Chapter 20

1. PowerPoint to accompany New Foundations in Therapeutic Massage and Bodywork First Edition Jan L. Saeger • Donna Kyle-Brown Chapter 20

2. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM Learning Outcomes • Chapter Objectives • Recognize the importance of ethical and professional standards. • Discuss basic rules and regulations governing massage and the scope of practice. • Recognize the difference between licensing and regulating massage therapists. • Identify appropriate forms of touch and client boundaries.

3. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Identify and comply with Health Insurance Portability and Accountability Act (HIPAA) regulations. • Recognize the role of the therapist in professional relationships. • Practice role-playing in scenarios involving ethical and other real-life situations.

4. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM Code of Ethics and Law Most professional organizations have established sets of standards, known as “codes of ethics”,to serve as guidelines for professional conduct. • A member’s adherence to a specified code of ethics ensures quality service as well as speaks to the personal character of the professional. • Simply put, a professional code of ethics is a reflection of the personal standards of the individual members of the larger group. • Whether or not you become a member of AMTA, ABMP, or IMA and have taken the certification exam of the National Certification Board for Therapeutic Massage and Bodywork or your state’s exam, as a massage therapist you should strive to uphold the principles set forth by these and similar organizations. • Keep in mind that these organizations offer more than codes of ethics; they also lend support to their members in numerous ways, from marketing techniques to networking opportunities to group rates for insurance. • One of these groups may meet your needs better than the others: you may simply be looking for insurance coverage, you may be interested in learning new marketing approaches and acquiring help with establishing good business practices, or you may be looking for an organization that will be your voice in current issues affecting the profession. It is important to join an organization that resonates with you and your massage therapy practice.

5. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Laws Governing Massage • The laws governing massage and massage therapists vary widely from state to state. • Although the majority of people practicing in the massage profession call themselves “massage therapists,” a growing number refer to themselves as “massage practitioners.” • For some, it may be a matter of semantics, while for others, being called a “practitioner” is a way to differentiate themselves from the “therapy” field, which denotes training in psychology. • States that do not license massage therapists regulate them by requiring proof of education, training, or competency. • Currently, 36 states and the District of Columbia license or regulate the profession of massage therapy and bodywork, with some of those states having multiple levels based on education and training or dual (massage and esthetician) licensing. E X A M P O I N T Some states license massage therapists (LMT) and massage practitioners (LMP), while others regulate them (regulated massage therapist or RMT).

6. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • There are several common denominators, however, such as • a specific definition of massage (scope of practice) • formal education • code of ethics • professional standards • and local laws or regulations • A new organization—the Federation of State Massage Therapy Boards—may accomplish the long-term goals of many therapists’ and practitioners’ by creating consistency across the nation for massage education, standards, and regulations. • Because laws governing the profession are continually defined and updated, check your state’s website for the most current information. • If your state regulates rather than licenses massage therapists and is not on this list, please check with your state commerce or health department, or the local massage therapy organization for requirements and contact information.

7. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM Scope of Practice E X A M P O I N T The massage therapist’s scope of practice—or the parameters within which a therapist may work—is based on the governing state’s laws. • This differs from state to state, with the common denominator being completion of a specified number of educational hours and strict adherence to the ethical and professional standards. • The laws also clearly define work that a massage therapist cannot perform. • A specific example is direct manipulation of the spine: this work is performed by chiropractors and is therefore outside of the scope of practice for therapeutic massage and bodywork. • Massage therapists are qualified to manipulate soft tissue (muscle, tendon, and fascia), which may indirectly affect structural alignment, but cannot under any circumstances “adjust” clients.

8. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Working Within the Scope of Practice • Massage therapists may perform only those modalities in which they are trained. • Therapists trained only in basic Swedish massage may not ethically perform an advanced modality such as neuromuscular massage, nor can they represent themselves as a certified Neuromuscular Therapist (NMT) without specific training and certification. • Remember to operate within the parameters of your training; • Do not let a client talk you into attempting to perform a massage modality in which you are not trained. • Ego needs to remain at the door and does not belong in the massage room. • Do not believe yourself to be any less of a therapist because you work differently than someone else. • Always do the best job you can with what you know and are capable of; let your work stand for itself.

9. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Outside the Scope of Practice • Another area of potential liability falls in the realm of diagnosing. • Massage therapists are not medical professionals who are qualified to diagnosis or treat disease. • A forceful client may press you for your opinion and take that to heart as an official diagnosis. • Stand your ground and recommend that your client see the appropriate medical professional. • Remember that it is not necessary for a client to have a prescription from a physician to receive massage unless you are filing an insurance claim. • A growing number of clients are interested in and may inquire about adjunct alternative healing modalities. • Handle these questions the same way as you would more traditional medical questions: refer out. • For example, unless you have had training in the use of herbal preparations, do not recommend or advise but rather keep on hand a list of qualified practitioners to whom you can refer clients. • In fact, it is an excellent business tool to build a referral list of persons who are experts in their field.

10. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Medical Massage within the Scope of Practice • Currently, debate within the industry is heated concerning the use of the term medical massage. • The term is a bit of a misnomer and often misunderstood by the public. • The misconception is that medical massage is massage performed by a therapist who has attended medical school. • It is more correct to say medical massage is clinical massage and bodywork that involves neuromuscular therapy and myofascial release and is performed by a licensed or regulated massage therapist, often under the tutelage of a physician or other health care provider and in a health care setting. • All massage therapists who have successfully completed their state’s requirements for massage practice and are licensed or registered within that state may • deliver massage therapy as a service • treat clients and file for reimbursement through insurance with a prescription from a physician if they are a provider and the insurance company approves the service • perform “medical massage” or therapeutic massage • Although additional training, specialized education in specific modalities, and certifications are beneficial, it is not necessary to acquire a certification in medical massage to deliver therapeutic or medical massage.

11. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Right to Privacy All clients have the “right to privacy”. • You may not share any information about a client with other clients, a client’s friends and relatives, or even with other medical professionals unless you have written consent to do so. • Keep this in mind as you build your client list if some of your clients come out of your associations with other medical professionals.

12. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Health Insurance Portability and Accountability Act On April 14, 2003, the first federal health care privacy protection standard was put into law. This law, the “Health Insurance Portability and Accountability Act (HIPAA)” was designed to protect the privacy of patients and clients and confidentiality of health records from insurance companies, doctors, hospitals, and other health care individuals. • As a massage therapist, you will document information about a client’s • past medical history • current health status • prescription use • and any other aspects regarding the health of your client that will also fall under this law • HIPAA regulations were developed by the U.S. Department of Health and Human Services (HHS). • They represent a uniform federal privacy standard across the United States. • Individual state laws that provide additional protections to consumers are not affected by HIPAA.

13. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • These regulations protect identifiable health information, whether in a computer, on paper, or communicated orally. • Some of the key provisions affecting massage therapy are: • Access to medical records. Clients should be able to see and obtain copies of their medical records and request corrections if they identify an error. The health care provider has 30 days in which to turn over records. You must always keep the original record, but the cost of making copies can be charged to the client. • Limits on use of personal records. The client must be provided with a release of information form to sign that designates what part of the records that have been requested by another health provider can be shared. For example, if a client has a massage weekly for a previous back injury and the orthopedic surgeon wants a copy of the client’s progress notes, you would not send the client’s history form that might include information about an abortion or a drinking problem. • Prohibition on marketing. The regulations address the selling of patient information (such as addresses and phone numbers) to companies involved in marketing. You may not sell a photograph or image of a client using your facility or include it in your own marketing brochures unless you have the written permission of the client. • State laws. When reporting a communicable disease or information about a possible crime involving a client, state laws covering such claims override the federal HIPAA regulations.

14. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Confidential communications. Under the privacy rule, clients can request that you not call their homes to confirm appointments or pass information about visits to family, coworkers, or friends. • Complaints. Clients may file a formal complaint regarding privacy practices to the HHS office for Civil Rights. • Health care insurance. If you file insurance reimbursement claims for massage therapy procedures, you may be responsible for following the medical HIPAA regulations as well as the nonmedical practice rules and regulations. • Civil and criminal penalties. Complaints are investigated by the Department of Justice. Penalties for civil violations, including honest mistakes, are up to $100 per violation, up to a total of $25,000 per year, for each rule violated. Criminal penalties can range up to $50,000 in fines and one year in prison, and up to $100,000 in fines and five years in prison if the offenses are committed under false pretenses. Penalties are up to $250,000 in fines and up to 10 years in prison if the offenses are committed to take advantage of a client or for personal gain and with intent to harm. • Written consent must be obtained from the client before any information is given out, and clients have the right to see a copy of their records, request corrections, and receive copies. • Clients also have the right to request information as to whom or what organization may have requested information. E X A M P O I N T Remember: Privacy rules apply to all forms of communication—oral, paper, and electronic.

15. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Right of Refusal and Informed Consent • Both the therapist and the client maintain the right to discontinue treatment. • The reasons may vary and may or may not have anything to do with the massage itself. • However, if the client is willing to discuss it, it can be helpful to the therapist to learn whether or not the quality of service or interpersonal relationship skills are involved in the client’s decision to stop treatment. • This is called “informed consent” and refers to the educational process a client goes through to make an informed decision on whether or not to get massage or a particular type of massage. E X A M P O I N T The therapist must disclose (an act often termed disclosure) the reason for invoking the “right of refusal”, whereas the client does not need to disclose the reason. E X A M P O I N T The client also has the right to be fully informed about the massage process.

16. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Working Smart,Working Safely • If you choose to be a sole proprietor, you must give careful consideration to the location of your business. • Chances are that you will be working alone at times if you rent office space or operate a business out of your home (if zoning permits). • To lessen the potential for problems, try to schedule massage appointments when other people are in adjacent offices or when family members are in the house. • Most health care workers follow these guidelines; in fact,many male doctors will not see a female patient without a female nurse or attendant present. • Therefore, office location will dictate the manner in which you acquire clients. • Marketing and advertising are essential to your success. • If you take clients on a referral-only basis, you may lessen the likelihood of finding yourself in an inappropriate or dangerous situation. • This manner of working, however, decreases the size of the pool of prospective clients.

17. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • If you advertise in the local paper or yellow pages, prospective clients are usually unknown to you. • Consider where and how you want to work. • Are you primarily making out-calls (home visits)? • Or are you working in rented office space or out of your home? • If you are making out-calls, common sense and gut reaction prevail. • First, get adequate information in the phone call to make the appointment. • Ask callers how they got your name. • Find out what kind of massage the caller is looking for. • Does it fall within your scope of training? • Is the caller asking for a reasonable time slot, or is he looking for a late-night appointment? • Learn to identify red flags by role-playing with fellow students or work through “what if” scenarios in your own mind.

18. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Take into consideration the location to which you will be driving. • Do you know it to be a safe area, a development housing mostly families, or is it a rural location without neighboring houses close by? • If at any time you are uncomfortable driving into a certain area, trust your gut instincts and refuse the appointment. • Regardless of whether you are working in an office or on an out-call, if a client begins to show signs of arousal but you do not believe it to be intentional (an expected physiological effect), you may do one of several things to change the situation: • change to a different modality, perhaps with a lot of stretching; • change the lighting or the music to be less soft and relaxing; • or alter the tactile sense and pressure by switching to working with your elbows and forearms instead of your hands.

19. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Questionable Outcalls • You have accepted the appointment, are dressed appropriately (including no jewelry), and have your table packed up. • Upon entering the residence, place your car keys and cell phone in a conspicuous place where they are easy to grab if need be. • Do not take anything into the appointment, such as a purse, that may get left behind if you have to leave quickly. • Set up the table, take a client history, and perform your massage with a professional attitude. • If at any time you feel you are in danger or are approached inappropriately either verbally or physically, end the massage immediately. • Pack up and leave if you are not in immediate danger; grab your car keys and cell phone and leave immediately if you are. • As soon as you are safely in your car, dial 911 and alert the authorities. • This may seem like a drastic measure, but we will not eliminate this scenario until the public realizes that unseemly behavior will not be tolerated under any circumstances. • You can always return with the appropriate authorities to collect your table and supplies. • Although this scenario is directed toward female therapists, it applies equally to male therapists.

20. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Male Therapists • Unfortunately, massage can be a tough business for male therapists at times. • Men who choose to enter the massage profession often find themselves having to place more emphasis on professional appearance and conduct so as to not be accused of inappropriate touch. • Learn to recognize red flags here as well. • Refer a female client to another therapist, preferably a female therapist, if she becomes too attached to you or exhibits what you deem to be inappropriate behavior toward you, such as asking for a date. • Be extremely careful with draping; • ask permission to work on areas such as the gluteal muscles over the draping, and obtain written permission to work on gluteal or pectoralis muscles with limited or no draping. This pertains to both male and female clients. • Dress must always be appropriate: • no “muscle shirts” or tight jeans

21. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Female Therapists • It goes without saying that female therapists also need to dress appropriately. • no tight shirts • short skirts • or other clothing that could be misconstrued as provocative • There is a time and place for certain attire; the massage session is definitely not the place for unprofessional clothing. • Perfumes and aftershaves are also not acceptable to wear while giving a massage because some clients may be sensitive or allergic to scents used in them.

22. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Professional Appearance • Traditional typical dress that is professional in nature for both male and female massage therapists are • scrubs • lightweight slacks or khakis • Shorts, even those that are midthigh or knee length, are inappropriate unless you are working at a spa that requires you to wear them. • Comfortable lightweight slacks (of a cotton or rayon blend) and a pressed cotton shirt are excellent choices. This material allows for ease of movement and a loose-fitting cut helps keep you cool; you do work up a sweat while giving a massage. • short-sleeve shirts or polo shirts • Appropriate footwear such as • athletic shoes • sneakers • or other flat shoes should be worn

23. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Long hair is to be tied back. • Wear only minimal jewelry and keep it simple. • A professional demeanor is illustrated by body language. • Appropriate body language is also dictated by culture. • In the West, specifically North America, we tend to place at least a foot of space between ourselves and another person to whom we are not related. • An out-stretched hand offered to greet clients or a hand gently placed on the shoulder to direct them toward the massage room is proper. • Once in the massage room, remember to give clear, concise instructions about the massage process before exiting the room. • Most clients pay for services after the massage. • This bookkeeping matter allows for a short period of time to transition from the massage itself, which invariably involves close contact, to a more distant salutation. • The session finishes with • the fee being paid • another appointment scheduled • and a wave good-bye

24. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Professional Demeanor • The massage therapist’s professional demeanor is as important as dress or appearance. • As a member of the health care field, you will no doubt be working with other professionals, including • medical doctors • chiropractors • and physical therapists • It is imperative that you not only speak the medical language but also pronounce and spell the medical terms correctly. • Especially if English is your second language, you must work extremely hard at being articulate. • Along with adhering to the code of ethics, being able to speak clearly and understandably reflects well on the profession in general and you in particular. • Remember that many references may come to you from other medical professionals; being able to converse with these professionals will keep those referrals coming your way.

25. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM Boundaries and Professional Relationships • A boundary is defined as “something that indicates a border or limit.” Personal and professional boundaries are defined as the areas or parameters within which you work, live, and play. • Personal Boundaries “Personal boundaries” are a protection of self: • You consciously and deliberately decide whom you let into your “inner circle” and whom you keep at arm’s length. • This holds true for situations as well. • Some situations you are comfortable in and others you are not. • Keep in mind that you have a right to privacy also. • You will not want clients to have knowledge of personal issues, positive or negative. • Make sure the client respects your “personal space.” • Some clients may have different personal boundaries from yours. • Always respect their boundaries and work within their comfort level.

26. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Professional Boundaries “Professional boundaries” are based on legal and societal rules. • They are conscious decisions that we make each and every day. • The codes of ethics are examples of documents that have been formulated by people who have a consensus of opinion regarding massage as a profession. • Asking all massage therapists to abide by the same code of ethics ensures consistency throughout the profession. • More obvious examples of professional boundaries are • using proper draping • respecting a client’s privacy • not forming a personal (dating) relationship with a client • With any question involving boundaries a good litmus test is to ask yourself if a potential action may have a detrimental affect on your client-therapist relationship.

27. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Multidimensional Relationships “Multidimensional or dual relationships”are relationships in which the therapist plays more than one role in a client’s life. • The therapist may also be a relative or friend, or have a previous connection with the client. • Personalization • Psychologists refer the phenomenon of personalization as embracing or transferring emotions between one’s self and another. • “Transference”occurs when the client personalizes the professional therapeutic relationship. • For example, a long-time client believes it proper to ask very personal questions or suggest an evening out. • “Countertransference”is the inability on the part of the therapist to keep the therapist-client relationship separate and professional. • For example, a massage therapist begins to have intimate feelings for the client and gives him or her extra time or attention during the massage. • Countertransference may lead to inappropriate actions on the part of the therapist, such as asking the client for a date.

28. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • One more important issue is that of working with friends or acquaintances. • Many texts currently state emphatically that you cannot work on friends or date clients. • Although on the surface, this is a valid statement, in reality, many therapists do work on friends. • In this practical, real-world text, the approach is to ask you to take appropriate measures to ensure that there will not be a detrimental effect on your friendship or professional relationship. • Clearly spell out, in writing if necessary, massage is your job for which you rightfully receive payment. • Consider a written agreement similar to a prenuptial marriage agreement partners sometimes make before the wedding. • As long as you and your friend abide by that agreement, you should be able to keep a professional and platonic relationship separate. • Dating, on the other hand, is an entirely different issue. • Your options are to refer the person to another therapist if they, he or she is under specific treatment, or to not accept payment. • Take it out of the confines of a professional relationship and place it within a very personal one. • Several husband-and-wife massage therapist teams, who worked on each other while dating, have continued to have a successful practice together.

29. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Emotional Release • Occasionally, a client may experience an emotional release during the massage. • It often happens with, but is not limited to, a client who has suffered from some form of inappropriate touch, or was emotionally, verbally, physically, or sexually abused as a child. • Clients who have suffered a separation from a divorce, death of a spouse, or breakup of a relationship may exhibit signs of being emotionally distraught. • Loss of a job and financial problems can create an enormous amount of stress that can erupt at any time and in many forms. • A chronic illness, pain, or anxiety can take its toll and manifest as many other issues. • An emotional release may happen for quite complex reasons. • We call this “muscle having memory”. • As the body is worked on, old memories from the past or relatively new negative experiences rise to the surface and become insurmountable. • The result can manifest as uncontrollable crying, shaking, and even nervous laughing.

30. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Not all emotional releases are overt and immediate. • Some may manifest later in the day or evening as flashbacks or dreams. • Feelings of helplessness or anxiety may manifest as withdrawal or being unresponsive or restlessness while on the table. • It is important for the massage therapist to not react but rather respect the person’s experience by quietly discontinuing the massage and waiting for an indication from the client of what the next step should be. • That next step may be ending the session or lending support. • A compassionate therapist can offer support by placing a hand on the client’s shoulder, offering tissues, or even simply allowing the person space by being present but not obtrusive. • Resume the massage only if and when the client asks you to.

31. CHAPTER 20: LAW, ETHICS, AND PROFESSIONALISM • Chapter Summary • As massage therapy and bodywork grows and gains recognition, it becomes even more important to recognize, internalize, and display the strength of character that allows one to operate as a professional in the health care field. • A good way to prepare for putting ethical principles into action is to practice such scenarios using role-playing with fellow students, such as those provided in the case studies section of this chapter. • Keep in mind that any action, positive or negative, on any one therapist’s part is a reflection on all therapists. • Be acquainted with the laws of your state and uphold the codes of ethics of local and national massage organizations.