Features Patient Care Practice
Empowering the client

A BRIEF HISTORY
When I became a registered massage therapist in 1984, we had no law requiring us to give information to the client and to obtain consent to treatment. However, most therapists understood the concept of working with our clients toward their goals for wellness rather than doing a treatment to the client.

The use of informed consent is now commonly practised by all health professionals throughout North America. For massage therapists, the procedure is well explained in the text Clinical Massage Therapy by Rattray and Ludwig, a text which is widely used in Canada.

When the Consent to Treatment Act¹ became law in Ontario in 1994, many therapists interpreted it as asking permission to massage “sensitive areas” only. In practice, the wording commonly used was, “Do I have permission to massage your glutes?” Since most laypeople were not familiar with the term “glutes,” and had no idea what the benefit of massaging this area might be, this was not a useful way to phrase the consent. We have gradually progressed to more effective ways of empowering our clients.

EXPERIENCES WITH INFORMED CONSENT
Over the years I have often been on the receiving end of informed consent – when I visit the physician, physiotherapist or dentist I hear the version each of them uses. Most have done an excellent job of informing me about the procedures to be done, and the benefits, goals and risks of the treatment, and of giving me the option to accept or decline the treatment.

My experience is that the more risk a procedure entails, the more complete and careful the consent process. For example, consent asked for surgical procedures is necessarily very careful, very thorough and given both verbally and in writing.

I have explained proposed massage treatments to hundreds of clients and received their consent. During my 15 years as a teacher I also taught the process of informed consent to hundreds of future RMTs. Students today have an advantage in that we now have the process down to a science and can give them a “script” to assist them in learning to ask their clients for consent.² It is very important that this script eventually translates into a meaningful dialogue with the clients, and this is where the challenge lies. Many therapists recite a memorized speech about benefits, risks and alternatives but then do not follow through by actually respecting the client’s wishes during the treatment.

A crucial aspect of the informed consent process entails following through with the proposed treatment and constantly empowering the client to modify or stop the treatment.

THE REALITY IN PRACTICE
I have had interesting, and sometimes frustrating, experiences as a massage therapy client, and would like to share some of these stories, along with ways to avoid these pitfalls.

1. Establish goals. The first involves establishing the client’s goals and giving choices. The initial aspect of the consent process requires us to interview the client to obtain the treatment goals.³

One young therapist started by informing me, “I am going to be doing a general full body massage.” I stopped him immediately and told him that I actually wanted a shoulder treatment. He had not established my goals.

2. Follow up on agreement. On some occasions the therapist has given me choices, but then has not followed up by doing the treatment I asked for. The consent constitutes an agreement that we have to honour. Consent must be obtained voluntarily and not obtained through misrepresentation or fraud.³

When consent has been obtained from a client but the therapist does not provide the treatment for which consent was given, this can be considered a misrepresentation.

On another occasion when I went for a massage, I was asked what treatment I wanted and I specified that I particularly wanted my back and neck massaged. The therapist treated my back and posterior legs and then informed me that he had run out of time and could not massage my neck. He did not provide the treatment he had agreed to.

3. Respect the client’s time. In a third situation, a massage therapist asked my treatment goals and agreed to perform a one-hour treatment for biceps tendonitis. After a long time lying face-down on the table, I started to wonder when she would get to my biceps tendon. When I asked, she stated that there were many imbalances in my body and she had to work other areas before treating the shoulder. After the massage I realized I had been on the table for more than two hours. While the therapist may have felt that she was giving me great value for my money, I had not agreed to a two-hour, full-body massage. Giving a client extra time may seem generous, but people have places to be and are on a schedule. If the agreement is understood to be a one-hour massage, then treating someone for two hours is not following the informed consent agreement.

HOW IS THE PRESSURE?
One of the basics of informed consent is the request that the client will let us know if the pressure of the massage is satisfactory. The process requires that the therapist will check periodically to determine the client’s level of comfort, and that treatment will be stopped or modified at any time at the client’s request.

I frequently hear from clients that they have received massage that was far too deep for their comfort level, and that the therapist did not lighten the pressure when requested to. In a recent edition of the Ontario College Standard, College of Massage Therapists of Ontario informed us that 14 per cent of their complaints last year were with regard to clients being hurt by excessively deep pressure during massage.

ARE YOU OK?
When checking to determine the client’s comfort level, we must think about how we word our questions. My experience is that many therapists ask, “Is that OK?” or “Are you OK?” I do not believe that this wording is sufficient. Many clients have no idea of what to expect during a massage. They do not know what the expected reaction is likely to be or what they should be feeling, so they have no way of judging if what they are experiencing is “OK.” Some clients have the expectation that massage must be painful in order to be effective, so if they are having pain they think that must be “OK.”

Added to this we have the power imbalance of the therapeutic relationship. It is difficult for a client to be assertive when lying on a table, unclothed, while the professional is standing and dressed.
 
IT’S HARD TO SAY NO
We are members of a polite society. Most people find it difficult to say “no” and possibly offend someone. It is important that we make it easy for the client to tell us when our manipulations are uncomfortable. Try to word questions so that the client can answer “yes.”

If we say, “Is this pressure okay?” the client is likely to respond that it is. Instead, we can say, “This muscle feels tight. Is there any discomfort when I press on it?” It should be easier for the client to say “yes” and acknowledge that the pressure is too deep.

Treating sensitive areas tests our ability to give good information to clients and to explain the benefits and procedures of our proposed treatment

Therapists do not have to rely solely on verbal input from the client. If we focus carefully we can observe non-verbal cues that will tell us when the pressure is too deep. If the therapist feels the muscles tightening or observes the client holding his or her breath or being unable to talk, we know that the pressure is too deep. If we can see the client’s
face, facial expressions will usually indicate if there is too much pressure.

CHANGING THE TREATMENT PLAN
Changes to the treatment plan should be proposed after the first treatment and updated whenever the treatment plan is altered. Consent to the changes should be obtained at that time, or at the start of the next treatment.³

I requested a treatment for low back pain and the therapist proposed treating my back and neck: I consented to this treatment. During the massage the therapist suggested that
it would be beneficial to also treat the gluteal muscles, piriformis and iliopsoas, and asked if it would be all right to massage those areas.

The imbalance of the therapeutic relationship made it difficult for me to refuse, although I really dislike having iliopsoas massaged. A client who is a layperson might not understand the terminology and would have no idea what he was agreeing to.

These changes or additions to the treatment plan should have been proposed after the first treatment. I could have considered them and made a decision before the next treatment. This is particularly important when manipulations are proposed for “sensitive areas” such as the gluteals, breasts or inner thighs. We want to be sure that the client has time to consider and be comfortable with the proposed treatment.

TREATING ‘SENSITIVE AREAS’
In Ontario, the Standards of Practice identify certain regions of the body as being “sensitive areas.” I believe that most therapists practising in North America would agree that these are areas of concern. These designated areas are the breast tissue, muscles of the chest wall, inner thigh and gluteal area. A CMTO Position Statement dated Feb. 17, 2004, discusses guidelines for obtaining consent to treat these areas of the body. Standards of Practice/Techniques Standards 16 and 17 address procedures for treating the breast and chest wall.

Individual clients may have issues about almost any area of the body: some people, for example, dislike having their feet massaged. However, the regions designated as “sensitive areas” are those which are generally regarded as potential targets for both misunderstandings of intent and actual sexual abuse.⁴

Treating these areas tests our ability to give good information to our clients and to explain the benefits and procedures of our proposed treatment. Treating sensitive areas requires a very conscious effort to continuously empower our clients. When it is necessary and appropriate to treat a sensitive area, it is suggested that a specific signed consent should be obtained and placed in the client’s file. This does not relieve the therapist of the responsibility to provide verbal information and obtain verbal consent. It is a written confirmation that this conversation has taken place and that verbal consent has been received, and there should also be a written record filed if this consent is withdrawn. Having a signed consent in the file is a protection for the massage therapist.

REVIEW YOUR PROCEDURES
Think about your informed consent procedures and ensure that they are meeting the highest ethical standards by keeping clear communication between you and your clients. Clients who feel empowered and respected will keep returning to your practice.

REFERENCES

1. Consent to Treatment Act: Ontario
2. Clinical Massage Therapy: Understanding, Assessing and Treating over 70 conditions. (Talus Inc)
3. CMTO Standards of Practice: Communications and Techniques” Standards 4, 7, 10
4. CMTO Position Statement Feb 17, 2004: Treatment of Sensitive Areas, Standards 16, 17

Lee Kalpin has been a registered massage therapist and clinic owner since 1984.  She has also written and taught courses for massage therapy programs for many years, and strives to remain current in the science and ethics of massage therapy.  Many past students continue to contact her for guidance and mentorship.