Working With Clients Who Have Experienced Assault Part 1

Content Warning: assault, sexual assault, rape.

By Robert Libbey

Practising as a Massage Therapist is an interesting and fulfilling career. Most therapists are comfortable treating from an orthopaedic perspective, testing and assessing functionality of patients and determining a course of treatment and rehabilitation. We help patients from all walks of life: young, less young, inactive, more active, weekend warrior, elite athlete, disabled, those challenged with pain and discomfort and so on.

This article discusses people living with a type of injury you unknowingly see regularly in your practice. And I will offer my professional perspective from treating patients suffering from this injury during my 25-year career.

It’s important for us as therapists to be knowledgeable about assault/violence and the various forms it takes. This subject matter is extensive.

What is Assault?

Assault occurs in many forms, locations, is committed by both sexes and can be classified into the following:

current and previous partner violence and emotional abuse since the age of 15
stalking since the age of 15
physical and sexual abuse before the age of 15
witnessing violence between a parent and partner before the age of 15
lifetime experience of sexual harassment
general feelings of safety.

Globally, the statistics are similar for most countries that have reported. Although for other countries the research just doesn’t exist.

This is a subject that many are unwilling to come forward to talk about.

According to the World Health Organization (WHO), sexual violence remains highly stigmatised in all settings. Even when studies take care to address the sensitivity of the topic, it is likely that the levels of disclosure will be influenced by respondents’ perceptions about the level of stigma associated with any disclosure, and the perceived repercussions of others knowing about this violence.

The person living with this injury is not typically discussed in massage therapy curricula nor is it discussed much, if at all, in other forms of manual therapy curricula globally.

The person seeking treatment is typically female (1 in 4 women, 1 in 17 men) over 15yrs old, acquired this injury by someone (male or female) they knew/know intimately (1 in 4 women, 1 in 13 men) or by a stranger (1 in 11 women, 1 in 4 men), while in their own house (40-55%).

The event causing the injury may have happened once or it may have been, or is currently, recurring.

Men are more likely to be physically assaulted by a male stranger at a place of entertainment or recreation. 9 out of 10 times the person suffering with this injury has not told anyone about it.

According to The National Center for Victims of Crime (USA), 1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse. Further, each year in the U.S., 321,500 Americans ages 12 or older are sexually assaulted or raped, according to the Rape, Abuse and Incest National Network.

In Australia, 17% of women and 4% of men experienced sexual assault since the age of 15. A study found 20.6% of women and 10.5% of men reported non-penetrative childhood sexual assault by the age of 16, and 7.9% of women and 7.5% of men reported penetrative childhood sexual abuse by the age of 16.

15% of women had been sexually assaulted by a known person, compared to 4% who were assaulted by a stranger.

Girls between 10 and 14 represent the greatest proportion of victims of sexual violence, followed by women aged 15-24.

Indigenous women are over-represented as victims of interpersonal violence.

Police figures show that interpersonal violence per head of population increases the further one lives from a capital city.

(source)

Some Positive Change, But Not Much…

The proportion of Australians experiencing violence in the last 12 months, has declined over the last decade, decreasing from 8.3% in 2005 to 5.4% in 2016. This decline was driven by a drop in experiences of physical violence, falling from 7.5% in 2005 to 4.5% in 2016.

For men the proportion experiencing physical violence in the last 12 months has almost halved since 2005, decreasing from 10% in 2005 to 5.4% in 2016. For women, the proportion has fallen from 4.7% in 2005 to 3.5% in 2016.

Over a shorter time period, since 2012, the proportion of men experiencing physical violence in the last 12 months decreased, falling from 8.5% in 2012 to 5.4% in 2016. The proportion of women experiencing physical violence in the last 12 months decreased from 4.6% in 2012 to 3.5% in 2016.

The proportion of women experiencing sexual violence in the last 12 months has remained steady between 2005 and 2016 (1.6% in 2005 compared to 1.8% in 2016). However since 2012, there has been an increase, from 1.2% in 2012 to 1.8% in 2016.

87% of women who experienced sexual violence by a male did not contact police.

(Source)

What Does Management of this Injury Look Like from a Massage Therapy Clinical Perspective?

Remember, we are not only therapists but also patients. Always consider how you as a patient would feel during an appointment with you as the therapist. It is important to remember that patients’ have a level of expectation from you, from the treatment and of the treatment environment.

Standards of Practice define the basic level of expected treatment from therapists and the safe, ethical, and competent delivery of care. When discussing Standards of Practice, we are primarily concerned with creating boundaries and obtaining informed consent to practice. Standards of Practice governing massage therapists differ globally so it’s best that you inform yourself of the standards that apply to you.

(Editor: Boundaries and Informed Consent are included in the AMT Code of Practice. Also refer to the AMT Code of Ethics.)

Boundaries

Sexual trauma is a severe boundary violation. An important part of recovery and healing is re-establishing what healthy connection and boundaries look and feel like.

The therapeutic relationship that exists between a health professional and a patient is inherently unbalanced in terms of power. In the 1996 article “Power Imbalances and Therapy”, Karla Kennedy Boyd, PhD informs us that within a functional therapeutic relationship, patients invest therapists with power and therapists use their privilege and power to help patients empower themselves. Therapy is impeded when the therapist fails to consider societal power dynamics, such as race, age, gender, religion, sexual orientation, ethnicity, cultural beliefs, ability, values, lifestyle and perception of dominant cultures. If the therapist fails to acknowledge and explore the power dynamics within the therapeutic relationship, there is potential for devaluation of the patients’ personal values and perceptions. It is the responsibility of the massage therapist to recognise and manage this power imbalance to provide patient-centred, safe, ethical, competent, and effective care.

Establishing both psychological and physical boundaries informs patients of what to expect when seeking care from you. Although massage therapy is a physical form of treatment, we know that it not only affects the patient’s physical body, but that it also affects the patient psychologically and emotionally. Communicating and forming clear boundaries ensures professional and respectful patient safety, comfort and dignity.

If your practice is like mine, we serve a diverse community rich with individual and cultural differences. Each patient presents with their own cultural and individual levels of comfort with touch and physical contact. Assault is not isolated to any one sex, culture or community. As such, it’s important to understand that each patient has their own personal sexualised/sensitive areas of their body. Communicating with the patient about their personal boundaries helps to minimise the occurrence of unintentional or incidental physical contact with those established areas.

As much as we try to empathise or understand a patient, we can never truly know what a patient is experiencing physically, psychologically or emotionally. It is important during treatment to regularly communicate and reaffirm that you are working within your patients’ level of comfort. Be aware of the patient’s non-verbal communication for signs of discomfort, such as:

increasing muscle tension or tone
physically shifting or attempting to move away from your touch.

Verbal communication from them saying that what you are doing is uncomfortable and/or unwanted should be respected.

Informed Consent

Informed consent involves providing the patient with sufficient information about the proposed treatment to enable them to decide if they would like to continue with treatment.

Informed Consent specific to victims of assault means that the massage therapist:

engages in shared decision-making with the patient
respects the patient’s autonomy
obtains consent prior to delivery of treatment
addresses the patient’s goal(s) and expectation(s) in seeking treatment
monitors and renews consent where appropriate throughout treatment
discontinues treatment if the patient withdraws consent at any time.

Informed consent includes the massage therapist providing information about:

areas of the patient’s body where treatment will be delivered
options for disrobing
options for draping during treatment.

Remember that physical and sexual abuse does occur before the age of 15. It is the responsibility of the massage therapist to inform themselves of the legal requirements pertaining to providing treatment to a minor, and ensuring that the child is comfortable with the guardian/parent accompanying them to the treatment.

(Editor: Refer to the section “Treatment of Minors” in the AMT Code of Practice.)

What’s Your Role?

Today more than ever, massage therapists treat from a biopsychosocial (BPS) perspective, recognising how psychological, emotional and physical dysfunctions and conditions affect the overall lifestyle of a person. Although we all have the innate desire to help someone, it is not our role to help the patient emotionally or psychologically. We need to approach these topics carefully, acknowledging where we are not counsellors/psychologists/psychiatrists nor do we receive appropriate education for the treatment of mental health issues or conditions.

Communication Suggestions

What do you say after a patient communicates to you that they are a survivor of abuse/violence?

When a patient confides in you, it’s important to pause for a brief moment before you instinctually respond. According to the Journal of General Internal Medicine, physicians’ interrupt within 11 seconds after the patient starts speaking. Taking pause as a health care provider and fellow human-being provides you the time to remember to respond from a place of empathy rather than sympathy.

How we present ourselves to our patients influences our outcomes and their mental and emotional state. Trust, respect, comfort of the environment and of the relationship create an opportunity where a patient feels safe. Hearing our patients’ stories pulls at out emotional strings. It’s important to remain neutral. You may find yourself getting lost in your own feelings and perspectives and creating fictional events in your own mind based on what you’ve been told. You may feel agitated, outraged, judgmental, angry, shame and guilt. It’s a challenge that we must contain our own emotional response and stay neutral and be a compassionate observer.

Recognise that it’s respectful to communicate in a way that is appropriate to the patient’s level of understanding, considering factors such as the patient’s age, language and cultural background. It’s easy to hurt other people and not even notice it. Words are powerful and have different meaning to different people. Sometimes, we say words to other people that don’t mean much to us, just to avoid an awkward silence or just to say … something.

Although your instinct may be to respond with a sympathetic “I’m sorry,” avoid saying this or something similar. You have done nothing to the patient that requires an apology. A more appropriate and respectful response would be “Thank you for sharing with me” or “I appreciate that you shared with me.” There is no awkward silence, nor any sense of pity. Acknowledge their story, then ask “How can I help you?” This response is more authentic and encourages an actionable outcome.

Listening can be challenging. As therapists, we are educated to assess and treat with a possible solution. Therapists of all kinds forget or do not recognise that listening and gentle acknowledgment is what our patients need most, not a solution.

Being heard is powerful. Be conscious of the chasm between what we believe a patient may be feeling and their true feelings. Avoid attempting to validate what you think the patients’ feelings are or guessing what they are feeling. Terminology is very individualistic so let the patient label their feelings and use their words.

If you don’t understand something the patient has communicated, rather than telling them what you think it sounds like, stop and ask them what they mean. Ask them for clarification. People appreciate not having someone guess at what they feel. They appreciate being understood.

Massage therapists have a unique experience with patients compared to other medical professionals. We can spend up to an hour or more alone with a patient, communicating with them verbally and non-verbally. As the professional relationship develops over time, both therapist and patient become comfortable with one another.

Vulnerability and Trust

The person in front of you is taking a courageous step just showing up to their first appointment. Trust is built not in huge defining moments, but over time with very small moments. Therapists typically reflect on different techniques or strategies they can utilise to treat an orthopaedic dysfunction. It’s time to recognise that it is equally important to reflect on how your verbal and non-verbal communication and interactions influence the building of trust within the therapeutic relationship.

Many of us remember growing up learning “Stranger/Danger!” The main threat with which stranger/danger campaigns were started was the concern of sexual abuse. The campaign continues today with the hope to solidify the idea or warning that all strangers can potentially be dangerous. It is an example of a moral panic that people experience regarding anyone that they are unfamiliar with in society.

Every new patient we see has a certain level of expectation of what they think they are about to experience. This expectation may come from another patient’s experiences with you, from experiencing treatment from other therapists of the same or different professions, from discussions the patient has had with friends/family/acquaintances, and from what they’ve seen on TV or in the movies etc.

Charles Feltman defines “Trust” as choosing to make something important to you vulnerable to the actions of someone else. As therapists, it is easy for us to forget that the person in front of us, who doesn’t know us, is about to trust us while placing themselves in a position that is most vulnerable. Trust is an important aspect of any treatment and it’s one of the strongest influencing factors in your therapeutic relationships.

Brene Brown defines “Vulnerability” as the feeling we get when we feel uncertainty, at risk or emotionally exposed. One of the life lessons we learn is that courage is an important value. We are encouraged to be brave in anything we attempt, but in the same breath, we are also taught that vulnerability is a sign of weakness. On one hand, we are taught to be brave, but on the other hand we are taught to never expose ourselves.

The reality is that there is no courage without vulnerability.

About the Author

Robert Libbey has been a Registered Massage Therapist (RMT) in Canada for over 25 years. He has been a Senior Clinical Examiner instructing Orthopaedic and Neurological Examination. He teaches Ligamentous Articular Strain Techniques (LAST) at international conferences and online. Along with teaching and lecturing, Robert maintains a full-time practice. Robert has a passion to advance and improve Manual Therapy education, encouraging innovation in manual skills and inspiring therapists to incorporate research into practice to better serve their community. Learn more about Robert and his courses here.