As RMTs gear up for what is typically a very busy season for new patients, I thought this would be a good time to talk about consent. It's in the news a lot, and in the wake of the #metoo movement, conversations about consent are more pertinent, and powerful than ever as people realize how validating and empowering consent is. While the the context for these conversations is usually intimate personal relationships, consent is truly an ongoing negotiation in virtually all of our relationships, including those relationships we have with our medical professionals.
Sandy* arrived at my office ready to go. It was clear to me she had spent a lot of time thinking about and deliberating over getting a massage. She was “...prepared for a long journey to recovery,” and it became more and more clear to me as she talked faster and faster and at ever greater length, that Sandy was pretty anxious about receiving a massage and had worked up a lot of courage to get to the office.
If you think about it, massage is a fairly intimate act. You are in an enclosed room with a stranger who is about to touch you, maybe all over, for the next hour. You might even be completely naked! Talk about vulnerable. Considering this vulnerability, putting myself in my client's shoes gives me a better perspective of the massage experience. If I'm the one getting on the table, I want to know that my therapist is going to respect me and care for me in a way that communicates clearly that they respect and care for me. Having a clear conversation about what to expect during the massage, what the boundaries are and how and when to communicate if you think something is wrong can save one from a lot of anxiety once that therapist steps out and leaves you to get ready on the treatment table.
Observing these anxieties in Sandy I knew consent was going to be a more detailed conversation than it usually is. First we thoroughly discussed what it was that brought her in and what she was expecting from the massage. Then we talked about EXACTLY what I planned to do, we looked at a diagram of the body to see what parts of her I would touch, we talked about pain and pressure and I repeatedly made it clear, Sandy is the boss of Sandy's body. After covering all the potential risks, side effects and benefits, alternative courses of treatment, what my expectations were and what our agreed upon boundaries were, we established a clear communication system for her comfort levels during the massage. By the end of the conversation, Sandy had already begun to relax. The concern left her eyes and the first drop of trust was established.
The College of Massage Therapists of Ontario is responsible for regulating RMTs on Ontario protecting the public. One of the ways they do this is by laying out our Standards of Practice. Communication/Public Health Standard 7 is our guide for conducting Consent. It is adapted from the Ontario Health Care Consent Act 1996 Part II Section 10. It describes a conversation between a medical professional and their client/patient in which the patient is fully informed of:
the proposed assessment or treatment
risks, benefits and side effects of treatment
consequences of not receiving treatment
alternative courses of action
...before treatment is to commence. It is only if this consent has been obtained can a medical practitioner of any kind in Ontario apply their proposed treatment plan. This consent is voluntary, and can be revoked at any time. Standard 7 includes the idea that consent is an ongoing process. Just because you said yes to something 20 minutes ago doesn't mean you still feel "yes" about it now. RMTs are required to continue checking in with a client throughout the treatment. This doesn't mean constantly asking if everything is ok, but rather making note of changes in depth of pressure, or encountering areas that feel different and asking for a little feed back. It means paying attention to all the communications your client gives you, verbal and non-verbal. It means not only creating space for the client to fully express their needs and boundaries, but demonstrating a willingness and commitment to working within them.
During Sandy's treatment our conversation of consent continued. As I moved to new body areas I would gently check in, “how's this feel when I work here?” “Is this area sensitive?” “My hands still feel ok?” And Sandy would mumble something along the lines of “muurrrmmmphramn.. yes...” between light snores and sighs of relief. When she rolled over she said “I think I've just had a lot of crappy massages. They have always hurt and I'd be so sore for days and I just thought it was supposed to be like that and I was a bad client.”
When therapists are able to communicate clearly with their clients, it becomes much easier for their clients to communicate with them. Trust begins to grow and and a real, therapeutic alliance can be developed.
After the massage, Sandy felt not just physical relief, but mental relief. She wasn't a bad massage client, she wasn't a wimp, she was just Sandy. Amazingly, when she returned for her follow up appointment one week later she said "I feel totally fine. The pain is completely gone. I thought this would take months!" I was just as shocked and pleased as she. Perhaps being able to fully relax and trust in being cared for by another was enough to ease the tension in her muscles, or allow her nervous system to come down from an orange alert to cool cucumber green. Sandy felt empowered, heard, and accepted for being Sandy, and maybe thats one thing we can all agree upn needing.
This is the power of consent. It allows you, the client, to set declare your needs and boundaries and to expect they will be met. The outlines for consent enable the practitioner to follow the rules and even begin to learn how to spot and pick up on the more subtle communications from their clients so they can meet their needs in a way that lets clients know they are heard, respected and cared for. Consent is an invaluable conversation and, done well, is the first step to building a solid foundation of trust.
*Name changed for confidentiality. References
Ontario Health Care Consent Act 1996
The College of Massage Therapists of Ontario; Standards of Practice 2006