deep and unconscious feelings and emotions in clients and the massage therapist, it is important that a massage therapist have an understanding of what happens in a therapeutic relationship and understand how what they do and say can influence the relationship.

The thing with counter-transference is that the roots of it are often so deeply embedded in who we are, we are unaware that the source of our feelings and reactions may be based on our own unmet needs from early childhood so we unknowingly jeopardize the therapeutic relationship.  It often shows up in the way we always want to help others, how we always want to give advice to clients, and in many other ways.

Maintaining the Therapeutic Relationship

The therapeutic relationship is based on the massage therapists ability to stay present with a client and not judge, fix or otherwise hinder the client’s process of healing. It requires that the massage therapist have a clear idea of what their own needs are and learn to get their own personal needs for appreciation, validation and to be needed met in other areas of their lives so that they can become and stay more present with the client for the clients healing process. Working within the therapeutic relationship requires that you be able to give empathy for the client. To be able to give empathy, one needs to have met their own needs for empathy first by doing the grief work that is related to not getting your needs met and working with a skilled peer supervisor or mental health counselor to rewire the brain and body for empathy.

Since so many of our needs are really unconscious, it is important to begin to become aware of our own needs and learn to take care of them outside of the therapeutic relationship so that we can become more present to witness the healing process in clients.

So often massage therapists find themselves crossing the boundaries between friendship and clients, wanting to fix a client, wanting to give more, getting paid less, giving advice and acting in other ways that will actually foster a client’s dependence on the massage therapist. The massage therapist will often start sacrificing their time and energy in order to help a client or so they think. There is such a fine line between helping and when helping is actually hurting that it is near impossible to distinguish until it is too late. The massage therapist will end up feeling resentful, burned out, facing physical injuries/illness which may lead to career ending events.

The presence of a massage therapist depends on their own awareness of themselves and the reasons why they feel compelled to help. Our early childhood is where it all starts. Our self esteem is developed at an early age. We begin projecting our unrecognized feelings on others shortly after birth. When our early needs for nurturing, appreciation and acceptance were not met, we see ourselves as less than worthy and it is reflected in all of our actions and reactions. When our own needs for empathy and mirroring are left unmet from early childhood, they often get in the way when we try to help others. We can learn to be of service more when we take the time to receive the empathy that we need for ourselves.

As a massage therapist, we owe it to our clients to do our own personal growth work and fill in the holes left by the wounds of our past. Learning about ourselves and setting clear boundaries in a massage practice can take you much farther in building your practice than any marketing plan. The clearer you get about who you are, what you are doing and why, the clearer your relationships with your clients and potential clients.

Massage Ethics are really what building a massage business or being a massage therapist is really all about.  To have a successful and rewarding (both financially, emotionally, mentally and spiritually) studying ethics and learning more about yourself and your values can help you in doing just that.

Many professional associations have a so called “Code of Ethics” which members are supposed to abide by.  The thing is that they are so general in nature that they can be widely interpreted.  Here are some sample code of ethics statements of professional associations:

The AMTA Code of Ethics:

This Code of Ethics is a summary statement of the standards by which massage therapists agree to conduct their practices and is a declaration of the general principles of acceptable, ethical, professional behavior.

Massage therapists shall:

1. Demonstrate commitment to provide the highest quality massage therapy/bodywork to those who seek their professional service.

2. Acknowledge the inherent worth and individuality of each person by  not discriminating or behaving in any prejudicial manner with clients and/or colleagues.

3. Demonstrate professional excellence through regular self-assessment of strengths, limitations, and effectiveness by continued education and training.

4. Acknowledge the confidential nature of the professional relationship with clients and respect each client’s right to privacy.

5. Conduct all business and professional activities within their scope of practice, the law of the land, and project a professional image.

6. Refrain from engaging in any sexual conduct or sexual activities involving their clients.

7. Accept responsibility to do no harm to the physical, mental and emotional well-being of self, clients, and associates.

The ABMP Code of Ethics is a little longer.

1. Commitment to High-Quality Care

I will serve the best interests of my clients at all times and provide the highest quality of bodywork and service possible. I recognize that the obligation for building and maintaining an effective, healthy, and safe therapeutic relationship with my clients is my responsibility.

2. Commitment to Do No Harm

I will conduct a thorough health history intake process for each client and evaluate the health history to rule out contraindications or determine appropriate session adaptations. If I see signs of, or suspect, an undiagnosed condition that massage may be inappropriate for, I will refer that client to a physician or other qualified health-care professional and delay the massage session until approval from the physician has been granted. I understand the importance of ethical touch and therapeutic intent and will conduct sessions with the sole objective of benefitting the client.

3. Commitment to Honest Representation of Qualifications

I will not work outside the commonly accepted scope of practice for massage therapists and bodywork professionals. I will adhere to my state’s scope of practice guidelines (when applicable). I will only provide treatments and techniques for which I am fully trained and hold credible credentials. I will carefully evaluate the needs of each client and refer the client to another provider if the client requires work beyond my capabilities, or beyond the capacity of massage and bodywork. I will not use the trademarks and symbols associated with a particular system or group without authentic affiliation. I will acknowledge the limitations of massage and bodywork by refraining from exaggerating the benefits of massage therapy and related services throughout my marketing.

4. Commitment to Uphold the Inherent Worth of All Individuals

I will demonstrate compassion, respect, and tolerance for others. I will seek to decrease discrimination, misunderstandings, and prejudice. I understand there are situations when it is appropriate to decline service to a client because it is in the best interests of a client’s health, or for my personal safety, but I will not refuse service to any client based on disability, ethnicity, gender, marital status, physical build, or sexual orientation; religious, national, or political affiliation; social or economic status.

5. Commitment to Respect Client Dignity and Basic Rights

I will demonstrate my respect for the dignity and rights of all individuals by providing a clean, comfortable, and safe environment for sessions, using appropriate and skilled draping procedures, giving clients recourse in the event of dissatisfaction with treatment, and upholding the integrity of the therapeutic relationship.

6. Commitment to Informed Consent

I will recognize a client’s right to determine what happens to his or her body. I understand that a client may suffer emotional and physical harm if a therapist fails to listen to the client and imposes his or her own beliefs on a situation. I will fully inform my clients of choices relating to their care, and disclose policies and limitations that may affect their care. I will not provide massage without obtaining a client’s informed consent (or that of the guardian or advocate for the client) to the session plan.

7. Commitment to Confidentiality

I will keep client communication and information confidential and will not share client information without the client’s written consent, within the limits of the law. I will ensure every effort is made to respect a client’s right to privacy and provide an environment where personal health-related details cannot be overheard or seen by others.

8. Commitment to Personal and Professional Boundaries

I will refrain from and prevent behaviors that may be considered sexual in my massage practice and uphold the highest professional standards in order to desexualize massage. I will not date a client, engage in sexual intercourse with a client, or allow any level of sexual impropriety (behavior or language) from clients or myself. I understand that sexual impropriety may lead to sexual harassment charges, the loss of my massage credentials, lawsuits for personal damages, criminal charges, fines, attorney’s fees, court costs, and jail time.

9. Commitment to Honesty in Business

I will know and follow good business practices with regard to record keeping, regulation compliance, and tax law. I will set fair fees and practice honesty throughout my marketing materials. I will not accept gifts, compensation, or other benefits intended to influence a decision related to a client. If I use the Associated Bodywork & Massage Professionals logo, I promise to do so appropriately to establish my credibility and market my practice.

10. Commitment to Professionalism

I will maintain clear and honest communication with clients and colleagues. I will not use recreational drugs or alcohol before or during massage sessions. I will project a professional image with respect to my behavior and personal appearance in keeping with the highest standards of the massage profession. I will not actively seek to take someone else’s clients, disrespect a client or colleague, or willingly malign another therapist or other allied professional. I will actively strive to positively promote the massage and bodywork profession by committing to self-development and continually building my professional skills.

Principle I – Respect For Persons

Meaning:

To value the dignity and worth of all persons regardless of age, race, culture,creed, sexual identity, gender, ability and/or health status.

Application:

Client autonomy is demonstrated by:

a) Ensuring that clients are as fully involved as possible in the planning and implementation of their own health care

b) Providing complete and accurate information in a sensitive and timely fashion to enable clients, or when necessary a client’s substitute decision maker, to make informed choices

c) Listening to and respecting a client’s values, opinions, needs, and cultural beliefs

d) Encouraging and being responsive to a client’s choice to accept, augment, modify, refuse or terminate treatment

e) Being informed about moral and legal rights of a client

f) Advocating for and supporting a client in exercising his/her moral and legal Rights

g) Safeguarding the client’s right to privacy and confidentiality by holding all personal and health in

formation in confidence unless otherwise required by law.

Principle II – Responsible Caring

Meaning:

Providing sensitive, compassionate and empathetic quality massage therapy.

Application:

Responsible care of a client is demonstrated by:

a) Listening to and respecting the client’s values, opinions, needs, and cultural beliefs

b) Promoting the client’s best interest and well-being, through the highest possible standard of professional practice

c) Seeking assistance when conflicts arise between the value systems of the practitioner and the client

d) Recognizing and referring the client to other health care providers when it is in the client’s best interest to do so

e) Being alert to and reporting, as required, any unethical practice by any member of the regulated health professions

f) Approaching and co-operating with substitute decision makers in assessing the client’s wishes and best interests in the event of incapacity

g) Protecting the client’s physical and emotional privacy

h) Collecting only that information which is relevant to the provision of health care.

Principle III – Integrity in Relationships

Meaning:

To practice with integrity, honesty and diligence in our professional relationships with ourselves, our clients, our

professional colleagues and society.

Application:

Commitments to Clients are demonstrated by:

a) Ensuring that we always act in our client’s best interest as defined by the client’s wishes and consistent with the standards of practice of the profession

b) Informing the client about health care services available to support them

c) Referring to other health care providers as necessary and appropriate

d) Obtaining assistance when value conflicts arise which threaten to impede client autonomy

e) Providing client-centered health care which includes the following:

i) Explaining to the client and advocating for his/her right to receive information about, and take control of his/her health care

ii) Providing information about the proposed treatment, alternative courses of action, the material effects, risks and

side effects in each case and the consequences of not having the treatment

ii) Assisting the client to comprehend information

iv) Responding to questions about our client’s health care/treatment

Commitments to Self are demonstrated by:

a) Being pro-actively committed to our own health and personal and professional development

b) Being competent, conscientious and empathetic practitioners

c) Being aware of our personal values and being able to identify when value conflicts interfere with client care

d) Keeping our professional commitment by integrating massage values and principles in our daily practice

Commitments to our Professional

Colleagues are demonstrated by:

a) Respecting our colleagues and working cooperatively with them

b) Intervening in situations where the safety and well being of a client is in jeopardy

c) Reporting to appropriate authorities any regulated health care practitioner who abuses a client physically, verbally, sexually or financially

d) Referring to other health care providers when necessary and appropriate

e) Co-operating with regulatory functions of the profession

f) Contributing to continuous quality improvement initiatives

g) Upholding standards and guidelines of the profession

h) Advocating with other health care providers to promote and support social changes that enhance individual and community health and well-being

i) Representing ourselves honestly, and performing only those services for which we are qualified

Principle IV – Responsibility to Society

Meaning:

To be accountable to society and conduct our selves in a manner that fosters and promotes high ethical standards.

Application:

Ethical practice is demonstrated by:

a) Pursuing continued career-long, professional learning

b) Advocating for and supporting a client’s ethical and moral rights

c) Participating in the promotion of the profession of massage therapy through advocacy, research and maintenance of the highest possible standards of practice

d) Being committed to promoting the welfare and well-being of all persons in society

e) Making every reasonable effort to ascertain that our clinical environment will permit provision of care consistent with the values in the Code of Ethics

f) Committing to continuous improvement and implementation of standards of massage practice

g) Collaborating with members of the other health professions to meet the health needs of the public

h) Continuing to develop ways to clarify massage therapist’s accountability to society.

Creating Your Own Code of Ethics

What does any of that really even mean?  The professional association guidelines are so general and undefined that anyone can interpret these in the way that suits them best.

The basics of ethics is uncovering your own beliefs and values and understanding what motivates your actions and thoughts.  In doing so you can create a massage business or find your ideal massage job that is a clear reflection of you and your values.   It is an ongoing process because most of our values are ‘inherited’ from our early upbringing and not really chosen by us.  They are taught to us by our parents and in school.

Massage clients also come to a massage therapist seeking help.  The dynamics of the helping relationship recreate the dynamics of the parent/child relationship.  It is important to be clear about what is what to become an effective massage therapist.  Situations will arise on a daily basis as a massage therapist that will constantly challenge your values and your core beliefs about yourself.  To help you unravel the underlying needs and perceptions participating in peer supervision groups or individual supervision classes can help you to do that.

Since we need to take ethics to meet continuing education requirements and to build successful careers finding the best massage ethics classes isn’t always so easy.  There are a handful of online classes that you can read some material and take a test.  While this fulfills the requirements for continuing ed having a live interactive class  or participating in supervision will help you in creating your own code of ethics and help you in learning to live by your values and create meaningful therapeutic relationships with you clients.  It is the therapeutic relationship that will help you build your career.

How can I help? Stories and Reflections on Service” Is the title of a book by Ram Dass written about the helping professions. I was first introduced to this book in massage school in 1987 and read it through briefly and didn’t really think much of it.

It is now the center of what is really some of the core issues in the massage profession and is the most tattered book on my shelf.

The main theory of the book is that there is a deeper reason as to why people help or feel a need to help. We need to boost our self esteem, we need approval and appreciation, we need to feel needed. But helping for the purpose of getting our needs met often leads to burnout and in the massage profession – a failing practice.
Because we work in a profession that works very closely with people, it is important to begin to always be working on ourselves to become more aware of our issues and blindspots.

It feels good to be working in a profession where we can ‘help’ others. But helping is different from being of service. Ram Dass says in the book

“Can we see that to be of most service to others we must face our own doubts, needs, and resistances?

What do you get out of helping? What purpose does it serve for you?

When you can begin to unlock the deeper meaning of ‘helping’ you can begin to uncover the unconscious beliefs that are usually the cause of our need to help others. When we come from a place of ‘needing’ to help others it gets in the way of the therapeutic relationship. It starts to become a massage session that is all about us and not the client. We are less likely to be able to really listen to a clients needs and concerns. We are more likely to bend our boundaries to accommodate clients thinking we are giving when in reality it is about much more than that. We give so we can get. We give up ourselves so that clients will stay clients because we fear not being able to make a living. We don’t have cancellation policies that support us – we let clients come and go as they please while our income suffers.

When we work to become more aware of our own issues and work through them with a counselor or in peer supervision/supervision our work changes.

As Ram Dass puts it:

“Our service then, is less a function of personal motive and more an expression of spontaneous, appropriate caring”

We get caught up in doing for others thinking it is what they need. We get caught up in giving advice or sermons thinking it is for their own good. When people don’t get better, we say we did all we could do and told them everything we knew. We forget to really listen and witness the process of healing.

We get caught up in thinking that all of our training, all of the extra hours of learning new techniques, all that you know is what makes you a ‘good helper’.
When you help from a place like this it becomes an addiction – like eating candy or drinking alcohol. You get your high from helping and like to think you are being useful. But when does that ‘helping’ begin to hurt more than it helps?

The more you can look at this act of helping and all of the needs and feelings associated with it, the easier it will be to fill your practice with the kind of clients who are nurturing and respectful of you and value your time and efforts to pay you what you are worth.

Questionnaire to further explore helping issues in the massage profession.

Ethics is defined by Webster as the study of standards of conduct and moral judgment; this system or code of morals of a particular person, religion,group, profession, etc.

Since each person is unique with their own experiences and beliefs, ethics can be difficult to define. There is no concrete answer.  As a professional, we are responsible for the comfort and safety of our clients.  We can serve them best when we understand their needs and rights.  We can serve them best when we have examined ourselves and worked through our own issues. We can serve them best when we focus on the development of ourselves.  We can only guide the client  to places that we have been willing to go ourselves.  The healing process can begin only when we realize that we are just facilitators in the process itself.  The healing is the responsibility of the client alone.  They must be given the information to determine what is right for them and what they are going through.

Informed Consent
Clients need to be able to make a decision as to whether they want you to work on them and what they want you to do. Tell the client what you’re doing and why. This is informed consent.  They must be given enough information, such as : what are the goals and purpose of the session, what are the possible consequences of the treatment, what risks are involved,  what are the possible benefits of a treatment, how much time will the treatment take, how much money will the treatment cost and how will it be paid for.  With this information, a client will be able to determine if they want the treatment for themselves or do they refuse the treatment.

Informed consent is the process in which a fully informed client can make conscious decisions about their health care or massage therapy session.  An informed consent statement does just what it says: informs clients to make them aware of your services so they can actively consent or participate in the service or not.

Informed consent for doctors usually is about protecting them in case things go wrong in their treatments that are much more invasive or even life threatening.  For Massage therapists, informed consent is more about letting people know of possible contraindications and keeping them safe.  It does not release the massage therapist if harm is done as in the case of doctors.

Writing a Statement of Informed Consent is crucial to the success of a massage practice.  

Many massage therapists overlook this process.

An informed consent statement can include:

• list of services that you offer

• scope of practice

• a specific definition of what those services are

• your intentions for the massage

• your philosophy on healing, massage and health

• treatment plans and goals

• risks involved in treatment/session

• guidelines for receiving massage

After informing a client of your services and philosophy it is necessary to confirm that the client understands what you mean.  Often, clients will just agree without hesitation because they don’t want to make waves.  You can specifically ask a client to tell you what they understand will be happening.  

Being direct with a client sets up proper boundaries for creating a therapeutic relationship.  When a client is informed, they have the opportunity to be more engaged in the process of massage and healing. 

The client or therapist can end the session at any time.  This is especially helpful in cases where men request ‘extra’ favors or with clients who are continually late or don’t show for their appointments.

Articles online on Informed Consent:

Examples of Informed Consent:

AMTA Informed Consent Agreement

Informed Consent Forms for Massage, Acupuncture, for Minors at www.sohnen-moe.com in .doc, PDF, wpf, and rtf format that you can edit and make into your own form.

Right of Refusal
Clients have the right to refuse the service for any reason at any time.  If they determine that the session should be stopped right in the middle, their needs must be respected.  Be aware that a session interrupted before completed may also cause a problem in the financial agreement.  Does the client owe for the whole time?
This same right also applies for the practitioner. You can end a session at any time, for any reason. The bottom line is to work on only people who are nurturing to you and do not drain your energy. If your mother just died of lung cancer it may not be advisable to work on someone who smokes.

Confidentiality
A clients information, both written and verbal belongs to the client.  Conversations that occur during a session, should not be repeated or included in the chart notes unless it is describing their physical condition. A client may also not want to be approached outside the treatment clinic.  If you see a client walking down the street and stop and say hello, this may violate their right of confidentiality, as they may not want it be known that they are seeking treatment.

Boundaries
A Boundary is a space within a perimeter that may be a physical, emotional or mental space.  The emotional (mental) space is determined by past experiences, values and morals. The physical space is the actual physical limits of space that is

 needed by each person to feel safe and secure.  Boundaries can be communicated by verbal conversations or body language.  Some people, especially those with a history of abuse of some sort, may not be aware of their boundaries let alone able to maintain their boundary.  Boundaries may be determined before a session to ensure the clients comfort.

Boundaries are often difficult to determine.  What may be good for one person, may not be appropriate for another.  It is important to explore boundaries and constantly readjust limits to accommodate each individual.
When boundaries are crossed, respect may be lost in the relationship.
There are a main types of boundaries we deal with include: Legal boundaries, professional boundaries, and personal boundaries.
Legal boundaries are those that of course deal with the law and the rules and regulations that are set up by each state, city or county. Your scope of practice is defined legally. Your scope of practice is the limits or boundaries that apply to your practice.  This may include areas you can work on and what you can or can not do. This will determine if you can do things like make diagnosis’s, do physical adjustments, work in the mouth or other body cavity and sell vitamins and other related items.
The laws vary so much that it is impossible to discuss here.  Make sure you contact your local authorities to determine what your legal boundaries are and that you work within the law.
Professional boundaries are determined by many things such as your type of practice, your business rules and practices.

Personal boundaries are just that- everything that determines your safety zone. They may be influenced by past experiences, beliefs and values.

Boundary violations usually begin quietly, little by little, and without many problems.  When you go through the process of looking at your values and needs and set your framework, boundary violations can be minimized.  Recognizing your own boundaries will be based on your values and needs.  There is no right or wrong here – only what is what is important to you.

Transference occurs when the client makes the professional relationship, personal.  Indications of transference are things like the client brings you additional gifts or asks to see you for lunch or outside the treatment. Personal conversation can also be an indicator.  What you do depends on each situation.  This can occur when a client is lacking in sufficient resources to take care of themselves.  Unresolved needs, feelings and issues are transferred to the helper or caretaker.

Counter-transference occurs when the therapist is unable to separate the therapeutic relationship from their personal feelings surrounding the client.  Some of examples of this is when a therapist feels inadequate if the client is not making progress or excessive thinking about the client after the treatment is over.  This occurs usually when the therapist plays the helper or fixer role.  We begin thinking that we can get rid of the persons pain when we really don’t do anything but facilitate the clients growth for their own healing of pain.  We begin to think that only we can fix the problem and we have all the correct answers.

Boundary violations usually begin quietly, little by little, and without many problems.

It is important to think of your practice as one of service to the client.
How can you serve that client best?

Knowing the basic principle of ethics is just the beginning to building a successful practice.  

Best Books on Ethics, Informed Consent:

I know that is a little harsh calling the massage profession codepedendent. I really think it applies to any and all helping professions and am seeing now how many people have issues around co-dependency.

I also hate the word codependency and wish there were another word for it but it pretty much does describe the phenomenon. The act of labeling the profession as such is also part of the problem. Rather than focusing on what kind of relationships we want to have, the focus is turned to the dysfunction which further promotes the dysfunction.

Codependency is defined by various psychologists and authors:

Robert Burney author of “Codependence: The Dance of Wounded Souls”

“Codependence is about having a dysfunctional relationship with self! With our own bodies, minds, emotions, and spirits. With our own gender and sexuality. With being human. Because we have dysfunctional relationships internally, we have dysfunctional relationships externally.”

Melodie Beaty author of “Codependent No More”

“A codependent is someone who has let another persons behavior affect him or her and is obsessed with controlling that other person’s behavior”

Ann Wilson Schaef in her book “Beyond Therapy, Beyond Science” refers to this definition proposed by Cermak.

Timmon Cermak in the Journal of Psychoactive Drugs (1986) argues that codependence can be defined within the DSM-m criteria for mixed personality disorder. He proposes five diagnostic criteria in the style of DSM-m. According to Cermak the essential features of codependency include (1) consensual investment of self-esteem in the ability to influence/control feelings and behavior in self and others in the face of obvious adverse consequences; (2) assumption of responsibility for meeting other’s needs to the exclusion of acknowledging one’s own needs; (3) anxiety and boundary distortions in situations of intimacy and separation; (4) enmeshment in relationships with personality disordered, drug dependent and impulse disordered individuals; and (5) exhibits (in any combinations of three or more) constriction or emotions with or without dramatic outbursts, depression, hypervigilance, compulsions, anxiety, excessive reliance on denial, substance abuse, recurrent physical or sexual abuse, stress-related medical illness, and/or a primary relationship with an active substance abuser for at least two years without seeking outside support.

How does this apply to the massage profession?

In general, I often see many massage therapists (including myself) who are wanting to “caretake” others at the expense of themselves. It shows up in many ways, shapes and forms. Everything from giving away massages for free or ridiculously low rates, going over the time allotted for a session, giving advice, working on people who aren’t very nurturing to work on just for the money, not wanting to market your business, giving up easily, and the list goes on.

It is also interesting how the profession itself acts to reinforce the codependent relationship. Ann Wilson Schaef describes how it is happening in the psychology profession:

“We have been trained to believe that we should be able to use our training and knowledge to control and manipulate clients in order to get them to do, see or feel, with what our greater knowledge and understanding is good for them.

We are taught that it was alright to use techniques, exercises or wise leads to pull out of people information that we knew and believed would be helpful for them and that, as professionals, we should know how and when to do that. Only recently, I fully understand the violence of this behavior: it truly rapes their souls, their beings and their process.

We were taught that dependency upon us was inevitable and helpful and that it was our responsibility to control the level. Of course, we were also going to be financially (and I believe, in most cases emotionally) dependent upon the client.

Finally we were supposed to have the knowledge to interpret the other person based, of course upon our knowledge and theory, which gave us an accepted position of “rightness. We were to set ourselves up as a power base, if for no other reason than we know more about the clients than they did about us. The very structure and makeup of the profession has perpetuated the disease process.”

While I know she is talking about the psychology profession, I believe the same could be said about the massage profession.

How I like to look at it is that we are all dysfunctional in some way or form. We are human and it is part of being human.

Codependence isn’t a thing that should be made to go away, but rather should be embraced and learned from. It is a great tool on the path to becoming aware and becoming our true selves. It is a process of becoming aware of just what we are thinking about unconsciously that brings us such pain and suffering that can lead us to peace and happiness.

We have the power to choose how we see things and the meaning we give to anything and everything that we experience.

We don’t have to be the codependent profession. It can be another way. But first we have to be able to acknowledge the codependent side of us just like we acknowledge the other parts of us.