The therapist has the power in the client-therapist relationship because they solve the client's problem or need. However, it is important for the therapist not to go beyond the scope of the profession. While the giver may be a massage expert, this does not mean an ability to solve every problem the client has. Whenever a therapist attempts to help the client in areas other than massage, there may be an abuse of power occurring.

I once knew a therapist with a thriving business who one day decided to add prayer to her massage. She would stop in mid massage, praying over her clients without warning. They never complained, they just stopped coming back and her business died and folded. She had overstepped her boundaries, even though she meant well.

Nor should a therapist expect too much from a client. While a therapist must provide empathy for the client, this doesn't mean the therapist can seek empathy. This one-way giving is not unique to massage therapists. It is common in the service industries. The therapist's needs must be met outside of the massage setting.

Because the therapist is engaged in a professional role which does not meet emotional needs, there must be other systems in place to address those personal requirements. These might include supportive co-workers, a satisfactory family life, nonprofessional relationships, and good physical health.

There are non-emotional needs, of course, that the job does meet. Financial well-being and the sense of accomplishment in providing a well needed service are just two of these.

It's important to remember the professional role of a therapist is a separate arena. While it involves nurturing, it's a one-way channel. The therapist must be careful to avoid the mother (quintessential nurturing) or maiden (seeking caring) while on the job.

A simpler example of the pedestal is the number one client complaint—that the therapist talks too much about themselves during the session. This is just another reminder that while the client may put the therapist on the pedestal, the emphasis is really on the client. The therapist is the caterer—not the date—at this party.

Part of the pedestal effect may be explained by transference. Sometimes the client sees the therapist as a blank canvas on which the client draws and colors from their imagination. The client takes “unresolved feelings, needs and issues” from other relationships and places them in the client-therapist relationship. The therapist becomes a substitute for someone or something else.

This is said to occur frequently in massage. The client tends to regress to a child-parent relationship. The client seeks extra attention and time (on and off the job), favors, help with personal problems, and overly friendly mutual physical contact, such as comforting hugs, from the therapist. A client suffering from transference may share too much about her or his personal life. A client may even propose marriage when heavily influenced by this problem. A scary thing about transference is the client may be unaware of the phenomenon, may think this way of dealing with the therapist is appropriate and normal.

When the therapist is unable to respond to this onslaught of unsession-related needs, the client may become disappointed, rejected and, ultimately, angry. But though the therapist practices in an empathetic profession, the unmet needs and issues of transference are not something she or he is professionally trained to handle.

The NCBTMB cautions therapists to “...recognize and limit the impact of transference and counter-transference between the client and the certificant.” The way therapists protect themselves against transference is through boundaries. The limits of the client-therapist relationship must be strictly observed. The therapist is in the room for a particular purpose and not to handle the client’s personal issues. Unlike the client, the therapist is aware (or should be) of transference and can guard against its interfering with the massage.

While outside the scope of this chapter, the therapist also falls prey to transference, then called counter-transference. When a therapist feels inadequate because a client wants to make their next appointment with someone else or lets a client’s argument change a professional decision, the therapist is allowing unresolved needs or wants to surface. These feelings cloud what should be an objective view of the situation. Basically, the client is entitled to the therapist’s professional efforts untainted by any emotional problems or issues the therapist has inside.

Again, being aware of the issue is half the battle. Once the therapist monitors for counter-transference, special effort to maintain boundaries can be made. This will prevent counter-transference from damaging the client-therapist relationship.

In a massage, the client trustfully gives up their body to the therapist and the therapist literally takes charge of it. (It would not be much of a massage otherwise.) This is one of the key reasons therapists hold the balance of power in the client-therapist relationship. One consequence of the therapist being handed this power is that the client may find it difficult to dissent from the therapist's suggestions.

A psychologist/marriage family therapist team makes the extraordinary assertion that “legal theorists regard the therapeutic relationship as having such a strong effect on a person that a client in a therapeutic relationship is considered unable to give informed consent, in much the same way a child cannot do so.”

The NCBTMB disagrees with this conclusion, requiring the therapist to obtain the client's consent: “The certified practitioner will obtain and record the informed consent of the client, or client's advocate, before providing treatment” (Code of Ethics X). Standard VI also requires informed consent before massaging various parts of the body, including the breasts.

Nonetheless, the NCBTMB is aware of some disparity between the roles of therapist and client. Therefore the NCBTMB cautions the therapist against conflicts of interest, requires one to act in the best interests of the client, and prohibits gifts from the client in certain categories (Code of Ethics XV, XVI).

Even if the psychological insight is overstated, it is useful as a reminder that the therapist needs to be careful when communicating with the client. Opportunities should be created for the client to express concerns or preferences. One way this can be done is by asking questions, “Is that OK with you?” This gives the client the chance to reply, “No, I'd prefer not to have the hot stone option” or “No, please don’t pray over me.” Likewise, “If anything is uncomfortable let me know” and the usual “do you have any concerns or questions before we get started?”

Asking questions implies listening to the answers. Have you ever had the experience of going through a fast food drive-through? “Do you want ketchup?” “No.” When you open the bag, there are five or six packets of ketchup. Why did the cashier ask the question?

It's possible to ask too many questions. It takes 6 questions and answers to get through a Burger King drive-through. That includes two variants of “Does that complete your order?” It would be better to ask fewer questions that are more personally tailored to the client. That's easier to do in the massage setting.

The client’s removal of clothing deepens the power differential. So you may want to ask if the client has any concerns about the massage before she or he disrobes. If they have any reservations about the clothing, they will bring it up at that time. A standing person generally has a position of power over a sitting one. This may be another reason to get input before the session begins. Other techniques which help create a safe environment for the client are:

Use plain language instead of technical language or medical jargon. Something which is very plain to you, your friends and fellow workers might be complete gibberish to the engineer in the massage room. Imagine a client telling you about aircraft wiring—you'd want to hear about it (if at all) in plain words.

Sit down (instead of standing) to achieve eye level when a client is flat on the table

Use visual models to illustrate a procedure

Smile

A more aggressive way to put a client at ease, thus lessening the reluctance to object, is to use praise. If the therapist can honestly compliment the client—“You look sharp today”—this may reduce barriers. Friendliness can achieve a similar result. If the client has discussed his or her job in the past, an inquiry (“They still working you those crazy hours?”) might help. If you’re glad to see them, say so.

Many therapists feel that the actual massage should be given in silence. So these techniques are best done before the session begins. If they really need to talk, listen. Then start out with a few minutes of response, gradually slowing your speech, and then simply drop out in mid sentence. It is their cue talk is over and they’re relieved to let it go and enjoy the massage.

Several authors suggest that a client giving gifts to the therapist indicates a power imbalance. (The alternative is it means a nice client!) Still, a sequence of gifts probably suggests complications. It may be appropriate to gently return to a strictly business relationship. If a multidimensional situation occurs (sometimes called a dual relationship), the therapist should be alert to the ethical and legal dangers there, which are discussed more fully in the next chapter.

The creation of an environment where it's safe for the client to object may take some effort. The therapist does not always feel like, “Isn’t this nice that I get to massage you.” If the therapist displays any of her or his personal angst, this becomes a barrier. Any sign of distraction may make the client shut down and not offer any input.

However, we should not have to act bubbly and joyful when it is not there. For the massage therapist, it is merely about setting their personal problems aside momentarily and focusing on someone else, the client. They need only make the client feel welcome. This is where a smile is helpful. The client is then less intimidated and can give consent or object appropriately.

Once again, as noted in the last chapter, psychologically, the therapist is giving far more than taking.

Most of us probably know of at least one therapist who has dated a client. It can almost make sense to do this. Perhaps the therapist and client are well matched. Perhaps they get to talking and sparks fly. Perhaps the client is the therapist’s one and only –grab it while you can- soul mate sent by the universe. So what’s wrong with dating a client?

Maybe nothing.

Maybe a lot.

The NCBTMB cautions against multi-dimensional relationships where the therapist and client interact outside of the client-therapist paradigm. The concern is different roles inside and outside the room might either impair the therapist's judgment while massaging or tempt the therapist to exploit the client. In other words, what happens in the room can have no effect on what happens outside or visa versa.

Warning signs that a personal relationship may be interfering with the professional one include

Finding it hard to ask for the fee

Willingness to bend policies on the client being late or not showing

Breaking rules for the client

Treating the client significantly differently than other clients

Giving advice

Fostering client's dependence upon therapist

If nothing else, multi-dimensional relationships can be confusing. The client gets “unconditional positive regard” in the session. The focus is all on the client. This feeling may be very attractive to the client—who wouldn’t like that? But moving the relationship to friendship will change that dynamic. Here the regard should be mutual and the focus shared between two people.

However, even if no one is harmed, there are ways multi-dimensional relationships can lead to trouble. Suppose the therapist and client hit it off really well and intimacy is on the horizon. Here both NCBTMB and at least one state throw on the brakes. The NCBTMB says the client-therapist relationship must end and a celibate period of 6 months must expire before intimacy can begin. (The Standard is silent on whether kissing is allowed. The no-sex clause of the psychologists' code of ethics, on the other hand, prohibits kissing.)

Greene and Goodrich-Dunn in their The Psychology of the Body write “the therapist must formally terminate the massage relationship with that person if they want to begin dating—whether or not the therapist anticipates sexual contact will occur” (page 74). This directive is apparently based on their opinions as psychologist and marriage family therapist respectively. They cite no law or regulation to support it. The stance goes far beyond the NCBTMB requirement. Another author suggests that all dating between therapist and client is prohibited. Again, this exceeds the NCBTMB’s ethics.

Be aware that states may also have laws which go farther than the NCBTMB. Washington reportedly has a law banning the therapist from dating a client for 2 years after the last session. Such a statute is probably vulnerable to a court challenge on constitutional grounds. For one thing, there may be a vagueness issue. How does one know one is violating the law? Is a shared coffee at Starbucks a date? But who can afford the attorney to fight it?

Minnesota had a law forbidding a massage therapist from having sexual contact with a former client for two years after the client received their last treatment. A therapist of 18 years' experience began an intimate relationship with a former client several months after stopping treatment, later marrying him.

A year after the marriage, the Department of Health, in response to a complaint filed by the husband's ex-wife, began a 3 years investigation into the alleged violation of the two years limit. The state “subjected her to an intrusive interrogation and required her to undergo a psychological examination with a state appointed psychologist, at her own expense.” The therapist was disciplined by the agency in 2007.

The agency declined to rule on whether the law was unconstitutional. The discipline was ultimately revoked shortly after the ACLU agreed to represent the therapist. Minnesota repealed the law the next year, probably at least in part due to this case's publicity.

The NCBTMB does enforce its Standards and recent violations are reported on its web site. Such sanctions have also been reported in their newsletter, NCBConnection.

One web article cites husband/wife as an example of a client-therapist multidimensional relationship. However, it is clear from NCBTMB Standard of Practice VI ( a ) that the therapist part of a non-celibate married couple cannot have the marriage partner as a client.

Another state adds a wrinkle. Florida prohibits discussion in the massage room of any off-site sexual tryst. As long as one was following the NCBTMB rule (wait), the occasion probably would not arise. But in Florida, even planning for the future activity is not allowed inside the massage room.

Warren Buffett’s bright-line application might explain some of the rules. (A bright-line rule is a rule whose objective is to leave no room for any other interpretation.) Warren Buffett became a large stockholder in Salomon Brothers, a Wall Street investment bank. Salomon was indicted for submitting false bids to the US Treasury in 1990 and 1991. To save the company, Buffett took over its management. (It is said in negotiation with the government, the federal officials had lots of people and calculators crunching numbers while Buffett did the figuring in his head.)

One of the ways Buffett caused Salomon Brothers to survive where two previous indicted Wall Street firms died was his bright-line idea. Certain trading transactions were legal but close to shady (and Salomon was famous for them). While the company could do those, under Buffett it would stay even farther back from the line between ok and not ok. Under Buffett, there would be a wide margin of safety in the company's ethical actions. Perhaps it is the intent for some states to achieve a similar bright-line or safety zone in establishing long lengths of time when a therapist cannot date a former client. They may want a great buffer zone between the profession and the therapist’s intimate relationships.

Also, the barrier that these state laws and the NCBTMB code of ethics provide is an opportunity to allow transference to diminish, if that issue was present. We have discussed therapists having power in the client-therapist relationship, how to make it easy for the client to maintain their space and caution in a romantic involvement. I hope you find this information helpful in your massage practice and with other relationships as well.