By Sharon Livingstone
Have you ever had a client who lingers after their appointment and simply won’t leave? How about a client who refuses to wear a mask or removes their draping entirely or insists on more regular appointments than you’ve recommended?
These are examples of professional boundaries being challenged.
What are Professional Boundaries?
Professional boundaries refer to the limits and parameters that are set within the therapeutic relationship. The establishment of clear boundaries is intended to create a safe and predictable place where treatment can take place.AMT Code of Practice
The Code of Practice goes on to describe situations that indicate a breach of professional boundaries, including developing relationships with clients outside of the clinic, gossiping or having personal conversations with clients, counselling clients, or treating clients when the therapist or the client is under the influence of drugs/alcohol.
Given the inherent power imbalance in the therapeutic relationship, the client should reasonably assume that they will not be emotionally, physically or financially exploited.AMT Code of Practice
Our boundaries are dynamic and subject to change depending on the client and current circumstances, including pandemics.
The onus is on the therapist to set and maintain these boundaries. That’s simple enough, isn’t it? But what happens when it’s the client pushing the boundaries? What do massage therapists do to maintain their professional boundaries?
Pushing the Boundary
I had a new client – a professional in his 60s. He’d regularly been to the clinic for physiotherapy and there was no cause for concern when I did the initial intake. Returning to the room after he’d changed, I applied draping. “I’m too hot,” he said and pushed the draping off. I explained the necessity for draping and how he would be draped for the treatment. I offered to uncover his feet, to turn the air-con to a cooler setting and reassured him that his body would cool as the treatment progressed. Still the draping was flung off. “I just want a massage!” he said, his voice rising. It was clear that no matter how I explained the requirement for draping, he would refuse to be draped. He had no history of diabetes or other condition that explained his behaviour. We decided that the treatment wouldn’t proceed and he offered to pay regardless, which I declined. He left the clinic in his long trousers, leather shoes with socks, long sleeved shirt, tie and put his jacket on as he walked out.
I asked his physio afterwards if she’d noticed anything peculiar about him and she only commented that he doesn’t like to do the exercises she prescribes. Why then had I been subjected to a tantrum any 2-year-old would have been proud of?
What could I have done better or differently to avoid this situation? What would you have done in the face of a volatile man pushing your boundaries?
I had a new client challenging my boundaries but for other massage therapists, it’s a regular client.
In a recent post in the AMT private Facebook group, a massage therapist asked for help to end a therapeutic relationship after the therapist felt their boundaries had been breached.
“(The client) seems to have become a bit desperate for help and was looking for help from me to the point where I had trouble bringing the conversation to an end by pointing out that the issues (they) experienced are out of my scope of practice. (During treatments, the client) held my hand and did not want to let go on several occasions. My general suggestions for them to consider, and that I advised after previous treatments, are not sinking in. After the most recent massage treatment, I decided that our therapeutic relationship had to end as I felt too uncomfortable working with them, mainly due to them persistently not being aware of the professional boundaries.”
How would you terminate the therapeutic relationship?
The COVID-19 Factor
Working during the time of COVID-19 has provided clients with more opportunities to push their massage therapist’s boundaries by refusing to wear a mask when requested, questioning the need to complete health screening at each appointment, and not complying with location check-in requirements.
Anne Ping Nam described her experience with a regular client refusing to wear a mask.
“I felt disappointed and let down that she refused to wear a mask (even though) it wasn’t mandatory at the time. She has not returned for any further treatment: her choice. I told her that our conversation would be very limited to just (about) the treatment, when necessary, as her position was supine for MLD. I felt that she didn’t consider my safety at all. I didn’t feel she would take on board any mask education at the time.“
Meredith Spark had a different experience:
“I had a regular on Saturday turn up without one on but pulled it out of his pocket when raised it was needed. I allowed him to loosen it when prone (still on) but got some resistance from him about putting on properly when supine. He tried to go with just resting it on his face but deep breathing sent that sucker flying. He said he didn’t have to from this week so what’s the point of 2 days.”
Put in the same situation again, Anne said she would focus on educating the client on the risks of how not wearing one would impact on us both. Anne now provides information to clients prior to their treatment:
“I don’t give people a choice now. In my COVID information and screening I send with their reminder text, I state that wearing a surgical mask is necessary for the appointment. I provide one if they don’t have one. If they arrive with a cloth mask, I let them know that when they are being treated in the supine position, I will be placing a surgical mask on them due to our faces being in close proximity.“
For Meredith, it was a learning opportunity and has since updated how she monitors clients during treatments:
“I didn’t realise I needed to watch closely part way through a treatment to see if a mask is still being worn but have added it to my list.”
If another massage therapist finds themselves in a similar situation, Anne suggests, “stand your ground. All the people you come into contact with need to be considered, not just you and the particular client at the time.”
The move by a number of massage therapists to include the mask requirement with their appointment reminders is a good way to avoid boundaries being pushed and awkward discussions/situations, as Katherine Potter demonstrates:
“I sent the intake forms (to a new client) to complete before attending and this includes a separate COVID agreement which must be opened and signed. I got a text message saying he wanted to cancel the appointment tomorrow, no reason given. I replied saying no problem and would he like to rebook and his reply was ‘No. Its ok. I refuse to wear a slave muzzle. I know it’s not your doing but yeah. I apologise.’”
Health Fund Compliance
Meredith Spark had a client who didn’t want to complete their client intake/medical history.
After this experience, Meredith says, “I now have my medical history and pre-screening forms emailed in advance”.
The Home Clinic Overstayer
Working in a home-based clinic requires strong boundaries around the difference between the work area and the home. Massage therapists with a home-based clinic regularly discuss clients forgetting that just because they work from home, doesn’t mean that they work 24/7 or don’t have commitments at home they need to return to. Robyn Deakin shared her experience of one client who blurred the boundaries of her time and home environment:
“Monthly appointments turned into fortnightly initially. Months into his treatments, I realised he went to the same primary school as me. Once he realised this, I noticed our relationship altered and his counselling appointments (with another practitioner) ceased. Appointments with me were weekly in the last number of months.
“I realised quite early on that my time was being taken advantage of. He would talk about the same thing over and over again, particularly with his PTSD. Then he found out that my husband (who worked night shift) knew mates of his and after his treatments with me, would try to catch up with him.
“My husband would make himself be seen when I had new male clients booked in, but I got to the point where I had to tell my husband to make himself scarce.
“I began to feel awkward around this client and it was soon after I made the decision to end the therapeutic relationship.”
I asked Robyn what she would do differently in the same situation:
“It’s shown me not only with that boundary, with any boundary that I implement in my room I need to follow through with it when it’s first noticed.”
The Impact on the Therapist
From my own experience, when clients push at my boundaries, I start to resent the client and dread their next appointment, knowing that I’m going to have to shore up my defences and, in my head, I prepare responses to what I anticipate them saying.
Robyn began to feel awkward around the client in her home-based clinic. Anne described her disappointment and felt let down. Meredith felt frustration, and anger at herself for the situation occurring.
In the AMT Code of Practice, it is suggested that having an experienced mentor or supervisor to provide objective advice, clarity and guidance is an effective way to ensure that the massage therapist is keeping themselves and their clients safe at all times. Discussing issues around clients pushing our professional boundaries with other massage therapists or trusted colleagues can help the therapist to understand what steps can or should be taken, including improving communication, updating procedures, or the decision to end the therapeutic relationship.
If you don’t have a mentor but interested in finding one, register here for the AMT Mentoring Scheme Information webinar being held at 8pm AEST on Monday 15 February 2021.
Ending the Therapeutic Relationship
I’ve only done this once. At the time I was dealing with a misogynist who repeatedly demonised women during our treatment sessions and I genuinely feared for my safety. I had the good fortune to work with a psychotherapist at the time, who suggested I email the client.
In the Facebook discussion I mentioned earlier on terminating the therapeutic relationship, it was obvious that there is no single course of action to take. Situations involving humans are rarely uncomplicated. The suggestions included: claiming the diary was booked out or hours have reduced, refer the client on, get the client to have Reiki, and a direct and frank face-to-face discussion.
Robyn Deakin explained how she terminated the therapeutic relationship:
“I did this by text. Before I sent the message I went over his clinical notes & that’s where I got my inspiration and motivation, if I can put it that way, to go through with it. I realised he was playing me with the areas he wanted worked on & that the pain level he was experiencing hadn’t at all changed.
“I sent the message and within 10 minutes the reply was abusive and extremely rude, saying that the treatments had been working wonders! Showing me exactly what I knew all along but I chose to ignore this kind of manipulation. I was certainly shocked by what he wrote but not surprised!
“The message included areas of reading over his clinical notes, areas not improving and to discuss further actions with the GP and the counsellor.”
The Final Word
The importance of boundaries cannot be understated. Have you written or reviewed your policy on boundaries recently? Are there boundaries that you need to work on?
I’ll leave the final word to Robyn Deakin on what having and reinforcing effective boundaries can mean for massage therapists.
“There are other boundaries I needed to work through at the same time as this client and an interesting thing happened when these boundaries were implemented and put back in place. These clients that had been ignoring the initial boundaries from the start moved on and I began seeing new clients making appointments! Interesting how that works, hey?”
About the Author
Sharon Livingstone is a massage therapist in Sydney, NSW. When not in the clinic, Sharon is on a bush trail, improving her photography and trying not to step on snakes.