Trusting connection: Victims of assault and the RMT, Part 1
By Robert Libbey
By Robert Libbey
Practising as a manual/massage therapist is a very interesting and fulfilling career in many ways. Most therapists are comfortable treating from an orthopedic perspective, testing and assessing functionality of patients and determining a course of treatment – and rehabilitation is commonplace.
Although this article will be a departure from the typical orthopedic perspective you may be used to reading, it discusses people living with a type of injury you unknowingly see regularly in your practice. You may be living with this injury. I won’t be discussing any particular treatment techniques or strategies to use in treatment but will offer my professional perspective from practising over the past 25 years treating patients suffering from this injury.
For this article, we will take a very brief look at assault and discuss how this knowledge can influence your practice. It’s important for us as therapists to be knowledgeable about assault/violence and the various forms.
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.
According to the World Health Organization (WHO), sexual violence remains highly stigmatized in all settings. Even when studies take great 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 school curriculums nor is it discussed much if at all in other forms of manual therapy curriculums globally. One in four women, and one in 17 men have been sexually assaulted. The person seeking massage therapy treatment at your office is typically over 15 years old and acquired this injury by someone (male or female) they knew/know intimately (one in four women, one in 13 men) or by a stranger (one in 11 women, one in four men), while in their own home (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. Nine out of 10 times the person suffering with this injury has not told anyone about it.
There has been some positive change: From 2005 to 2016, the proportion of men experiencing physical violence has almost halved, 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.
The proportion of women experiencing sexual violence has remained steady between 2005 and 2016 (1.6% in 2005 compared to 1.8% in 2016).
The proportion of men who experienced partner violence increased between 0.4% in 2005 and 0.8% in 2016. The proportion of women who experienced partner violence has remained relatively stable between 1.5% in 2005 and 1.7% in 2016.
What does management of this injury look like from a Manual Therapy clinical perspective?
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 manual therapists differ globally so it’s best that you inform yourself of the standards that apply to you.
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 Boyde (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 patient’s personal values and perceptions. It is the responsibility of the health professional to recognize and manage this power imbalance in order to provide patient-centered, 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/manual 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.
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 sexualized/sensitive areas of their body. Communicating with the patient about their personal boundaries, helps to establish boundaries minimizing the occurrence of unintentional or incidental physical contact with those established areas.
As much as we try to empathize 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 patient’s level of comfort. Be aware of their 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.
We all have patients that we have been providing treatment to for many years. You may have known them from when they were single, to just dating, getting married, and during rearing of their children. The therapeutic relationship can become blurred over time and both parties become relaxed around one another. Be mindful that the comfort felt is based on years of professional trust established as part of the therapeutic relationship, not as a close personal friendship.
Informing patients and involving them in decisions about their treatment is essential to providing professional care. Obtaining consent is not just a one-time occurrence that happens at the beginning of an appointment. It is part of an ongoing functional therapeutic relationship based on creating equality and minimizing any power imbalances. Continual communication and confirmation of consent during each treatment ensures that consent is informed and voluntary. Informed consent involves providing the patient with sufficient information about the proposed treatment enabling them to decide if they would like to continue with treatment.
Informed consent involves:
- Engaging in shared decision-making with the patient
- Respecting the patient’s autonomy
- Obtain consent prior to delivery of treatment (including assessment, treatment and re-assessment)
- Addressing the patient’s goal(s) and expectation(s) in seeking treatment
- Monitoring and renewing consent where appropriate throughout treatment
- Discontinue treatment if the patient withdraws consent at any time.
Proposed treatment includes: initial intake of the patient, a treatment plan, assessment, massage therapy during a first session, massage therapy during a subsequent session, and/or home care The therapist should be providing information about:
- Areas of the patient’s body where treatment will be delivered
- The anticipated benefits and possible negative effects of the treatment
- The therapeutic rationale for the proposed treatment
- Options for disrobing
- Options for draping during treatment.
In some cases, you may need to acquire consent from a person considered by law to be a minor/infant. Minor/infant describes a person under the legal age in your part of the world. In Canada, the legal age is 19. Remember that physical and sexual abuse does occur before the age of 15. It is your responsibility as a health care professional to inform yourself of the legal requirements pertaining to consent for providing treatment to a minor. Depending on where you practice, you may be required by law to obtain written informed consent from the parent/guardian. This may be only required at the initial appointment, whenever the treatment plan changes, or it may be required before every appointment.
Today more than ever, manual therapists treat from a biopsychosocial perspective (BPS), recognizing 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, you must remember, it is not your role to help the patient emotionally or psychologically. Some manual therapists may have received some training on the topic of counselling, but this is most likely from an emotional awareness point of view. We need to approach these topics carefully, acknowledging we are not counselors, psychologists or psychiatrists, nor do we receive appropriate education for the treatment of mental health issues or conditions.
So, 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. 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 influence our outcomes and their mental, emotional state. Trust, respect, and comfort of the environment and of the relationship create an opportunity where a patient feels safe. It’s important to remain neutral. You may feel agitated, outraged, judgmental, angry, shameful and guilty. Recognize 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.
Although your instinct may be to respond with a sympathetic “I’m sorry,” avoid saying this or something similar. You as a health care provider 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 you can help them. 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 recognize 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.
Manual 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
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 of your patients’ 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 very 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.
Going forward into part 2, it’s important to reflect on some key information:
The person seeking massage therapy treatment who has/is living with a history of assault, has possibly been doing so since they were about 15 years old. They have come to you with a specific perception and belief of what they think they are about to receive as a treatment and from you as a therapist. It’s important for you to attempt to exceed their expectations and provide the most welcoming, safe and respectful experience you can.
Establishing common terminology, effective communication and setting mutual boundaries helps to diminish vulnerability, any perceived power imbalances within the therapeutic relationship and helps to develop trust.
In part 2 we migrate our focus to the therapists’ perspective. We’ll discuss why you should choose to provide service to people with a history of abuse, and what that might look like. We will look at how you manage the clinical environment and your conversations to improve your mutually desired outcomes, along with suggestions for taking care of yourself as a caregiver.
This is an important subject that rarely is discussed professionally. I hope this influences your practice and improves the quality of life of your patients.
Robert Libbey, RMT, practices full time and instructs LAST courses across Canada. Both live and online courses are accredited for CECs by all Canadian provincial massage therapy regulatory bodies and also the NCBTMB in the U.S. For more information on LAST visit www.lastsite.ca.