Professional Ethics of Today (4 CEs)

By: Dr. Jeffrey M. Cullers, DC, BS, LMT

Course Objectives

After completing this course, participants will be able to:

1. Identify at least five (5) commonly held ethical values and philosophies which AMTA, NCBTMB, and ABMP all possess.
2. Explain the three basic conditions that must be met in the process and practice of “informed consent.”
3. List at least two (2) examples of what is considered a “conflict of interest” as it relates to the therapeutic relationship.
4. Recognize signs of transference in order to set appropriate boundaries with clients.
5. List five (5) boundary classifications and how each can affect the therapeutic relationship.
6. Describe at least two (2) ethical decision-making models/framework that can be used when presented with an ethical dilemma.
7. Differentiate between a law/regulation and an ethical code or standard.
8. Define scope of practice and the dangers of working outside of this scope.

Introduction

The field of massage therapy and bodywork has evolved immensely over the last decade primarily because individual states began regulating the profession more stringently which helped to eliminate unethical massage practices while also contributing to the credibility of the profession. Licensing, certification, and defining scope of practice for massage therapists have transformed the publics’ perception of the massage profession. Massage therapy continues to become increasingly important in the health and wellness professions and the number of massage therapists entering the profession is rising dramatically. Research estimates that massage therapy was a $12.1 billion industry in the country in 2015.¹

The Bureau of Labor Statistics projects massage therapist employment growth of 22 percent between 2014 and 2024, adding 36,500 more professionals to this field. The health care support field (allied health) is predicted to be one of the fastest-growing job segments in the next decade.² In July 2015, more than fifty-one (51) million American adults (16 percent) had discussed massage therapy with their doctors or health care providers in the previous year, consistent with past years’ data.³

While massage therapists work in a variety of work environments, individual practitioners account for the largest percentage of practicing therapists (67 percent). Of all therapists, 60 percent work at least part of their time at a client’s home/business/corporate setting, 35 percent at their office, 38 percent at their home, 23 percent in a health care setting, and 29 percent in a spa setting.⁴ Between July 2014 and July 2015, roughly 39.1 million adult Americans (18 percent) had a massage at least once.⁵

Why is this Important?

Ethics exist to ensure quality, safety and reputation. Ethics is a sense of professional responsibility that obligates the professional to act in the client’s best long term interest. As an increasing number of states adopt licensing requirements and standards for therapists, the practice of massage is likely to be respected and accepted by more people, as a way to treat pain and to improve overall wellness. Similarly, as more healthcare providers understand the benefits of massage, demand will likely increase as these services become part of treatment plans.⁶

Well, as more massage therapists enter the field and more clients desire massage therapy, a viable question to ask is what will make your practice stand apart from numerous other professional massage therapists in the business? One primary factor to success is developing personable, yet professional client relationships. To build a successful therapeutic relationship, it requires trust, just as with any other type of relationship. To become a successful massage therapist, these relationships are vital. Your personal ethics are as important as your professional ethics. It is one thing to know what you should do – what you are told you should do – but another thing to want to take the ‘correct’ course of action. Clearly, membership of a professional body requires adherence to a code of ethical conduct.

ETHICAL CODE OF STANDARDS

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.⁷

A code of ethics helps therapists navigate their way through client interactions while providing services. The client/therapist relationship is more complex now because of legal implications and the code of conduct is the foundation all therapists can reference when meeting ethical dilemmas in the client/therapist relationship.

As complex situations and experiences present themselves in daily business practices, the standards or code of conduct is the reference point for all massage therapists as it covers the issues relating to client/therapist relationships such as boundary issues, informed consent practices, confidentiality and privacy. To maintain professionalism, ethical codes are vital.

To understand human behavior and how values and morals are formed, it is important to review the definitions of values, principles, and morals; how they differ and how they relate to ethics. We also need to ask “why are ethics so important?

THE IMPORTANCE OF VALUES & ETHICS

Each individual possesses their own code of “personal” ethics. When a person asks, “what do I do,” and “why do I do it” they are checking their ethical code. What is right and wrong?

Values are essential to ethics. Ethics is concerned with human actions, and the choice of those actions.

Ethics evaluates those actions, and the values that underlies them. It determines which values should be pursued, and which shouldn’t. Ethics is a code of values.⁸

THE DIFFERENCE BETWEEN VALUES, PRINCIPLES, ETHICS AND MORALS
Our own values, interests and experiences are the filter through which we view any situation. It is important for us to be aware of those filters because they could influence our professional judgment.

It is impossible to discuss ethics without first considering related key terms such as values and morals. Simply put, “values describe what is important in a person’s life, while ethics and morals prescribe what is or is not considered appropriate behavior in living one’s life.⁹

Ethical decisions are made on a daily basis though most people are not consciously aware of this until they are presented with an ethical dilemma in their personal or professional life. One example follows:

One common example of a personal ethical dilemma most of us have experienced is when a cashier returns to much money to you after the purchase. Some people ignore the mistake and take the extra money, then others may tell the cashier and return the portion the cashier has overpaid. For some people, it will depend upon the amount – as to whether they inform or ignore the issue. If it is change of less than a dollar, it is easier for some to justify and accept the money. The point is that our own personal values have played into the decision making process.

So, where do we get these “values” from? How does each person arrive at their decision when presented with an ethical dilemma? Most people learn ethical norms at home, at school, in church, or in other social settings. Although most people acquire their sense of right and wrong during childhood, moral development occurs throughout life and human beings pass through different stages of growth as they mature.¹⁰

“Values” are the things people determine to be the most important in their lives i.e. ‘Paul values making money’. Ethics and morals however, determine what is or is not considered appropriate behavior in the pursuit of those values i.e. ‘how does Paul go about making money?’ ‘Does he pay therapists working for him, fairly?

Our values tell us what we want to achieve/do and our principles, ethics and morals evaluate the right or wrongness of our options. Values that relate to ethics and morality are those which have a component of rightness or wrongness to them. Therefore, if we value fairness and someone being lazy is contributing to a greater burden being placed on someone else, we may consider this unfair and thus unethical/immoral.¹¹

Therefore, values are principles which guide a person’s life. When a person encounters an ethical dilemma, their values will dictate their course of action and behavior (figure 1.2). A person’s values derive from family, institutions, peers, religion, society, and science. This is how our belief system is formed.

THE RELATIONSHIPS BETWEEN VALUES, ETHICS, & PRINCIPLES

From knowing a person’s values alone, we cannot know how, specifically, the person is going to behave. Some people, driven by their high priority value of Achievement/Success, will do anything it takes to achieve their goal – some athletes, for example, will take illegal drugs to boost their chances of success. On the other hand, we all know people driven by the same value, who do not cheat to win. (Chippendale & Colins, 2002).¹²

Because we live in a society, we cannot live our values any way we want. The impact of how we live our values on other people and the environment must be considered. This is where codes of behavior (i.e. ethics, morals, norms of behavior, laws, and the like) come in.¹³

As the diagram in Figure 1.3 depicts, codes of behavior spell out how we are expected to live our values.¹³

Thus, knowing a person’s values gives us a general idea of what they want to do in their life, knowing their ethical or moral stance, informs us as to how they will live their values. The difference between values and ethics may be summarized as: Values motivate – ethics & morals constrain. (Chippendale & Colins, 2002)

Knowing the values in which people believe, provides a means to understand why they behave the way they do. Since a person lives and works within a society, they cannot live their values any way they would like therefore, ethical standards are developed and laws are enacted.

When people engage in a behavior motivated by their values, they don’t see the actual consequences of their actions, rather, the consequences of their actions are filtered through their values – they see what matches their values, and don’t see what does not match.

In the well-known book entitled, The Ethics of Touch, by Dr. Ben Benjamin & Cherie Sohnen-Moei, ethics is defined as “the study of moral principles and appropriate conduct.” This can be applied to individuals, groups or professions.
In general, ethics in somatic therapies involve behaving honorably; adhering to prevailing laws; upholding the dignity of the profession; respecting each client; staying committed to high-quality care; working within the appropriate scope of practice; being client-centered; and remaining service-oriented. Values are based upon beliefs and attitudes; they involve what is desirable, rather than what is right and correct. Principles comprise an individual’s code of action and enable a person to behave with integrity.”¹⁴

In an article on the website of the National Institute of Environmental Health Sciences, Dr. David Resnik explains “the study of ethics is important because it sets the code for normative behavior in any profession.” He also explains that ethics keep researchers and other professionals accountable to the public and focused on achieving the good of society as a whole. Furthermore, he states, “Many different disciplines, institutions, and professions have standards for behavior that suit their particular aims and goals. These standards also help members of the discipline to coordinate their actions or activities and to establish the public’s trust of the discipline.” For instance, ethical standards govern conduct in medicine, law, engineering, and business.

ETHICS AND THE LAW

So, the term ethics can be simply interpreted as knowing the difference between right and wrong. Because each person’s interpretation of right and wrong may differ, ethical standards of conduct are created for professions, institutions, membership organizations, etc.… As their names suggest, codes of ethics have a weighing upon decisions made by individuals and companies, whereas codes of conduct have a bearing upon actions taken by individuals as well as organizations.¹⁵

There are many instances when actions taken by individuals or organizations are well within the written law and its spirit, though such actions may be looked down upon by the society. For example, a man marrying his cousin may be permissible by law, but certainly goes against codes of ethics that is set by the society, not the law of the land. In the western world, abortion is one act that is allowed by the law, but if you ask any church official, he will decry abortion as against humanity.¹⁶

TOP ETHICAL DILEMMAS FOR MASSAGE THERAPISTS

It is important for massage therapists to recognize ethical dilemmas within their profession. Following are a few areas where massage therapists commonly encounter ethical dilemmas, as per AMTA:

1. Balance of power among client and massage therapist. (power-differential)
2. Maintaining proper boundaries. (Roles and Boundaries)
3. Becoming aware of professional limitations regarding scope of practice. (Scope of Practice)
4. Maintaining effective policies for cancellations, late appointments, expectations of massage therapists.

These dilemmas will be discussed, in detail, later in the section. For now, we need to delve into the history of the profession to understand the progress the massage field has made over the centuries, so we may look to the future of the profession and its role in healthcare.

HISTORY TIMELINE OF MASSAGE THERAPY PROFESSION

As massage therapists study the history of the profession, most understand how the massage field started in ancient times with the Greeks. Instead of beginning with the Greeks or any period before, a review of events starting from the colonial period that advanced the profession will be discussed.

Tracing the professional lineage of massage therapists in America today takes us back to colonial times and continues through generations of practitioners, advancing to the present day. Progress through the decades was impacted by national and world events, advances in science and medicine, and religious and social movements—the larger context in which massage therapists of the past lived and worked.¹⁷

1700’S

Back in the 1700’s, massage therapists were called “rubbers” and they treated orthopedic issues and assisted with patient rehabilitation after surgery. They were primarily women in the occupation who had a skill for “hands-on” therapy. Just like today, rubbers integrated joint movements into their treatments to increase range of motion. They also modified their techniques to achieve various different outcomes. It is known that most rubbers worked for surgeons but they also worked independently, as well, in competition with doctors.

When medical licensing laws starting limiting the practices of rubbers, they were replaced by highly skilled “masseuses” in the 1900’s. This was a gradual process but eventually led to manual therapy techniques.

1800-1900’S

The titles masseuse and masseur became common in the 1880s, referring to manual therapists trained in the soft tissue manipulations developed by a European medical doctor named Johann Mezger. Mezger outlined the classic categories of massage techniques: effleurage, petrissage, friction and tapotement. Vibration was added later. ii It wasn’t until the 1900’s when “massage” became the known term for manual therapy manipulation.¹⁸

Swedish massage had evolved by the 1930s. This was not what we call Swedish massage today, but a whole system of physiotherapy. Swedish masseuses and masseurs utilized soft tissue manipulation, movements, hydrotherapy and electrotherapy for applications ranging from general health promotion to treating diseases to rehabbing injuries. (Benjamin, 2015).

1943

The Swedish massage was the known treatment and Doctors referred their patients to the masseuses and masseurs regularly. In the year 1943, the American Association of Masseuses and Masseurs (AAMM), now called the American Massage Therapy Association (AMTA), started to build the foundation for the massage therapy profession. At this time, educational standards, as well as ethical codes of conduct, were established. In 1954, AAMM issued a policy statement asserting the right of masseuses and masseurs to practice independently from organized medicine, and reaffirming the usefulness of Swedish massage as a natural healing approach. (Benjamin, 2015).

1960’S

It wasn’t until the 1960’s when the word “massage parlor” started to denote “a parlor of prostitutes” that the terminology “massage therapist” and “massage therapy” began to appear and become related with the profession. In 1958, the AAMM changed its name to the American Massage & Therapy Association (AMTA), and the profession from this point forward was called “massage therapy” and those who practiced, were named “massage therapists.” The term therapist helped the reputation of the profession by adding more credibility to the occupation.

1970-2000

Between 1970 and 2000, the field of massage therapy was transformed. New types of manual therapies were introduced along with “hands-on” approaches. America began learning about the different types of wellness therapies, including shiatsu from Japan, acupressure from China, and Ayurvedic massage from India. The term bodywork was coined to encompass the diversity of manual therapies that surfaced in this period. The wellness movement, fitness boom, concern about unhealthy stress, and growth of alternative medicine all contributed to a rising public interest in massage therapy, which expanded its scope to include diverse massage modalities. Escalating consumer demand for massage therapy, and an increasing number of men and women wanting to become massage therapists, revitalized a field that had become somewhat stagnant. (Benjamin, 2015).

THE NEED FOR REGULATION

As the field of massage therapy has evolved, so has the need to protect the public. Massage therapy has a significant impact on a person’s health and well-being. The public has a right to expect that a massage therapist has the qualifications needed to practice effectively and safely.

Reasons to Regulate a Profession

The AMTA provides reasons why regulations are necessary. Legal recognition of the practice of massage therapy and clearly-stated requirements to practice are essential to promote the profession and protect the health, safety and welfare of the general public. Following are some valuable reasons provided by AMTA on why the profession needs to be regulated¹⁹:

1. Legal recognition of massage therapy in the form of state licensure creates standards of minimum competency. Competency is measured and enforced through formal education, training, and examination requirements.
2. Legal recognition of massage therapy ensures that individuals have met the eligibility requirements needed to practice massage therapy and that they are qualified to represent themselves to the public as state licensed massage therapists.
3. By providing a legal definition of the scope of massage therapy practice, professional licensure helps consumers identify the responsibilities and services unique to a massage therapist. It allows consumers to select the most appropriate massage therapy professional for their needs and brings the benefit of open access to the selection process.
4. Legal recognition of massage therapy through licensure enables a state or jurisdiction to discipline a massage therapist. States do not have the ability to regulate a profession that is not formally recognized in statute. Professional licensure laws enhance public safety by enforcing disciplinary actions against non-compliant practitioners.
5. Legal recognition of massage therapy through licensure protects the public in other ways as well. It establishes a consistent standard of practice which is enforceable by a professional code of ethics. In addition, it establishes a formal grievance process for consumers that helps prevent unethical and/or non-compliant massage therapists from continuing to practice

Licensure and State Regulation

Licensure is a non-voluntary process by which an agency of government regulates a profession. Licensing is always based on the action of a legislative body. Once a licensing law has been passed, it becomes illegal for anyone to engage in that occupation unless he or she has a license. The health care professions are typically licensed at the state and/or local level, but not usually at the federal level.

Under U.S. law, authority rests with states to regulate professions that have an impact on the health, safety and welfare of the public. This isn’t something that is done through national legislation. State licensure requires that only a person who holds a valid license from the state can engage in the practice of massage therapy or advertise to the public that they are practicing massage therapy. It also applies criminal penalties for people who practice without a valid massage therapy license. Professional licensure laws establish a minimum level of competency necessary to safely and effectively practice.

Currently, there are 45 states and the District of Columbia that regulate massage therapists or provide voluntary state certification. In states that regulate massage therapy, massage therapists must meet the legal requirements to practice, which may include minimum hours of initial training and, as mentioned earlier, passing an exam. In states that do not regulate massage therapy, this task may fall to local municipalities. Most states that license massage therapists require a passing grade on the Massage & Bodywork Licensing Exam (MBLEx).

The growth and credibility of the massage therapy profession is attributed to the massage and bodywork organizations and associations who have moved the profession into the 21st Century. This was successful only due to these organizations and specific professionals and academics who contributed their time and resources to establish the following:

1. Provide consistent scopes of practice and entry level standards across the country.
2. Provide valid and reliable licensing exam that would be accepted by all jurisdictions.
3. Provide a common database with licensing and disciplinary information and the ability to store critical documents.

In the last decade, major strides have taken place to advance the field of massage therapy and bodywork. As mentioned previously, this would not be possible without the contributions of major organizations. These organizations include:

• Alliance for Massage Therapy Education (AFMTE)
• American Massage Therapy Association (AMTA)
• Associated Bodywork & Massage Professionals (ABMP)
• Commission on Massage Therapy Accreditation (COMTA)
• Federation of State Massage Therapy Boards (FSMTB)
• Massage Therapy Foundation
• National Certification Board for Therapeutic Massage & Bodywork (NCBTMB)

In previous years, the growth of massage therapy as a profession had been hindered by the lack of a formal foundational statement describing scope of practice; educational requirements; knowledge, skills, and abilities and common terminology, along with a professional body of knowledge.

This lack of entry level standards, a licensing exam, and state regulations became an issue in areas of wellness practices, and is especially problematic for massage within the health care community. Without a strong, consistent foundation, the profession would have continued to lack full acceptance by the general population, the medi­cal community, and other allied health care fiel

Professional associations offer resources to help their members succeed in the business world. This can include everything from website tools to the use of a well-known and respected logo. The organizations are also sources of information, as well as advocates for the profession as a whole.

Following is a brief summary of these important organizations and their implementation of ethics and standards of conduct. Each organization develops an ethical code/standard, and many of these standards crossover. Some standards of conduct are common sens, but there are those ethical codes which need to be explained in more detail, as they occur in daily practice, usually when dealing with the client/ therapeutic relationship.

NATIONAL MASSAGE THERAPY ORGANIZATIONS AND THEIR ROLES INVOLVING ETHICS

It is always sensible to understand how the field of massage therapy was founded, who the major contributors to the profession are, and how each serves the therapist, the public, and the legislators. The American Massage Therapy Association started advancing the field in the 1940’s and is a major contributor to the progress of the massage and bodywork profession, even today.

In the Beginning There was the American Massage Therapy Association (AMTA)

Since 1943, AMTA has been working to advance the profession. Their name was originally American Association of Masseurs and Masseuses (AAMM). In August of 1943, the Postgraduate class of College of Swedish Massage in Chicago, met in an open forum and created a new professional association called the American Association of Masseurs and Masseuses (AAMM) whose pledge of membership was commitment to service, ethical practice and the massage therapy profession. It wasn’t until 1949 when official efforts to help legitimize massage therapy through state laws were initiated. The Massage Registration Act was created as the model law for states to register legitimate massage therapists. In 1958, their name changed to American Massage & Therapy Association (AM&TA). The first code of ethics was adopted in 1960 – they also incorporated as a non-profit organization. Finally, in 1983 the “&”was dropped and the name was revised as American Massage Therapy Association (AMTA).

In 1988, AMTA Board members, along with several esteemed authors, massage therapists, school owners, and leaders of the profession, began to brainstorm the needs of the profession. At this time, only a handful of states regulated massage therapy—which meant that in several states, someone could dream about becoming a massage therapist and decide the next day to open a business. Despite their good intentions, these therapists did not have the necessary training to help the public with healing therapies.

AMTA is pivotal contributor to the profession and where it is today. AMTA is the largest non-profit, professional association serving massage therapists, massage students and massage schools. Part of their mission is advancing the art, science and practice of massage therapy. AMTA works for fair licensing of massage in all states, and actively supports research. The association now has 51 active chapters throughout the United States and offers its members liability insurance options, education, and research findings.

The AMTA’s Code of Ethics is a summary statement of the standards of conduct that define ethical behavior for the massage therapist. The code is divided into two parts:

• The Principles of Ethics
• The Rules of Ethics

The Principles of Ethics form the first part of the Code of Ethics from AMTA. They are aspirational and inspirational model standards of exemplary professional conduct for all members of the association. These principles should not be regarded as limitations or restrictions, but as goals for which members should constantly strive.

• Demonstrate commitment to provide the highest quality massage therapy/bodywork to those who seek their professional service.
• Acknowledge the inherent worth and individuality of each person by not discriminating or behaving in any prejudicial manner with clients and/or colleagues.
• Demonstrate professional excellence through regular self-assessment of strengths, limitations, and effectiveness by education and training.
• Acknowledge the confidential nature of the professional relationship with clients and respect each client’s right to privacy within the constraints of the law.
• Project a professional image and uphold the highest standards of professionalism.
• Accept responsibility to do no harm to the physical, mental and emotional well-being of self, clients, and associates.

For AMTA, The Rules of Ethics are mandatory and direct specific standards of minimally-acceptable professional conduct for all members of the association. The Rules of Ethics are enforceable for all association members, and any members who violate the Code shall be subject to disciplinary action. The Rules of Ethics consist of the following:

1. Conduct all business and professional activities within their scope of practice and all applicable legal and regulatory requirements.
2. Refrain from engaging in any sexual conduct or sexual activities involving their clients in the course of a massage therapy session.
3. Be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.
4. Refrain from using AMTA membership, including the AMTA name, logo or other intellectual property, or the member’s position, in any way that is unauthorized, improper or misleading.
5. Refrain from engaging in any activity which would violate confidentiality commitments and/or proprietary rights of AMTA or any other person or organization.

The American Massage Therapy Association has consistently and successfully advocated for professional standards and consistent regulatory requirements across the nation. Their efforts have contributed directly to the credibility of the profession and the future momentum entering into the allied health spectrum of healthcare.

National Certification Board for Therapeutic Massage & Bodywork (NCBTMB)

NCBTMB originated with a focus of protecting the public, as well as upholding a national standard for the industry that, until that time, did not exist. The current goals of NCBTMB are:

• Establish certification as a recognized credential of professional and ethical standards.
• Promote the worth of certification to health, therapeutic massage and bodywork professionals, public policy makers and the general public.
• Assure and maintain the integrity, stability and quality of the certification program.
  Periodically update the program to reflect state-of-the-art practices in therapeutic massage and bodywork.

The NCBTMB program promotes the status and credibility of the profession to advance more uniform standards of practice and ethical conduct.

In 1990, the AMTA Board of Directors invited a handful of massage therapy professionals to create a test that would help with reciprocity throughout states. With this test, massage therapists would prove they had graduated from a formalized massage therapy program. Most importantly, the test would be accepted in the few states that regulated massage therapy. Successfully passing this test would show a higher understanding of massage therapy, as well as how to work with the body.

As stated earlier, the main purpose of creating this credential in 1992 was to create reciprocity throughout the United States. In 2005, State board members from 22 states come together to discuss about aligning the profession and creating standard licensure requirements. The National Certification Board for Therapeutic Massage & Bodywork (NCBTMB), along with the Federation of State Massage Therapy Boards (FSMTB), created an entry level licensure examination throughout the country, the MBLEx, which is the exam taken today.

NCBTMB is an independent, private, nonprofit organization founded in 1992. Their mission is to define and advance the highest standards in the massage therapy and bodywork profession.

In 2014, NCBTMB agreed to no longer offer licensing examinations to the public, focusing exclusively on Board Certification, Approved Providers, and Assigned Schools. In the US, 39 states use the National Certification Board for Therapeutic Massage and Bodywork’s certification program as a basis for granting licenses either by rule or statute.

Each candidate for certification must read and agree to uphold the Code of Ethics and Standards of Practice. The Code of Ethics statement reads: Massage therapists and bodyworkers shall act in a manner that justifies public trust and competence, enhances the reputation of the profession and safeguards the interests of individual clients.

The Standards of Practice were developed to help the public understand the duties and responsibilities of practitioners – and to provide practitioners with a definitive guide to professional conduct and practice. NCBTMB revised their “code of ethics” in 2008 which follows:

The “Code of Ethics” developed by NCBTMB are as follows:

1. Represent their qualifications honestly, including education and professional affiliations, and provide only those services that they are qualified to perform.
2. Accurately inform clients, other health care practitioners, and the public of the scope and limitations of their discipline.
   Acknowledge the limitations of and contraindications for massage and bodywork and refer clients to appropriate health professionals.
3. Provide treatment only where there is reasonable expectation that it will be advantageous to the client.
4. Consistently maintain and improve professional knowledge and competence, striving for professional excellence through regular assessment of personal and professional strengths and weaknesses and through continued education training.
5. Conduct their business and professional activities with honesty and integrity, and respect the inherent worth of all persons.
6. Refuse to unjustly discriminate against clients and/or health professionals.
7. Safeguard the confidentiality of all client information, unless disclosure is requested by the client in writing, is medically necessary, is required by law, or necessary for the protection of the public.
8. Respect the client’s right to treatment with informed and voluntary consent. The certified practitioner will obtain and record the informed consent of the client, or client’s advocate, before providing treatment. This consent may be written or verbal.
9. Respect the client’s right to refuse, modify or terminate treatment regardless of prior consent given.
10. Provide draping and treatment in a way that ensures the safety, comfort and privacy of the client.
11. Exercise the right to refuse to treat any person or part of the body for just and reasonable cause.
12. Refrain, under all circumstances, from initiating or engaging in any sexual conduct, sexual activities, or sexualizing behavior involving a client, even if the client attempts to sexualize the relationship unless a pre-existing relationship exists between an applicant or a practitioner and the client prior to the applicant or practitioner applying to be certified by NCBTMB.
13. Avoid any interest, activity or influence which might be in conflict with the practitioner’s obligation to act in the best interests of the client or the profession.
14. Respect the client’s boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs and the client’s reasonable expectations of professional behavior. Practitioners will respect the client’s autonomy.
15. Refuse any gifts or benefits that are intended to influence a referral, decision or treatment, or that are purely for personal gain and not for the good of the client.
16. Follow the NCBTMB Standards of Practice, this Code of Ethics, and all policies, procedures, guidelines, regulations, codes, and requirements promulgated by the National Certification Board for Therapeutic Massage & Bodywork.

NCBTMB has identified five goals in its Strategic Plan, which include:

1. Scope of certification: NCBTMB’s certification program is in sync with the practice of massage therapy and bodywork and reflective of the profession’s evolution.
2. Knowledge of the environment: NCBTMB understands the issues affecting the practice of massage therapy and bodywork and uses this information to make knowledge-based decisions.
3. Value of the credential: Massage therapy and bodywork professionals and those who use and/or regulate their services will recognize and value the credential.
4. NCBTMB positioning: The NCBTMB program is respected as a model of excellence within the certification community.
5. Organizational effectiveness: NCBTMB is a well-managed, effectively governed, fiscally sound organization responsive to stakeholders’ needs.

More will be discussed within this course on NCBTMB’s ethical code, as the focus will turn to their Standards of Conduct, and how to apply these Standards in difficult situations when dealing with ethical decisions or dilemmas. For now, the continued review of prominent and influential organizations in massage and bodywork and their various code of ethics and/or standards continues.

The Associated Bodywork and Massage Professionals (ABMP)²⁰

In 1987, ABMP was founded by Sherri Williamson to provide massage and bodywork practitioners with an effective service organization. Started out of her home, ABMP outgrew three different offices in six years. In April 1996, ABMP was sold to a group of four people who now comprise the core of the company’s management team. In 2011, more than 79,000 practitioners belong to ABMP.

ABMP was not the first massage membership association in the United States. This association began a full 44 years after the industry’s first professional organization, the American Massage Therapy Association (AMTA), was founded. AMTA’s worthwhile focus during the past 10 years has been the recognition of massage therapy by the medical profession, opening the door to respect for practitioners and eligibility for reimbursement by health insurance companies.

Associated Bodywork & Massage Professionals (ABMP) serves the massage, bodywork and somatic therapy professions. ABMP is a professional membership association devoted to promoting ethical practices, fostering acceptance of the professions and protecting the rights of legitimate massage, and bodywork practitioners. Massagetherapy.com is a public education site powered by ABMP and it educates the public and the news media on the benefits of massage, including comprehensive information on various types of bodywork, what to expect during a massage, industry metrics, and a searchable database of members for consumers. It has an online referral service, and also publishes an award-winning Massage & Bodywork magazine offering resources to practitioners who want to deliver the very best “experiences” to their clients.

ABMP has their own ethical code of conduct for their members:

1. Commitment to High-Quality Care

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

2. Commitment to Do No Harm

Members 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 the member see signs of, or suspect, an undiagnosed condition that massage may be inappropriate for, they 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. Members 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

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

4. Commitment to Uphold the Inherent Worth of All Individuals

Members will demonstrate compassion, respect, and tolerance for others. They will seek to decrease discrimination, misunderstandings, and prejudice. They 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 their personal safety, but members 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

Members will demonstrate their 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

Members will recognize a client’s right to determine what happens to his or her body. They 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. Members will fully inform clients of choices relating to their care, and disclose policies and limitations that may affect their care. Member therapists 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

Members 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. Members 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

Members will refrain from and prevent behaviors that may be considered sexual in their massage practice and uphold the highest professional standards in order to desexualize massage. Members 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 themselves. Members understand that sexual impropriety may lead to sexual harassment charges, the loss of massage credentials, lawsuits for personal damages, criminal charges, fines, attorney’s fees, court costs, and jail time.

9. Commitment to Honesty in Business

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

10. Commitment to Professionalism

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

COMMON ELEMENTS OF ETHICAL CODES AND STANDARDS

When speaking of the major organizations promoting and progressing the massage and bodywork therapy field, AMTA, NCBTMB, and ABMP are primary contributors. When reviewing each of their philosophies and ethical standards, common elements can be found. All ethical codes these organizations and eventually state boards have implemented involve behaving honorably; adhering to prevailing laws; upholding the dignity of the profession; respecting each client; staying committed to high-quality care; working within the appropriate scope of practice; being client-centered; and remaining service-oriented.

Most professionals in the allied health care and personal care fields are required to establish relationships with their clients. To build worthwhile relationships, requires a massage therapist professional to be honest, trustworthy, and capable of the service to be provided. This is the common theme to various ethical codes of conduct.

For instance, the first standard from AMTA’s The Principles of Ethics, which forms the first part of their Code of Ethics, is to “demonstrate a commitment to provide the highest quality massage therapy/bodywork to those who seek their professional service.” The National Certification Board of Therapeutic Massage and Bodywork (NCBTMB) also places emphasis on the same principle, first, in their Code of Ethics, which states, “to have a sincere commitment to provide the highest quality of care to those who seek their professional services.” Again, with ABMP, “Commitment to High-Quality Care” is their first ethical requirement.

The same is true for all the ethical standards in these organizations. They classify certain behaviors as unethical. When analyzed, it is apparent that each professional therapist:

• Represent their qualifications honestly, stay within the scope of practice and all legal and regulatory requirements
• Not discriminate and 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.
• Safeguard the confidentiality of all client information, demonstrate a commitment to protect client confidentiality.
• Respect personal and professional boundaries of clients. Respect the client’s boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs and the client’s reasonable expectations of professional behavior.
• Refrain from and prevent behaviors that may be considered sexual in their massage practice. Refrain, under all circumstances, from initiating or engaging in any sexual conduct, sexual activities, or sexualizing behavior involving a client.

American Medical Massage Association (AMMA)

The largest organizations in the massage and bodywork field are AMTA, ABMP, and NCBTMB, but there are also quite a few smaller membership associations, some of them tailored to specialties or niche markets. One of these is the American Medical Massage Association.

The American Medical Massage Association was specifically created to represent the image, growth and protection of medical massage therapists. The AMMA seeks to promote Medical Massage Therapy as an allied health care profession, while encouraging unity within the massage profession. This goal is achieved through professional standards, education, and testing.²¹

The definitive goal of the AMMA is to establish medical massage as an effective therapy in health care facilities via education and awareness. This association strives to educate and help therapists who want to grow their medical message practice. The American Medical Massage Association is an affiliate of the American Manual Medicine Association which is a membership directed nonprofit corporation. The AMMA sponsors and provides a number of ongoing special training programs in medical massage, manual medicine and practical acupuncture. More information can be found on their website.

Federation of State Massage Therapy Boards (FSMTB)

The mission of the Federation is to support its Member Boards (U.S. States) in their work to ensure that the practice of massage therapy is provided to the public in a safe and effective manner. In early 2005 Associated Bodywork and Massage Professionals (ABMP) convened a meeting of massage regulators and educators to re-energize a former “Alliance” of the massage regulatory community. Attended by representatives from seven regulated states, along with educators from around the country, this group recognized the need to establish an organization that could bring the regulatory community together in its mission of public protection.

In September 2005, the FSMTB held its formalizing meeting in Albuquerque, New Mexico prior to the annual American Massage Therapy Association (AMTA) convention. The meeting was attended by 22 states and the District of Columbia. During this landmark event, bylaws were unanimously adopted and the first formal board was elected.²² Three areas of focus included:

1. The need for consistent scopes of practice and entry level standards across the country.
2. The need for a valid and reliable licensing exam that would be accepted by all jurisdictions.
3. The need for a common database with licensing and disciplinary information and the ability to store critical documen

The regulation of massage therapy is done on a state-by-state basis. Currently, 47 states/territories regulate the massage therapy profession in some form to ensure that safe and competent practitioners are the only legal massage therapy professionals practicing on the public. Currently, the following FSMTB members are state regulatory boards and agencies who oversee the profession of massage therapy and are charged with the mission of public protection.

Agreement between FSMTB and NCBTMB

The Federation of State Massage Therapy Boards (FSMTB) and the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) entered into an Agreement in October 2014 whereby, effective February 1, 2015, NCBTMB agreed to no longer offer any of its examinations for the intended use by State Boards for licensure eligibility. NCBTMB agreed that it would not develop or implement an examination for licensure. Currently, NCBTMB has one examination – its Board Certification Examination. The BCETM is intended to be used for NCBTMB certification only. FSMTB developed and administers the FSMTB Massage and Bodywork Licensure Examination (MBLEx).

The FSMTB wants to ensure best practices are utilized in the regulation of the massage therapy profession so the organization provides assistance by offering regulatory resources to state boards, hosting annual meetings, providing government relation services and by governance of the Massage & Bodywork Licensing Examination (MBLEx).

The Massage Therapy Foundation (MTF)

The Massage Therapy Foundation was founded by the American Massage Therapy Association in 1990 with the mission of advancing the knowledge and practice of massage therapy by supporting scientific research, education, and community service. The Foundation is able to provide these services by individual gifts, industry support, and fundraising events. Their mission is to advance the knowledge and practice of massage therapy by supporting scientific research, education, and community service.

Goals of the Massage Therapy Foundation

• Advance research on therapeutic massage and bodywork.
• Foster massage therapy initiatives that serve populations in need.
• Promote research literacy and capacity in the profession.
• Support the evidence-informed practice of therapeutic massage and bodywork based upon available research, client factors, and practitioner experience and judgment.
• Fortify the Foundation’s financial resources and organizational effectiveness.

ETHICS AND NCBTMB

When discussing ethics and standards of conduct, this organization (NCBTMB) is important as they are the association which has worked diligently to help the profession’s credibility. Along with the Federation of State Boards of Massage Therapists (FSBMT), NCBTMB has also worked with state boards on general regulations regarding scope of practice, licensing requirements, and policy.

When learning about a professional code of conduct, NCBTMB articulates standards of conduct, effectively. By reviewing NCBTMB’s ethics and code of conduct is beneficial in that it reminds massage therapy professionals of assessing their own personal value system and how it may affect their professional ethical code. These standards keep therapists centered in what is acceptable and what is not allowed.

Some participants may feel these values and principles are “common sense,” but the fact is daily interactions with others occur, whether these people are other professionals, peers, or clients, and this guiding doctrine can be very helpful in resolving difficult decisions. At times, a split second is all that is available before “action” is taken in response to a problematic situation. By reviewing and adopting the professional code of conduct, the reactions of massage therapists can be second nature.

Moving forward in this course, an examination of NCBTMB’s ethics and standards will help massage and bodywork therapists understand how to deal with ethical dilemmas when they arise. First, the ethical principle is stated, secondly it is discussed, whether classified as “ethics” or within the “standard of conduct.” Finally, an example is presented, where noted.

NCBTMB ETHICS²³

1. Represent their qualifications honestly, including education and professional affiliations, and provide only those services that they are qualified to perform.

   Trust and communication are required to establish a healthy relationship with the client. When a therapist exaggerates their education and/or states they are qualified to perform techniques they are not, they are only putting their client at risk. If a massage therapist performs a service they are not qualified to perform and the client is injured, they could face a lawsuit, disciplinary measures, including loss of their license, depending on the regulations of their state. To further advance the profession of massage and bodywork, credibility is key.

   For example, a client may assume that a bodyworker or massage therapist can give a full assessment of the range of motion in a knee. Some therapists can identify a problem, but a full evaluation and cause of malfunction may be beyond the scope of practice for some practitioners.²⁴

2. Accurately inform clients, other health care practitioners, and the public of the scope and limitations of their discipline.

   At times, a client may assume a massage therapist can perform any technique they may hear about from family or friends, or from programs/videos off the Internet. Again, the therapist must explain their “scope of practice” and if necessary, refer the client to the appropriate provider who is qualified to either diagnose or treat the client’s issue. For a therapist to perform services that they are not trained in, or licensed to practice, is against the scope of practice.

   If a client should ask you to “crack” their back, well that would be a clear violation of the scope of practice. Some violations are not so clear. For example a therapist is allowed to give a foot massage, but if they gave someone a foot massage, but called it foot reflexology, that would be a misrepresentation of their skills and abilities. Both of these examples would fall under the violation of the scope of practice.²⁵

3. Acknowledge the limitations of and contraindications for massage and bodywork and refer clients to appropriate health professionals.

   It is the therapist’s obligation to act in the best interest of the client. Many therapists have legitimate concerns about working with clients who may not be perfectly healthy. Massage therapists must be knowledgeable of their scope of practice and be aware of their professional limitations. This includes knowing when to terminate treatment and when to refer out to the appropriate provider. When progress has stopped, but pain persists, it might be time to refer them to a different health care provider.

   Massage therapists have a lot more responsibility of health hazards to be aware of than ever before, because of the changing place of massage in the context of health care. Below is a case study example from Ruth Werner, BCTMB:²⁶

   You are mid-session of your massage, and your client has a sign (symptom) that indicates caution. What are your choices now?

   • Skip the area—treat it as a local contraindication.
   • Request or require that he or she visit a doctor before your next appointment.
   • Change your tactics: use a different type of bodywork.
   • Stop everything and terminate the session.

   Resolution

   Remember, this is for the client’s benefit above all.

   • Acknowledge scope of practice
   • Keep personal judgments out of the conversation.
   • Listen to, and seek to understand the client’s reaction.
   • Respect your own boundaries for client (and therapist) safety

   Communicate to the client:

   • State your observation—in non-frightening, non-judgmental terms.
   • State your concerns—again, in a non-frightening, non-judgmental way.
   • State your choices for today

   Evaluate the conversation:

   Ignore it.

   • Were you clear in communicating your concerns?
   • Were you able to keep personal judgment out of the conversation?
   • Was the scope of practice clearly stated?
   • Did you listen to and seek to understand the client’s reaction?
   • Did you maintain safety boundaries?

4. Provide treatment only where there is reasonable expectation that it will be advantageous to the client.

   During treatment, it is important to continue to evaluate the client to assess client’s progress and the effectiveness of the treatment.

5. Consistently maintain and improve professional knowledge and competence, striving for professional excellence through regular assessment of personal and professional strengths and weaknesses and through continued education training.

   Professional development is a life-long commitment and each massage therapist must keep well-informed of new techniques, current research and statistics, along with new policies, regulations, and ethical issues. Continuing education is one method to stay updated but most professional organizations in the field will help each therapist stay on top of “hot issues.”

6. Conduct their business and professional activities with honesty and integrity, and respect the inherent worth of all persons.

   Acknowledge the importance and individuality of each person when dealing with peers, clients, and others involved in business. A person with integrity possesses the characteristic of honor, honesty, and reliability, to name a few.

7. Refuse to unjustly discriminate against clients and/or health professionals.

   Regardless of age, religion, race, ethnicity, education, socio-economic status, sexual orientation, or gender. Unjust discrimination also refers to client’s body type, political affiliation, state of health, or habits. A client can file a complaint with the State Board or bring charges against a massage therapist for discrimination. This is a serious issue, to say the least.

8. Safeguard the confidentiality of all client information, unless disclosure is requested by the client in writing, is medically necessary, is required by law, or necessary for the protection of the public.

   If two of your clients are siblings and one asks you about whether or not the other came to see you last week, is it a breach of confidentiality to answer the question actually? Why or why not? Confidentiality can be tricky. Confidentiality means keeping all privileged information private unless as stated above, it is medically necessary, required by law, or the client has in writing notified the therapist, or to protect public health.

9. Respect the client’s right to treatment with informed and voluntary consent. The certified practitioner will obtain and record the informed consent of the client, or client’s advocate, before providing treatment. This consent may be written or verbal.

   Informed consent consists of the voluntary agreement of a competent individual to receive treatment based on an adequate understanding of the treatment’s nature, purpose, and implications.

   The process and practice of informed consent is grounded in the ethical principle of respect for autonomy and requires health service practitioners, including massage therapists, to meet three basic conditions. These conditions are: (a) that the client be fully informed as to the proposed treatment including its purpose, risks and benefits; (b) that the client is capable of understanding the information provided; and (c) that the decision to undergo treatment is being made free from undue influence.²⁷

10. Respect the client’s right to refuse, modify or terminate treatment regardless of prior consent given.

    Some clients may feel the type of environment provided is not their cup of tea, or they may have a personal issue with the type of technique or with the massage therapist. Many people do not express themselves easily and at times, a client may just want to terminate the treatment to be free of the conflict.

11. Provide draping and treatment in a way that ensures the safety, comfort and privacy of the client.

    Every client should undress and dress in private; the state of undress is up to the client. Some clients remain fully clothed except for their shoes. Others wear a hospital-type gown, leave their underwear on or are nude. A client should always be securely covered or draped with a sheet or towel, which should be tucked in or draped in such a way that it will not easily move.²⁸

12. Exercise the right to refuse to treat any person or part of the body for just and reasonable cause.

    A massage therapist practitioner also has the right to refuse to treat a person or part of their body. If a client has a specific disease process, it is not wise to work on them without supervision from a medical professional. If a client is not respecting the boundaries of the therapist, the therapist may refuse to treat them.

13. Refrain, under all circumstances, from initiating or engaging in any sexual conduct, sexual activities, or sexualizing behavior involving a client, even if the client attempts to sexualize the relationship unless a pre-existing relationship exists between an applicant or a practitioner and the client prior to the applicant or practitioner applying to be certified by NCBTMB.

14. Avoid any interest, activity or influence which might be in conflict with the practitioner’s obligation to act in the best interests of the client or the profession.

15. Respect the client’s boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs and the client’s reasonable expectations of professional behavior. Practitioners will respect the client’s autonomy.

    Two massage therapists are in an elevator and one begins to discuss her client’s condition and treatment protocol while other people are present on the elevator. This is not respecting the autonomy of the client. If the other people were not there, would it make a difference?

16. Refuse any gifts or benefits that are intended to influence a referral, decision or treatment, or that are purely for personal gain and not for the good of the client.

17. Follow the NCBTMB Standards of Practice, this Code of Ethics, and all policies, procedures, guidelines, regulations, codes, and requirements promulgated by the National Certification Board for Therapeutic Massage & Bodywork.

NCBTMB STANDARDS OF CONDUCT

The Standards of Conduct from NCBTMB consists of six (6) practice standards along with precise values and principles which apply to each specific standard. As each standard is discussed further, case studies are provided to help explain how to deal with various situations that may arise in the daily practice of massage therapy and bodywork. The therapeutic relationship can be a complex one depending on the type of client, therefore the first practice standard involves “professionalism.” Remaining professional when interacting with troublesome personalities or struggling to provide optimum services due to contradictions of the client, is one of the most important aspects of providing therapeutic services.

Standards of Practice

Standards of Practice and the roles and procedures for professional contact and quality of care followed by members of a profession. They are guiding principles by which massage and bodywork professionals should conduct themselves and their day to day business.

Successful bodyworkers pay close attention not only to the techniques they use, but also to the many details involved in cultivating and maintaining the client relationship. Ethical issues often play an important part in this partnership, and the therapist should be aware as challenging situations can happen.²⁹ The Standards of Practice follow with in depth discussions on some standards which are more applicable and may need some explanation. Other standards are common sense but should be reviewed, as well.

STANDARD I: PROFESSIONALISM

The certificant or applicant for certification must provide optimal levels of professional therapeutic massage and bodywork services and demonstrate excellence in practice by promoting healing and well-being through responsible, compassionate and respectful touch. In his/her professional role the certificant or applicant for certification shall:

1. Adhere to the NCBTMB Code of Ethics, Standards of Practice, policies and procedures.
2. Comply with the peer review process conducted by the NCBTMB Ethics and Standards Committee regarding any alleged violations of the NCBTMB Code of Ethics and Standards of Practice.
3. Treat each client with respect, dignity and worth.
4. Use professional verbal, nonverbal and written communications.
5. Provide an environment that is safe and comfortable for the client and which, at a minimum, meets all legal requirements for health and safety.
6. Use standard precautions to insure professional hygienic practices and maintain a level of personal hygiene appropriate for practitioners in the therapeutic setting.
7. Wear clothing that is clean, modest, and professional
8. Obtain voluntary and informed consent from the client prior to initiating the session.

9. If applicable, conduct an accurate needs assessment, develop a plan of care with the client, and update the plan as needed.

   
   The diagram “Informed Consent” illustrates what is basically involved with this process. The massage therapist must discuss the nature of treatment, the benefits of the treatment modality, any risks associated with the type of treatment, and what alternatives may exist. The client should always have the opportunity to ask any type of question(s) they may have.

   Assessment and Informed Consent

   Assessment appears to have four specific components: health-history, client goals, other assessments, and evaluation. Assessment begins with the client’s health history. During this phase the therapist discovers if there are contraindications for massage treatment and considers referral to more appropriate practitioners, if needed. This assessment should also include the client’s goals. Are the clients coming to a massage therapist to alleviate pain, to relax in order to reduce their stress level, improve range of motion or function, or just for a feeling of well-being and peacefulness? These answers will lead the therapist to other assessments, depending on the client’s choice of goals.

   The intake/assessment process is the foundation on which to build a successful therapeutic treatment plan with the client. Once the assessments are concluded, the therapist must evaluate the data. Once the evaluation is completed, a “client-centered” plan of care is then reviewed with the client.

   Informed consent is a process by which a fully informed client consents to participate in the massage treatment. It originates from the ethical (and legal) right of the client to direct what happens to his body, and from the ethical duty of the therapist to involve the client in choices related to his wellness. In order for the client’s consent to be valid, he must be considered competent to make the decision to consent, and that consent must be voluntary. Parents or legal guardians must provide informed consent for minors, or for those unable to consent on their own due to mental or physical challenges.³⁰

   
   

   

10. Use appropriate draping to protect the client’s physical and emotional privacy.
11. Be knowledgeable of his/her scope of practice and practice only within these limitations.
    
    Massage therapists do not diagnose medical diseases or musculoskeletal conditions and massage is not a substitute for medical examination and treatment. Massage therapists do not prescribe herbs or drugs, including aspirin or ibuprofen, or medical treatments. They do not perform spinal adjustments and they cannot counsel clients about emotional or spiritual issues as would be provided by a mental health professional or spiritual leader.³¹
    
12. Refer to other professionals when in the best interest of the client and practitioner. Seek other professional advice when needed.
13. Respect the traditions and practices of other professionals and foster collegial relationships.
14. Not falsely impugn the reputation of any colleague.
15. Use the initials NCTMB only to designate his/her professional ability and competency to practice therapeutic massage and bodywork, or the initials NCTM only to designate his/her professional ability and competency to practice therapeutic massage
16. Remain in good standing with NCBTMB.
17. Understand that the NCBTMB certificate may be displayed prominently in the certificant’s principal place of practice.
18. Use the NCBTMB logo and certification number on business cards, brochures, advertisements, and stationery only in a manner that is within established NCBTMB guidelines.
    CASE STUDYScope of Practice and Referral

    Jim has been your next door neighbor for quite a while now and just the other day, he injured his knee and now is dealing with some type of painful condition. He explained to you he was in need of your services to identify why he cannot easily move his knee. Jim has always acknowledged the credibility of massage and told you a couple of stories of how his friends have been helped through the years by different massage techniques which have saved them thousands in medical bills. Now, he needs your “specialized skills,” so an appointment is set.

    The public assigns power to professionals and, in turn, many professionals act on this power because clients expect them to. This power develops from a psychological expectation, in many cases, rather than actual facts.

    For example, when Jim discusses his injury during the assessment phase, he assumes that a massage therapist or bodyworker can give him a full assessment of the range of motion in his knee. Some bodyworkers can identify a problem, but a full evaluation and cause of malfunction may be beyond the scope of practice for some practitioners. Jim wants to save money by avoiding a medical practitioner, though his intentions are not immoral, he is looking for a quick evaluation and treatment to get him back on his feet.

    A client’s assumptions can give a massage therapist great power. This shift of authority in the client-therapist relationship is called a power differential. A responsible therapist is consciously aware of the dynamics that can happen within this power differential and takes care not to take advantage of the client.

    It is common for clients to look to a therapist for advice regarding their overall health. While a therapist may be familiar with symptoms and diseases to help formulate a proper treatment program for a client, it is beyond the scope of practice for therapists to diagnose a condition or disease for a client. When clients start talking about what may be physically wrong with them and venture into forbidden territory, the bodyworker can respond by explaining that it is beyond the scope of practice for a bodyworker to diagnosis conditions.

    Adapted from:
    Massage Bodywork magazine, July/August 201029

19. Not duplicate the NCBTMB certificate for purposes other than verification of the practitioner’s credentials.
20. Immediately return the certificate to NCBTMB if certification is revoked.
21. Inform NCBTMB of any changes or additions to information included in his/her application for NCBTMB certification or recertification.

STANDARD II: LEGAL AND ETHICAL REQUIREMENTS

The certificant or applicant for certification must comply with all the legal requirements in applicable jurisdictions regulating the profession of therapeutic massage and bodywork. In his/her professional role the certificant or applicant for certification shall:

1. Obey all applicable local, state, and federal laws.
2. Refrain from any behavior that results in illegal, discriminatory, or unethical actions.
3. Accept responsibility for his/her own actions.
4. Report to the proper authorities any alleged violations of the law by other certificants or applicants for certification.
5. Maintain accurate and truthful records.
6. Report to NCBTMB any criminal conviction of, or plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction (other than a minor traffic offense) by him/herself and by other certificants or applicants for certification.
7. Report to NCBTMB any pending litigation and resulting resolution related to the certificant or applicant for certification’s professional practice and the professional practice of other certificants or applicants for certification.
8. Report to NCBTMB any pending complaints in any state or local government or quasi-government board or agency against his/her professional conduct or competence, or that of another certificant, and the resulting resolution of such complaint.

   Massage therapy ethical dilemmas arise when personal beliefs, feelings and attitudes conflict with responses expected of professionals. Complaints against massage therapists rarely describe poor hands-on technique or inadequate positioning. Conflict between therapists and clients usually occurs as a result of:

   • Poor communication
   • Ethical breaches
   • Inappropriate or ungrounded clinical decision-making

   Pamela Fitch, 2015 AMTA National Convention, Pittsburgh, PA

9. Respect existing publishing rights and copyright laws, including, but not limited to, those that apply to NCBTMB’s copyright-protected examinations.

With regard to the legal standards, it is imperative to understand the laws and rules in the state where the therapist is licensed. This ethical requirement (b) expresses, in detail, “To refrain from behavior that is illegal, discriminatory, or unethical.” If massage therapists do not refrain from this type of behavior, certain consequences are to follow. One being a client complaining to the state board or professional association, or a client may file a civil or criminal lawsuit. To alleviate malpractice law suits and/or complaints made by clients to state boards, there are several practices to incorporate and be consistent in their use:

• Gather and complete an accurate medical history from each client.
• Obtain as much information as possible from the other members of the client’s healthcare team (if referral and collaborating with other professionals).
• Have the client sign an “informed consent” sheet and HIPPA paperwork disclosure.
• Use common language when talking to clients.
• Be courteous and professional.
• Document each interaction with clients, including phone calls, session notes, email correspondence, etc.
• If a problem occurs with a client during a session, immediately discuss it with the client (or family member, if a child or mentally incapacitated adult).

In court, the elements that a client must prove by a preponderance of the evidence are:

1. A duty of care owed by the practitioner to the client
2. A breach of that duty
3. A causal relationship between the breach
4. Damage to the client

Healthcare practitioners, including massage therapists, are held to a standard of care and skill of the average member of the profession.

STANDARD III: CONFIDENTIALITY

The certificant or applicant for certification shall respect the confidentiality of client information and safeguard all records. In his/her professional role the certificant or applicant for certification shall:

1. Protect the confidentiality of the client’s identity in conversations, all advertisements, and any and all other matters unless disclosure of identifiable information is requested by the client in writing, is medically necessary, is required by law or for purposes of public protection.
2. Protect the interests of clients who are minors or clients who are unable to give voluntary and informed consent by securing permission from an appropriate third party or guardian.
3. Solicit only information that is relevant to the professional client/therapist relationship.
4. Share pertinent information about the client with third parties when required by law or for purposes of public protection.
5. Maintain the client files for a minimum period of four years.
6. Store and dispose of client files in a secure manner.

STANDARD IV: BUSINESS PRACTICES

The certificant or applicant for certification shall practice with honesty, integrity, and lawfulness in the business of therapeutic massage and bodywork. In his/her professional role the certificant or applicant for certification shall:

1. Provide a physical setting that is safe and meets all applicable legal requirements for health and safety.
2. Maintain adequate and customary liability insurance.
3. Maintain adequate progress notes for each client session, if applicable.
4. Accurately and truthfully inform the public of services provided.
5. Honestly represent all professional qualifications and affiliations.
6. Promote his/her business with integrity and avoid potential and actual conflicts of interest.

   Conflicts of interest arise in the massage and bodywork profession just as in many other fields.
   A conflict of interest is a situation in which someone, in a position of trust, has a competing professional or personal interest. These competing interests make it difficult for him or her to objectively execute their primary duty or responsibility, which is to first and foremost serve the best interests of their clients. Here a few examples³²

   What do all these behaviors have in common?
   1. A massage therapist promotes his business by pressuring his clients into participating in print testimonials, even though some of them feel uncomfortable doing this.
   2. A massage therapist, working in a spa, is required as part of his job description to sell spa products as well as services. However, he and a colleague have developed their own bath additive products and he is secretly selling his products to the spa customers at a discount.
   3. A massage therapist, currently working in a clinic, is planning to start his own business and is secretly recruiting the clinics’ clients for his own new clinic.
   4. A massage therapist, who is the head of the Education Department at a Massage Therapy College, hires a friend as one of the instructors.
   5. A Massage Therapy Association accepts corporate sponsorship for a Massage Therapy Workshop it is hosting knowing that the sponsor will expect the Association to exclusively endorse and promote its’ products and services at their upcoming Annual General Meeting
   They are all examples of situations that pose a conflict of interest.

   If we go back to our examples, in the first case, the massage therapist who is pressuring his clients to promote his clinic through print testimonials, despite their discomfort in doing so, has introduced a competing interest – namely his desire to promote his clinic as a business to the detriment of some of his client’s well-being or at least comfort.³⁰

   2. A massage therapist, working in a spa, is required as part of his job description to sell spa products as well as services. However, he and a colleague have developed their own bath additive products and he is secretly selling his products to the spa customers at a discount.

   In this example the massage therapist, as an employee of the spa, has a primary duty and loyalty to the spa business, which in this case at least quite clearly includes promoting and selling the spa’s product line. By offering spa clients his own products, he is in effect competing with the spa and promoting his own personal interests to the detriment of the spa’s interests.

   3. A massage therapist, currently working in a clinic, is planning to start his own business and is secretly recruiting the clinics’ clients for his own new clinic.

   Example number three is similar to example number two in that the massage therapist has a professional duty and obligation to be honest, ethical and loyal to the clinic he is currently employed by. By actively recruiting clients away from this clinic to his own he is clearly serving his own interests first.

   4. A massage therapist, who is the head of the Education Department at a Massage Therapy College, hires a friend as one of the instructors.

   In example number four, the massage therapist who is the Education Department Head at a Massage Therapy School and hires a personal friend to be an instructor there, is clearly in conflict as he has a responsibility to support an objective and equitable hiring process. By offering his friend the position he is placing his personal interests, in this case his desire to help his friend, above his primary duty which is to ensure that the College’s hiring process is fair and based on objective criteria.

   5. A Massage Therapy Association accepts corporate sponsorship for a Massage Therapy Workshop it is hosting knowing that the sponsor will expect the Association to exclusively endorse and promote its’ products and services at their upcoming Annual General Meeting.

   In our last example, the massage therapy Association has a professional ethical duty to be objective and impartial in all its dealings with all persons and organizations. By accepting this specific corporate sponsorship opportunity they are in effect committing themselves to preferential treatment to this particular corporate sponsor at the detriment of other massage therapy suppliers.

   Now, some might argue that a conflict of interest only exists if an unethical or improper act results. The reality is that a conflict of interest exists even if there are no improper actions as a result of it.

   Think of it this way, in a conflict of interest scenario, a massage therapist is placed in a situation in which he or she has to play two roles with two separate job descriptions; one of these is to protect their client’s best interest and the other to promote their own. Many times these two interests will not coincide and often they will conflict. However, whether they do or do not conflict does not change the fact that there are two roles with two potentially competing agendas and therefore a conflict of interest does exist.

   Moreover, even if no unethical or inappropriate act results from a conflict of interest scenario, conflict of interest scenarios can create an appearance of impropriety that can undermine confidence in the practitioner and in the profession.

   Returning to our massage therapy department head example, even if the department head chose to endorse his friend for the position because he truly and sincerely believed that he was the best qualified for the job, others, based on the inherent competing interests in a situation such as this, might not believe this and feel that he is simply trying to support his friend.

   How to handle a conflict of interest

   The best way to handle conflict of interest scenarios is to avoid them altogether. A person should not place themselves in a position where they will be dealing with conflicting interests. Massage therapists need to play one role at one time with each and every person they provide massage therapy services to.

   If despite best efforts, a therapist simply can’t avoid being involved in a conflict of interest scenario, disclosure of the actual or potential conflict of interest situation, to the relevant person(s) or bodies involved, should be done.

   Once the massage therapists has disclosed they are in a conflict of interest scenario, they need to make sure that the, themselves abstain from decision-making where a conflict of interest exists or could be perceived to exist.

   If at all possible, seek professional guidance and support from an ethics committee that can act as an independent third-party and provide an impartial evaluation of the situation.

   Remember, for this evaluation to be valid, the committee must be made up of independent individuals who are indeed arms lengths from the situation and who, as a result, can provide an impartial and fair perspective.

   Moving on, we continue to review the elements within Standard IV-Business Practices by discussing advertising and misrepresentation.

7. Advertise in a manner that is honest, dignified, accurate and representative of services that can be delivered and remains consistent with the NCBTMB Code of Ethics and Standards of Practice.
8. Advertise in a manner that is not misleading to the public and shall not use sensational, sexual or provocative language and/or pictures to promote business.
9. Comply with all laws regarding sexual harassment.
10. Not exploit the trust and dependency of others, including clients and employees/co-workers.
11. Display/discuss a schedule of fees in advance of the session that is clearly understood by the client or potential client.
12. Make financial arrangements in advance that are clearly understood by and safeguard the best interests of the client or consumer.
13. Follow acceptable accounting practices.
14. File all applicable municipal, state and federal taxes.
15. Maintain accurate financial records, contracts and legal obligations, appointment records, tax reports and receipts for at least four years.

STANDARD V: ROLES AND BOUNDARIES

The certificant or applicant for certification shall practice with honesty, integrity, and lawfulness in the business of therapeutic massage and bodywork. In his/her professional role the certificant or applicant for certification shall:

1. Recognize his/her personal limitations and practice only within these limitations.
2. Recognize his/her influential position with the client and not exploit the relationship for personal or other gain.
3. Recognize and limit the impact of transference and counter-transference between the client and the certificant.

   Most massage therapists are well aware of the ultimate physical boundary: that of sexual touch or sexual impropriety with a client. Sometimes they are less aware of the very important emotional boundaries. In order to understand the concept of “transference” and “counter transference,” it will be helpful to consider the therapeutic relationship and how it is different from social relationships.³³

   In a social relationship or friendship, the people involved may confide in each other, share stories and problems, and occasionally vent their feelings. In the therapeutic relationship, the focus should be entirely on the client, with the therapist giving his or her total attention to the client’s needs and to the treatment being performed.31

   Transference and counter-transference are terms that originated in the field of psychology. In transference the client projects on to the massage therapist. In counter-transference, the massage therapist projects on to the client. In either case, the “other person” is commonly an individual in one’s life, past or present, about whom there are strong emotional feelings or thoughts.

   Transference as defined by NCBTMB is:
   The displacement or transfer of feelings, thoughts, and behaviors originally related to a significant person, such as a parent, onto someone else, such as a massage therapist (or doctor, psychotherapist, teacher, spiritual advisor, etc.).

   Counter-Transference as defined by NCBTMB:
   A practitioner’s unresolved feelings and issues which are unconsciously transferred to the client. Counter transference represents a shift in the therapeutic relationship, in which the therapist is using their client as a confidante, counselor, mother or father figure: a person to whom they tell their plans and troubles.

   It is disconcerting when clients express that their therapist has shared personal problems with them. Some clients realize that this is inappropriate and it decreases their satisfaction with the massage treatment. There is a power differential in the relationship between client and therapist that makes it difficult for most clients to express their dissatisfaction when the therapist spends the session talking about his or her personal life.³⁰

   The massage therapist must remember that the time the client spends on the massage table is their time. During that treatment time the therapist’s attention and focus should be totally on the client, with the client’s physical concerns, comfort and emotional needs always the top priority, not the therapist’s personal problems, or gossiping about others’ problems.

   Case StudyMANAGING CLIENTS CONFUSION AND TRANSFERENCE

   Let’s say your client is experiencing transference with you. They see you as a person they want to have as a friend. They ask you to go to the movies with them and then dinner on Friday.

   How do you honor this person, retain them as a client, have them not feel rejected and avoid entering into the dual role?

   Authentic, compassionate, professional, and courageous communication! However you would sincerely let them know, and in a forth coming way that you do not socialize with your clients as it has a negative impact on the therapeutic relationship. That’s how!

   If you need more tips on how to have these difficult conversations you may want to role play with a colleague, talk to a mentor, or read more about this very normal professional action that massage therapists have to engage in often.

   IDENTIFYING TRANSFERENCE TO MAINTAIN BOUNDARIES

   IDENTIFYING TRANSFERENCE & MAINTAINING BOUNDARIES IN THE THERAPEUTIC RELATIONSHIP
   The following is adapted from The Ethics of Touch: The Hands-on Practitioners Guide To Creating a Professional Safe and Enduring Practice, by Ben Benjamin and Cherie Sohnen-Moe.

   The power of touch in stimulating transference hasn’t been formally studied, but anecdotal evidence suggests that touch, especially when it’s intentional and done with care, can create regressive experiences.

   Clients frequently disclose personal information, talk about their emotional problems or demand special treatment. On an unconscious level, clients often expect practitioners to help them emotionally and in other areas, as well. These are transference reactions. Practitioners need to understand and deal with these situations in a gentle, appropriate manner. In mature adult clients, these feelings will likely be recognized and not control their behavior; however, in individuals incapable of handling these feelings, transference may become the dominant reality and cause frequent disappointment and feelings of rejection, often followed by anger and withdrawal. Maintaining clear boundaries is crucial for handling transference and ensuring it does not negatively impact the therapeutic relationship.

   Signs of Transference
   • The client frequently asks you personal questions.
   • The client calls you at home, knowing that calls should be placed to your office.
   • After only one or two treatments, the client is overly complimentary of you and your work.
   • The client tries to bargain with you for a reduced rate.
   • The client regularly requests that you change your schedule to accommodate his or her schedule.
   • The client brings you gifts.
   • The client repeatedly invites you to social engagements and feels rejected when you explain your policy of separating your work and social life.
   • The client asks you to do “a little bit more” at the end of most treatment sessions and expresses disapproval if you don’t comply.
   • The client asks you to help him/her solve personal problems.
   • The client frequently asks you questions in areas that you’ve previously explained aren’t within your scope of practice.
   • This client often mentions that you remind him/her of someone.
   • The client has difficulty maintaining a physical boundary and attempts to inappropriately hug or touch you at the end of each session.
   • The client has difficulty leaving after the session and tries to engage you in conversation.
   • The client gives you intimate details about his or her personal life.
   The Blending of Transference and Counter-Transference

   Together, transference and counter-transference form a potentially volatile mixture within power differential relationships. Transference and counter-transference affect the answers to the questions we posed before:

   How is the person who holds the power using that power, and how is the person with less power responding?

   When both individuals in a relationship are psychologically mature, there is greater assurance that they will use or handle power in a healthy way; nevertheless, such maturity doesn’t ensure that transference and counter-transference won’t occur.

   The practitioner working with psychologically immature clients has a serious responsibility, because such clients may be unaware of the transference they bring to the therapeutic relationship. The practitioner must cultivate his/her own awareness of both transference and counter-transference and consciously mitigate against their effects. Individuals more prone to transference include children or adolescents, needy clients, and clients that have been referred by mental-health professionals to assist in the processing of psychological issues.

   A good goal for practitioners is to minimize the potential for unconscious “acting out” of power issues in the therapeutic relationship; nevertheless, the person who holds the power in a relationship may have difficulty recognizing transference and counter-transference. Getting supervision on a regular basis gives the practitioner the opportunity to explore these issues, gain clarity and learn methods for dealing effectively and ethically within the situation.

   BOUNDARY CLASSIFICATIONS

   A boundary defined by NCBTMB states, “A boundary is a limit that separates one person from another. Its function is to protect the integrity of each person.” There are five types of boundaries; physical, social, emotional, sexual, and professional boundaries. Each therapist must understand the basic areas surrounding these classifications. According to Terrie Yardley-Nohr, in her article for AMTA entitled, “Maintain Boundaries, Ethics and Etiquette,” she explains the dilemmas involved in these divisions of boundaries:

   Physical Boundary
   This is the line a therapist or client must not cross. In some states, laws and regulations clearly define physical boundaries, but the bottom line is the boundary lies in a safe zone for both the client and therapist.

   For example, when working the inner thigh of a client, the draping creates a physical boundary that the therapist should not cross. A securely tucked sheet gives the client a feeling of safety. It is important for a therapist to also know his or her own comfort zone.

   But what if the client does not like being draped? This may be against a state regulation and it’s clearly against associations’ codes of ethics; those facts can be communicated to the client. If there are no rules to fall back on, a therapist must rely on his or her own boundaries. Again, it’s crucial to establish firm foundations with clients. When a therapist tells a client that full draping is his or her policy, the statement holds more weight than simply saying draping is someone else’s rule.

   We have all had clients who may not be able to articulate their comfort zones. The client who barely gets undressed or feels uncomfortable when the therapist works certain areas of the body can send nonverbal messages that a comfort zone is being crossed. Paying close attention to both the verbal and nonverbal communication will help both therapist and client have a more rewarding session.

   Social Boundary
   How do you keep the relationship professional and not social? This is one of the gray areas of boundaries because opinions vary widely. When a client invites you to his or her home for a party, your relationship shifts from professional to social if you choose to accept the invitation. Some therapists are comfortable with this transition. But, family and friends aside, many therapists do not want to cross this line. It can be challenging when you work on a client for years and you may know a good deal about the client’s personal life just through casual conversation.

   A good rule of thumb is to ask yourself if you would feel comfortable inviting this person to your house for a party. If so, then this is probably a person with healthy boundaries who respects you as a professional and whom you respect as a person, but also appreciate as a client.

   MORE ON BOUNDARIES:

   A boundary defines the difference between acceptable and unacceptable behavior. Most massage therapists believe they have a solid sense of their own boundaries and that it’s crucial to have strong foundations. The challenges usually occur with clients they do not know or individuals who push their boundaries–knowingly or unknowingly. It is important to be aware of a client’s concept of the boundaries in a variety of categories and how we can address related issues.

   When a boundary has been crossed, we may say someone has “crossed the line” or “gone too far.” In many cases, a client crosses a boundary in a very innocent way. For example, a therapist may be working on a client’s posterior neck when the client may ask the therapist if he or she could adjust the neck, anticipating the equivalent of a chiropractic adjustment.

   A client may not understand that this is beyond the scope of practice for a massage therapist. Simply educating the client can end that discussion. If the client knows that massage therapists aren’t allowed to do neck adjustments and he or she still pushes to have this maneuver done, then he or she is crossing the line.

   Resources such as state laws, rules, regulations, or an association’s code of ethics are good foundations for therapists. Confidence and a solid professional foundation go a long way when handling boundary issues.

   Emotional Boundary

   There are definite limits when exploring the personal feelings and emotions of not only the client, but also the therapist. A therapist may have a client who asks a lot of questions and wants to know too much about the therapist’s life. These questions can vary from professional to personal. Therapists know that clients relax better by just breathing and remaining quiet, but perhaps the client is having a difficult time relaxing.

   There is always the danger of clients talking about their problems and the therapist being drawn into client dramas. It is difficult not to have compassion for a person who has been hurt or abused in some way. These emotions can easily be released as part of their massage session. There is a gentle way of letting a client know that you acknowledge that she has had pain by gently telling her you are sorry for what has happened and she is here now to relax and let go.

   It is dangerous–and outside an MT’s scope of practice–for the therapist to become a part of the client’s emotions by offering advice. A savvy therapist will have a mental health professional’s contact information on hand to suggest to clients.

   Sexual Boundary

   Massage should never be sexualized. Usually this boundary is specifically spelled out in laws, rules, and regulation. This seems like a given boundary and in the case where a client asks for sex, it is very easy to see that the boundary has been crossed.

   What may be more difficult to see is when human nature enters into the client/therapist relationship. For example, what happens if you start to feel an attraction for the client? These feelings may be subconsciously conveyed through your hands and body language. The client may pick up on your signals and proceed, or may feel uncomfortable and decide not to come back.

   If a therapist has feelings for a client beyond the therapeutic relationship, he or she should either get under control or refer the client to someone else. We cannot change human nature, but we can change how the situation evolves. If a client has feelings for a therapist, the therapist needs to explain his or her professional boundaries or refer the client to a different therapist.

   Professional Boundary

   Many entities have guidelines and expectations for therapists’ professional behavior including associations, states laws, and employers. All therapists are responsible for knowing these guidelines, fully understanding them, and abiding by them. When in doubt, call the originators of the expectations. For example, if a state law mandates that a therapist have proper training in a modality before performing the work, but does not specify the hours or training that is expected, the therapist should contact the state board for clarification.

   Another professional boundary that should be respected is discussing other therapists or professions. A client may tell you about other treatments or professionals. It is important to respect the fact that the client is here with you now for a reason. Talking unprofessionally about other therapists is not appropriate or helpful to the client.

   Maintaining Boundaries

   In many situations, educating the client on your scope of practice and your office policies will be sufficient for a positive therapeutic session with the client. If a client chooses to push your boundaries, then the therapist must either end the session or relationship, refer the client to someone else, or decide the client is no longer a suitable client candidate.29

   Continuing with the next principle of the current standard, we move to dual relationships and client exploitation. It is impossible to not have dual relationship as they are already established. A massage therapist may have a brother involved in sports they happen to treat with medical massage techniques, or two therapists may get together each week to play poker. Multiple relationships are just a fact of professional and personal life. It is more important to stay aware of the type of engagement with others and be able to recognize the signs when these relationships may be entering the danger zone.

   Following, is the principle on dual relationships of Standard V, Roles and Boundaries, along with a great tool to incorporate, developed by a professional massage therapist who now educates others, Jill Kristen Berkana.

4. Avoid dual or multidimensional relationships that could impair professional judgment or result in exploitation of the client or employees and/or coworkers.
   

   TYPES OF DUAL ROLES:

   TYPES OF DUAL ROLES: I always tell my students that they WILL manage dual-roles and the FEWER they have to manage the better. Figuring out the type of dual role you are considering and how to manage the first step in recognizing these roles.

   Yellow Flag: I explain to my students that the only dual roles you want to manage are those occurring with the people you are in some kind of personal or professional relationship with prior to providing massage therapy. In other words, they are in your life in a significant role before you became their massage therapist. These are easier to manage when the role they were in with you was in the past, such as they WERE your realtor, or they WERE your daughter’s soccer coach in high school. Still, the therapist must strongly consider is it worth the risk of damage to the pre-existing relationship to work with this person? It may simply be a better idea to refer them to another excellent massage therapist.

   Red Flag: The dual relationships to avoid at all costs are those that start to develop with someone who is your client. For those people who end up in your life because they came to you from the beginning for massage therapy I recommend you do everything you can to keep them in that role only, and forever. Will there be exceptions to the rule? Of course, but these exceptions should be incredibly rare and thoughtfully entered into for the health of both of you. This might be a good time to bring in a Mentor help you figure it all out.

   Random Flags: Things are not always black and white. One day you may be at work and your boss gets on the table. One day your mother in law wants a session. One day you go to a birthday party and realize your best friend’s brother is your client. One day (hopefully once out of the 20,000 massages you give in your career) the love of your life shows up in your practice. One day you are teaching a class and one of your new students was at a party you were at last week. Always have positive intent, be professional, do what you know is right and call your mentor for advice. If you don’t have a mentor, get one.

   In her blog, Jill Kristin Berkana, explains for therapists the types of dual relationships and provides a great tool for therapists to monitor themselves by recognizing various dangerous areas when in a dual or multidimensional relationship areas. For her full blog, access her website at https://bodywork-art.com/2014/12/20/managing-dual-roles-remedial-advice-for-massage-therapy-professionals/

5. Not engage in any sexual activity with a client.
6. Acknowledge and respect the client’s freedom of choice in the therapeutic session.
7. Respect the client’s right to refuse the therapeutic session or any part of the therapeutic session.
8. Refrain from practicing under the influence of alcohol, drugs, or any illegal substances (with the exception of a prescribed dosage of prescription medication which does not impair the certificant).
9. Have the right to refuse and/or terminate the service to a client who is abusive or under the influence of alcohol, drugs, or any illegal substance.

STANDARD VI: PREVENTION OF SEXUAL MISCONDUCT

The certificant or applicant for certification shall refrain from any behavior that sexualizes, or appears to sexualize, the client/therapist relationship. The certificant or applicant for certification recognizes the intimacy of the therapeutic relationship may activate practitioner and/or client needs and/or desires that weaken objectivity and may lead to sexualizing the therapeutic relationship. In his/her professional role the certificant or applicant for certification shall:

1. Refrain from participating in a sexual relationship or sexual conduct with the client, whether consensual or otherwise, from the beginning of the client/therapist relationship and for a minimum of six months after the termination of the client/therapist relationship unless a pre-existing relationship exists between a certificant or applicant for certification and client prior to the certificant or applicant for certification applying to be certified by NCBTMB.
2. In the event that the client initiates sexual behavior, clarify the purpose of the therapeutic session, and, if such conduct does not cease, terminate or refuse the session.
3. Recognize that sexual activity with clients, students, employees, supervisors, or trainees is prohibited even if consensual.
4. Not touch the genitalia.
5. Only perform therapeutic treatments beyond the normal narrowing of the ear canal and normal narrowing of the nasal passages as indicated in the plan of care and only after receiving informed voluntary written consent.
6. Only perform therapeutic treatments in the oropharynx as indicated in the plan of care and only after receiving informed voluntary consent.
7. Only perform therapeutic treatments into the anal canal as indicated in the plan of care and only after receiving informed voluntary written consent.
8. Only provide therapeutic breast massage as indicated in the plan of care and only after receiving informed voluntary written consent from the client.

QUESTION AND ANSWER ON SEXUAL RELATIONSHIPS FROM A MEMBER OF AMTA

Romance & the Therapeutic Relationship

Being ethical means you will do the right thing regardless of whether there are possible consequences—you treat other people well and behave morally for its own sake, not because you are afraid of the possible consequences. Simply put, people do the right thing because it is the right thing to do.³³

Both parties, the client and the therapist, have a role to fulfill in the therapeutic relationship. A successful relationship occurs when both parties understand and honor each other’s boundaries. Not all clients will be aware of boundaries, so it is left to the massage and bodywork professional to establish strong yet skilled boundaries for the therapeutic relationship.

Most all therapists are aware that it is not acceptable to be in a personal relationship with a paying client. Once a professional relationship extends beyond the massage session to more of a social setting or romantic venue or conversation, is to invite a host of ethical dilemmas. Some states have specific regulations pertaining to the romantic involvement with a client and the states usually designate a period of time before the parties involved can date each other. In the state of Washington it is illegal to date a client within two years of the last session.

Everyone, no doubt, has heard the expression “Do the right thing.” It is the essence of ethics: Do the right thing, no matter what. Ethical dilemmas present themselves when there is a conflict of principles and a behavioral choice needs to be made. Before making a choice, ask “is this the right thing to do?”

More will be discussed on resolving ethical dilemmas later in this section. Before we delve into this subject matter, it is always wise to review material on behavioral health and the defense mechanisms people use to cope with stressors in life. All people have psychological defenses they use to cope with stress.

CLIENTS AND PYSCHOLOGICAL DEFENSES

Defense mechanisms are a type of process or coping that results in automatic psychological responses exhibited as a means of protecting the individual against anxiety (Dziegielewski 2010).³⁵ Being able to identify and note defense mechanisms of clients are an important part of the assessment and treatment process.

People develop these defense mechanisms to deal with the stress of life. Some people are consciously aware while others seem to be unaware of these processes when they occur. The chart that follows describes various types of defense mechanisms and gives an example of each.³⁶

Repression
This was the first defense mechanism that Sigmund Freud discovered, and arguably the most important. Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. Thoughts that are often repressed are those that would result in feelings of guilt from the superego. For example, in the Oedipus complex, aggressive thoughts about the same sex parents are repressed.

This is not a very successful defense in the long term since it involves forcing disturbing wishes, ideas or memories into the unconscious, where, although hidden, they will create anxiety.

Denial
Denial involves blocking external events from awareness. If some situation is just too much to handle, the person just refuses to experience it. As you might imagine, this is a primitive and dangerous defense – no one disregards reality and gets away with it for long! It can operate by itself or, more commonly, in combination with other, more subtle mechanisms that support it. For example, smokers may refuse to admit to themselves that smoking is bad for their health.

Projection
This involves individuals attributing their own thoughts, feeling and motives to another person. Thoughts most commonly projected onto another are the ones that would cause guilt such as aggressive and sexual fantasies or thoughts. For instance, you might hate someone, but your superego tells you that such hatred is unacceptable. You can ‘solve’ the problem by believing that they hate you.

Displacement
Displacement is the redirection of an impulse (usually aggression) onto a powerless substitute target. The target can be a person or an object that can serve as a symbolic substitute. Someone who feels uncomfortable with their sexual desire for a real person may substitute a fetish. Someone who is frustrated by his or her superiors may go home and kick the dog, beat up a family member, or engage in cross-burnings.

Regression
This is a movement back in psychological time when one is faced with stress. When we are troubled or frightened, our behaviors often become more childish or primitive. A child may begin to suck their thumb again or wet the bed when they need to spend some time in the hospital. Teenagers may giggle uncontrollably when introduced into a social situation involving the opposite sex.

Sublimation
This is similar to displacement, but takes place when we manage to displace our emotions into a constructive rather than destructive activity. This might for example be artistic. Many great artists and musicians have had unhappy lives and have used the medium of art of music to express themselves. Sport is another example of putting our emotions (e.g. aggression) into something constructive.

For example, fixation at the oral stage of development may later lead to seeking oral pleasure as an adult through sucking ones thumb, pen or cigarette. Sublimation for Freud was the cornerstone of civilized life, arts and science are all sublimated sexuality.

Rationalization
Rationalization is the cognitive distortion of “the facts” to make an event or an impulse less threatening. We do it often enough on a fairly conscious level when we provide ourselves with excuses. But for many people, with sensitive egos, making excuses comes so easy that they never are truly aware of it. In other words, many of us are quite prepared to believe our lies. Massage therapist and bodywork professionals experience this when a client is late to their appointment and they rationalize their tardiness by explaining how much traffic slowed them down, or how it was someone else’s fault they are late.

ETHICAL DILEMMAS-DOING THE RIGHT THING

Many ethical dilemmas are either right or wrong, white or black, but there are some which present themselves in the “gray” area, and this is when help is needed in order to make the appropriate choice, according to the standards of the massage therapy profession. An ethical dilemma is a situation that is presented with options that may be right or wrong. The consequences of unethical behavior can range from embarrassment to suspension, loss of job, or even jail time, depending on the act.³⁷ Ethics does not provide simple answers, except on the most patently obvious issues. That does not mean ethics are of no value. They are truly lane markers along the highway of life. They offer guidance in lines of action.³⁸

If you rationalize your decisions by saying, “Everyone does it,” you should reconsider. Unethical behavior is not only what you believe to be right and fair, it is a reflection of your personal brand and what people can expect from you personally and professionally.³⁵

In order to know what to do in a given situation, we need to explore the issue carefully in terms of the action involved, its consequences and the context in which it takes place. Once we have clarified these points, our personal values will guide us in making the final decision.³⁶

So where do you stand?

The situation will depend on two things:

1. Values
2. Priorities

As discussed earlier in the first section, values are the things that we hold important for our sense of who we are. They are expressed in statements such as “human life and dignity should be protected,” or “cheating is wrong.” They develop over time and are influenced by family, religion, education, peers and a whole range of experiences, both good and bad, that have helped shape us.36

In some situations even people who agree on the same values will disagree on the right choice because a particular situation brings different values into conflict and requires us to prioritize our values. This might occur when discussing the need for war. Most people agree that killing people is wrong, but some may argue that such action is necessary to achieve a greater good.

Sometimes, there will be no clear right and wrong, and both terms of a choice will appear equally bad. This can be called an ethical dilemma. In order to resolve these types of dilemmas professionally, it is important for the massage and bodywork professional to understand the standards by which they operate within, and to understand how to assess themselves periodically to evaluate their own values and priorities.

Many ethical gray areas concern the complex balance of power between client and therapist. This is called a power differential. When the therapist can identify their own power struggles and their own history of power, they are more prepared to utilize their power in the therapeutic relationship in a healthy, safe, and positive manner. Self-awareness is the key which opens the door to understanding another’s behavior. A self-assessment can be done quickly, utilizing it as a “check-in” for the therapist to acknowledge where they may feel vulnerable, what seems challenging, and where their priorities are. Massage therapists should be doing a self-assessment on a regular basis. It may also help to keep the therapist “centered” in their own power. Only if a few questions are asked daily or weekly?

• What are my strengths?
• What perceived weaknesses do I need to watch?
• How am I doing with setting boundaries with clients?
• Are there any clients coming in today with whom I a difficult time dealing with? Do I feel prepared to deal with them in a professional, caring, ethical manner?

On those days when emotions are close to the surface, ask:

• Am I tired?
• Do I feel stressed and if so, by what?
• Am I able to focus?

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.³⁷

The Josephson Institute⁴⁰ defines character as being composed of six core ethical values:

When therapists are tired, frustrated, stressed out, or unable to focus, the tendency to cross the boundaries of others is quite high.

Effectively communicating policies can help massage therapists avoid losing time, money and potential clients. Additionally, employers having written policies that outline the expectations they have of their employees is very helpful. Things like mandatory staff meetings and professional expectations should be covered in employee agreements in order to prevent any misunderstandings between the owner and the staff. It is also best practice to discuss ethics with employees to protect the reputation of the practice.³⁹

• Trustworthiness
• Respect
• Responsibility
• Fairness
• Caring
• Citizenship

This is a comprehensive description of character. Consider how some people perceive other people; it’s their character that defines who they are. Can you depend on him? Is she fair? Does he respect you? Just as these ethical pillars define other peoples’ character, they also define your character to other people. Customers ask the same questions about you: Can I trust her? Will he give me fair pricing? Is she honest? Does he care about the best interest of my business?³⁸

When clients begin to answer these questions, they form an opinion, which becomes your reputation.

Overall character, as judged by other people, is your reputation. Reputation defined is “The common opinion that people have about someone or something: the way in which people think of someone or something” (Merriam-Webster Online Dictionary, 2016). http://www.merriam-webster.com/dictionary/reputation

FRAMEWORK & MODELS FOR ETHICAL DECISION MAKING

A Framework for Ethical Decision-Making:⁴¹

Being a professional in any health and wellness related occupation, each practitioner has an obligation and duty to protect their client’s well-being. Ethical decision making can be a complex matter if the appropriate tools and resources are not available. Each state that regulates the massage and bodywork profession can be a valuable resource when encountering difficult situations with peers, clients, medical professionals, and authoritative figures.

The following is a detailed framework to assist the therapist in the process of ethical decision making. Making ethical choices requires the ability to make distinctions between competing options. Good decisions are both ethical and effective. This material was adapted from the Steps of the Ethical Decision-Making Process by Douglas R. May, Professor and Co-Director of the International Center for Ethics in Business.39

Summary of the Steps of the Ethical Decision Making Process

1. Gather the facts
2. Define the ethical issues
3. Identify the affected parties (stakeholders)
4. Identify the consequences
5. Identify the obligations (principles, rights, justice)
6. Consider your character and integrity
7. Think creatively about potential actions
8. Check your gut
9. Decide on the proper ethical action and be prepared to deal with opposing arguments.

GATHER THE FACTS

• Don’t jump to conclusions without the facts
• Questions to ask: Who, what, where, when, how, and why.
• However, facts may be difficult to find because of the uncertainty often found around ethical issues
• Some facts are not available
• Assemble as many facts as possible before proceeding
• Clarify what assumptions you are making!

DEFINE THE ETHICAL ISSUE(S)

• Don’t jump to solutions without first identifying the ethical issue(s) in the situation.
• Define the ethical basis for the issue you want to focus on.
• There may be multiple ethical issues – focus on one major one at a time.

IDENTIFY THE AFFECTED PARTIES

• Identify all of the stakeholders
• Who are the primary or direct stakeholders?
• Who are the secondary or indirect stakeholders?
• Why are they stakeholders for the issue?
• Perspective-taking — Try to see things through the eyes of those individuals affected

IDENTIFY THE CONSEQUENCES

• Think about potential positive and negative consequences for affected parties by the decision (Focus on primary stakeholders to simplify analysis until you become comfortable with the process).
• What are the magnitude of the consequences and the probability that the consequences will happen.
• Short term vs. Long term consequences – will decision be valid over time.
• Broader systemic consequences – tied to symbolic and secrecy
  • Symbolic consequences – Each decision sends a message.
  • Secrecy consequences – What are the consequences if the decision or action becomes public?
• Did you consider relevant cognitive barriers/biases?
• Consider what your decision would be based only on consequences – then move on and see if it is similar given other considerations.

IDENTIFY THE RELEVANT PRINCIPLES, RIGHTS, AND JUSTICE ISSUES

• Obligations should be thought of in terms of principles and rights involved
  1. What obligations are created because of particular ethical principles you might use in the situation?
     • Examples: Do no harm; Do unto others as you would have them do unto you; Do what you would have anyone in your shoes do in the given context.
  2. What obligations are created because of the specific rights of the stakeholders?
• What rights are more basic vs. secondary in nature? Which help protect an individual’s basic autonomy?
• What types of rights are involved – negative or positive?
• What concepts of justice (fairness) are relevant – distributive or procedural justice?
• Did you consider any relevant cognitive barriers/biases?
• Formulate the appropriate decision or action based solely on the above analysis of these obligations.

CONSIDER YOUR CHARACTER & INTEGRITY

• Consider what your relevant community members would consider to be the kind of decision that an individual of integrity would make in this situation.
• What specific virtues are relevant in the situation?
• Disclosure rule – what would you do if the New York Times reported your action and everyone was to read it.
• Think about how your decision will be remembered when you are gone.
• Did you consider any relevant cognitive biases/barriers?
• What decision would you come to based solely on character considerations?

THINK CREATIVELY ABOUT POTENTIAL ACTIONS

• Be sure you have not been unnecessarily forced into a corner
• You may have some choices or alternatives that have not been considered
• If you have come up with solutions “a” and “b,” try to brainstorm and come up with a “c” solution that might satisfy the interests of the primary parties involved in the situation.

CHECK YOUR GUT

• Even though the prior steps have argued for a highly rational process, it is always good to “check your gut.”
• Intuition is gaining credibility as a source for good decision making – knowing something is not “right.”
• Particularly relevant if you have a lot of experience in the area – expert decision-making.

DECIDE ON YOUR COURSE OF ACTION AND PREPARE RESPONSES TO THOSE WHO MAY OPPOSE YOUR POSITION

• Consider potential actions based on the consequences, obligations, and character approaches.
• Do you come up with similar answers from the different perspectives?
• Do the obligation and character help you “check” the consequentialist preferred action?
• How can you protect the rights of those involved (or your own character) while still maximizing the overall good for all of the stakeholders?
• What arguments are most compelling to you to justify the action ethically? How will you respond to those with opposing viewpoints?

RIPS Model of Ethical Decision Making

There are many ethical decision-making tools but they really do not apply to the types of dilemmas. The RIPS model (an acronym for Realms, Individual Process, Situation) has been adapted primarily for physical therapists and is the result of a lot of work by Rushworth M. Kidder, who wrote the book, How Good People Make Tough Choices. The model can be applied to the massage therapy field, as well. The RIPS framework deals in realms, individual process and situation.

Is there is an ethical issue? Some things make you feel uncomfortable. This is the hardest part; accurately defining the problem, why we are concerned about the situation and what it is that is making us feel uncomfortable. Can you identify the ethical principles? Are they conflicting ethical principles? Is there a problem or distress or a dilemma?

RIPS model was developed by L. Dolly Swisher and the Ethics and Judicial Committee of the APTA.

Why is it a problem?

• Professional: Does it conflict with professional values?
• Personal: Does it conflict with personal values?
• Economic: Is there a financial problem that may evolve? Are there going to be financial difficulties for you if you leave a particular situation?
• Intellectual: Is it something you cannot understand or you cannot justify from a purely intellectual point of view?
• Societal: Is this going to have an overall impact on society?

Which ethical principles are involved?

• Autonomy: patients have the right to make some decisions as well as we do.
• Beneficence: care in the best interest of the patient
• Non maleficence: “do no harm”
• Justice: equity or fair treatment
• Veracity: truthfulness

Test for Right versus Wrong Adapted from Kidder’s four point test.

1. Legal test: Is it legal? Know your practice act and rules and regulations.
2. “PU” test: Does it feel or “smell” wrong?
3. Front page test: How would it look on the front page of the newspaper?
4. Mom/Dad Test: How would your parents feel if they knew what you were doing?
5. The professional ethics test: What do the Code of Ethics, Standards of Ethical Conduct say?

What course of action are you going to take?

• Use your moral imagination. Is there another way to do it other than the obvious ways? Is the course of action consistent with ethical principles, with the Code of Ethics, with your practice act and rules and regulations?

What will happen when you take this course of action?

• Analyze the course of action. Are there any barriers to implementation from your organization or company or does the action require moral courage to implement?
• After the action has been taken, were there any unexpected results, any collateral damages or anything that you may not have expected? Is there any further action required? What did you or anybody else involved learn from the process? Do any organizational structures or policies require revision?

3 Questions Model for Ethical Decision Making

In their book, The Power of Ethical Management, Blanchard & Peale⁴² explain a simple and quick method to evaluate one’s decision to help keep them in check with their own values. Many people contend that nowadays there is a big gray area between right and wrong, and they use that gray area as an excuse not to worry about being ethical. We question that logic.

Three questions to ask when confronted with an ethical dilemma:

1. Is it legal? – Will company policy or any civil or criminal law be violated?
2. What does our code of conduct or ethical standards state? Is if fair to all concerned in the short term as well as the long term? Does it promote a “win-win”?
3. How will it make me feel about myself? Will it make me proud? Would I feel good if my decision was published in the newspaper? Would I feel good if my family and friends knew about it?

The PLUS Ethical Decision Making Model

Seven Steps to Ethical Decision Making –

• Step 1: Define the problem – The most significant step in any decision-making process is to determine why a decision is called for and identify the desired outcome(s). How you define a problem shapes your understanding of its causes and where you will search for solutions. By defining the problem in terms of outcomes, you can clearly state the problem.
• Step 2: Seek out relevant assistance, guidance and support – Once the problem is defined, it is critical to search out resources that may be of assistance in making the decision. Resources can include people (i.e., a mentor, coworkers, external colleagues, or friends and family) as well professional guidelines and organizational policies and codes. Such resources are critical for determining parameters, generating solutions, clarifying priorities and providing support, both while implementing the solution and dealing with the repercussions of the solution.
• Step 3: Identify alternatives – The key to this step is to not limit yourself to obvious alternatives or merely what has worked in the past. Be open to new and better alternatives. Consider as many as solutions as possible — five or more in most cases, three at the barest minimum. This gets away from the trap of seeing “both sides of the situation” and limiting one’s alternatives to two opposing choices (i.e., either this or that).
• Step 4: Evaluate the alternatives – As you evaluate each alternative, identify the likely positive and negative consequence of each. It is unusual to find one alternative that would completely resolve the problem and is significantly better than all others. As you consider positive and negative consequences, you must be careful to differentiate between what you know for a fact and what you believe might be the case. Consulting resources, including written guidelines and standards, can help you ascertain which consequences are of greater (and lesser) importance.
• Step 5: Make the decision – this is the natural next step after selecting the best alternative.
• Step 6: Implement the decision – While this might seem obvious, it is necessary to make the point that deciding on the best alternative is not the same as doing something. The action itself is the first real, tangible step in changing the situation. It is not enough to think about it or talk about it or even decide to do it. A decision only counts when it is implemented. As Lou Gerstner (former CEO of IBM) said, “There are no more prizes for predicting rain. There are only prizes for building arks.”
• Step 7: Evaluate the decision – Every decision is intended to fix a problem. The final test of any decision is whether or not the problem was fixed. Did it go away? Did it change appreciably? Is it better now, or worse, or the same? What new problems did the solution create?

When decisions are classified as being “business” decisions (rather than “ethics” issues), values can quickly be left out of consideration and ethical lapses can occur. At key steps in the process, the person should stop and work through these considerations, making sure that the ethics issues rooted in the decision are considered. In order to use this model effectively, the considerations are grouped into the mnemonic PLUS.

P = Policies

Is it consistent with my organization’s policies, procedures and guidelines?

L= Legal

Is it acceptable under the applicable laws and regulations?

U = Universal

Does it conform to the universal principles/values my profession has adopted?

S= Self

Does it satisfy my personal definition of right, good and fair?

In the massage therapist’s professional life, there will be constant decisions needing to be made. Some will become ethical dilemmas when the answer is not clear cut. At times, these dilemmas will need to be acted upon as quickly as possible, while the experience is occurring. The 3 quick questions to ask may work better than a seven step method. There will be those instances where more thought is required to make a decision. It may be those times that intense scrutiny over the dilemma is needed before action is taken. The other methods are quite comprehensive.

Another Format for Ethical Decision Making

1. State the problem (e.g. “Do I have a conflict of interest?” or even “This makes me uncomfortable”)
2. Check facts (some problems disappear upon closer examination of situation; others change radically).
3. State specifications (limits and objectives)—laws, professional code, and corporate rules to be satisfied, cost constraints (e.g. under $200), children to feed, place in life plan (e.g. save company).
4. Develop list of at least five options (be imaginative, try to avoid “dilemma”—not “yes” or “no” but who to go to, what to say).
5. Test options, using such tests as the following:
   • Harm test—does this option do less harm than any alternative?
   • Publicity test—would I want my choice of this option published in the newspaper?
   • Defensibility test—could I defend my choice of this option before a Congressional committee, a committee of my peers, or my parents?
   • Reversibility test—would I still think the choice of this option good if I were one of those adversely affected by it?
   • Virtue test—what would I become if I choose this option often?
   • Professional test—what might my profession’s ethics committee say about this option?
   • Colleague test—what do my colleagues say when I describe my problem and suggest this option as my solution?
   • Organization test—what does the organization’s ethics officer or legal counsel say about this?
6. Make a tentative choice based on steps 1-5. Did you solve the problem with which you began?
7. Make final choice (after reviewing steps 1-6), act, and then ask: What could make it less likely you would have to make such a decision again?
   • What precautions can you take as individual (announce policy on question, change job, etc.)?
   • What can you do to have more support next time (e.g., seek future allies on this issue)?
   • What can you do to change organization (e.g., suggest policy change at next dept. meeting)?
   • What can you do to change larger society (e.g. work for new statute or EPA regulation)?

OBSTACLES TO MAKING ETHICAL DECISIONS

Following are some common rationalizations that can cloud someone’s judgment when they are involved in making tough ethical decisions.38 Most of these rationalizations are familiar as they have been used in some context or another.

If it’s necessary, it’s ethical: This approach often leads to ends-justify-the-means reasoning and treating non-ethical tasks or goals as moral imperatives.

The false necessity trap: “Necessity is an interpretation and not a fact.” We tend to fall into the “false necessity trap” because we overestimate the cost of doing the right thing and underestimate the cost of failing to do so.

If it’s legal and permissible, it’s proper: This substitutes legal requirements for personal moral judgment. This alternative does not embrace the full range of ethical obligations, especially for those involved in upholding the public trust. Ethical people often choose to do less than what is maximally allowable but more than what is minimally acceptable.

It’s just part of the job: Conscientious people who want to do their jobs well often compartmentalize ethics into two categories: private and job-related. Fundamentally decent people may often feel justified doing things at work that they know to be wrong in other contexts.

It’s for a good cause: This is a seductive rationale that loosens interpretations of deception, concealment, conflicts of interest, favoritism, and violations of established rules and procedures.

I was just doing it for you: This rationalization pits values of honesty and respect against the value of caring and overestimates other people’s desire to be “protected” from the truth. This is the primary justification for committing “little white lies.”

I’m just fighting fire with fire: This is the false assumption that promise-breaking, lying, and other kinds of misconduct are justified if they are routinely engaged in by those with whom you are dealing. This rationale compromises your own integrity.

It doesn’t hurt anyone: This rationalization is used to excuse misconduct when violating ethical principles so long as no clear and immediate harm is perceived. It treats ethical obligations as simply factors to be considered in decision-making rather than as ground rules.

Everyone’s doing it: This is a false “safety in numbers” rationale that often confuses cultural, organizational, or occupational behaviors and customs as ethical norms.

It’s OK if I don’t gain personally: This justifies improper conduct for others or for institutional purposes.

I’ve got it coming: People who feel overworked and/or underpaid rationalize that minor “perks” (acceptance of favors, discounts, gratuities, abuse of sick leave, overtime, personal use of office supplies) are nothing more than fair compensation for services rendered.

I can still be objective: This rationalization ignores the fact that a loss of objectivity always prevents perception of the loss of objectivity. It also underestimates the subtle ways in which gratitude, friendship, anticipation of future favors and the like affect judgment.

Acting ethically is the right thing to do but not always the easiest thing to do. Conforming to a high standard of conduct is not about clear-cut right and wrong decisions, but choosing the “lesser of two evils.” Some decisions require that you prioritize and choose between competing ethical values and principles.

CONSEQUENCES FOR UNETHICAL BEHAVIOR

• Criminal charges and/or fines
• Lawsuits
• Ruined careers
• Injured organization reputation
• Wasted time
• Low morale
• Recruiting difficulties
• Oppressive legislation
• Fraud and scandals

Boards have confronted unethical issues such as abandonment (inappropriate discharge), veracity (lying on documents or bills) and justice (unfair distribution of services). If the behavior is covered by the practice act, yes, there may be consequences. If it is not, many times the board’s hands are tied. Boards often recognize that certain individuals have very limited skills in the ethical decision-making arena. How can boards assist licensees in making right decisions? What kinds of tools can boards give them? What is the best way to integrate skills in ethical decision making into their clinical practice?⁴³

Aristotle said, “Do not seek any answers that are more precise than the field of inquiry allows.” Ethics does not provide concrete answers. It provides the opportunity to say, “This is one good way to handle it, but on the other hand, there is another good way to handle it, but on the third hand, if you should happen to be born with three hands, here is another way to handle it.”

It does not give you that comfort zone for a solid decision to be made. The nature of ethical decision making is a little bit different than the kind of decision making used when making a clinical decision or evaluating a patient or client. It has a logic used to make clinical decisions, but it is not mechanical. Unethical behavior usually results in a loss of trust among the public.⁴⁰

DISCIPLINARY MEASURES FOR VIOLATIONS

Disciplinary actions are taken by regulatory authorities (boards, committees, programs) in response to a violation of the law or rules. Different kinds of actions may be taken depending on the severity of the offense, the history of previous violations, efforts made to correct the violation, the harm to the victim(s), the likelihood of a repeat violation, and other matters related to each particular case.

These actions are taken to protect and promote the health, safety, and welfare of the citizens of the state where each massage therapist is licensed. Each year, massage and bodywork therapists are charged with various violations – a majority of them dealing with sexual misconduct issues, as in the article from an online newspaper, The Ledger in Florida, which told the case of a Florida massage therapist convicted of sexually violating clients.⁴⁴

Every profession comes with situations that might give practitioners pause, and massage therapy is no different. Whether just entering the profession or a veteran provider of massage therapy, confronting situations that give rise to questions and confusion isn’t uncommon.⁴⁵

Many massage therapy state regulating agencies will post licensee violations on their website. This way the public can access the data to make a more informed decision on which therapist to see, what and if they have been disciplined, what violation occurred and the current status of the violation.

If a client reviews these state violations and finds their choice of massage therapist has been disciplined for sanitary issues, or practicing beyond their scope of practice, the client has the freedom to choose another therapist. Most people would have an issue with a practitioner that does not practice within their scope or makes false claims of being proficient in a specific technique. This type of violation can harm clients and is a serious matter in all states. Common violations found around the country seem to include

1. Practicing without a license.
2. Massage Therapy Establishment not being certified or licensed.
3. Sexual misconduct, engaging in sexual contact.
4. Allowing unlicensed persons to perform massages.
5. Failure to maintain client records.
6. Failure to provide initial consultation documents or assessments.

In most states, there seems to be a commonality with violations of sexual misconduct. A consensual, sexual relationship with a client who currently receives massage therapy from the consensual partner is never appropriate, and violates not only AMTA’s Code of Ethics, but also ethical boundaries you need to maintain as a massage therapist. This ethical provision is grounded in the vulnerability of the client who expects to be in a safe and nurturing environment during a massage therapy session.

Massage and bodywork therapists need to thoroughly understand the laws and regulations governing their state and local jurisdictions, as some states will have a time period stipulating how long the client–therapist relationship must be terminated before a sexual relationship may begin. Other professions ban such relationships altogether.

SCOPE OF PRACTICE VIOLATIONS

There are many things that a therapist can do to get themselves in hot water with their governing board. One of those things is going beyond the scope of practice. What does that actually mean? For some the answer depends on what state they live in. Since high blood pressure is a contraindication for massage, some well-trained massage therapists might want to take a client’s blood pressure prior to massage. Did everyone get trained in massage school to use a sphygmomanometer and stethoscope? Chances are that unless you were trained or were taught how to use them safely, you may injure your client.⁴⁶

To fully understand where to draw the line, there needs to be a solid definition. As stated at the beginning of this course, in 1995 the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) adopted a code of ethics. Of special interest on this topic are parts #2, 3, 4 which state:

#2 ”Represent their qualifications honestly, including education and professional affiliations, and provide only those services which they are qualified to perform.”

#3 “Accurately inform clients, other healthcare practitioners, and the public the scope and limitations of their discipline.”

#4 “Acknowledge the limitations of and contraindications for massage therapy and bodywork, and refer clients to appropriate health professionals.”

The AMTA has specific language in their code of ethics regarding similar standards, such as “perform only those services for which they are qualified and represent their education, certification, professional affiliations and other qualification honestly.” State regulations are designed to protect the general public by demanding accountability from the profession.

THE IMPORTANCE OF STAYING WITHIN YOUR SCOPE OF PRACTICE

Staying within the scope of practice is an important ethical consideration, but it can be complicated to sort out what territory is within the “scope of practice.” As massage therapists have become more knowledgeable in addressing muscular problems, they have had an understandably more difficult time outlining their base of expertise. For instance, it can be difficult to distinguish where massage therapy ends and physical therapy begins. On the other side of the issue, as we’ve become more sophisticated and successful in working with clients’ painful conditions, we have sometimes been tempted to inflate what we do know, and some therapists have deliberately presented themselves as having knowledge they don’t.⁴⁷

Case Example: Dangers when not staying within your scope of practice

For years, AMTA has been working to improve the current regulatory environment through the creation of a centralized government relations strategy designed to achieve fair and consistent licensing in all states.

The first step in the effort to achieve consistent licensure standards is to guarantee the inclusion of “must have” and “should have” elements in any and all baseline massage therapy practice acts. A list of these elements are available for view on AMTA’s website. Most states now have a massage therapy practice act, so be sure to check with your state.

According to law, only doctors can diagnose illness and prescribe medications. A massage therapist can only assess for treatment purposes what is needed to administer a massage to the patient. Scope of practice by definition defines the rights and activities legally acceptable to the licenses of a particular occupation or profession. Working within your own scope of practice and intelligently referring clients to appropriate disciplines is key to developing a safe and effective massage and bodywork career.⁴⁶

Massage Therapy Practice Act

The primary purpose of a Practice Act is to protect the health, safety and welfare of the public. The Legislature declares that the practice of Massage Therapy is a healthcare profession in need of regulation and that only qualified persons be permitted to engage in the practice as defined herein.⁴⁸

Many states have established a “massage therapy practice act” that includes rules on therapists’ scope of practice and what this entails.

Massage Therapy Boards and the Practice Act⁴⁹

In medical or health professions, a qualified professional has been trained in the physiological effects, indications, contraindications, and proper application of a technique or skill. Typically, this is confirmed through educational guidelines, licensing examination(s), and/or a competency evaluation. The board ensures that these qualifications have been met.

In the field of massage therapy, the scope of practice varies from state to state. For example, in New York, “The practice of the profession of massage therapy is defined as engaging in applying a scientific system of activity to the muscular structure of the human body by means of stroking, kneading, tapping, and vibrating with the hands or vibrators for the purpose of improving muscle tone and circulation.”

Ohio identifies massage therapy as “the treatment of disorders of the human body by the manipulation of soft tissue through the systematic external application of massage techniques, including touch, stroking, friction, vibration, percussion, kneading, stretching, compression, and joint movements within the normal physiologic range of motion; and adjunctive thereto, the external application of water, heat, cold, topical preparations, and mechanical devices.”

Texas describes massage therapy as “the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for the purpose of body massage and includes effleurage (stroking), petrissage (kneading), tapotement (percussion), compression, vibration, friction, nerve strokes, and Swedish gymnastics.”

DIFFERENCE BETWEEN LAW AND ETHICS

Ethics and law differ in that ethics are social guidelines based on moral principles and values while laws are rules and regulations that have specific penalties and consequences when violated. The following table explains the comparison.

Read more: http://keydifferences.com/difference-between-law-and-ethics.html#ixzz4HALN8it7

MASSAGE AND HEALTHCARE

In July 2015, more than fifty-one million American adults (16 percent) had discussed massage therapy with their doctors or health care providers in the previous year, consistent with past years’ data. Today, massage therapists are frequently working with other professionals as part of a team of health care providers, yet they are often excluded from receiving compensation due to lack of both standardization and recognition as an established profession. Massage Therapists are often a first point of contact for the consumer in prevention, identification, assessment, treatment and rehabilitation of many pathologies and conditions.⁵⁰

In an article by the Chair of the NCBTMB Board of Directors, Leena S. Guptha stated, “To move forward as a profession, is important to ensure we understand our past, our present and our priorities for the future. We did not make it to this point alone. We have dedicated so much of our time, energy and resources to an advanced credential, Board Certification, and an evolving Approved Provider Program — reminding all massage therapists and the public that credentials matter”.⁵¹

Throughout the years following 1992, states began regulating massage therapy and many utilized NCBTMB’s test as one of their entry level requirements for obtaining a state license. Over time, it seemed that within massage therapy the boundaries and functions of the two credentials (licensure and certification) were blended together and the value of the certification credential was slowly diluted.

When compared to healthcare and other medical arenas, however, certification is typically regarded as a higher voluntary credential beyond entry level licensure. These professions are not satisfied with only entry level requirements. In fact, many healthcare professions embrace various higher level certifications — why should massage therapy be any different?

Licensure and certification are not the same. Licensure is a mandatory, entry level credential that allows a massage therapist to practice legally within his/her state. Board Certification is a voluntary, higher level credential that extends beyond the basic entry level requirements. It shows a deeper commitment to both the profession and the public, including more education, hands-on experience and requires a background check.

If a massage therapist is licensed, it does not necessarily mean they are certified. They must meet the minimum requirements for NCBTMB Board Certification, as well as pass the Board Certification exam, to become Board Certified in Therapeutic Massage and Bodywork and hold the credentials BCTMB.

Board Certification was created to mirror other healthcare and medical professions and to tier the massage therapy profession. With this credential, NCBTMB Certificants can be proud of achieving higher credentials than an entry level massage therapist. For some, Board Certification also presents the opportunity to seek out and embrace stronger, more rewarding positions within the medical profession and high-end spas. Certificants who have obtained Board Certification can proudly state and prove that they have obtained the highest, voluntary credential within the massage therapy profession.

Just like in other allied health and medical professions, a new graduate takes a licensing exam and then gathers greater training and experience, all of which actively advances one to become “board eligible.” In medicine, once a physician is considered board eligible, he/she may so choose to become Board Certified with a specific focus, such as Internal Medicine. After further fellowship and professional development, he/she also has the option to sit for a specialty board certification. All massage therapy associations and organizations together want to advance the massage therapy profession into this realm in the future in order to integrate with other medical professionals in an allied healthcare setting.

FUTURE OF MASSAGE THERAPY

Massage therapy has a long history in healthcare throughout parts of the world. However, in the United States, its use as a healthcare practice greatly diminished with the rise of technological medicine and the pharmaceutical industry in the early twentieth century. For example, although once an integral part of physical therapy, massage gradually became a much smaller part of this profession in the latter half of the twentieth century.⁵²

It wasn’t long ago that healthcare professionals in the United States scoffed at the idea of massage as a serious modality for a wide array of healthcare complaints ranging from musculoskeletal injury to pain management for cancer patients. Today, views are changing significantly. Groundbreaking studies on alternative medicine use by researchers such as David Eisenberg and Daniel Cherkin have shown a consistent pattern of both increased use and acceptance of massage as not only a viable healthcare modality, but a valuable one.⁵⁰

Consumers are understanding that massage is not only a personal care service but Physicians led the way in recommending massage to their clients (54 percent vs. 59 percent in 2014), chiropractors (46 percent vs. 49 percent in 2014) and physical therapists (37 percent vs. 43 percent in 2014) also recommended massage therapy when their patients discussed it with them.⁵³

Massage and other complementary and alternative medicine (CAM) practices are gaining interest with students in traditional medical schools, which is an indicator of even greater acceptance of these approaches by tomorrow’s physicians. A picture of the profoundly expanding use of massage as a healthcare practice can be gleaned from several studies on the use of massage in the United States. Recent investigations show that between July 2014 and July 2015, roughly 39.1 million adult Americans (18 percent) had a massage at least once.⁵⁴

Ineffective results in traditional medical treatment for musculoskeletal disorders has driven millions of Americans to seek better care through massage and the bodywork practices. In order to keep moving the field forward, there is need for additional research into the effects of massage to improve evidence-based practice in the profession. This is vital for the profession to continue to grow and evolve, as well as for increasing acceptance in the medical and allied health care communities.

Therapists offering healthcare massage are found in private clinics, sports settings, and other healthcare facilities. Increasingly, massage therapy practitioners’ work in chiropractic and physical therapy clinics, doctors’ offices, hospitals, universities, or other healthcare establishments.

Massage is also an integrated healthcare program in professional sports, dance, and other physically demanding professions. We can look for greater inclusion of massage in mainstream settings, such as hospitals and primary care health clinics. We can also expect massage to continue to garner greater respect, and thus referral, by traditional medical practitioners.⁵⁵

IN SUMMARY

The field of massage and bodywork therapy has changed immensely over the last few decades. Fifty-two percent of adult Americans who had a massage between July 2014 and July 2015 received it for medical or health reasons such as pain management, soreness/stiffness/spasms, injury rehabilitation, or overall wellness, a slight decrease from 2014 data

These increased numbers represent the need for regulation in order to protect the health and well-being of the public. Currently, massage therapists are licensed in 44 states and the District of Columbia. Current regulations in most states, include a code of ethics and/or standards of conduct to abide by in order to practice.

A code of ethics helps therapists navigate their way through client interactions while providing services. The client/therapist relationship is more complex now because of legal implications and the code of conduct is the foundation all therapists can reference when meeting ethical dilemmas in the client/therapist relationship.

Through the commitment of AMTA, NCBTMB, and others, massage has grown into a modality that is gathering far more respect than in previous times.

NCBTMB – Glossary of Terms

The following terms were taken from the website of NCBTMB and clearly define the terminology within this content.

• Acceptable Accounting Procedures: Rules, conventions, standards, and procedures that are widely accepted among financial accountants.
• Boundary: A boundary is a limit that separates one person from another. Its function is to protect the integrity of each person.
• Competency: Study and development of a particular professional knowledge base and skills associated with and applied in practice within that knowledge base.
• Counter-Transference: A practitioner’s unresolved feelings and issues which are unconsciously transferred to the client.
• Dignity: The quality or state of being worthy, honored or esteemed.
• Dual Relationships: An alliance in addition to the client/therapist relationship, such as social, familial, business or any other relationship that is outside the therapeutic relationship.
• Genitalia, Female: Labia majora, labia minora, clitoris and vaginal orifice.
• Genitalia, Male: Testes, penis and scrotum.
• Impugn: To assail by words or arguments, oppose or attack as false.
• Integrity: Honesty. Firm adherence to a code of values.
• Multidimensional Relationships: Overlapping relationships in which the therapist and client share an alliance, in addition to the therapeutic relationship.
• Progress Notes: Notes written, by a practitioner certified by NCBTMB, and kept in a separate client file that indicates the date of the session, areas of complaint as stated by client, and observations made and actions taken by the practitioner.
• Sexual Activity: Any verbal and/or nonverbal behavior for the purpose of soliciting, receiving or giving sexual gratification.
• Sexual Harassment: Sexual harassment consists of unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when:
  1. Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment;
  2. Submission to, or rejection of, such conduct by an individual is used as the basis for employment decisions affecting such individuals; or
  3. Such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, or offensive working environment.
• Scope of Practice: The minimum standards necessary for safe and effective practice and the parameters of practice determined by the certificant’s professional training and education, and, when applicable, regulatory bodies.
• Therapeutic Breast Massage: Manipulation of the non-muscular soft tissue structure of the breast up to and including the areola and nipple.
• Transference: The displacement or transfer of feelings, thoughts, and behaviors originally related to a significant person, such as a parent, onto someone else, such as a massage therapist (or doctor, psychotherapist, teacher, spiritual advisor, etc.).

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