Boundaries are important to establishing the therapeutic relationship. They are also paramount for establishing professional and ethical ones. Boundaries are defined as “limits between acceptable and unacceptable behavior.” As a massage therapist, you agree to boundaries in a variety of ways, from ethical standards to the regulatory laws that guide your practice.
Therapeutic boundaries not only help ensure the needs and goals of an individual client are being met, but they also serve the professional interest of massage therapists collectively by providing guidelines that establish the scope of our therapeutic practice and affect client expectations as a whole.
Here are a few examples of areas in which boundaries are important for massage therapists:
- Physical Boundaries: These boundaries demarcate everything from proper draping techniques and respect for each client’s level of modesty to understanding client preferences or any contraindication.
- Emotional Boundaries: Massage therapists are limited by scope of practice and need to feel willing and confident to refer a client to a mental health professional when a client is in need of psychological support you can’t provide. Therapists also need to have self awareness if they are facing emotional challenges that require them to distance themselves from a situation.
- Professional Boundaries: While broad in scope, these help serve the betterment of industry and affect both public and client perceptions of the massage therapy profession. These can encompass how you represent your abilities and competencies, how present you are during treatment (e.g., not being intoxicated), observing laws and regulations, your hygiene, professional attire, communication and client education skills, and recordkeeping.
- Social Boundaries: The line between personal and professional also involves social boundaries. Social relationships are complex with many levels of interaction. For example, clients may often feel awkward in the silence of the treatment room and feel the need to “chit-chat” in ways that do not fit into their treatment plan; you may remind clients that silence is OK. Also, in the day and age of social media, social boundaries also may need to be reflected on as you manage the lines of your social networking and privacy settings.
The power differential refers to the role difference between a therapist and client that results in a vulnerability on the part of the client, and the power differential is implicated in all levels of therapeutic boundaries. Therapeutic boundaries exist to control the power differential between a therapist and a client and to allow for a safe connection based on serving the clients’ needs, including their needs for confidentiality.
Two types of boundary issues are commonly recognized: boundary crossings and boundary violations.
Of the two, boundary violations are unequivocally recognized as harmful and exploitative. A boundary violation occurs when a therapist crosses the line of decency and integrity and misuses his/her power to exploit a client for the therapist’s own benefit. Such may involve exploitative business (e.g., operating outside of one’s scope of practice) or sexual violations. For more resources on sexuality and boundary issues, you may refer to this resource on guidelines for safe and ethical conduct by Dr. Ben Benjamin. Boundary violations are always unethical and frequently illegal.
Boundary crossings are less clear and generally refer to situations in which there has been a deviation from classical therapeutic activity, perhaps even in a way that is supportive of the therapy itself. Examples include hugging clients when they leave their sessions, gift giving, “out-of-office” contact, and dual relationships. Boundary crossings are ethical and professional gray zones because they may be harmless and non-exploitive. Both boundary crossings and boundary violations may arise from the therapist or from the client.
Dual relationships are always boundary crossings but not necessarily boundary violations. Dual relationships refer to situations where two or more connections exist between a therapist and a client, for example, when a client is also a student, friend, employee or business associate of the client. When a dual relationship is exploitative, it is a boundary violation. I’ve been losing my ability to have normal sex very gradually over several years. Now I know that I should have talked to my MD the very moment I found myself unable to satisfy my wife. I decided to go to my doctor only when my illness became way too serious to ignore. He prescribed me Cialis and it helps with most of the symptoms. However, I have to take it regularly.
Boundary crossings may occur without dual relationships, such as extending the therapeutic hour when needed, self-disclosure, or bartering.
While dual relationships may be sometimes unavoidable, massage therapists need to be aware of the potential of harm that can arise from them, especially if there is a conflict of interest. A conflict of interest refers to a situation in which regard for one duty leads to disregard of another or might reasonably be expected to do so.
Slippery Slope Concept
The argument of a slippery slope claims that boundary crossings inevitably lead to boundary violations. This argument refers to the idea that the failure to strictly adhere to the rigid boundaries will ultimately foster exploitative, harmful relationships through a snowball effect, and as such, boundary crossings should be avoided or minimized.
In practice, both dual relationships and boundary crossings may occur. For example, individuals who live in small communities may find some level of dual relationship to be unavoidable. Also, boundary crossings, such as disclosures or gift-giving, may at some level enhance a therapeutic alliance and treatment outcomes, though therapists need to evaluate this in light of the slippery slope concept.
Further, while it is recognized that in light of the power differential of the therapist-client relationship, it is the responsibility of the therapist to avoid situations that may lead to boundary violations. The therapeutic boundary requires striking a balance between, on the one hand, recognizing the therapist’s responsibility to establish professional boundaries and respect whatever unique boundaries a client may have and, on the other hand, the recognition that careful therapists will still make mistakes with their clients’ boundaries. For example, a massage therapist may make allowances for a specific client who is regularly late for appointments and realize that this is not conducive to the demands of the practice.
Transference & Countertransference
Transference occurs when the client makes the professional relationship personal. The client may transfer feelings about a third-party onto their therapist. This may happen if a client brings you additional gifts, asks to see you for lunch, requests extra time, or contacts you outside the office.
Countertransference occurs when the therapist transfers onto the client their own issues from the past. It also occurs when the professional is unable to separate the therapeutic relationship from their personal feelings surrounding the client. The therapist is supposed to learn to recognize countertransference. Examples of countertransference for massage therapists may include:
- Feeling inadequate if the client is not making process
- Experiencing excessive thoughts about the client’s problems after the session ends
- Playing a helper or fixer role
- Thinking you can relieve the client’s pain when you are facilitating healing
- Thinking that only you can fix the problem and that you have all the right answers
While an absolutist position on therapeutic boundaries cannot be taken, clear and effective treatment boundaries can help massage therapists and their clients, as well as society, by defining the therapeutic territory and allowing the best interest of the clients to be the primary focus. Effective therapeutic boundaries also create a safe place for clients to heal and enhance public perceptions and expectations about the massage profession.