This article was originally published by the Registered Massage Therapist Association of Ontario in their Spring 2020 edition of Massage Therapy Today Magazine.
During our training we learn the skills needed to perform massage therapy for our patients in accordance with the basic tenet do no harm. That one seemingly small sentence packs a lot of punch. There is a lot that goes into professional conduct and it is more than not using your powers for evil; the way you conduct yourself in your therapeutic relationships has just as much to do with communicating your boundaries as knowing when massage therapy may be contraindicated. When we know our own boundaries we are better able to ensure that the therapeutic relationships we conduct remain within those boundaries. It is not just the safety of our patients that we are responsible for in our treatment rooms; we must also keep in mind the safety and well being of ourselves too.
As laid out by the CMTO in the Standards of Practice (SOPs), and the Maintaining Professional Boundaries and Preventing Sexual Assault document, the creation and maintenance of the therapeutic alliance is the responsibility of the RMT. It is us who builds and maintains the context of the therapeutic relationship. While we are trained to understand our professional obligations we often fail to see how the quality of our boundaries supports us in meeting those obligations. During the initial appointment is when we communicate our framework to our patients. While it is imperative that we gather information about our patients it is equally important to explain to them what we can and cannot do in the context of the therapeutic alliance we are creating. With everyone being clear and transparent about the relationship, it is possible to consider the consents we obtain – and give – fully informed.
So where are our boundaries and how do we communicate them? For the scope of this article I will focus on these areas:
1. The Practice Framework + Clinical Policy and Procedures
2. Negotiating the Therapeutic Contract
By introducing your new patient to the rules of conduct in your treatment room you are using your boundaries to shape the relationship you are about to embark upon. As the professional the maintenance of these boundaries is your responsibility and makes up a significant part of your work. Knowing your own rules inside and out, communicating them clearly, and remaining consistent with them makes the therapeutic alliance safer for all participants and thus more likely to achieve success.
Framework + Clinical Policy and Procedures
Regulated provinces have standards and regulations that provide the initial outline of the framework our practices are bounded by. In Ontario RMTs are obligated to conduct themselves in accordance with the Massage Therapy Act, Regulated Health Professions Act, and the CMTO's Standards of Practice and published guidelines. We know that we will be communicating our fee schedule, how payment can be rendered, what that block of time will include, and the policies regarding missed appointments or late arrivals (SOP 2). We know we will be performing an interview to obtain the patient goals, performing an assessment to identify how we might be able to help the patient (SOPs 4-5), determining if massage is indicated, creating a treatment plan, and obtaining consent to said treatment plan (SOPs 7-10).
The framework is established further by the systems and details of our unique professional practices. Location, hours of availability, fee schedule and methods of payment, means of communication and contact, knowledge sources and methods of treatment describe the basic details of how the public may engage with us as professionals as well as how we inform our work. In essence, the framework marks the perimeter of your individual professional territory. All our patients must respect these boundaries in order to receive care from us and, as such, these things must facilitate the work we want to be doing by making us accessible to the people we can best help within our framework.
While this information is generally accessible we can't be certain that the people sitting across from us at that first appointment have fully read and comprehended it. Thus the initial appointment is the time at which the therapist and patient can make very clear how all of these things occur in your practice and will provide some of the shape to the therapeutic contract that will later be negotiated. Without having this clarity in place we can find ourselves giving more to our patients than we want to or engaging in negotiation about things that are in fact non-negotiable for us.
In addition, these boundaries are also for us; as they inform our clinical policies and procedures we need to keep our capacities and interests in mind. Providing care asks a great deal of us physically and psychologically. These boundaries must be drawn in ways that support our well-being and longevity as professionals and as people. This can ask us to consider some difficult things; what is my capacity for providing massage therapy per day? Per week? What kind of treatment styles and methods am I best suited for? As a professional, what are my obligations and how do they align with my personal values? What are my financial needs and how can I meet them given my realistic capacities for providing care? What kind of support and care do I need so that I can provide the support and care my patients are seeking?
When we are clear about the work we want to do, what our capacities as professionals are, and what our personal life needs are we find the limits of our practice, what it can provide for our patients and what it can provide for us. With this perspective in place, clearly communicating and maintaining these boundaries at the beginning of the therapeutic relationship becomes much easier. By acknowledging our limits to care demonstrate how respect works in our practices. When our personal limits influence our professional boundaries we can trust our professional decisions to support our personal and professional lives. Respect for our patients can not work without being grounded in respect for ourselves.
Negotiating the Contract
Likely most of us have never considered that the initial appointment includes an element of negotiation and contract building. Something for RMTs to keep in mind is what type of relationship we are building. Though we perform caring in our work it is not personal – we are getting paid to provide a care-based service. As such, the relationship is a business relationship and not a personal relationship. Therefore all parties are agreeing to a transactional therapeutic contract. We will provide xyz and the patient will pay us for the agreed upon services. The book Talking Body Listening Hands by Pam Fitch RMT outlines the transactional contract in 4 basic steps:
1. The patient seeks treatment.
2. The therapist describes the terms of providing care.
3. The patient accepts the plan of care.
4. The therapist provides the care and accepts payment.
The contract built is one that is unique to the patient presenting in front of you for that first appointment. As we can see above it is initiated by whatever brought the patient in for care and is framed out by the therapist. We provide the terms by describing our frameworks and policies. We ensure the patient understands that there are certain things we are obligated to do such as performing assessments and gathering personal health information. Much of this negotiation will take place between steps one and two. We propose the best course of action with our boundaries considered and then solicit from the patient any modifications they require to that plan of action. It is here that both parties create the foundations of the therapeutic contract and outline what the rights and responsibilities are of both the patient and the therapist. In essence, this is the treatment plan and, when done well, includes the limitations of the patient and their personal life context plus the boundaries of the therapist.
Clear Boundaries = Safe Practices for Therapists and Patients alike
With a clear framework and policies, our ability to form an effective treatment plan with appropriate boundaries is optimized. We know what we can and cannot do and we understand why we have these limits on our practices. This clarity allows us to see when patients are trying to get more from us than we can give and emboldens us to saying no to requests that go beyond our limits for care. Knowing our boundaries and being able to clearly communicate them also helps us build practices that are safe for us. Our boundaries help us be clear about what our responsibilities are and what responsible care looks like in our treatment rooms. When we overstretch ourselves we risk providing care that we are not properly able to. This can lead therapists to feelings of resentment and even injury which does not serve our purposes as RMTs.
When we know our limits our patients know where we stand with them and where they stand with us; they know what we can and cannot do and can better trust us to behave as we say we will. Demonstrating respect for ourselves shows our patients how we expect them to behave with us and how they can expect us to behave with them and this can go a long way to fostering trust in our therapeutic alliances. With a clear framework and a collaborative negotiation process in place we are all less likely to need to fix the boundaries of our relationships later and can more readily spot when the relationship is moving in a direction that does not facilitate the therapy we are there to provide. Setting these boundaries in the very beginning provides structure throughout the therapeutic relationship, helps us guide its growth, and keep things on track and within our mandated responsibilities.
Fitch, Pamela. (2015) Talking Body Listening Hands Upper Saddle River, NJ. Pearson Education Inc.