Massage Therapy and Informed Verbal Consent

What is Informed (Verbal) Consent, and why is it necessary for a massage therapy assessment or treatment?

Ignorance is NOT bliss in the massage therapy profession.

I remember my first few weeks of massage therapy school – making new friends, touching people I didn’t know, and the overwhelming amount of information involved, not the least of which was trying to wrap my head around informed verbal consent.(also known as informed consent) I was more “fortunate” than most of my peers, because I had actually had an awful first experience with massage therapy which, as a student and later a therapist, instilled in me the need to advise my clients of what to expect during treatment.

I swear that the massage therapist who treated me for my very first treatment could have been the poster child for what NOT to do to a new client. He didn’t tell me what to expect, he used pressure so deep I wanted to cry, and he talked about how much he hated his ex girlfriend. Wow, did I ever feel vulnerable, and had I known I could discontinue the treatment I would have. With a first experience like that it’s amazing that I ever went to another massage therapist, let alone became one.

So basically, the definition of informed (verbal) consent is: obtaining client agreement to the impending treatment based on full disclosure by the therapist as to what the client should expect before, during and after the treatment. The client consents on the treatment with full knowledge of what’s going on.

Why is Informed Verbal Consent so important?

There are a few purposes to obtaining informed verbal consent, not the least of which is that the client has a right to know what is going to happen – this is not rocket science. Would you buy a car or a house without knowing the specifications? Probably not. And certainly where a client’s health is concerned, he or she must be presented with sufficient information to make an informed decision concerning the treatment, and then give you permission to do it. Informed consent is about empowering the client through knowledge and trust. This knowledge and empowerment protects the best interests of the client. After all, it shouldn’t take too much imagination to remember how it feels to be lying in a very vulnerable position, mostly undressed, in a closed off room with just you and a complete stranger.

Informed consent helps establish trust between the therapist and the client – which is the foundation of a productive therapeutic relationship. When you say to expect XYZ and the client receives XYZ, then he or she knows you are a person of your word. If a client feels pain during treatment, and you stop whatever you’re doing when you are asked, the client understands that you are there to look out for her best interest.

Informed verbal consent protects the therapist, too. When therapists take the time to advise a client on the various points of informed consent, he or she is ensuring that whatever happens will not alarm, scare or cause undue pain to a client. A therapist should document that he or she received permission to continue with the treatment for each treatment – a simple IVC next to the treatment date should suffice. And therapists should remember that any time any new area or body part is worked on, or different treatment modality is used, consent must be obtained from the client.

What should be included in basic Informed Verbal Consent?

1) The nature of the treatment – tell the client what body parts you’ll be working on, as well as how much pressure you’ll be using. I like to explain to my clients how the will be undraped (uncovered) and that the only part of the body that will be uncovered is the part that I am working on.

I also tell clients to undress to their comfort levels, though it is more effective if I work directly on the skin. If my new client looks unsure, I usually tell him he can leave their underwear on, and I will leave the room so he can undress and get on the table in privacy. I also make sure before I do leave the room that my client doesn’t need any assistance with either.

2) The benefits of treatment – If your client comes in for a relaxation treatment, then a benefit should be that she will be more relaxed and may sleep better. If a person comes in specifically for treatment of an injury, then the benefit of treatment should be the same as the treatment goals – i.e. decreased pain, increased mobility etc.

3) What are the risks and side effects of the treatment? A risk is generally more long term in nature, whereas a side effect is more immediate. For example, a side effect is that a client may be a little “woozy” when he or she gets off of the table, but a risk of a more vigourous treatment is that your client may be a little sore the next day.

4) Advise your client of alternatives to treatment. This is described in the context of massage therapy – for example, if a client presents with scar tissue, you can advise your client that you will be performing Frictions (aka friction massage therapy). In the event that this is too much for your client to tolerate, you should advise that an alternative is to do petrissage and deep kneading to the area.

5) What are the consequences of not having treatment? If a client doesn’t have treatment, then he or she can expect to NOT achieve the goals and aims of treatment and not improve. So, if a client presents with limited range of motion of the right shoulder, and opts out of treatment designed to increase the ROM, then a consequence of not getting the treatment would be no improvement of shoulder range of motion.

6) The client ALWAYS has the right to stop or modify the treatment. Period.

Sometimes clients look a little confused when I say this, so I tell them “if anything makes you uncomfortable in any way, please let me know and I’ll stop what I’m doing. If you feel that you have had enough of the treatment, then we can finish.”

7) Ask the client if she understands what you have told her AND if she has any questions. This presents her with the opportunity to speak up if she is unsure about anything.

8 ) Ask the client if you have her permission to proceed with the treatment as you have described it. This might seem obvious, but you don’t ever want to get caught on a technicality. This gives her the ability to “Yes” or “No” the treatment, enabling you to carry on with confidence.

This is basic informed consent that every therapist should use when treating a new client.

For those candidates preparing for the College of Massage Therapists’ of Ontario (CMTO) certification exams (i.e. the MCQ and OSCE exam), informed consent is a little more involved. (OSCE = Objectively Structured Clinical Evaluation).

Though informed verbal consent (aka informed consent) may seem tedious, once you establish your own way of doing it, it should become second nature to you. And remember, it serves both you and your clients, and builds the therapeutic relationship on a foundation of trust.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy Client Rights

Question: At my first massage therapy appointment, I asked the therapist some questions concerning the treatment. I found her to be evasive, and a little impatient with me. As a client, don’t I have right to know what is going to happen?

Yes, you certainly do. Here is a list of some of the rights you have as a massage therapy client.

1) Get some advice on how to find a licensed massage therapist – you have the right to know what qualifications your therapist holds. Ask where he or she went to school, to what professional association or college he or she belongs, and if they have any additional training. And remember, don’t discount a therapist just because he or she has recently graduated – there are some really fantastic new therapists who begin their careers every year.

2) You have the right to be informed about what to expect during and after a treatment. This is known as Informed Verbal Consent and is a set of statements designed to make the client aware of expectations concerning the treatment, as well as his or her rights as a client. Informed verbal consent goes above and beyond some typical quesitons, such as “do I have to take off all of my clothes” or “is it normal for the treatment to hurt?”. For any Canadian massage therapist who practices in compliance with the CMTO standards, informed verbal consent is mandatory before assessment or treatment begins and provides the client an opportunity to ask questions.

I have been disappointed to hear from clients who, when they’ve seen me for the first time, tell me that no
massage therapist has ever gone over informed consent with them. I cannot speak for students educated in the US, but Canadian massage therapists should really know better. We are obligated to advise clients what is going to happen. Period.

3) You have the right to receive treatment in a safe and hygienic setting. This is everything from the entryway of the clinic, to the bathroom and waiting facilities, and most certainly extends to the linens, towels etc that come into direct contact with the client. Linens should only be used with one client, and anything that comes into contact with the client’s skin needs to be washed after each use.

Equipment should also be safe, clean and in good repair, and there should be nothing on the floor on which a client could trip or lose footing. If the linen looks dirty, the equipment is wobbly or obviously broken or the
clinic is obviously unhygienic, you have every right to turn around and leave. (and I suggest you do)

4) You have the right to receive treatment from a massage therapist who is clean and hygienic herself. If there appears to be “hygiene” issues, you have the right to voice your concern and leave, you are not obligated to receive a treatment from someone who makes you uncomfortable or is unclean. I can pretty much guarantee that if a therapist doesn’t pay attention to his or her personal hygiene, that the linen and equipment will be lacking in this department as well.

5) You have the right to refuse treatment from a therapist who is ill. Your therapist should advise you in advance (preferably) or when you arrive if he or she isn’t feeling well or has a cold, and should not charge you if you decide to postpone treatment until he or she is feeling better.

6) You have the right to stop or modify the treatment at any time. If you are in a lot of pain, or for ANY reason you are uncomfortable, you do have the right to tell the therapist you want to stop. The therapist should respect your request and allow you to get off of the table and get dressed in privacy.

A massage therapists needs to receive informed verbal consent from you if he or she is going to be working in a “sensitive area” – for example, breast massage is not typically performed unless it is clinically indicated by your presentation or health history. Either way, it is always your choice whether or not to receive or refuse treatment.

If you feel that any inappropriate touching or remarks have been made, whether of a sexual nature or not, you have the right to report the therapist to his or her professional association. Please do so, as therapists who violate massage therapy professional standards and a position of trust do not deserve to call themselves massage therapists. In addition, therapists who engage in sexual misconduct commit a crime for which there should be repercussions.

7) You have the right to be advised of the massage treatment fees when you book your appointment. You also have the right to not be subjected to “upselling” or pressure sales tactics. The College of Massage Therapists of Ontario, and any provincial massage therapy association who follows their guidelines, require therapists and clinics to post their fees in a visible space for all clients to see. Anyone who doesn’t do this is in violation of the policy.

8 ) You have the right to know what products are being used on you. If you have a health issue such as an allergy, or an objection (for example) to products tested on animals, you need to ask this when you are booking your appointment. Remember, though, that a therapist also has the right to know of any issues in advance so he or she can be honest with you, whether or not he can accommodate your request.

9) You have the right to receive your treatment on time. Occasionally a therapist may run a little behind, for example, if the previous client was late; however, if this is habitual, then it shows an issue with your therapist’s time management. While the duration of the appointment will probably be reduced if YOU are late, if your therapist is late, you should receive your full treatment.

If the therapist is so late as to keep you from other commitments, you have the right to leave without incurring a charge. After all, you were ready at the agreed upon time.

The above points are some of your rights, but do realize that a therapeutic relationship between a massage therapist and client is based on mutual respect. If for any reason you don’t feel the situation is working out for you, please consider finding a therapist with whom you have a “good fit”.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy – is the customer always right? (Part 2)

As a follow up to my post a few days ago – “Massage Therapy – Health Profession or Customer Service? “, I’m pretty sure that you know where I’m going with this.

At the forefront of my thoughts when talking about massage therapists and customer service (as in “is the customer always right?”) is that ultimately because the health and well-being of our clients is our responsibility during treatment, it supersedes the customer service aspect of the profession.

That being said, for the most part therapists will very seldom encounter situations where they have to pull out their “health professional first” hat and decline a customer request. Ultimately, if what you do as a massage therapist during treatment presents a risk of harm to the client, then you need to stick to your decision if you decide to refuse or alter a treatment. Cases where this might happen:

1) Your client refuses to fill out a health history form.

This is pretty basic – I won’t treat a client if I don’t know what is going on with his or her health. End of story. The client may say “my health is fine”, but really, what does fine mean? “Fine” is different between members of the general public and health professionals, and most people, as previously discussed, don’t have the knowledge to have any kind of discernment when it comes to therapeutic techniques. Can you imagine getting a severe diabetic client who wants scar tissue work done, or a client with a history of TIA (transient ischemic attack) or stroke who wants to “work the kinks out” of his or her neck. These are two conditions which require precaution when treating, and for which certain techniques are contraindicated.

How to approach this? Tell your client that there are often conditions which require a treatment to be modified, or that treatment may even be unsuitable. You as a therapist are unable to plan and deliver the best treatment possible without this health information. You can also remind them that the health history is fully confidential and their information will not be disclosed. If they are really sticky, you can quite simply say that you are not willing to be liable for any injury caused because you weren’t informed, and that you will not treat them. (

*Any time you have this type of conversation with a client, you need to keep an incident report of it, even if you didn’t end up treating them. This will cover all of your bases in the event that the client feels like accusing you of being unprofessional. (Personally, I haven’t ever heard of this, but it’s better to be safe than sorry))

2) Your (new) client is adamant about getting “really deep pressure”.

This is actually quite common, and I have had to finesse my way around this several times. John (or Jane) Doe may say “My therapist uses really deep pressure, it’s the only thing that works for me.” and you start treating and suddenly your client finds your moderate pressure too much. Why is this? It’s because everything is relative and subjective – what is deep to one person is too light for another, or too much. What feels good to one client may be excruciatingly painful to another. Your colleague’s pressure might be considered deep, but relative to whom? This is a situation where being creative and flexible really comes in handy.

The fact of the matter is that it is always better to use the first appointment as a trial run, so to speak. I’m not saying to just put oil or gel on your client and spread it around so that he or she gets no benefit – that would just be annoying and I can pretty much guarantee they wouldn’t rebook. What I’m suggesting is that you use moderate pressure (I love that word) and check in frequently – and don’t forget to advise your client that he or she may feel a bit sore the next day (informed verbal consent should have done even before getting them on the table anyway).

How to approach this? You can say to your client “Since I haven’t seen you before, I’m not sure how you are going to react to the treatment, or my pressure. What I usually do is use moderate but firm pressure during the first appointment, and then if you react well to the treatment, I’ll use more pressure next time. This is to prevent you from getting really sore in case I use too much pressure – you might not realize this until it’s too late, and you could be sore for days.” This is usually sufficient, but if the client argues further, I will say that I rarely have complaints about my pressure being too light, or my clients being too sore (but this my experience, you’ll have to figure out your own explanation )

3) Your client shows up with a bad cough, fever or chills

Many clients will show up when they are getting ill with acute bronchitis or flu-like symptoms because “everything hurts” and they think that a massage will make them feel better. At this point you should ask them if you can call a cab for them and rebook when they are feeling better. Don’t take “no” for an answer. Seriously.

It’s not just that treating someone with an acute or systemic infection will be really bad for them (after all, they body is already trying to fight off a virus or bacteria – increasing circulation won’t help them at this point) – you are also putting yourself, other clients and your clinic at risk of infection. Remember the SARS epidemic (Sudden Acute Respiratory Syndrome) in Ontario, Canada in 2003? It was absolute chaos for a while, and massage therapists all over Ontario received guidelines from the CMTO concerning protocol in preventing the spread of infection. The last thing you need is to be remembered as the therapist or clinic that was an incubator for infection – even if it wasn’t your fault.

What I would suggest that you say to a client in these or similar events is something like this “Since you are not feeling well, I believe that it is in your best interest to go home and rest until you get better, the massage won’t help you and may make you worse. Let your body deal with the infection, and then call me in a week or so to rebook.

The bottom line is this, a client will 99% of the time appreciate that you are making his or her health as a priority. If a client cannot see reason in your commitment to her health or well-being, then you may risk losing her business. But, in my experience, I would rather have 20 clients who respected my knowledge and professional judgement than 40 who did not.

For more information on building and maintaining a practice, check out a fantastic, tried and true resource – Business Mastery: A Guide for Creating a Fulfilling, Thriving Business and Keeping it Successful

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

Massage Therapy – Health Profession or Customer Service? part 1

Nine years ago when I graduated from my Massage Therapy Diploma program, I was so excited to start practicing – after all, I had toiled for 2 years to earn not only my diploma, but also to earn my Registered Massage Therapist designation through the College of Massage Therapists of Ontario, which I did 4 weeks after graduating.

For those not familiar with massage therapy regulation in Canada, Ontario is one of 3 provinces in which massage therapy is a Regulated Health Profession, and a massage therapist must have passed College of Massage Therapists of Ontario (CMTO) Board exams. The purpose of the professional college is the protection of the public and maintenance of the integrity of professionals by establishing standards and quality assurance guidelines. By being a member of this professional college, I take great care to uphold the standards of the college and do my best to serve my clients in a responsible and ethical way. This however, can sometimes be easier said than done.

What I quickly found out after graduating is that no amount of instruction or coaching can replace real-life
experience, and I’m sure that is true of everything in life. For those of us who do have some customer service experience, we quickly found out that that massage therapists hold a unique position in an industry which has one foot in service, and the other in health care.

People outside of the profession may wonder why this “foot in both worlds” makes a difference to the practice of massage therapy. After 9 years of practice, I have learned that it all boils down to this: being a health-care practitioner obliges us to caring for client health first and foremost, with the customer service aspect falling a distant second, even if it means potentially losing the almighty (and necessary) business dollar.

In this industry, is the client “always right”?

No, absolutely not. And before customer service gurus go crazy at this statement, let me tell you why.

The ultimate responsibility of a massage therapist is to improve or enhance the health and functionality of a client within a therapeutic relationship of mutual trust and respect. Add to that privacy and confidentiality issues, and one can understand the depth of this responsibility. Since most clients coming in to see massage therapists have little to no knowledge of human anatomy and physiology, and even less of how massage therapy can affect the human body, they often don’t have the level of discernment necessary to dictate to a therapist what is needed.

How many times has a client asked me “Why are you looking at my neck, the pain I have is in my elbow?” Questions such as this are very valid, and give the massage therapy community the perfect opportunity to educate our clients one-on-one about the profession and about their own bodies. How else would a client know that irritated nerves in the cervical spine can affect sensory or motor function of the upper limb? The only way many clients ever learn anything is by spending time with a health professional who takes the time to educate them. Massage therapists are in the position of privilege and should take advantage of the opportunity to educate their clients.

Does this mean that every therapist takes the time to educate their clients? No, and sometimes it may not be necessary. What I would like to instill in new therapists is that while clients might not actually care why or how a certain symptom comes about, this lack of knowledge or caring doesn’t give a client by default the right to dictate to a therapist what needs to be done.

Case in point: I recall on one occasion when speaking with a potential client on the phone, she became very belligerent when she said she would refuse to fill out a health history form, and I then had to tell her that I would not be able to treat her. She proceeded to tell me that “it is absolutely none of your business what my health issues are or have been”, to which I replied “It is my business, as there may be an issue which may adversely affect your health if I treat you without being aware of it.”

Let’s just say that that conversation did end with my losing a potential client, and that was perfectly fine. I
had the confidence at that point to place the responsibility I had as a therapist above her desire to dictate how I perform my job. I can also tell you this – I would not want to be in a defendant’s chair in a lawsuit where I treated a client without adequate knowledge of her health, and she ended up getting hurt. If such were the case, and I lost the suit, not only could I end up paying a lot of money, I could lose my profession.

Part 2 to follow: Massage therapy – is the customer always right?

For a great read on the practice and business of massage therapy, check out Business Mastery by Cherie Sohnen-Moe.

© Copyright 2008-2009
Jodi Forsythe
www.whymassagetherapy.com
All Rights Reserved.

My first massage therapy treatment – is it normal to be sore?

A frequent question that I hear from new clients is “My (Aunt Betty) had a massage, and she was so sore she could hardly move the next day. Will I be sore, too?”

We have all heard horror stories about the therapist who had bone-crushing pressure and didn’t listen when asked to back off. I’ve heard another client of mine tell me that when she asked her (previous) therapist to lighten up, the response was “I’m not using a lot of pressure, and it has to hurt to work.”

I’m hear to tell you that this is NOT the case – and that massage can be very effective when applied with moderate pressure. It takes intuition, experience and time to learn just how much pressure the tissue (and a client) can take, and this amount of time varies from therapist to therapist. I’d also like to add that your massage therapist should never brush off indications of pain – as a massage therapist myself I wouldn’t go to someone else who seemed to have no regard for my pain tolerance.

Does Massage Therapy “have” to hurt?

Let me put it this way – it is normal, especially if you’ve never had a therapeutic massage before, for muscles to feel a little stiff or sore after a treatment. I think of it much the same as working out, after all, muscle tissue is being manipulated and worked, so a little discomfort is not unusual. If a person has never been to the gym before, it is not a good idea to ask him or her to leg press 100lbs, any more than it is wise for a massage therapist to put all of his or her weight behind their elbow as they perform muscle stripping on the back of a new client. Either way you look at it, if you’ve never had a treatment before, you have NO idea how your body will react or how much pressure is “enough”, and the therapist really has NO idea what “deep” means to a client. Depth of pressure is very subjective, and pain is a subjective response – what hurts to client A might feel great to client B – there is just no way to tell.

It didn’t take me long to learn that the size of the client has absolutely no bearing on how much pressure he or she can take. I have been able to use deep pressure effectively and painlessly with some very small women, and much less pressure with some very muscular and burly men. My approach is now this – when I first start treating a new client, I use broad, firm pressure, and resist the urge to “go deeper” even at their request. What I tell them before they get on the table is that the first treatment I will be very moderate because I’m not sure of how they will react – they may feel great in the days following the treatment, in which case next time I will go deeper. (here’s a question to consider – does the saying “the customer is always right” apply in this scenario?) If my client feels not so great in the days following a treatment, then I know I need to do something different and will adapt subsequent treatments to suit my client.

In a nutshell, what I would tell a client is that while some discomfort is normal, your request to a therapist to lessen the pressure should never be ignored or brushed off. You are paying for a treatment, and you always have the right to stop or modify what is happening (an FYI in case your therapist doesn’t tell you this.) If you are a therapist, especially a new one, take the time to listen to your client and his or her muscle tissue – not everyone is created the same, and it does take time to learn how much is “enough”. Also, be sure to advise your client of any possible side effects or risks associated with the treatment (informed verbal consent), and let him or her decide what is right for their body.