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Covering massage fundamentals, techniques, and anatomy and physiology, Susan Salvo’s Massage Therapy: Principles and Practice, 5th Edition brings a whole new meaning to the word ‘comprehensive.’ This student-friendly text boasts more than 700 illustrations and expanded sections on  neuroscience, research, and special populations, plus new line drawings in the kinesiology chapter of origins and insertions that match the painted skeletons found in most classrooms. It makes the essential principles of massage therapy more approachable and prepares you for success in class, on licensing and board certification exams, and in a wide range of therapeutic practice settings.

  • Clear, straightforward approach simplifies complex content for easier understanding.
  • Complete anatomy and physiology section, in addition to material on techniques and foundations, gives you all the information you need in just one book.
  • Certification Practice Exam on Evolve mimics the major certification exams in format and content, builds confidence, and helps increase pass rates.
  • Over 700 high-quality illustrations, including line drawings and halftones, clarify difficult concepts in vibrant detail.
  • Case studies challenge you to think critically and apply your understanding to realistic scenarios, foster open-mindedness, and stimulate dialogue.
  • Profile boxes provide an inspirational, real-world perspective on massage practice from some of the most respected authorities in massage and bodywork.
  • Clinical Massage chapter focuses on massage in clinical settings like hospitals, nursing homes, and medical offices to broaden your career potential.
  • Two business chapters loaded with skills to make you more marketable and better prepared for today's competitive job market.
  • Video icons refer you to the Evolve site featuring about 120 minutes of video covering techniques, routines, client interaction sequences, and case studies that facilitate the learning process and the practical application of the material. 
  • Evolve icons listed in each chapter encourage you to go beyond the lecture and reading assignments and learn more on the Evolve site.
  • Evolve boxes at the end of each chapter list Chapter Extras found on Evolve that reinforce concepts learned in the chapter.



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Published 25 March 2015
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EAN13 9780323352390
Language English
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Principles and Practice
Co-Director and Instructor
Louisiana Institute of Massage Therapy
Lake Charles, LouisianaTable of Contents
Cover image
Title page
Unit One Foundations for Practice, Basic and Complementary Methods, and
Business Practices
Chapter 1 History of Massage Therapy
The Prehistoric World
The Ancient World
The Middle Ages
The European Renaissance and Enlightenment
The Modern Era
The Esalen Institute
Massage Professional Organizations and AssociationsHuman Trafficking: a Dark Chapter in Massage History
Activities and Assessments
Chapter 2 The Therapeutic Relationship
The Therapeutic Relationship
Types of Boundaries
Transference and Countertransference
Boundary Management
Dual Relationships
Sexual Misconduct
Activities and Assessments
Chapter 3 Tools of the Trade
Massage Tables
Massage Table Features
Table Fabric
Table and Chair Accessories
Massage Linens
Choosing a Lubricant
Massage Room Environment
Safety GuidelinesBibliography
Activities and Assessments
Chapter 4 Self-Care: Physical Activity, Nutrition, and Stress Management
Massage Therapists are Athletes
Regular Physical Activity
Stress Management
Wellness Model
Activities and Assessments
Chapter 5 Research Literacy and Massage Therapy
What is Research?
Scientific Method
Periodicals and Research
Anatomy of a Research Article
Types of Research
Evidence-Based Practice
Research and the Massage Profession
Keep Up-to-Date
Research Funding
Get Involved
Activities and Assessments
Chapter 6 Massage Therapy Effects: Research-Based
IntroductionHow Massage Therapy Works
Cardiovascular System
Lymphatic System and Immunity
Musculoskeletal System
Connective Tissues
Nervous System
Endocrine System
Internal Organs and Other Systems
Massage Therapy: Indications for Conditions and Populations
Activities and Assessments
Chapter 7 Body Mechanics, Client Positioning, and Draping
Body Mechanics
Principle 1: Prepare Yourself
Principle 2: Workspace & Table Considerations
Principle 3: Foot Stances
Principle 4: Align Your Spine
Principle 5: Move From Your Center of Gravity
Principle 6: Techniques and Lubricant
Principle 7: Relax
Modified Body Mechanics While Clients are Sitting in a Chair or Lying on the Floor
Client Positioning
Towel Draping
Sheet Draping
Assisting Clients Onto and Off the Massage TableBibliography
Activities and Assessments
Chapter 8 Massage Techniques, Joint Mobilizations, and Stretches
Qualities of Massage Techniques
Massage Techniques
Cautionary Sites
Joint Mobilizations and Stretches
Wrist and Hand
Ankle and Foot
Activities and Assessments
Chapter 9 Infection Control and Emergency Preparedness
Disease Awareness
Chain of Infection
Disease Transmission
Disease Transmission and Immune ReponsesContraindications
Standard Precautions
Hand Hygiene
Emergency Preparedness
Activities and Assessments
Chapter 10 Treatment Planning: Intake, Assessment, and Documentation
Scope of Practice
Client Intake
Client Interview
Informed Consent
Treatment Planning
PPALM: Assessment Domains
Formulating the Plan
After the Massage and Subsequent Sessions
Other Charting Formats
Networking with Other Health Care Providers
Activities and Assessments
Chapter 11 Special Populations: Pregnant Women, Infants, Children and Adolescents,
Elderly, Clients with Impairments, and Near the End-of-Life
Special Populations: General Suggestions
Pregnant Clients
Massage during the First Trimester
Massage during the Second TrimesterMassage during the Third Trimester
High-Risk Pregnancies
Massage Postpartum
Infant Massage
Children and Adolescents
Elderly Clients
Clients with Impairments
Hospice: Nearing the End of Life
Activities and Assessments
Chapter 12 Hydrotherapy: Clinical Applications, Spa Therapies, and Aromatherapy
Cold and Heat
Cryotherapy Applications
Thermotherapy Applications
Choosing between Cold and Heat Application
Bath and Shower Techniques
Specialized Methods
Activities and Assessments
Chapter 13 Foot Reflexology
Theory of ReflexologyMap of the Body: Zones, Landmarks, and REFLEX POINTS
Basic Techniques
Treatment Guidelines
Foot Reflexology Session
Activities and Assessments
Chapter 14 Clinical Massage and Sports Massage
Rehabilitation and Massage Therapy
Treatment Planning for Clinical Massage
Postural Assessment
Gait Assessment
Clinical Massage Techniques
Trigger Points
Common Treatment Areas
Sports Massage
Activities and Assessments
Chapter 15 Seated Massage
Buying a Massage Chair
Client Safety and Infection Control
Seated Massage Routine
Activities and Assessments
Chapter 16 Energy-Based Bodywork Therapy: Shiatsu, Ayurveda, and Thai MassageIntroduction
Asian Bodywork Therapy
Five Phases or Five Elements
Evaluating Energetic Imbalances
Zen Shiatsu
Techniques: Palming and Thumbing
Hara Evaluation
Thai Massage
Activities and Assessments
Chapter 17 Business, Marketing, Accounting, and Finance
What is Your Message?
Employment Opportunities
Business Entity
Licenses, Permits, and Registrations
Business Resources
An Average Day
Professional Burnout
Business PlanBibliography
Activities and Assessments
Unit Two Anatomy and Physiology
Chapter 18 Introduction to the Human Body: Cells, Tissues, and the Body Compass
Anatomy and Physiology
Medical Terminology
Levels of Organization
Cellular Processes: Passive and Active
Cellular Metabolism
Body Systems: Anatomy and Physiology
Body Compass
Body Regions
Activities and Assessments
Chapter 19 Skeletal System
Bone Cells
Bone Tissues
Classification of Bones
Anatomy of a Long Bone
OssificationRegions Of The Skeletal System
Synovial Joints
Joint Movements
Joints Classified by Shape
Joints Classified by Movement
Pathologies of the Skeletal System
Activities and Assessments
Chapter 20 Muscular System
Skeletal Muscle Anatomy
Muscle Contraction
Motor Units and Recruitment
Energy Sources for Contraction
Types of Skeletal Muscle Fibers
Muscle Fiber Architecture
Parts of a Skeletal Muscle
Muscle Actions
Types of Contractions
Lever Systems
Stretching and Stretch Receptors
Posture and Muscle Tone
Muscular Pathologies
Activities and AssessmentsChapter 21 Kinesiology
Lesson One: Bones of the Upper Extremity
Lesson Two: Bones of the Lower Extremity
Lesson Three: Bones of Axial Skeleton
Lesson Four: Muscles of Scapular Movement
Lesson Four Review: Muscles of Scapular Movement
Lesson Five: Muscles of Shoulder Joint Movement
Lesson Five Review: Muscles of Shoulder Joint Movement
Lesson Six: Muscles of Elbow & Radioulnar Joint Movement
Lesson Six Review: Muscles of Elbow & Radioulnar Joint Movement
Lesson Seven: Muscles of Wrist and Hand Movement
Lesson Seven Review: Muscles of Wrist Movement
Lesson Eight: Muscles of HIP and Knee Movement
Lesson Eight Review: Muscles of Hip Movement
Lesson Eight Review: Muscles of Knee Movement
Lesson Nine: Muscles of Ankle and Foot Movement
Lesson Nine Review: Muscles of Ankle and Foot Movement
Lesson Ten: Muscles Of Neck And Facial Movement
Muscles of Mastication
Lesson Ten Review: Muscles of Mandibular Movement
Lesson Ten Review: Muscles of Neck Movement
Lesson Eleven: Muscles of Trunk & Vertebral Column Movement
Lesson Eleven Review: Muscles of VERTEBRAL Movement
Lesson Twelve: Muscles of Respiration
Activities and Assessments
Chapter 22 Integumentary SystemIntroduction
Structure of the Skin
Skin Color
Skin Glands
Touch and Skin Receptors
Pioneers in Touch Research
Dermatologic Pathologies
Activities and Assessments
Chapter 23 Nervous System
Organization of the Nervous System
Cells of the Nervous System
Classifications of Neurons
Nerve Impulses
Central Nervous System
Spinal Cord
Peripheral Nervous System
Autonomic Nervous System
The Senses
Neurologic Pathologies
Activities and Assessments
Chapter 24 Endocrine System
Hormones and Regulation
Pineal Gland
Pancreatic Islets
Organs that Possess Endocrine Cells
Endocrine Pathologies
Activities and AssessmentsChapter 25 Reproductive System
Male Reproductive System
Female Reproductive System
Menstrual Cycle
Sexual Intercourse
Reproductive Pathologies, Conditions, and Sexually Transmitted Infections
Activities and Assessments
Chapter 26 Cardiovascular System
Blood Vessels
Paths of Blood Circulation
Blood Pressure
Cardiovascular Pathologies
Activities and Assessments
Chapter 27 Lymphatic System and Immunity
Lymph and Lymphatic Vessels
Movement of Lymph
Lymphatic Organs and Structures
Immune Dysfunctions
Lymphatic and Immune Pathologies
Activities and Assessments
Chapter 28 Respiratory System
Respiratory Tract
Reflexes that Affect Breathing
Respiratory Pathologies
Activities and Assessments
Chapter 29 Digestive System
Gastrointestinal Tract
Oral Cavity
Small Intestine
Large Intestine
Accessory Organs and Glands
Gastrointestinal Pathologies
Activities and Assessments
Chapter 30 Urinary System
Urinary Bladder
Nephrons: Blood Flow
Filtration Process
Body Fluids and Fluid Balance
Urinary Pathologies
Activities and Assessments
Appendix SOAP NotesAppendix SOAP Notes
Why Use SOAP Notes?
What is a SOAP Note?
Illustration Credits
Chapter 1
Chapter 2
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 18
Chapter 19
Chapter 20
Chapter 21
Chapter 22
Chapter 23
Chapter 24Chapter 25
Chapter 26
Chapter 27
Chapter 28
Chapter 29
Chapter 30
Short Biography Index
IndexC o p y r i g h t
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Knowledge and best practice in this field are constantly changing. As new research
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Practitioners and researchers must always rely on their own experience and
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Last digit is the print number: 9 8 7 6 5 4 3 2 1

This textbook is divided into two units and thirty chapters. Unit One is devoted to
foundational concepts such as history, body mechanics, massage techniques,
complementary methods, and business. Unit two discusses anatomy, physiology, and
pathology with signi cant coverage of kinesiology. These chapters re ect essential
subjects as identi ed by the Entry Level Analysis Project (ELAP) and the Massage
Therapy Body of Knowledge (MTBOK).
Audiences for This Book
This book is intended for massage students, instructors, and practicing therapists.
This book provides massage students with information needed to complete their
studies during school. Students bene t from the common-sense approach and
meaningful simplicity. Vibrant images clarify di. cult concepts. Sections on
pregnancy, childhood, adolescence, senescence, disability, impairments, and
pathology help students formulate client-centered and condition-appropriate
treatment plans. This edition also discusses the new board certi cation. Lastly,
terri c online resources make study, review, and exam preparation fun. These online
resources are located at http://evolve.elsevier.com/Salvo/MassageTherapy.
Massage instructors like the book's straightforward organization, engaging
writing style, and visual appeal. Instructors instantly recognize the quality of
information and appreciate the peer-reviewed materials by subject matter experts
and medical professions. Research references within each chapter support the
validity and e. cacy of massage while frequent mention of online resources provides
gateways to instructional technologies. Robust assessments in “Test Your Knowledge”
help instructors move students up the learning ladder from terminology
identi cation (Matching), application of knowledge (Think about it), synthesizing
information (Discussion), and locating/evaluating sources of information and
educational materials (Webquests). These assessments can be used online or in
physical classrooms. Additional resources such as question banks, answer keys,
downloadable forms, image collections, lesson plans, and PowerPoint presentations
can be found online at http://evolve.elsevier.com/Salvo/MassageTherapy. NOTE: It
is vital that instructors review each chapter before teaching it as much of the information
previously taught in massage school has changed.
Massage school graduates and practicing therapists can use this book to keep
their knowledge base current, prepare for licensing and board certi cation exams,
and as an invaluable resource.
Distinctive Features
Spotlight on research—Numerous summaries of published studies emphasis research
and research findings.
Terms and their meanings—These tables help students learn word origins used in
anatomy and physiology. This knowledge improves comprehension as well as test
Biographies—Biographical pro les and candid interviews provide a real-world
perspective from the most respected authorities and pioneers in massage and
bodywork.Chat—This feature gives students an inside look at the profession, provide
additional resources, personal vignettes, and tips for remembering test material.
Students LOVE this feature.Thought-provoking quotes—Quotes are found at the beginning and within each
chapter. These provide rich discussion forums, inspiration, and emphasize the
affective or emotional domain of learning.
Activities and assessments—Robust activities and assessments such as matching
questions, case studies, discussion questions, and inquiry-based Webquests promote
critical thinking, encourage dialogue, foster open-mindedness, and promote cultural
awareness.Online resources—Free online resources include educational activities, ash cards,
photo galleries, videos, audio glossaries, downloadable forms, and practice tests.
Videos demonstrate massage techniques, routines, procedures, and client intake
interviews. These and other resources are available at
http://evolve.elsevier.com/Salvo/MassageTherapy.New for Fifth Edition
Kinesiology—This edition features action-oriented illustrations of body movements
and painted skeletons with origins in red and insertions in blue to coincide with
anatomical models. These new images help students accurately identify, locate, and
palpate muscles.Clinical massage—This chapter contains expanded information on pain theories,
neuromatrix model, pain management, and current guidelines for massage after
surgery and injury. This information is essential when working in rehab or sports
clinics, in physician-referred practices, or multidisciplinary clinics.Thai massage—Thai massage has been added to Chapter 16. Thai massage is
currently widely popular and students should consider oAering this modality to their
future clients.Special populations and Pregnancy—This chapter is completely revised and
focuses on pregnancy, children and adolescents, the elderly, and hospice patients.
Clients with disabilities and impairments are also discussed.Research—In recent years, research and evidence-based practice is a central focus
of massage education. Because of this, two chapters are devoted to research and how
to apply research findings into massage practice.Hydrotherapy—Over one third of all massage therapists are now working in spas,
massage franchises, or rehab clinics. We responded to this trend by expanding
sections on clinical applications of heat and cold, safe use of hydrotherapy, and
specialized methods such as hot stones and shirodhara.Business—Blogging, digital marketing, and ethical use of social media have been
added to help students navigate today's job landscape. We also added discussion of
websites, online scheduling, and social networking.
Self-care—Massage is a physically demanding profession. The self-care chapter

has been expanded to include recommendations for physical exercise and nutrition
and features the USDA “My Plate” which replaces the food pyramid.
Infection control—Reducing disease transmission is a primary focus in massage
education. Chapter 9 contains the most current information on standard precautions,
contraindications, and recommendations for emergency procedures such as heart
attack, strokes, choking, and seizures. This will prepare students to act quickly and
decisively during medical emergencies.
Getting the Most From This Textbook
To get the most from this book, glance at the table of contents and glossary. This will
give you an idea about how this book is organized and a sense of the vocabulary you
need to master while in school. Before reading a chapter, preview it. Read headings,
subheadings, and bolded terms. Glance at gures, gure legends, charts, and tables.
This will show you the chapter's main ideas. Look at the assessment sections at the
end of each chapter. This will help you identify key concepts as you are reading.
As you are reading, give your full attention and avoid distractions such as
extraneous noises or unnecessary technologies. Comprehension depends on how well
you focus, extract, and retain information. Try reading aloud; reciting information
helps retain it.
One last thing … don't be afraid to write in your book. Underline sentences or
highlight in color important words. Jot down your personal reactions in page
margins while you read it or as you are listening to lectures. During the nal days of
class, ask your classmates and teachers to sign the inside front cover or rst fewpages. This way, your textbook can double as your class yearbook. Let this book be
your friend during your educational journey and beyond. It is a valuable resource
and will hold its value during your post-graduate practice.2
A c k n o w l e d g m e n t s
I have gathered together a wonderful group of contributors. They are my “dream
team” and I could not have done it without them. Big warm THANK YOU to Judith
Delany, Richard Gold, Allissa Haines, Megan Lavery, Til Luchau, Katherine
Mayerovitch, Alice Sanvito, Joellen Sefton, Ralph Stephens, and Micheal Tarver.
Thank you to the contributors of previous editions which include Sandy Grover
Mason, Laura Allen, Sandra Anderson, Celia Bucci, Rita LeBleu, Monica Reno,
Hayley Salvo, and Kenneth Zysk. Their work has provided the foundation for this
edition. Special thanks to Chris and Suzanne Salvo for their wonderful photography
for this and previous editions. Special thanks to Joseph Muscolino for use of his
illustrations for the kinesiology chapter and to Elan Schacter for his help with the
wonderful student resources on Evolve. Hugs to all of you!
A nal word of appreciation to the many reviewers who have shared their insights
and suggestions. The reviewers for this edition are Michelle Alley, Lindsey Ardoin,
Christine Bailor-Goodlander, David Ballard, Robert Balza, Bizhan Bandarchi, Patricia
Berak, Jennifer Bloch, Jennifer Boyd, Michael Breaux, Felicia Brown, Ed Buresh, Jill
Burynski, Susie Byrd, Michelle Carbonneau, Andrew Char, Laurie Craig, Gautam
Desai, Sattaria Dilks, Donald Quinn Dillon, Richard Finn, Holly Foster, Trisha
Fuhrman, Jimmy Gialelis, Julie Goodwin, Bodhi Haraldsson, Renee Hicks, Rodney
Travis Holley, Heather Huang, Heather Huber, Brent Jackson, Brian James, Jeanne
Johnson, Rhonda Johnson, Christopher Jones, Jennifer Kemp, Joseph Kulaga, Annie
LaCroix, Jaime Landman, Sheila Lasella, Megan Lavery, Kelli Lene, Joe Lubow, Til
Luchau, Justin Magnuson, Mike Mcaleese, Lisa Mertz, Yvonne Meziere, John
Morgan, Annie Morien, Matthew Nolan, Nicole Pinaire, Tim Reischman, Genevieve
Reiter, Monica Reno, Richard Royster, Alice Sanvito, Elan Schacter, Lisa Severn,
Deborah Solomon, Renee Stenbjorn, Richard Sussan, Donald Thigpen, Ravensara
Travillian, Lisa Turek-Shay, Dennis Walker, Nicolas Warner, Anthony Weinhaus,
Andrew Weiss, Kelli Wise, and Charles Woodard. I want to also thank the past
reviewers for their work on previous editions. Your reviews have improved the
quality of information in this edition.
The editorial team can make or break a project. I was blessed with a great group
of individuals such as Shelly Stringer, Becky Leenhouts, Laurel Berkel, Liz Fifer,
Marquita Parker, Julie Eddy, and Amy Buxton.I also want to thank my Facebook friends, massage students, massage instructors,
massage clients, university professors, and massage therapists who have attended my
presentations at state conferences. I have relied heavily on you for vetting
information and for continual inspiration.D e d i c a t i o n
Mentors guide you through your journey. Some serve by their example and some
through direct counsel. Sometimes you don't fully realize their full impact until you take
time to reflect. This book is dedicated to one of my most significant mentors …
Sattaria S. Dilks
Tari has assumed many “mentor” roles in my life from good friend, to psychotherapist,
to reviewer, and academic advisor. Her diverse background is one of the reasons she
is such a remarkable mentor. Tari has the ability to think about issues from many
different points of view and she has the emotional capacity for compassionate and
empathetic deliberation. There is a little bit of “Tari” in all my books—and they are
better for it. I am deeply grateful for all Tari has given me, mostly by her kindness and
generosity. Thank you, Tari, for your friendship, your wisdom, and your advice even
when it took me awhile to “hear” it. You are amazing!
Susan G. Salvo
F o r e w o r d
Most early classics and most knowledge, before printing, were passed down from
person to person through conversation, discussions, and live performances. Homer
wrote The Odyssey, but research has shown the story was sung and recited by
traveling singers and orators for hundreds of years before it was written down.
So it is with this book you have in your hands. It is a written encounter with the
hundreds of years of knowledge and people who have “sung the song,” enthralled
with touch and the healing it provides since the beginning of humanity.
Author Susan Salvo heard the stories and experienced the traditions of massage
theory and practice from many teachers. Being the devoted student she is, she
thoroughly dialogued with them. Then she, through active collaboration with
hundreds of other teachers, wrote down all she had heard, organizing this knowledge
and passion for touch for the rst time in the history of massage. With this fth
edition, Susan presents us with the greatest orchestration ever of massage therapy's
principles and practice.
So imagine that you are not just reading a book, but more deeply you are
encountering a vast number of people who, just like you, were and are fascinated by
the world of touch and its e ects. Through Susan, they are speaking to you! And you,
in reading, are meeting their thoughts and feelings with your own. You, as a young
therapist, are about to sing your own songs and tell your own tales that will take this
incredible profession into the future!
Massage Therapy Principles and Practice has been the standard bearer for the
massage profession and education since its original publication in the 1990s. It was
perhaps the rst book in the massage and bodywork not merely to re ect material
the author had collated for his or her school's curriculum.
This loyalty to the whole truth and the best way to represent it through words,
charts, photos, drawings, and on-line resources has been a great distinction of Susan
Salvo's work. On every page, you can feel the excitement and the sense of discovery
that pervades the best learning and education to date.
Massage Therapy Principles and Practice is a book that itself is an incredible Memory
Palace. A “memory palace” was a practice used by ancient cultures to create a kind
of palace in the mind wherein important things they wanted to remember could%
“reside” and be more easily recalled. Within the memory palace of this book, there
are treasures and precious learnings from the entire history of hands-on practice,
anatomical and physiological knowledge, the psychology of touch, and the various
categories of technique from all around the world and from all time. Each is in their
place, each a chapter in the grand story of the principles and practice of massage
This latest edition brings us right up to the present day. It includes a new and
balanced discussion of the virtues and challenges of evidence-based approach to
research and practice. It covers, encourages, and equips us to do the research that
will help us con rm with fact-based con dence the health bene ts of massage
therapy. It has hundreds of astonishing illustrations so you learn not just through
ideas in words, but directly experiencing this knowledge through vision. It takes the
history chapter right up to the present. There is a thorough discussion of pain—
appropriately since more and more therapists are being met with clients'
expectations for relief from speci c pains, not only for relaxation. There is a much
expanded appreciation of the nervous system as we have learned over the last
decade that the mind and nervous system are a ected by massage as much or even
more than muscles. The business section has been updated to re ect the utilization of
social media and on-line resources to support your success.
Susan's periodic use of profound and poetic quotes and portraits of real people
whose fascinating work informs and enlivens the massage eld to this day, helps the
book remain not only a primary source for information, but also for inspiration.
Massage is not just rooted in science, but also in the art of touching with inspiration
and compassion. It is rooted in real people helping real people.
When it comes to practical issues of passing licensing exams or passing additional
massage exams in the future, the astounding breadth and depth of this book make it
an unparalleled resource. While there are various shorter preparatory courses and
books for exams, there is no substitute for the fullness and comprehensive approach
you nd here. This memory palace, every time you walk through, will reveal
treasures to you that you didn't even see the rst or second times through. Even if
you have older editions, I recommend you invest in this new one—both old and new
treasures are here in abundance.
It is rare to say a book contains everything you need to know—like a whole world.
But some books are classics which indeed contain everything, a whole world of
knowledge. This book that you hold in your hands is such a work—it is with great
pleasure and anticipation that I issue this “foreword” to this world. Thank you to
Susan Salvo and her many comrades for the writing, composition, and publication of
this the fifth and best edition of Massage Therapy Principles and Practice.
This stunning portrait of a profession and a body of knowledge doesn't just re ect%
one person's vision of our eld. Uncannily it seems to re ect and clarify everyone's
vision. And through its astonishing clarity it gives us a much clearer idea of what we
do, how valuable it is, and how beautiful a thing is this profession that uses the most
sophisticated tool in the known universe, the human hand, guided by the human
mind and heart, to foster the highest level of health and care.
Most important, it is an invitation for you to meet all these wonderful people and
ideas, to hear what they have said, learn what they have learned, so you can tell
your own story, sing your own songs, and make the world new through the work of
your hands.
David Lauterstein The Lauterstein-Conway Massage School Austin, TexasContributors
Judith Delany LMT
Director and Certified NMT Instructor
NMT Center
St. Petersburg, Florida
Clinical Massage and Sports Massage
Richard Gold PhD, LAc
President and Executive Producer of Metta Mindfulness Music
Pacific College of Oriental Medicine
San Diego, California
Energy-Based Bodywork Therapy: Shiatsu, Ayurveda, and Thai Massage
Allissa Haines BS, LMT
Owner, Haines Massage
Guest Faculty, Bancroft School of Massage Therapy
Plainville, Massachusetts
Biographical Sketches
Megan Lavery LMT, BS
Faculty Zero Balancing Health Association
Faculty, Natural Health Institute of Bowling Green
Bowling Green, Kentucky
The Therapeutic Relationship
Til Luchau BA NCTMB, CMP
Director and Lead Instructor, Advanced-Trainings.com
®Faculty, Rolf Institute of Structural Integration
Boulder, Colorado
History of Massage Therapy
Alice Sanvito LMT
Licensed Massage Therapist
St. Louis, Missouri
Clinical Massage and Sports Massage
Joellen M. Sefton PhD, ATC, CMT
Director, Warrior Research Center/Warrior Athletic Training ProgramDirector, Neuromechanics Research Laboratory, School of Kinesiology
Auburn University
Auburn, Alabama
Research Literacy and Massage Therapy, Massage Therapy Effects: Research-Based
Ralph R. Stephens BSEd, LMT, NCTMB
President, Ralph Stephens Seminars, LLC
Coralville, Iowa
Seated Massage
H. Micheal Tarver PhD
Professor of History, Arkansas Tech University
Russellville, Arkansas
History of Massage Therapy
Laura Allen BA, LMBT, NCTMB
Approved Provider of Continuing Education under the NCBTMB
Rutherfordton, North Carolina
Biographical Sketch
Sandra K. Anderson BA, LMT, NCTMB
Co-Owner, Tucson Touch Therapies
Tucson, Arizona
Test Your Knowledge, Glossary
Celia Bucci MA, LMT
Chicago, Illinois
Biographical Sketches, Case Studies
Rita S. Lebleu LMT, MA
Rhetorical and Interpersonal Communication
DeQuincy, Louisiana
Biographical Sketches
Sandy Grover Mason BA, LMBT 4403, CMT, AMTA, NCTMB
Clinical Education Coordinator and Instructor, Therapeutic Massage
Forsyth Technical Community College
Owner, Body Therapeutic
Winston-Salem, North Carolina
Appendix: SOAP Notes
Monica J. Reno LMT
Continuing Education Provider
Touch Education, LLC
Lady Lake, Florida
Clinical MassageHayley A. Salvo
Bachelors in Journalism, Magna Cum Laude
The English Centre
Málaga, Spain
Biographical Sketches
Kenneth G. Zysk PhD, DPhil
Associate Professor
Institute for Cross-Cultural and Regional Studies
Department of Asian Studies
University of Copenhagen
Copenhagen, Denmark
Energy-Based Bodywork Therapy: Shiatsu and AyurvedaReviewers
Michelle J. Alley MS, LMT, AP
Orlando, Florida
Lindsey Ardoin RN, LMT
RN Branch Manager
Angels of Care Pediatric Home Health
Austin, Texas
Massage Techniques, Joint Mobilizations, and Stretches
Christine Bailor-Goodlander RN, LMT, CSI, CIPI
Owner, Nurse Massage Therapist
The Body Essential Holistic Wellness Center
Williamsville, New York
David Hilton Ballard MS
Medical Student, School of Medicine
Louisiana State University Health Shreveport
Shreveport, Louisiana
Respiratory System; Digestive System; Urinary System
Robert O. Balza Jr, PhD
Associate Professor of Biology, Wisconsin Lutheran College
Milwaukee, Wisconsin
Introduction to the Human Body
Bizhan Bandarchi MD, FCAP, FASCP
Consulting Dermatopathologist, University of California, Los Angeles
Medical Director, American Specialty Laboratory, Inc.
Los Angeles, California
Introduction to the Human Body; Integumentary System; Endocrine System;
Reproductive System; Lymphatic System and Immunity
Patricia C. Berak NCTMB, BHSA, MBA
Program Director, Baker College of Clinton Township
Clinton Township, Michigan
Jennifer Bloch RMT
Registered Massage TherapistToronto, Ontario, Canada
Research Literacy
Michael A. Breaux LMT
Past Owner, Louisiana Institute of Massage Therapy
Past Chairman, Louisiana State Board of Massage Therapy
Lake Charles, Louisiana
Clinical Massage
Felicia Brown LMBT, LMT, Certified Guerrilla Marketing Coach
Author, Business and Marketing Coach
Greensboro, North Carolina
Business, Marketing, Accounting, and Finance
Ed Buresh LMT, MTI
Massage Therapy Instructor
Dripping Springs, Texas
Therapeutic Relationships; Clinical Massage; Kinesiology
Jill Burynski LMBT, NCTMB
Lead Instructor, Living Sabai Continuing Education
Asheville, North Carolina
Susie Byrd MTI
Director, Instructor
The Edge School of Massage
Fayetteville, Arkansas
Michelle Leigh Carbonneau BA, LMT, Certified Yoga Instructor
Director of Education, Licensed Massage Therapy, and Anatomy Teacher
Yogissage, LLC
Honolulu, Hawaii
Andrew Char LMT, Kaneohe, Hawaii
Laurie Craig BS, MS
Co-owner, Lead Instructor of Anatomy, Physiology, and Pathology
Georgia Massage School
Suwanee, Georgia
Gautam J. Desai DO, FACOFP, CPI, Certified Medical Acupuncturist
Associate Professor, Department of Family and Community Medicine
Kansas City University of Medicine and Biosciences
Kansas City, Missouri
Sattaria S. Dilks DNP, PMHNP-BC, FAANP
Professor, McNeese State UniversityLake Charles, Louisiana
Therapeutic Relationships
Donald Quinn Dillon RMT
Practitioner, Author, Speaker
Toronto, Ontario, Canada
Business, Marketing, Accounting, and Finance
Massage Therapist, Pittsburgh School of Pain Management
Pittsburgh, Pennsylvania
Nervous System
Holly A. Foster LMBT
Program Coordinator, Lead Instructor
Wilkes Community College
Wilkesboro, North Carolina
Trisha Fuhrman MS, RD, LD, FADA
Ballwin, Missouri
Digestive System
Jimmy Gialelis LMT, NCTMB, BS
Instructor, Arizona School of Massage Therapy
Tempe, Arizona
History of Massage; Cardiovascular System; Lymphatic System and Immunity
Julie Goodwin BA, LMT
Author, Educator, Massage Therapist
Pima Community College
Tucson, Arizona
Bodhi G. Haraldsson RMT
Director of Research
Registered Massage Therapists' Association of British Columbia
Vancouver, British Columbia, Canada
Research Literacy
Renee Hicks NCLMBT #2281
Owner, Director, Instructor, Massage Therapist
Maiden School of Massage and Bodywork Therapy
Maiden, North Carolina
Rodney Travis Holley LMT, CNWC, CSNC
Program Director, Miller-Motte Technical CollegeAugusta, Georgia
Heather Huang MD
Assistant Professor, University of Wisconsin
Madison, Wisconsin
Heather A. Huber BA, MEd, MS, LMT, MTI
Brent Jackson BS, LMT
Academic Program Manager, Massage Therapy
Central Carolina Technical College
Sumter, South Carolina
Clinical Massage
Brian James
Infection Control and Emergency Preparedness
Jeanne M. Johnson MA, LMT
Program Chair, Western Technical College
La Crosse, Wisconsin
Rhonda L. Johnson EdD, MSN, RN
Assistant Professor, College of Nursing Continuing Education Coordinator
McNeese State University
Lake Charles, Louisiana
Special Populations and Pregnancy
Christopher V. Jones MS, LMT, BCTMB, CES
Clinical Massage Therapist
Fitchburg, Massachusetts
Research Literacy; Massage Techniques, Joint Mobilizations, and Stretches; Skeletal
System; Nervous System
Jennifer Kemp BS, LMT
Director, Central New York Massage Therapy Alliance
Utica, New York
Joseph Kulaga DC
Center for Chiropractic & Rehabilitation
Lake Charles, Louisiana
Annie Lacroix
Columbia River Institute of Massage Therapy
Wenatchee, WashingtonRespiratory System
Jaime Landman MD
Professor of Urology and Radiology, University of California, Irvine
Orange, California
Urinary System
Sheila Lasella BA, LMT, NCBTMB
Owner, Stillpoint Massage Therapy, LLC
Fairfield, Connecticut
Endocrine System; Reproductive System
Megan E. Lavery BS, LMT, CZB, NCTMB
Faculty, Zero Balancing Health Association
Columbia, Maryland
Faculty, Genesis Career College
Bowling Green, Kentucky
Treatment Planning
Kelli Lene LMT, NCTMB, AA Health Sciences
Owner, Director, Spa Kamp
Owner, Director, Time Well Spent Massage and Therapeutic Spa
Tulsa, Oklahoma
Tools of the Trade
Joe Lubow
Sarasota School of Massage Therapy
Sarasota, Florida
History of Massage
®Til Luchau BA, CMP, CAMT, Certified Advanced Rolfer
Director, Lead Instructor
Lafayette, Colorado
Justin Andrew Magnuson MA, LMT
Louisville School of Massage
Louisville, Kentucky
History of Massage; Introduction to the Human Body
Mike Mcaleese
School of Holistic Massage and Reflexology
Downers Grove, Illinois
Foot ReflexologyLisa Mertz PhD, LMT, Chautauqua, New York
Muscular System; Infection Control and Emergency Preparedness
Yvonne Meziere LMP
Faculty, Massage Studies
Clover Park Technical College
Lakewood, Washington
John D. Morgan LMBT, ND
Program Director, Western North Carolina School of Massage
Asheville, North Carolina
Body Mechanics, Client Positioning, and Draping; Special Populations and
Annie Morien PhD, PA-C, LMT
Senior Lecturer, Florida School of Massage
Gainesville, Florida
Integumentary System
Matthew E. Nolan BS, LMT, LMTI, CEP
Medical Massage Therapist, Lorenzen Chiropractic Clinic
Richardson, Texas
Seated Massage; Lymphatic System and Immunity
Nicole Pinaire PhD
Associate Professor in Biology
St. Charles Community College
Cottleville, Missouri
Skeletal System
Tim Reischman BS, DC, ST, LMBT, CCA
Curriculum Area Coordinator, Spa Services
Carteret Community College
Morehead City, North Carolina
Genevieve Reiter
Chair, Massage Therapy Program
New York College of Health Professions
Syosset, New York
Monica J. Reno BS, LMT
Spa Manager, MVP Athletic Club
The Villages, Florida
Richard M. Royster PhD, MA, AP, LMT
Lead Instructor Director, Richard Royster Institute
Instructor, Agaplesian AcademyHeidelberg, Germany
Fortbuildung Centrum, Hannover Pschick Academy
Regensburg, Germany
Clinical Massage
Alice Sanvito LMT
Licensed Massage Therapist
St. Louis, Missouri
Research Literacy
Elan Schacter LMT
Massage Therapist
Matthews, North Carolina
Introduction to the Human Body; Muscular System; Kinesiology; Integumentary
Lisa Severn
Customer Service Representative, Oakworks, Inc.
New Freedom, Pennsylvania
Tools of the Trade
Deborah K. Solomon LMT, CRT, CPT, Tulsa, Oklahoma
Hydrotherapy and Spa
Renee Stenbjorn LMT, BS, MPA
Faculty, Licensed Massage Therapist
East West College of the Healing Arts
Portland, Oregon
Effects of Massage Therapy
Richard Sussan MS, LMT
Instructor of Science and Massage Therapy
Anton Aesthetics Academy, Inc., School of Massage Therapy
West Palm Beach, Florida
Kinesiology; Respiratory System
Donald Thigpen BS, DC, Chiropractic Physician
Hydrotherapy and Spa
Ravensara S. Travillian PhD, NA-C, LMP
Research Scientist, School of Medicine, University of Washington
Director, Northwest Institute of Professional Massage Therapy
Seattle, Washington
Lisa Turek-Shay DC, LMT, BS
Instructor, Wisconsin Indianhead Technical College, New Richmond
New Richmond, WisconsinDennis M. Walker MD, MA, FAAOS, FRCS(C), Orthopaedic Surgeon, Retired
Skeletal System; Muscular System; Nervous System
Nicolas Warner CMT, DC
Instructor, Cortiva Institute of Massage Therapy
Scottsdale, Arizona
Body Mechanics, Client Positioning, and Draping; Hydrotherapy and Spa
Anthony J. Weinhaus
Assistant Professor, University of Minnesota
Minneapolis, Minnesota
Lymphatic System and Immunity
Andrew Weiss DAOM, LAc, LMT, MS, NCCAOM, NCBTMB, Certified Yoga
Doctoral Candidate
East Asian Medicine Practitioner
Energy-Based Bodywork Therapy
Kelli A. Wise BS, LMP, Olympia, Washington
Business, Marketing, Accounting, and Finance
Charles B. Woodard MD, FACC
Department of Internal Medicine, Lake Charles Memorial Hospital
Lake Charles, Louisiana
Cardiovascular SystemU N I T O N E
Foundations for Practice, Basic
and Complementary Methods,
and Business Practices
Chapter 1 History of Massage Therapy
Chapter 2 The Therapeutic Relationship
Chapter 3 Tools of the Trade
Chapter 4 Self-Care: Physical Activity, Nutrition, and Stress Management
Chapter 5 Research Literacy and Massage Therapy
Chapter 6 Massage Therapy Effects: Research-Based
Chapter 7 Body Mechanics, Client Positioning, and Draping
Chapter 8 Massage Techniques, Joint Mobilizations, and Stretches
Chapter 9 Infection Control and Emergency Preparedness
Chapter 10 Treatment Planning: Intake, Assessment, and Documentation
Chapter 11 Special Populations: Pregnant Women, Infants, Children and
Adolescents, Elderly, Clients with Impairments, and Near the End-of-Life
Chapter 12 Hydrotherapy: Clinical Applications, Spa Therapies, and
Chapter 13 Foot Reflexology
Chapter 14 Clinical Massage and Sports Massage
Chapter 15 Seated Massage
Chapter 16 Energy-Based Bodywork Therapy: Shiatsu, Ayurveda, and Thai
Chapter 17 Business, Marketing, Accounting, and FinanceC H A P T E R 1
History of Massage Therapy
H. Micheal Tarver, Til Luchau, Susan G. Salvo
“If you would understand anything, observe its beginning and its development.”
Learning Objectives
After completing this chapter, the student should be able to:
1. Define massage therapy and bodywork.
2. Discuss views and uses of massage during the prehistoric world, the ancient world, and the Middle Ages.
3. Explain the role of the European Renaissance and Enlightenment on the massage therapy profession.
4. Distinguish contributions of Pehr Henrik Ling, physicians, therapists, and early massage organizations during the Modern Era.
5. Describe the impact the Esalen Institute and later massage therapy organizations had on the development and popularization of massage
6. Discuss the dark chapter of massage history including human trafficking.
The history of massage and healing touch is long and multifaceted, with currently more than 80 di. erent methods of massage and bodywork;
the latter is a generic term used to describe any therapeutic or personal self-development practice that may include massage, healing touch,
movement, or energetic work. However, the terms massage and bodywork are frequently used interchangeably. Archaeological and historical
evidence indicates that massage and bodywork have been practiced for thousands of years in all regions of the globe.
The evolution of massage-related touch has its roots in grooming behavior of primates and early man, which might have played an
important role in social structures. Massage itself is instinctive and intuitive. It is a natural response to rub our aches and pains, whether we
are familiar with the “whys” behind these actions.
Massage therapy is manual manipulation of the soft tissues of the body for the purpose of establishing and maintaining good health and
promoting wellness. The therapist uses speci4c techniques to assist a client in ful4lling his or her therapeutic goals. These goals are
established through an intake process followed by proper and e5 cient treatment planning. Examples of client therapeutic goals are
relaxation and stress reduction, injury rehabilitation, management of symptoms during a long-term illness, and enhancing personal growth.
Massage has taken on an important role in modern health care. It has been shown to be bene4cial in reducing stress, increasing lymph
7ow, decreasing pain, promoting sleep, reducing swelling, enhancing relaxation, lessening depression and anxiety, recovering from
exerciseinduced soreness, and increasing joint range of motion (see Chapter 6). Massage has also been recognized for alleviating certain cancer
treatment side effects and postoperative pain.
In this chapter, we will examine the history of massage from its earliest records to the present (Figure 1-1). This historical perspective will
take us down the path that leads us to where we are as a profession currently and will instill a sense of connection with those who preceded
us. You need not memorize every name mentioned in the following pages, although some are important enough that you should know them.
The names, with their di. erent nations of origin, tell us is that the development of massage is a global endeavor; people from around the
world contribute to the knowledge base that transforms massage from folk remedy to health care modality.FIGURE 1-1 Massage time line.
It should be noted that from the beginning of this chapter, the word massage is used to refer to soft tissue manipulation, even though the
term did not come into use until the middle of the nineteenth century. The origin of the word massage is unclear, but can be traced to
numerous sources: the Hebrew word mashesh, the Greek roots masso and massin, the Latin root massa, the Arabic root mass'h, the Sanskrit
word makeh, and the French word masser.
By no means is this study of massage history complete and exhaustive. A detailed history of massage would take volumes and entail years
of research. However, this chapter should provide a thorough sense of how the profession developed and in what direction it appears to be
The Prehistoric World
Archaeologists have found artifacts that depict the use of massage in many prehistoric world cultures. Although no direct prehistoric evidence
veri4es the use of massage for medical reasons, the indirect evidence clearly implies that it was used in this manner. For example, European
cave paintings (c. 15,000 BC) depict what appears to be the use of massage after battle. In this period, extensive pictorial records show the
use of massage for these and other instances.
Log on to the Evolve website for Massage Therapy: Principles & Practice, ed. 5, at http://evolve.elsevier.com/Salvo/MassageTherapy and register
for student resources that accompany this text. Select a password to use each time you log on. Once the registration process is complete, peruse all
the Evolve assets at your disposal. ▪
The Ancient World
Concern with illness has been documented in China for several millennia, and written records have revealed the practice of massage goes
back as early as 3000 BC. Chinese medicine began to take shape between the second century BC (200 to 101 BC) and the 4rst century AD (AD
1 to 100). Manuscripts found in China dating from the second century BC discuss massage as one of the treatments for illnesses. However,
acupuncture was not mentioned in Chinese medical writings until 90 BC.
Using their knowledge of massage and later, acupuncture, the Chinese developed a style of massage they termed amma, amna, or anmo.
Amma is regarded as the original massage technique in China, and the precursor to all other therapies there, manual and energetic. The
Chinese were the first to train and employ massage therapists who were blind.
As early as the 4rst century AD, various schools of medical thought had been founded and had already begun to produce diverging ideas.
These various ideas and beliefs were compiled under the name of the mythical Yellow Emperor and became the classic scripture of traditional
Chinese medicine, the Huang-ti nei-ching. Although the exact date of the original writing of the work is unknown, it was already in its present
form by approximately the 4rst century BC. The work, commonly known as Nei Ching, contains descriptions of healing touch procedures,
herbal medicines, acupuncture, and their uses. Some debate is ongoing over the actual date of this work, with some historians arguing that it
was written around 2760 BC. By 700 AD, a Chinese ministry of health and a public health system had been established.By the sixth century AD, the use of massage was well established in China and had found its way into Japan. In Japan, amma was
practiced for many centuries. Eventually it evolved into shiatsu, literally meaning finger pressure, a term first coined in the early 1900s.
Shiatsu is a Japanese method based on the same traditional Chinese medicine concepts as acupuncture, namely that energy 7ows in the
body in streams called channels or meridians. When these channels become blocked or depleted, pain and discomfort result. Acupuncturists
use needles at speci4c points to balance the 7ow of energy; shiatsu therapists use their 4ngers, thumbs, forearms, elbows, and even their
knees and feet to balance the client's energy. Shiatsu can be performed on each channel, or at speci4c points called tsubos. Tsubos are
openings into the channels. Like the Chinese, the medieval Japanese employed blind massage therapists.
Massage on Alabaster
In the Pergamon Museum in Berlin, a 2000-year-old alabaster from Syria relief depicts a massage treatment.
Besides China and Japan, other ancient Asian cultures practiced massage. On the Indian subcontinent, the practice of massage has also
existed for more than 3000 years. Knowledge of amma massage had probably been brought to India from China, and it gradually became an
integral part of Hindu tradition, as exempli4ed by the inclusion of massage in the sacred practice of ayurveda (c. 1800 BC). Ayurveda,
literally meaning code of life or science of life, deals with rebirth, renunciation, salvation, the soul, the purpose of life, the maintenance of
mental health, and the prevention and treatment of diseases.
As for medicine, the most important ayurvedic texts are the Samhitas. A later work, the Manav Dharma Shastra (c. 300 BC), also mentions
The concept of health and medicine in the West began to take shape during the seventh and sixth centuries BC. During that time, the
legendary Greek physician Æsculapius (Asclepius) evolved into a god who was responsible for the emerging medical profession. His holy
snake and sta. still remain the symbol of the medical profession. In Greece, around 500 BC, various ideas of healing and treatments were
merged into a techne iatriche, or healing science. During this process, two individuals, Iccus and Herodicus, concerned themselves with exercise
and the use of gymnastics.
Among the followers of this new science was Hippocrates of Cos (460 to 375 BC) (Figure 1-2). With his emphasis on the individual patient
and his belief that the healer should take care to avoid causing any additional harm to the patient, Hippocrates is generally recognized as the
father of modern Western medicine. Although we know little about him, Hippocrates is reputed to have been a 4ne clinician, a founder of a
medical school, and the author of numerous books, although most of the works attributed to him were written by other members of the
hippocratic school. These works are collectively known as the Corpus Hippocraticum, which summarized much of what was known about
disease and medicine in the ancient world. During the four centuries after the development of the techne iatriche, several debates occurred
within the healing profession, one of which placed great stock in the value of massage.
FIGURE 1-2 Hippocrates of Cos.
In his essay On Joints, Hippocrates wrote, “ ε ν π σε ι , α τα ρ ση κα ι ”
(“The physician must be skilled in many things and particularly friction,” section IX, lines 25-26). Hippocrates also noted that after
reduction of a dislocated shoulder, friction should be done with soft, gentle hands (section IX, lines 31-33). Clearly, Hippocrates was a
proponent of massage.
During the transitional period between Greek and Roman dominance in the ancient world, a few individuals helped pass on the medical
knowledge of the Greeks and incorporated it into Roman medicine. One such individual was Aulus Celsus, who is regarded by manyresearchers to be the 4rst important medical historian. His De Medicina is an outstanding account of Roman medicine, and it bridges the gap
between his times and those of Hippocrates. During this period, massage had gained such acceptance that Julius Caesar (c. 100 to 44 BC) used
it to help his epilepsy.
A group of Greek physicians residing in Rome, known as the Methodists, supported a simplistic view of healing and restricted their
treatments to bathing, diet, massage, and a few drugs. The founder of this school of thought was Asclepiades. Among his many contributions
to Roman medicine was a treatise on friction (massage) and exercise. Although the work is no longer in existence, Aulus Aurelius Cornelius
Celsus (c. 25 BC to AD 50) cited it in his writings on friction.
“Do not seek to follow in the footsteps of the wise. Seek what they sought.”
Matsuo Basho
A later follower of Hippocratic medicine was Galen of Pergamon (c. AD 130 to 200). Galen was a Roman physician who studied medicine
in Alexandria (Egypt) and became the personal physician to the Roman emperor Marcus Aurelius. In at least 100 treatises, Galen combined
and uni4ed Greek knowledge of anatomy and medicine; his system continued to dominate medicine throughout the Middle Ages and until
relatively recent times. Among his many works, Galen's De Sanitate Tuenda considers exercise, the use of baths, and massage. After the Roman
Empire divided into eastern and western halves, the decline in learning was much more rapid and severe in the Roman West than in the
Greek East (Byzantium). The ancient Slavs also reportedly used massage.
In the Americas, the Mayas and Inca have been documented as practicing joint manipulation and massage. The Inca also used the
application of heat in their treatments of joint disorders through the use of the leaves of the chilca bush. Records also indicate that the
Cherokees and Navajos used massage in their treatments of colic and to ease labor pains.
The Middle Ages
After collapse of the Roman Empire (AD 476), Western medicine experienced a period of decline. In reality, it was only because of the writing
e. orts of a few Western physicians (e.g., Oribasius, Alexander of Tralles) that ancient medical knowledge of the Greeks and Romans was
preserved. After the decline of the Roman Empire, the hippocratic-galenic tradition survived in the Greek-speaking Eastern part of the
Byzantine Empire. Then, after the fall of Alexandria (AD 642), knowledge of Greek medicine spread throughout the Arabic world.
After the expansion of the Islamic world in the seventh and eighth centuries AD, a comprehensive body of Greco-Roman medical doctrine
was adopted and was combined with extensive Persian and Hindu medical knowledge. One such example of this synthesis of knowledge was
an encyclopedic work the Kitabu'l Hawi Fi't-Tibb, The Comprehensive Book of Medicine, by the Persian physician Rhazes (Abu Bakr Muhammad
ibn Zakariya al-Razi) (c. AD 850 to 932), which discussed Greek, Roman, and Arabic medical practices, including massage. Another important
work was by the Persian physician Abu-Ali al-Husayn ibn-Sina (AD 980 to 1037), generally known as Avicenna. He authored numerous
medical books that remained standard textbooks until the seventeenth century.
Avicenna's Canon of Medicine was an especially famous medical text, one that compiled the theoretical and practical medical knowledge of
the time. The work illustrates tremendous in7uence of Galen on the medical knowledge of this era; the text makes numerous references to the
use of massage. In fact, by the end of the ninth century, almost all of Galen's lengthy medical texts had been translated into Arabic. In fact, if
it was not for these translations, much of the ancient Greek and Roman knowledge of massage would have been lost. The Muslims
incorporated Greco-Roman medical knowledge into the Islamic medical frameworks. Through Latin translations of these Arabic authors, most
of the knowledge of Greek medicine was revived in the Christian West (i.e., Europe).
As you know, the Odyssey tells the story of Odysseus' return from the Trojan War. Log on to Evolve to view a Bas-Relief depicting Odysseus
receiving massage. ▪
For the most part, Western medical practitioners of the Middle Ages abandoned massage in favor of other treatments. Massage did,
however, remain an important procedure for folk healers and midwives, and was passed on as a healing art form. No early compilation of
these techniques and procedures was undertaken.
During the later Middle Ages, classical medical knowledge was collected, preserved, and transmitted. After the twelfth century, medieval
medical knowledge in the West expanded, thanks in part to the existing works by the Muslims, who had earlier translated Greek and Latin
medical texts into Arabic.
By the thirteenth century, medical knowledge had advanced to the point that three major European centers (Montpelier and Paris, France,
and Bologna, Italy) were offering degrees in medicine. In 1316, Mondino dei Luzzi wrote Anothomia, the first modern treatise on anatomy.
The European Renaissance and Enlightenment
The Renaissance (c. 1250-1550) was an exciting period in the history of medicine and medical treatments. The word renaissance means
rebirth. With the revival of classical Greek learning during the Renaissance, Western medicine was revitalized by new translations of old
Greek and Latin texts. Among the newly revived texts was Aulus Celsus's De Medicina, which came into circulation again, thanks to the newly
invented printing press. The Flemish physician, Andreas Vesalius (1514-1564) established the foundations of modern human anatomy in the
West during this time. His De Humani Corporis Fabrica (On the Fabric of the Human Body, 1543) is considered one of the most important
studies in the history of medicine. The Swiss physician Philippus von Hohenheim (1493-1541), better known as Paracelsus, laid the
foundations of chemical pharmacology, as opposed to herbal remedies.
New surgical procedures were also established, particularly those by the French military surgeon Ambroise Paré (c. 1510-1590). He invented
several surgical instruments, and was among the earliest modern physicians to discuss the therapeutic e. ects of massage, especially in
orthopedic surgery cases. He also classified various types of massage movements.
Log on to the Evolve website to see illustrations of Galen of Pergamon and Ambroise Paré. ▪
Two other notable Renaissance physicians were Girolamo Mercuriale (1530-1606) and Timothy Bright (c. 1551-1615). Mercuriale spentseveral years in Rome examining manuscripts of ancient writers. His extensive knowledge of the attitudes of the Greeks and Romans toward
diet, exercise, and their e. ects on health and disease is evident in De Arte Gymnastica (The Art of Gymnastics, 1569), considered to be the 4rst
book in the field of sports medicine.
This book compiled history of gymnastics up to that time, synthesizing all that had been written on the use of exercise (for both the purpose
of health and the treatment of disease). Bright's 4rst work (c. 1584) was divided into two parts, Hygienina on Restoring Health and Therapeutica
on Restoring Health. In these works, Bright discussed baths, exercise, and massage, and he began teaching his ideas to students at Cambridge
University in Cambridge, England.
About the sixteenth century we see two important East Asian works that dealt with massage. The Chinese published Chen-chiu ta-ch'eng,
which contained a chapter on pediatric massage, and the Japanese published San-tsai-tou- hoei, which mentioned both passive and active
massage procedures.
By the end of the seventeenth century, Western medicine had experienced a revolution in both ideas and knowledge. In Italy, Giovanni
Alfonso Borelli (1608-1679) carried out extensive anatomic dissections and had analyzed the phenomenon of muscular contraction.
In England, William Harvey (1578-1657) had demonstrated that blood circulation in animals is impelled by the beat of the heart through
arteries and veins. This discovery enhanced the acceptance of massage as a therapeutic measure.
Another crucial development during the seventeenth century was the realization of the necessity to compile complete clinical descriptions
of disease, generally at bedsides, and to develop speci4c remedies for each speci4c disease. In this area, the English physician Thomas
Sydenham (1624-1689) was most prominent. At the same time these scienti4c advances were being made, massage was reemerging as a
therapy that was acceptable to the medical profession and as a therapeutic practice for health and disease.
The European Renaissance and Enlightenment era also had an impact on Western medicine. What emerged was an optimistic outlook
concerning the role and bene4ts of the 4eld of medicine. The widely held belief asserted that health was a natural state to be attained and
Within this new philosophy, massage came to be viewed as a popular treatment in Europe. Simon André Tissot (1728-1797) published
several works on gymnastic exercises that recommended massage for various diseases and gave indications for its use. The eighteenth century
also saw the creation of new medical systems that incorporated the anatomic, physiologic, and chemical discoveries of the previous 200 years.
Some people believed that the gathering and dispensing of this new knowledge would add prestige to the medical profession and help weed
out the quacks.
“Oftentimes, when people think about history, they think of it as something that's passed. However, the only really important history is the history
that's still alive, that's affecting us today.”
David Lauterstein
The Modern Era
The era of modern massage began in the early nineteenth century when a wide variety of authors were advocating massage and developing
their own systems.
One of the most important of these writers was Pehr Henrik Ling (1776-1839), a Swedish physiologist and gymnastics instructor (Figure
13). Pehr Henrik Ling was born in Småland, one of the southern provinces of Sweden. After being expelled from school for disciplinary
problems, Ling traveled through Europe and eventually returned to Sweden, where he learned fencing. In 1804, he accepted a post at the
University of Lund, where he taught fencing and gymnastics. At the same time, he studied anatomy and physiology. While teaching fencing
techniques, he noted that the movements he often wanted his pupils to make were hindered by motions that the student had learned from
habit. Ling therefore resolved to teach the movements of the body in a systematic manner. For Ling, this training was important for military
concerns, because he viewed fencing as an important part of gymnastics. He felt that soldiers could be taught to use weapons and move
muscles in ways that were new to them.
FIGURE 1-3 Pehr Henrik Ling (1776-1839).
Through his experiences at the University of Lund and the Swedish Royal Central Institute of Gymnastics, Ling developed his own system of
medical (or Swedish) gymnastics and exercise, known as the Ling System, Swedish Movements, or Swedish Movement Cure. The primary focus of
Ling's work was on gymnastics or movements applied to the treatment of disease and injury. Massage was viewed as a component of Ling's
overall system. He blended massage with physiology, which was just emerging as a science. Shortly thereafter, the term Swedish massage was
used to describe the massage component of Ling's system. For this reason, Ling is often regarded as the father of Swedish massage. While he
did not invent massage, he is credited with helping develop it into a formal treatment modality. His followers used massage techniques in
tandem with the movements described previously. Swedish massage and Swedish gymnastics were noted to improve circulation, relieve
muscle tension, improve range of motion, and promote general relaxation. This system eventually led to the development of physical therapy
as a profession. In the early years, massage was a major component of physical therapy. In later years, physical therapy and massagetherapy diverged into two separate professions.
According to Ling, Swedish gymnastics is a therapeutic system by which we—by means of in7uencing movement—overcome discomfort
that has arisen through abnormal conditions. Ling's system consists of three primary movements: active, passive, and duplicated. Active
movements were stretching movements done by the patient alone (e.g., exercise). Passive movements were movements of the patient
performed by the therapist (e.g., stretching, joint mobilizations). Duplicated movements were those performed by the patient with the
cooperation of the therapist (e.g., active assistive movements). As part of duplicated movements, the therapist may oppose (restrain) the
patient's movements (active resistive movements). Other terms used to describe Swedish gymnastics are remedial gymnastics, table stretches,
and range-of-motion exercises. In Ling's system, very little, if any, mechanical apparatus was involved.
Ling was not a physician, and his system of Swedish gymnastics was bitterly opposed by many people within the medical profession during
much of his lifetime. However, many of his students were physicians, and these individuals were convinced of the usefulness of massage and
therapeutic exercise in the practice of medicine. They spread his teachings and began to publish success stories of his techniques in respectable
medical journals. From 1813 to 1839, Ling taught his techniques at the Royal Central Institute of Gymnastics in Stockholm, Sweden, which he
founded with government support. Medical physicians could complete Ling's Swedish gymnastics program in just 1 year, compared with 2 to
3 years for nonphysicians. As more physicians were trained, massage became more acceptable as a traditional medical procedure and
practice. Ling's in7uence was so great that by 1839, 38 schools located throughout Europe were teaching his system of gymnastics and
massage. Among the biggest cities with established schools that were teaching Ling's methods were St. Petersburg, London, Berlin, Dresden,
Leipzig, Vienna, and Paris. After years of failing health, Pehr Henrik Ling died in 1839. His legacy is seen today throughout the health
professions, especially in the teachings of massage therapy, physical therapy, kinesiology, and gymnastics.
Another key individual in the history of massage was the Dutch physician Johann Mezger (1838-1909). Mezger is responsible for making
massage a fundamental component of physical rehabilitation. The French language was the international language of the nineteenth century
and Mezger is credited with introducing the still-used French terminology to describe massage techniques (e.g., eT eurage, pétrissage,
tapotement). The French also translated several Chinese books on massage, and this e. ort probably explains why French terminology to
describe massage techniques has become so common in massage laws and legislation and massage textbooks like this one.
As a physician, Mezger was much more able than Ling to promote massage using a medical and scienti4c basis. In this regard, he was quite
successful in getting the medical profession to accept massage as a bona 4de medical treatment for disease and illness. A signi4cant number
of European physicians began to use massage therapy and to publish its positive e. ects scienti4cally, and massage began to be included in
the science of medicine.
Two brothers, Drs. George Henry Taylor and Charles Fayette Taylor, introduced the Swedish movement system in the United States in 1856.
The Taylors had studied the techniques in Europe and returned to the United States, where they opened an orthopedic practice with a
specialization in the Swedish Movements. The two physicians published many important works on Ling's system. George Taylor wrote the
first American textbook on the subject in 1860 entitled An Exposition of the Swedish Movement Cure.
A third prominent American follower of the Swedish movement system was Douglas O. Graham. Not only was Dr. Graham a practitioner of
the system, but from 1874 to 1925, he also authored several works on the history of massage.
Another prominent 4gure in the United States was Hartvig Nissen, who in 1883 opened the Swedish Health Institute for the Treatment of
Chronic Diseases by Swedish Movements and Massage (Washington, D.C.). This is considered the 4rst massage school in the United States. In
1888 Nissen presented the paper Swedish Movement and Massage, which was subsequently published in several medical journals. The result of
publication was numerous letters from physicians who wanted to know more about Ling's system, and this inquiry led him to publish Swedish
Movement and Massage Treatment in that same year. Taken together, Nissen's book and Graham's A Treatise on Massage, Its History, Mode of
Application and Effects (1902) are generally credited with arousing interest by the U.S. medical profession in the benefits of massage.
While the Taylor brothers, Graham, and Nissen were convincing the medical community of the bene4ts of massage and gymnastics, several
other individuals were busy convincing the general public. Among the most famous of these individuals was John Harvey Kellogg (1852-1943)
of Battle Creek, Michigan. He wrote numerous articles and books on massage and published Good Health, a magazine that targeted the
general public (Figure 1-4). Some books Kellogg wrote, such as the Art of Massage: A Practical Manual for the Nurse, the Student and the
Practitioner, were not published until after he died in 1943. Efforts by men such as Kellogg helped popularize massage in the United States.
FIGURE 1-4 John Harvey Kellogg.
The end of the nineteenth and beginning of the twentieth centuries witnessed important changes in the use of massage, the most important
of which was the development of the 4eld of physical therapy. Physical therapy, which developed from physical education, was responsiblefor training women to work in hospitals, where they used massage and therapeutic exercise to help patients recover.
World War I provided countless opportunities for the use of massage therapy, exercise, and other physiotherapeutic methods
(electrotherapy and hydrotherapy) in e. orts to rehabilitate injured soldiers. The earlier ideas of Just Lucas-Championniere (1843-1913), an
advocate of massage and passive-motion exercises after injuries, were important in treating war victims.
By the beginning of the twentieth century, procedures of massage were accepted and the massage profession began to be used throughout
the West. In Great Britain, several women who realized the need for the standardization and professionalization of their trade formed The
Society of Trained Masseuses (1894). The organization was successful in several key areas: establishing a massage curriculum, accrediting
massage schools which underwent regular inspections, requiring quali4ed instructors for the massage classes, and establishing a board
certification program. By the end of World War I (1918), the Society had nearly 5000 members.
In 1920 the Society merged with the Institute of Massage and Remedial Exercise, and the new group became known as the Chartered
Society of Massage and Medical Gymnastics. This new group took some important steps at professionalism. Among the new membership
requirements were physician referrals and the issuance of certi4cates of competence to persons who passed the required tests. By 1939 the
membership in the organization numbered approximately 12,000.
After World War I, medical organizations such as the American Society of Physical Therapy Physicians also formed. In the 1920s and 1930s,
programs for physical therapists were becoming standardized, while at the same time physicians were being trained in the 4eld. In 1926 John
S. Coulter became the 4rst full-time academic physician in physical medicine at the Northwestern University Medical School in Evanston, Ill.
By 1947 the field of physical therapy and rehabilitation was established as a separate medical specialty.
Although many masseurs and masseuses frowned on the encroachment of the medical profession on their art form, the events just described
can be viewed with excitement. By the early part of the twentieth century, the Western medical profession had begun to realize what the
Chinese and masseurs and masseuses had long preached: Massage had an important place in the treatment of illnesses and diseases. The
professionalism of medical gymnastics (now called physical therapy) simply meant that, in addition to learning the art of massage, the
therapist needs also to acquire the scienti4c background necessary to understand human anatomy, physiology, and pathology. As this
textbook illustrates, the authors and contributors also believe in a well-educated, well-trained massage therapist.
As the health care system in the United States became in7uenced by biomedicine and technology in the early 1900s, physicians began
assigning massage duties to nurses because massage therapy is labor intensive and time-consuming. Gradually, massage per se became less
common in medical contexts; it became one procedure in the arsenal of rehabilitation. As one consequence, the British Chartered Society of
Massage and Medical Gymnastics changed its name to the Chartered Society of Physiotherapy. The 1930s and 1940s saw a continuing decline
in the number of nurses practicing massage therapy, until it was eventually dropped from nursing school curricula in the 1950s.
The Esalen Institute
The Esalen Institute is a retreat center and educational institution in California that, since its founding in the early 1960s, has served as a
crossroads for many of the intellectual and cultural forces that in7uenced the development and popularization of massage therapy, and
changed the way we view massage in the United States. Because of Esalen, for the 4rst time since the gymnastics movement in the 1800s,
massage therapy was again associated with personal development, mind/body well-being, and overall health, as opposed to being a
primarily fitness-associated or rehabilitative discipline practiced in health clubs, hospitals, or rehabilitative centers.
Esalen is located near natural hot springs, which were used in the 1870s by tourists who su. ered from arthritis. In 1910, the hot springs
were bought by Henry Murphy, a physician who converted the settlement into a European-style health spa. In the early 1950s, Michael
Murphy and Richard Pierce, founders of the Esalen Institute, went to Stanford University together, where they studied comparative religion
and Indic studies. They became good friends in the early 1960s, after Price su. ered a psychotic break, and Murphy traveled to India to stay in
several ashrams. They traveled to Big Sur in 1961, where Murphy's family lived, and began planning a center that would encourage people to
discover their human potential. They envisioned Esalen as a think tank for the ideas that came to shape what became known as the
“counterculture” in America.
Murphy and Pierce had the Esalen Institute up and running by 1962 with help from Murphy's grandmother who managed the property;
Frederic Speigelberg, their Indic studies professor at Stanford; Alan Watts, a writer of Eastern philosophy; Aldous Huxley, author of Brave New
World; Gerald Heard, a philosopher and writer; and Gregory Bateson, a social scientist. They o. ered guests classes in world mythology,
spiritual healing, Tantric practices, hypnosis, and massage. In fact, massage has always been part of Esalen's course offerings.
Many teachers in the gymnastics movement migrated to the United States after being displaced by World Wars I and II. These teachers
included psychologist Wilhelm Reich, who developed ideas behind many body-mind approaches; Bess Mensendieck, whose work in7uenced
posture training methods used by East Coast prep schools and private universities; and Charlotte Selver, whose sensory awareness practices
in7uenced thousands of teachers and therapists until her death at age 102 in 2003. Like the gymnastics movement in the 1800s, Esalen's
practices were part of larger cultural trends that focused on “natural” health. For many people, Esalen was their 4rst exposure to massage
and where many came to learn massage.
Founders and therapists of di. erent massage methods came to debate and learn from each other. Some of these early teachers include F.
Matthias Alexander, Moshe Feldenkrais (founder of the Feldenkrais Method, which increases self-awareness through movement), Alexander
Lowen (developer of bioenergetics, a form of mind-body psychotherapy), Ida Rolf, (founder of structural integration or Rol4ng), and Fritz
Smith (founder of Zero Balancing).
Ida Rolf (1898-1979) in particular, in7uenced the teachings at Esalen Institute, which in turn, shaped the way America views massage
(Figure 1-5). Her method, Rol4ng, or structural integration, is one of the in7uential styles of body therapy with roots at Esalen. Although Ida
Rolf did not have a background in massage therapy, she did have background in biologic sciences (receiving her PhD in organic chemistry
from Colombia University), in Eastern and esoteric practices like yoga, and in the American tradition of osteopathic manipulation, having
worked for some time as an understudy and secretary to William Garner Sutherland (1873-1954), a key 4gure in the development of the
cranial osteopathy. Sutherland, in turn, listed among his early in7uences Civil War surgeon Andrew Taylor Still (1826-1917), who, horri4ed
by the brutality of battle4eld medicine, developed practices aimed at optimizing health (Figure 1-6). Rolf's teachings brought together the
long-running osteopathic teachings with the awareness and personal development focus at Esalen. Visiting teachers at Esalen have included
many leaders in health and healing, such as Andrew Weil, Deepak Chopra, and Don Hanlon Johnson. Teachers and residents at Esalen inrecent decades include Dub Leigh (Zen Bodywork), Betty Fuller (Trager), Bonnie Bainbridge Cohen (Body/Mind Centering), Emily Conrad
Da'oud (Continuum), Judith Aston (Aston Kinetics), Thomas Hannah (Somatics), John Upledger (Craniosacral Therapy), Hugh Milne
(Visionary Craniosacral), Til Luchau (Advanced Myofascial Techniques), Dean Juhan (author of Job's Body), and many others.
FIGURE 1-5 Ida Rolf, founder of Structural Integration or Rolfing.
FIGURE 1-6 Andrew Taylor Still, helped develop cranial osteopathy.
Massage therapists at Esalen developed a distinct style, Esalen Massage. Since the 1980s, Esalen massage has been taught internationally
by several schools and has its own professional association.
Massage Professional Organizations and Associations
In 1943, postgraduates from the College of Swedish Massage in Chicago created the American Association of Masseurs and Masseuses
(AAMM). The AAMM changed its name to the American Massage and Therapy Association in 1958 and then again to the American Massage
Therapy Association (AMTA) in 1983. It is the second largest massage therapist organization, with 58,000 members in 51 chapters (all 50
states and Washington, D.C.), and additional members in 18 other countries.
Log on to the Evolve website and access the additional resources for Chapter 1. View the membership pin of the American Association of Masseurs
and Masseuses from the 1960s, the current logo of the American Massage Therapy Association, and the current logo of the American Bodywork and
Massage Professionals. ▪
The Associated Bodywork and Massage Professionals (ABMP) was founded in 1987 as an organization that would include not only massage
therapists but also all current and emerging bodywork styles. As of 2010, it has grown to more than 70,000 members and is currently the
largest organization that serves massage therapists. One signi4cant di. erence between the two organizations is that AMTA's board is elected
and ABMP's board is appointed. Another important difference is that the AMTA has state chapters and the ABMP does not have state chapters.
“When you steal from one author, it's plagiarism; if you steal from many, it's research.”
Wilson Mizner
In the last 25 years, popularity has risen for massage therapy in the United States. This increase has been especially important for
individuals looking for alternative and complementary therapies (e.g., nutrition, physical 4tness, herbal remedies, acupuncture, acupressure,
massage therapy) to supplement medical treatments and improve health and wellness. Massage has been shown to be bene4cial for many
people and has become a respected and much-used health care modality.
In 1988 the AMTA encouraged the development of national certi4cation, and created the National Certi4cation Board of Therapeutic
Massage and Bodywork (NCBTMB). In 1992, NCBTMB became an independent organization and began o. ering a National Certi4cation
Exam. Initially, NCBTMB o. ered a single examination, the National Certi4cation Exam for Therapeutic Massage and Bodywork (NCETMB).
This exam included both Eastern and Western principles. In 2005 a second examination was o. ered, the National Certi4cation Exam for
Therapeutic Massage (NCETM), which focused solely on Western principles. These exams were adopted by most states as a licensure
The use of the same exams for both certi4cation and licensure was unique among professional credentialing. In other professions,
certi4cation is an advanced credential that distinguishes the certi4cant from those with only entry-level skills. For example, physicians
become licensed 4rst; after additional training, experience, and passing of exams, he or she becomes Board Certi4ed. Accountants becomelicensed first then can obtain Certified Public Accountant (CPA) status by completing certain criteria.
In 2013 NCBTMB retired the National Certification credential and launched a Board Certification credential. (See Chapter 17 for a summary
of certi4cation criteria.) In 1990 AMTA established the American Massage Therapy Association Foundation to further advance massage by
supporting scienti4c research. In 2004, the foundation shortened its name to the Massage Therapy Foundation and became an independent
organization, no longer under the AMTA. Along with massage research, the foundation includes services such as education and community
Another important event in massage history is the establishment of the Touch Research Institute in 1992 by Dr. Ti. any Field at the
University of Miami School of Medicine. The Institute's team of researchers is the 4rst in the world to study solely the e. ects of massage and
touch therapy and its applications in science and medicine and the treatment of disease. Much of their research has shown that massage
therapy has numerous beneficial effects on health and well-being.
The Federation of State Massage Therapy Boards was formed in 2005 to address the need for a valid and reliable licensing examination and
the desire to bring commonality in licensing requirements to assist with reciprocity and professional mobility. To this end, the Federation
developed the Massage & Bodywork Licensing Examination (MBLEx), which was released in 2008. In 2014, the MBLEx became the only exam
offered to massage therapists for state licensure.
In 2008 organizations tied to the massage therapy profession came together to discuss the development and adoption of a single body of
knowledge. A profession's body of knowledge is generally described as a compendium of what an individual must know and/or be able to do
to successfully accomplish work in a speci4c 4eld. This document would serve the profession as a living resource of competencies, standards,
and values that would inform and guide domains of practice, licensure, certification, education, accreditation, and research.
Most bodies of knowledge are produced by the professional association for that 4eld. Since massage therapy does not have a single
professional association, a stewardship group was formed by 4ve of the major organizations in the 4eld: American Massage Therapy
Association (AMTA), Associated Bodywork & Massage Professionals (ABMP), Federation of State Massage Therapy Boards (FSMTB), Massage
Therapy Foundation (MTF), and National Certi4cation Board for Therapeutic Massage & Bodywork (NCBTMB). In 2009 this Stewardship
group appointed an independent task force to create the inaugural Massage Therapy Body of Knowledge (MTBOK), which was released in
2010. In 2014, the Entry Level Analysis Project (ELAP) was released as suggestions for entry-level massage therapy instruction programs.
To date, approximately 80 massage methods have been classi4ed. Although space limitations prohibit detailed discussions of these
procedures, a listing of several styles has been compiled on the Evolve website. These styles have been categorized according to their primary
approach on the human body, mind, and spirit. Most of these styles were developed in the United States after 1960.
Pehr Henrik Ling
Did you ever wonder what is so Swedish about Swedish massage, when the language often used to talk about it is French and the
movements are used throughout the world? The answer lies in the life of Pehr Henrik Ling, known everywhere as the father of Swedish
Ling was born in Småland (the traditional province in southern Sweden) in 1776. Far from showing promise in his studies, he was
expelled from school for bad behavior, then traveled Europe for a while before 4nally returning to Sweden. Upon his return he took up
fencing, the classical sport of sword 4ghting. Eventually, he accepted a position at the University of Lund, where he taught fencing and
gymnastics and studied anatomy, physiology, and kinesiology.
Naturally, Ling's growing understanding of the human body started to impact his teaching. He noticed that the movements his students
made were far from ideal from a physiologic perspective, but so habitually ingrained that it was di5 cult for the students to learn
movements that were more e5 cient. Ling decided to dedicate himself to teaching better movement, feeling that this would be good not
only for students and athletes, but also the Swedish military, which had recently lost Finland in a war with Russia.
Ling's new system of movement education for physical rehabilitation and retraining (called Swedish gymnastics) required very little
equipment, and focused on the use of simple stretches. Some were active movements done by the student alone. Some were passive
movements, during which the student relaxed and another student guided the body's movement. Others were cooperative movements, in
which the student provided the impetus for the movement, and another student would either assist or resist.
Ling's work took on a new dimension in 1813, when he opened the Swedish Royal Central Institute of Gymnastics. It was here that he
expanded on his system of rehabilitative gymnastics and exercise, which was known variously as the Ling System, Swedish Movements,
and The Swedish Movement Cure. While Ling's main focus was on the medical use of movement training (which laid the foundations of the
modern field of physical therapy), massage was also a part of the Swedish Movement Cure, giving rise to the term Swedish massage.
Ling died in 1839, after years of failing health, but his impact on the medical world has only spread further with time. The 4elds of
physical therapy, massage therapy, kinesiology, and gymnastics all owe a huge debt to Pehr Henrik Ling, the renegade remedial
gymnastics teacher and father of Swedish massage.
Although the use of movement and massage for health promotion and rehabilitation is now well-established, the medical profession did
not always take kindly to Ling's new system during his lifetime. This is not surprising given his background; imagine what would happen if
a high school dropout and football coach decided to open up a physical therapy clinic today.
Although Ling's lack of formal education in medicine aggravated many in the medical establishment, quite a few of his students were
physicians, and these students spread rave reviews of Ling's system all across the country, even publishing success stories in reputable
medical journals. By 1851, Ling's system was so popular that 38 schools were teaching his signature combination of gymnastics and
massage all across Europe, which goes to show what one can do with solid observations when faced with prejudices rooted in tradition.
Human Trafficking: a Dark Chapter in Massage History
Historically, prostitution has used the term massage therapy as cover for their operations. Although great strides have been made to
distinguish legitimate massage therapy from the sex trade, as of 2010, there were still an estimated 525 massage parlors that o. ered sex
services in New Jersey alone. In 2011, an estimated 5,000 fake massage businesses operated in the United States. A study done by the
Sociology Department of Columbia University found that sex workers disguised as massage therapists have been able to locate clients through
the Internet. This has allowed sex workers to move from street walking to indoor markets like “massage parlors.” This dark chapter in
massage history is still among us.
Human tra cking is the unlawful trade of people; it is modern-day slavery. Victims are usually women; about half are children. Poor
socioeconomic conditions and promises of a good job, an education, and a better life are often part of the 4rst encounter between tra5 ckers
and victims. To hold up their end of the bargain, victims are forced to provide services; these services range from commercialized sexual
exploitation (the most common form of human tra5 cking) or work in farms, factories, or hotels. It can also involve organ removal and
surrogacy. According to data provided by the Polaris Project (forerunners of human tra5 cking research, outreach, and victim identi4cation),
victims of tra5 cking who work under the cover of massage are often young women from Asia, South America, and the former Soviet Union.
Underage Americans are also tra5 cked across state borders to work in massage parlors as prostitutes. According to the Polaris Project,
human trafficking is the third largest source of profit for organized crime, just behind drug trafficking and gun or firearm trafficking.
Several diploma-mill “massage schools” have arisen that fabricate training and sell massage diplomas and transcripts to tra5 ckers who
distribute the documents to their sex trade workers. This is an attempt to impart a cover of legitimacy to illegal practice of massage.
Thirtyone massage schools were found to be illegitimate by The California Massage Therapy Council in 2010.
To combat the problems associated with human tra5 cking in massage, the FBI has been conducting operations in suburbs to help free
young women. Congress passed the Tra5 cking Victims Protection Act in 2000, which created public awareness programs in countries from
which young women are usually tra5 cked, monitoring and sanctions programs at the state level, a visa program for victims who wanted to
go back to their families and severe penalties for criminals who engaged in these crimes. This act also created the O5 ce to Monitor and
Combat Tra5 cking in Persons in 2001, and launched the Innocence Lost National Initiative, which helped rescue almost 900 children and
convict more than 500 pimps and others involved with trafficking.
The NCBTMB is drawing attention to human tra5 cking by including an antihuman tra5 cking pledge dated and signed by every assigned
school, approved continuing education provider, and every certificant.
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Wide AG. Handbook of medical and orthopedic gymnastics. Funk and Wagnall: New York; 1905.
Zysk KG. Religious healing in the Veda, with translations and annotations of medical hymns in the Rgveda and the Atharvaveda and renderings
from the corresponding ritual texts. American Philosophical Society: Philadelphia; 1985.
Activities and Assessments
Place the letter of the answer next to the term or phrase that best describes it.
A. 3000 BC
B. Amma
C. Arte Gymnastica
D. Ayurveda
E. China
F. Hippocrates of Cos
G. Pehr Henrik Ling
H. Massage therapy
I. Johann Mezger
J. Middle 1900s
K. Nei-ching
L. Swedish gymnastics
_____1. What is the manual manipulation of the soft tissues of the body?
_____2. Records have revealed that the practice of massage goes back as early as _______.
_____3. What is the original massage technique in China?
_____4. In what country did the first written accounts of therapeutic rubbing (massage) originate?
_____5. Who is the father of modern Western medicine?
_____6. What is the classic scripture of traditional Chinese medicine?
_____7. Who is regarded as the father of Swedish massage?
_____8. When did the term massage first come into use?
_____9. What is the sacred practice of the Hindu tradition; means code of life?
_____10. The individual whose efforts led to the use of French terminology to describe massage techniques.
_____11. The work generally credited as being the first book in the field of sports medicine.
_____12. According to Ling, a therapeutic system by which we, by means of influencing movement, overcome discomfort that has arisen
through abnormal conditions.Think about It
Help Wanted
It is your responsibility to hire a massage therapist for a position that has just become available. Write a job description. Be sure to include
minimum academic, licensure, certi4cation, and/or experience requirements. If available, post your job description on an Internet-based
discussion board monitored by your instructor.
This Webquest will help to familiarize yourself with the organizations that inform and serve our profession. Use the Internet to look up the
following organizations.
• American Massage Therapy Association http://www.amtamassage.org/
• Associated Bodywork and Massage Professionals http://www.abmp.com/home/
• Federation of State Massage Therapy Boards http://www.fsmtb.org/
• National Certification Board for Therapeutic Massage and Bodywork http://www.ncbtmb.org/
• Massage Therapy Foundation http://www.massagetherapyfoundation.org/
• Massage Therapy Body of Knowledge http://www.mtbok.org/
Locate information regarding their history and current events. Write a brief paragraph about each organization and share it with your
class. Post your work on an Internet-based discussion board monitored by your instructor (if available).
The Many Faces of Massage
This chapter mentions many methods and styles of massage therapy and there are many not mentioned. Choose a method and write a 50 to
75 word summary. You can use the Internet or call a local therapist who has received training in the method you have selected as a resource.
If you used a website, be sure to include the link at the end of your summary. Post your summary on an Internet-based discussion board
monitored by your instructor (if available).C H A P T E R 2
The Therapeutic Relationship
Megan E. Lavery, Susan G. Salvo
“Today I shall behave, as if this is the day I will be remembered.”
—Dr. Seuss
Learning Objectives
After completing this chapter, the student should be able to:
1. Define the therapeutic relationship and state several key characteristics.
2. Discuss the importance of professionalism, including confidentiality and mandatory reporting.
3. Define boundaries and describe types of boundaries.
4. Compare and contrast transference and countertransference, as well as how to manage boundaries.
5. Define and discuss dual relationships and reasons why they can be problematic.
6. Define and give examples of sexual misconduct, sexual risk management, and identify steps to take when a
colleague is accused of sexual misconduct.
Interpersonal skills help form the relationship between massage therapists and their clients. This relationship,
the therapeutic relationship, is the basis of all treatment approaches regardless of their speci%c aim. During our
initial contact, a client needs to feel that we are reliable, trustworthy, and consistent. The client needs to also
feel that the relationship will be conducted within appropriate and clear boundaries. A boundary helps establish
personal and professional space, can impart a sense of self, and promote feelings of safety and security.
The therapeutic relationship is a creative process and distinct to each therapist. Although this relationship
serves the best interest of the client, each person brings to the table his or her own uniqueness. The e( cacy of
the therapeutic relationship can be substantiated scienti%cally. Research has found repeatedly that a good
therapeutic relationship is one of the best predictors of positive outcomes in therapy.
The Therapeutic Relationship
The therapeutic relationship is the relationship between the therapist and the client in which the therapist
provides services that bene%t the client. We agree to act in the client's best interest and we are held accountable
for our actions. If we behave irresponsibly, there may be legal consequences, such as malpractice lawsuits,
licensing violations, and even criminal charges. Clients also have a responsibility: to comply with the
agreedupon treatment plans.
The quality of the therapeutic relationship is based on our ethical behavior, interpersonal skills, and capacity
to communicate each person's roles and expectations. It also depends on our ability to gather client
information, apply this information to our knowledge of health and illness, and then formulate a condition
appropriate client-centered session and to do this process repeatedly.
Everything we do for our clients emerges from this relationship. It provides a framework for our thoughts,
feelings, and actions. This relationship is established during the %rst session and maintained throughout
subsequent sessions. However, the duration of this relationship is highly variable and depends on the length of
service, which spans anywhere from a single session to the client's lifetime. Other terms used to describe the
therapeutic relationship are therapeutic alliance, helping alliance, working alliance, or therapeutic use of self.
Carl Rogers, an American psychologist, asserts three characteristics that promote positive growth and change
and that these must be present in the therapeutic relationship: empathy, unconditional positive regard, andgenuineness. To this list, we will add respect as a component of unconditional positive regard, congruency to
signify genuineness, and trust as essential characteristics of the therapeutic relationship (Figure 2-1).
FIGURE 2-1 Therapeutic relationships: key characteristics.
This chapter o4ers guidance in navigating the landscape of therapeutic relationships, which involves
recognizing what does belong in the relationship and what does not belong. We will also focus on ethical
behavior, professional boundaries, confidentiality, and conflict resolution.
Empathy is the ability to comprehend the unique world of another person through their perspective. Empathy is
often described using metaphors such as “standing in someone else's shoes” or “seeing through someone else's
eyes.” Empathy is recognizing and understanding the client's feelings and experiences without mistaking them
for your own. Sympathy, on the other hand, is feeling the client's feelings as your own; it is a comingling of the
client's world with yours without di4erentiation. Empathy depends on knowing yourself deeply and having
good boundaries.
E4ective treatment planning often depends on our ability to empathize. Clients are often more willing to
disclose information if they feel the therapist is empathetic to their needs, genuinely wants to know more about
them, and has the capacity to process their information. Empathy and deep understanding are also
demonstrated in situations where the client's goals are met best by collaboration with or referral to other health
care providers.
Empathy has another important aspect to massage. Studies indicate that when physical touch is combined
with empathy, the hormone oxytocin is released. Oxytocin is associated with a deep sense of emotional
connection, a feeling of bonding, and a peaceful happy state of mind. Discussions about oxytocin were initially
focused on its roles in childbirth and lactation, but newer studies give a broader perspective.
Respect is the choice to treat someone or something with value and consideration. Respect can be given to
yourself, to others, and to situations regardless of con: icting beliefs. Respect is exhibited through words and
actions. How do we show respect?
We show respect when we take care of ourselves by making healthy choices, eating the right foods in the
right amounts, by exercising regularly, by getting enough rest, by expressing our emotions appropriately, and
by using proper body mechanics. Chapter 4 is dedicated to self-care.
We show respect for emotions when we acknowledge our feelings and the feelings of others. We show respect
for privacy when we deliberately refrain from disclosing personal information. We show respect when we
explain the who, how, why, and when of treatment. We show respect when we listen to clients and respond to
their questions. We also show respect when we modify pressure during the massage when requested by the
We show respect by having and implementing professional boundaries. We value and take into considerationthe client's personal space, their thoughts and feelings, their time, and any %nancial restrictions they may have.
Draping, a physical as well as an emotional boundary, can be viewed as an act of respect.
We show respect when we refer clients to appropriate health care providers as needed to help clients ful%ll
therapeutic goals. We also demonstrate respect when we acknowledge and do not abuse the power di4erential
that is inherent to therapeutic relationships.
We show respect to our colleagues and to other health care providers by not denigrating them or their
methods. Working within our scope of practice shows respect for the legal parameters of our professional
activities. We show respect to our profession and other professions by not performing services for which we are
not licensed (such as joint manipulations, prescriptive exercise, or counseling, all of which are under the
practice of chiropractic, physical or occupational therapy, and psychotherapy, respectively). We show respect
by following our code of ethics and by dutifully following laws that apply to the society in which we live.
We also show respect for people from other cultures by a willingness to learn about them and by accepting
their customs, their beliefs, and way they view the world. What may be commonplace to us may be
inappropriate to others. For example, the “thumbs-up” symbol in America is a sign of approval but in the
Middle East, it means to “stick it where the sun does not shine.” The “okay” sign means satisfactory in America,
but it means money in Japan and zero or worthless in France. In Brazil, the “okay” symbol is the equivalent of
sticking up your middle finger.
Unconditional Positive Regard
Unconditional positive regard is acceptance of another person regardless of what he or she says or does.
When we accept the whole person unconditionally, we validate and respect their humanity including physical,
mental, spiritual, and emotional aspects.
This validation has the potential to be deeply healing for the client. Too few times in life do people truly feel
understood and accepted for who they are. Rogers is given credit for this term and he believed that
unconditional positive regard is essential to the therapeutic relationship and provides the best possible
environment for positive therapeutic outcomes.
This means that we use our knowledge, skills, and abilities to best serve the client goals without inserting our
own agenda. For example, when clients request relaxation massage because they feel extreme stress, you do not
derail the session by turning it into a clinical massage session for their neck and shoulders. Their goal for the
session was relaxation. Targeted techniques on the neck and shoulders or o4ering stretching tips and feedback
about their tight upper back muscles would invalidate the client's wishes and not be in accord with
unconditional positive regard. When a therapist puts their own goals ahead of the client's goals, the client may
leave feeling like they were not heard by the therapist.
Unconditional positive regard means that we acknowledge to ourselves that while treatment planning is a
cocreative process, ful%llment of therapeutic goals is dependent on factors out of our control. We suspend our
own therapeutic agendas and truly regard and accept the client's progress or lack of progress. For example,
while reassessing range of motion, we avoid thoughts or statements such as “I wish you would stretch more,” or
“I wish you would relax more.” Accept clients for who they are right now and let go of thoughts that reduce
your acceptance of them. The ability to hold clients in a container of unconditional positive regard (also called
highest personal regard) shows deep respect, because we accept them even if we do not agree with them.
Unconditional positive regard is demonstrated legally when we obtain consent for therapy, stating that we
cannot discriminate, specifically in regards to race, nationality, gender, religion, or sexual orientation.
“When we work from a place of compassion, it is a place of non-judgment, non-comparison, without the need to
understand. With compassion we are not entrained in the drama of the client's story, we are just with them. This is
love, which resides in the heart.”
Fritz Frederick Smith
Compassion into Action
Sometimes having unconditional positive regard means we have to look at our own judgments and identify
our own prejudices. We have to really see the client as a person and %nd a way to view them with
compassion. Imagine a client who comes in complaining of severe neck pain from her shoulders to her
occiput. She states that she does not want for you to work on her in the prone position, because it wouldmess up her makeup. She lays supine on your table and instructs you not to work on her scalp or mess her
hair up. It is not hard to imagine that it would be frustrating to try to work with this client and that many of
us would have judgmental thoughts about her insistence that her hair and makeup not be mussed. Now think
about this woman's self-worth, her self-esteem. What led her to the belief that looking good is more
important that being pain-free? What was she told as a child about what was good and valuable about
herself? How was she loved? How does she feel about herself? When we think of these aspects of who she
may be, using empathy, most of us would have a change of attitude. We now see her as more than just a
person who does not want her makeup messed up. And from this place we can hold her in compassion, in
unconditional positive regard. And when we do, we can most likely be very creative and %nd a way to work
on her neck and shoulders while honoring her requests.
—Megan Lavery
Trust is a feeling of con%dence in someone or something. It requires a willingness to take risks and to be
vulnerable to the actions of another. Trust and con%dence grow when risk taking is met with ful%lled
expectations. If expectations are fulfilled, the person is likely to trust again.
Within the therapeutic relationship, feelings of trust may lead to clearer communication and better
identi%cation of client goals and expectations, which may result in better therapeutic outcomes. Be sure to
disclose what the client can expect from your treatment methods. This includes bene%ts and potential negative
side e4ects, such as soreness and bruising. Even when negative side e4ects occur, clients are more likely to
perceive you as trustworthy when you disclose all the facts.
If your demeanor, attire, or speech is inconsistent with the level of professionalism that the client expects, he
or she may become alarmed and mistrustful of the competence of care (Figure 2-2).
FIGURE 2-2 The massage therapist is a professional in demeanor, dress, and speech.
Trust is also demonstrated when we safeguard the therapeutic relationship. This is accomplished by
professional boundaries, which protect the sanctity of the therapeutic relationship. Clear boundaries and a
relationship that is predictable help promote feelings of trust and safety.
Trust can be easily upset by important issues and by seemingly insignificant things. For example, it is best not
to tell a client that he or she can call you anytime. Although you may be sincere in wanting to help the client,
you may be uncomfortable receiving a call at 3:00 AM. A careless statement may mislead the client, weaken
trust, and possibly damage the therapeutic relationship. Do not make or imply promises you cannot keep.
Power Differential and Vulnerability
Each person in the therapeutic relationship has a di4erent role. One person, the client, has a particular need
and asks for help from another person, the therapist, who has knowledge, skills, and abilities in speci%c areas.
This situation creates a power differential with the client in the more vulnerable role.
A power di erential is an increase in the amount of power that exists in any position of authority. Power
itself is neutral. It can be used to help or to harm. Anytime one person has knowledge and skills or things
needed by another person, that person is in a position of power and the other person is in a position of
vulnerability. Vulnerability is susceptibility of being wounded or harmed physically, mentally, and
emotionally. There are many types of vulnerability such as social, cognitive, economic, and institutional. An
example of power di4erentials and vulnerability is if a young healthy man left his car lights on and his car
battery died. He is in a vulnerable position. If an older adult woman has jumper cables and parked next to him,
she would be in a position of power. She can jump-start his car, using her power for good or she can laugh anddrive away, using her power to make him more vulnerable.
In therapeutic relationships, this imbalance of power occurs naturally and, in and of itself, is not a problem.
However, problems can arise when power is used to serve our own interests instead of the client's best interest.
When the person with the greater power and authority does not recognize or respect power or it is not
wellbounded, client abuse and neglect can occur. Problems can also arise when therapists do not acknowledge or
are uncomfortable in the position of power. New therapists may not view themselves as powerful. There may be
a belief that therapists and clients are equals because we collaborate during treatment planning. And although
we do collaborate with our clients, we still are in the position of power. Not accepting the power that goes with
our role as therapists can make it more di( cult to maintain boundaries. Maintaining boundaries is our
responsibility (Box 2-1).
Box 2-1
In the Service of Life
In recent years the question “How can I help?” has become meaningful to many people. But perhaps there is
a deeper question we might consider. Perhaps the real question is not how can I help, but how can I serve?
Serving is di4erent from helping. Helping is based on inequality; it is not a relationship between equals.
When you help you use your own strength to help those of lesser strength. If I am attentive to what is going
on inside of me when I am helping, I %nd that I am always helping someone who is not as strong as I am,
who is needier than I am. People feel this inequality. When we help we may inadvertently take away from
people more than we could ever give them; we may diminish their self-esteem, their sense of worth,
integrity, and wholeness. When I help I am very aware of my own strength. But we do not serve with our
strength, we serve with ourselves. We draw from all of our experiences. Our limitations serve, our wounds
serve, even our darkness can serve. The wholeness in us serves the wholeness in others and the wholeness in
life. The wholeness in you is the same as the wholeness in me.
Helping incurs debt. When you help someone they owe you one. But serving, like healing, is mutual. There
is no debt. I am as served as the person I am serving. When I help I have a feeling of satisfaction. When I
serve I have a feeling of gratitude. These are very different things.
Serving is also di4erent from %xing. When I %x a person I perceive them as broken, and their brokenness
requires me to act. When I %x I do not see the wholeness in the other person or trust the integrity of the life
in them. When I serve, I see and trust that wholeness. It is what I am responding to and collaborating with.
There is distance between ourselves and whatever or whomever we are %xing. Fixing is a form of
judgment. All judgment creates distance, a disconnection, an experience of di4erence. In %xing there is an
inequality of expertise that can easily become a moral distance. We cannot serve at a distance. We can only
serve that to which we are profoundly connected, that which we are willing to touch. This is Mother Teresa's
basic message. We serve life not because it is broken but because it is holy.
If helping is an experience of strength, %xing is an experience of mastery and expertise. Service, on the
other hand, is an experience of mystery, surrender, and awe. A %xer has the illusion of being causal. A server
knows that he or she is being used and has a willingness to be used in the service of something greater,
something essentially unknown. Fixing and helping are very personal; they are very particular, concrete,
and speci%c. We %x and help many di4erent things in our lifetimes. But when we serve we are always
serving the same thing. Everyone who has ever served through the history of time serves the same thing. We
are servers of the wholeness and mystery in life.
The bottom line, of course, is that we can %x without serving. And we can help without serving. And we
can serve without %xing or helping. I think I would go so far as to say that %xing and helping may often be
the work of the ego, and service the work of the soul. They may look similar if you are watching from the
outside, but the inner experience is different. The outcome is often different, too.
Our service serves us as well as others. That which uses us strengthens us. Over time, %xing and helping
are draining and depleting. Over time we burn out. Service is renewing. When we serve, our work itself will
sustain us.
Service rests on the basic premise that the nature of life is sacred, that life is a holy mystery which has an
unknown purpose. When we serve, we know that we belong to life and to that purpose.Fundamentally, helping, %xing, and service are ways of seeing life. When you help, you see life as weak.
When you %x, you see life as broken. When you serve, you see life as whole. From the perspective of service,
we are all connected: All su4ering is like my su4ering and all joy is like my joy. The impulse to serve
emerges naturally and inevitably from this way of seeing.
Lastly, %xing and helping are the basis of curing, but not of healing. In 40 years of chronic illness I have
been helped by many and %xed by a great many others who did not recognize my wholeness. All that %xing
and helping left me wounded in some important and fundamental ways. Only service heals.
By Rachel Naomi Remen, MD
“In the Service of Life,” adapted from a talk given by Rachel Naomi Remen at IONS fourth annual conference,
first appeared in the Noetic Sciences Review, (Spring 1996, issue number 37), published by the Institute of
Noetic Sciences (IONS), and is reprinted with permission of IONS (www.noetic.org), all rights reserved.
Copyright 1996.
The law holds the professional to a higher standard of behavior because of the power di4erential. The power
di4erential can disempower clients—it may be di( cult for clients to say “no” easily. Laws exist to protect
vulnerable populations such as children and elderly from maltreatment. This is called the “duty to protect.”
More information can be found in the section on Mandatory Reporting. Clients come to us and are often in pain
or under considerable stress. Clients lie down, often undressed and draped, while we stand over them. This
position during therapy may enhance vulnerability in clients who already feel vulnerable. We should do
whatever we can to reduce feelings of apprehension by respecting the therapeutic relationship and by using our
position to serve the best interests of our clients.
Congruency occurs when the external presentation of your words and actions coincide with your internal world
of thoughts and feelings. It means that you are sending a picture of the real you. When you are authentic and
genuine, what is displayed outside matches with what is going on inside. Rogers calls the integration of
thoughts, feelings, and actions congruency.
Congruency is conveyed by listening to and communicating with clients without distorting their message. You
must sincerely believe that clients and their problems are important and worthy of consideration. When this
type of connection is made, a deeper examination of their problems, implications, and solutions are possible.
Being congruent and authentic also means that while I am aware of my thoughts and feelings, I choose
whether or not to express them. We self-re: ect before we self-reveal and disclose only what is appropriate in
professional settings. This does not mean that you say everything that you think or feel. It does mean that what
you say and do is consistent with your understanding.
Being congruent also means that we maintain a conscious awareness of where our thoughts and attention are
during the session. This heightened self-awareness and focused attention is called mindfulness. We acknowledge
(nonverbally) any personal feelings we have when we are with clients. We hold all feelings as normal, be it
fear, anxiety, joy, peace, or boredom. We can be most fully present for our clients when we fully embrace
ourselves nonjudgmentally %rst. When we accept who we are, our faults, our strengths, our past, our wounds,
when we have self-knowledge and self-love, then we can truly be with and accept others.
Think about a situation where you felt someone's words did not match their body language. Perhaps a social
situation where we were taught to say little white lies, such as we enjoyed a meal when we did not like it at all.
It is confusing when we hear untruths—it undermines trust. Our words and actions must match. For example, if
a client asks us how our day is going and we are not having a good day, it may be confusing for clients to hear
we are doing great when we look like we are not. Instead say that we are happy to see them and de: ect the
question by asking how they are doing. To do this, we have to know ourselves well. Being congruent and
genuine allows me to be present with clients while allowing my own experience to emerge. This type of
presence is not possible when you are detached emotionally and not honoring yourself.
When you are congruent and genuine, your clients are more likely to trust and respect you, which may lead
to a more meaningful relationship. You also become a role model for congruency and help clients evolve a more
authentic sense of self. The classic children's story The Velveteen Rabbit talks about what it means to be real.“When a child loves you for a long, long time, not just to play with, but REALLY loves you, then you become real
… by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in the
joints and very shabby. But these things don't matter at all, because once you are Real you can't be ugly, except
to people who don't understand.”
Margery Williams
Neuroscience and the Therapeutic Relationship
There are many new areas of research that are investigating how the nervous systems of two people interact.
One remarkable %nding is mirror neurons. They were discovered in the early 1990s when scientists noticed
that a certain set of neurons %red in the brains of monkeys when they picked up a peanut. The same set of
neurons %red when monkeys watched a laboratory assistant pick up a peanut. These “mirror neurons” %red
whether monkeys did the task or observed the same task (Di Pellegrino and associates, 1992). Scientists have
mapped similar neural patterns in humans using MRI technology. It turns out that “humans… have mirror
neurons that are far smarter, more : exible, and more highly evolved than those found in monkeys… The
human brain has multiple mirror neuron systems that specialize in carrying out and understanding not just
the actions of others, but their intentions, the social meaning of their behavior, and their emotions”
(Blakeslee, 2006).
Mirror neurons may also help us empathize. Research has shown when participants observed expressions
of emotions, such as smiles or frowns, portraying feelings of happiness, sadness, or pain, their brains reacted
as if they themselves were experiencing the same emotion as they saw on the faces of others (Keyers, 2011).
Empathy can give us a deeper understanding of clients and facilitate attunement. Attunement is an
experience of connectedness that is shared between two people (Erksine, 1998). The ability to “tune in” to
clients rests on our capacity to be mindful or fully present, to listen actively and understand what clients are
saying, and to communicate this understanding back to clients. Attunement is metaphorically being in your
client's skin.
Mindfulness comes from our ability to be aware of our surrounding, both in external and in internal
environments. Awareness of our internal physical environment, such as sensations from muscles, the heart,
or intestines, is called interoception (Seigel, 2012). This awareness helps us monitor how our nervous system
is responding as we interact with clients. If you notice tension in your shoulders and your heart, and the
breathing rate increases in response to what your client has said, you may also notice your client is having
the same responses in their body. Conversely, if you notice that your shoulders are relaxed and that your
heart and breath rates are slowed, you may also notice the same patterns in your client. This information
can help you better serve your clients through a deeper connection with and understanding of their
Professionalism is the adherence to a set of values and obligations, formally agreed-upon codes of conduct,
and reasonable expectations of clients, colleagues, and co-workers. Key values of professionalism include acting
in the client's best interest and putting their interest before your own, maintaining standards expected of other
members of the profession, and staying current with changes and discoveries in the %eld. Knowing and abiding
by the laws and standards that govern the profession are part of our responsibilities as massage therapists.
Professionalism needs to be understood, practiced, and refined as much as one's technique.
Professional standards include many aspects of ethics and the therapeutic relationship, such as con%dentially,
integrity, decency, accountability, responsibility, and honor. Health care professionals should possess
psychosocial and humanistic qualities, such as caring, empathy, humility, compassion, social responsibility, and
sensitivity to the culture and beliefs of others.
Professional Appearance
Your professional appearance includes attire and grooming. Your appearance should be consistent with other
professionals in your locality, and for the type of setting in which you work (Figure 2-3). What is appropriate
for working in a day spa in Boston may be very di4erent than what is appropriate when working a triathlon in
Hawaii.FIGURE 2-3 Therapists in professional attire.
In any setting your appearance should be clean and neat, no scents or odors, nails trimmed and hair held
back from the face. Your clothing should be such that it will not drape or hang on the client during the session
yet it should not be so tight fitting as to be revealing, or so low cut as to show cleavage on women.
Tattoos, body art, and body piercing are becoming more common. While this represents personal choice,
therapists who have visible body art might consider how clients might view them. A 20-year-old client from Los
Angeles might view body art di4erently than a 60-year-old client from Tulsa. Body art could have a negative
impact on a job interview or during the initial contact with a new client; your professionalism might be called
into question. Because of this, weigh all pros and cons when considering alterations in your appearance.
From the initial contact and throughout the therapeutic relationship, clients will disclose their past and current
medical information and treatment goals. When clients share personal information such as their thoughts,
feelings, ideas, and insights, it is called disclosure. Over time, clients will disclose more information if they feel
you are empathetic, trustworthy, and genuinely curious about them.
Clients often want to have some sense of who you are as a person. They are disclosing personal information, as
well as letting you massage them. They may feel more comfortable knowing something about the person with
whom they are in a relationship. This may lead to personal questions about you.
Revealing our own thoughts, feelings, and personal history to clients is called self-disclosure. There is a %ne
line between disclosing too much and too little. This topic is debated among professionals. Many scholars in the
%elds of psychotherapy, medicine, ethics, and massage recommend that we disclose very little about our
personal selves, letting us be a blank slate so the relationship is entirely about the client. Others argue that
giving clients some personal information can help them relax and feel comfortable, knowing we are human.
Appropriate information might include how long we have lived in the area and why we moved there. Clients
often want to know about our family. This level of factual information is generally considered safe to
Too much self-disclosure or inappropriate self-disclosure can be confusing for clients, especially if therapists
disclose their own current needs or problems or when there is no clear connection to the client's goals.
Especially important is not disclosing your personal experience related to a similar problem your client ishaving. It is important that clients have their own experience and this type of self-disclosure may lead clients to
minimize their own experience and perceive your experience as more signi%cant. For example, if your client is
grieving after the death of a parent and you share your own experience of a parent that died the previous year,
the client may feel overly concerned about your feelings, and discontinue talking about their own grief. This
may prevent your client from having their needs met because they are concerned with taking care of you. Too
much self-disclosure can also lead to transference (discussed later in the chapter).
When disclosing personal information, consider your reason for doing so. Does it serve the relationship, the
client, or you? Does it create boundary problems? One clear sign that it is not in your client's best interest is
when you self-disclose to satisfy your own social needs and that you are using your client as a friend.
Finally, ask yourself if you are disclosing personal information without realizing it. Social media makes our
personal lives more accessible to our clients. Are you disclosing more than you intended? What would clients
%nd if they did a Google search on you? How will you respond to a client's friend request on Facebook or
Twitter? Allowing clients to be Facebook friends with you allows them into your inner circle. How much
personal information do you share on Facebook? Consider that privacy settings really do not create privacy and
anything you post can get reposted. How will a client respond to seeing you at a party? Or on vacation skiing?
Or wearing revealing clothes? Could transference issues be in: amed more? What might happen if clients see
you doing something that does not %t with their views of you as a therapist? How will they feel or react if they
see that you support a group or viewpoint that they disagree with? All of the information about you online is
available for your clients to see.
Electronic Communications and the Therapeutic Relationship
Many people communicate primarily by e-mail or texting. It is worth planning ahead how you will
communicate with clients. If you use either of these forms of communication, neither is fully private. You
need to consider the Health Insurance Portability and Accountability Act (HIPAA) requirements for electronic
communication. And you need to consider the boundary issues about communication with clients outside of
session time. If communications are limited to scheduling appointments, it is %ne. But what if a client uses
email to continue the session? To ask for more information about stretches or self-care you discussed? What if
they want to report about the after e4ects of an emotional response? What if it happens once? What if it
starts to happen every session? How quickly will you respond? Is there a di4erence in the response time
expected if the communication is by e-mail or text? All of these things are issues that you need to have clear
policies about to maintain clear boundaries with clients.
Confidentiality is the act of keeping information private or secret. In the assurance of con%dentiality, the
client is “con%dent” you will not disclose information without consent. Even as we discuss our cases with other
therapists and health care providers, client information should not be traceable back to them and their identity
should remain unrevealed. A breach of confidentiality is often both illegal and unethical (Box 2-2).
Box 2-2
Legal Versus Ethical Issues
Legal issues are associated with laws, rules, and regulations. The primary purpose of massage therapy laws is
to protect the public from injury or from fraud. This is done by providing rules for obtaining and
maintaining licensure. Ideally, laws promote smooth functioning of a society. If laws are broken, then civil
or criminal charges may occur. Upon conviction, therapists may be %ned, imprisoned, have their licenses
revoked, or suffer other penalties as determined by the courts.
Ethical issues are associated with human duty, appropriate right conduct, and responsibility. Professional
ethics are the values and ideals that a particular profession creates for itself, setting the standards of conduct
for its members. If these principles and standards are not followed, professionals may be suspended or
evicted from the professional society of which they have membership, as decided by peers.
Thus not renewing a state license and continuing to practice massage is illegal. O4ering stone massage
after only watching a video is unethical, but not illegal.
Can an issue be both illegal and unethical? Yes. An example of this is a breach of con%dentiality. And in
some states any issue that is unethical is also considered illegal. For example, your state licensing law may
include a provision that all licensed massage therapists adhere to the state board's code of ethics. Therefore,
any action that is listed in the code of ethics as unethical (such as dating a client, or providing services
without adequate training) would also be illegal and could result in a fine or suspension of license.
Personal information shared by the client is closely guarded and every client has the right to privacy in the
therapeutic relationship. Even the fact that they are a client cannot be disclosed. And although you cannot
disclose this information, clients can certainly tell family and friends details of their session and their perceived
quality of care they received.
Even in social situations, avoid disclosing that someone is your client. If you disclose this fact, you risk
o4ending the client and may weaken trust. Name-dropping is rarely impressive and only reveals us as
therapists who do not protect a client's privacy.
When you receive a referral from a client, avoid sharing information regarding the common acquaintance
with either client. This means not disclosing when the other has an appointment, even when asked directly. Let
us take this concept one step further; if you are treating a married couple separately, refrain from answering
questions about the other. Avoid answering even caring questions such as “Was my spouse's neck range of
motion better when you saw her yesterday?” Your reply might be “Due to con%dentiality I cannot share this
information with anyone other than that client. I hope you understand” or “I can't answer that, but I'm sure she
In social settings that include both you and your client, avoid initiating a conversation with him or her.
Perhaps make eye contact, smile, and give a nod of politeness. If the client initiates a conversation, do not
reveal treatment information if other people are nearby. Because many social settings exist in which both you
and your client may be present, you may wish to discuss how these situations will be handled beforehand,
perhaps as part of your initial visit during discussions of informed consent and your policies regarding
confidentially (see Chapter 10).
Respecting con%dentiality also means that treatment rooms are in a private setting and should be soundproof
so that people nearby cannot hear conversations in the room with the door shut. Additionally, client interviews
are conducted in private, never in public areas.
Limits to Confidentiality
The code of ethics published by the National Certi%cation Board of Therapeutic Massage and Bodywork states
that certificants will: Safeguard the con dentiality of all client information, unless disclosure is requested by the client
in writing, is medically necessary, is required by law, or necessary for the protection of the public.
What does that mean? If clients instruct us to share their information, we are obligated to do so. They have
the right to have their treatment notes released to other health care providers so that congruent treatment plans
can be developed. Clients may instruct us to release their information to lawyers or insurance companies, or
even to a translator to reduce a language barrier. In these cases, obtain the client's dated signature before
releasing the information (see Chapter 10).
When might it be medically necessary to disclose client information? If a client had a medical emergency
while at our o( ce, we need to disclose necessary medical information to %rst responders if clients are unable to
do so. For example, we would disclose information regarding medical conditions, such as diabetes;
prescriptions; medical devices, such as a pacemaker; or prior surgeries.
What is required by law varies greatly state to state. Every massage therapist should have carefully read their
own state laws and reread them when questions arise. One universal legal requirement is to comply when client
records are subpoenaed by court order.
Other situations when we must breach con%dentiality include suspicions of child or elder abuse/neglect or
when there is a threat to self or others.
Mandatory Reporting
Mandatory reporting is legislation that requires speci%c individuals or professions to report concerns of
neglect or abuse to protection agencies. Individuals or professions who are required to report usually have
regular contact with vulnerable populations such as children, disabled persons, and the elderly. In most states
health care providers, mental health counselors, and teachers are mandatory reporters and the physician-clientprivilege does not apply. It is important to know what your state laws are and if you are a mandatory reporter
(in which case you must break con%dentially to report) or if you are not (in which case you would not break
con%dentially). A document entitled Mandatory Reports of Child Abuse and Neglect is available from the Child
Welfare Information Gateway [www.childwelfare.gov]. This website also contains a State Statute Search to help
you determine if you are a mandatory reporter and, if so, who you report to. For example, in Kentucky (KY),
“all health professionals” are required to report but the extensive list of professionals does not include massage
therapists. However, KY law also clearly states, “All persons are required to report,” which would include
massage therapists. KY law also states that “privileged communications” shall not be grounds for refusing to
report, except attorney-client privilege. So therapists licensed in KY are mandatory reporters and if you suspect
abuse or neglect toward or by a client, you must break confidentially to report.
Similar information about the duty to report elder abuse can be obtained from the National Center on Elder
Abuse at http://www.ncea.aoa.gov. Follow the links to State Resources and locate the state in which you
Mandatory reporting legislation applies to you even when they are not addressed speci%cally in your state
massage laws.
Another possible legal reporting requirement is when a client poses a risk to self or others. If a client makes a
direct reference to suicide, mental health professionals are required to take action. This is called the Duty to
Protect and many other health care professionals are also required to take action. These professions are trained
to assess the validity of a threat and diagnose mental health conditions. But rules vary greatly from state to
state. Be sure to investigate whether your state law considers massage therapists to be health care professionals
(some do, some do not) and then you need to know what your state requirements are regarding threats to self.
If you work in a hospital or other setting where a health care professional supervises your activities,
reporting the incident to your supervisor is the best action. If your supervisor, or their supervisor, has a higher
level of medical quali%cation then the duty transfers to them. And it is up to them to determine the appropriate
There is also a Duty to Warn in many states when a client makes a direct threat to harm another person. The
rules about this are complicated and usually apply to mental health care professionals and medical
professionals. In some states the professional may breech con%dentially, in other states they must. If your client
makes a direct threat to harm another person while in your o( ce, seek advice from an attorney with expertise
in client con%dentially. Ask if you, as a massage therapist, have any duty and if you are legally required to
breach confidentially and to whom you should report.
Human Sex Trafficking
According to the Federal Bureau of Investigation or FBI, human sex tra( cking is the fastest growing business
of organized crime and the third largest criminal industry in the world. As massage therapists, this impacts us
since massage is the most common front for tra( cking organizations. Fake massage businesses use force,
fraud, and/or coercion to control women and get them to provide sex. Most women are not United States'
citizens, are in debt, and are isolated from any source of support. They are promised a better life in the
United States and arrive here to %nd they are indebted, have no job, no legal status, and no choices. They
are moved frequently from state to state and not able to create a support network. There are also an
increasing number of victims who are U.S. minors, recruited or forced as young as 12 years old into
The NCBTMB asks all certi%cants to sign an Anti-Tra( cking Pledge agreeing to be informed on human
tra( cking and to support NCBTMB's e4orts to combat tra( cking. More information about human sex
trafficking is found in Chapter 1.
“The quality of the therapeutic relationship has consistently been shown to be more important than the therapist's
clinical outlook.”
Kalman Glantz and John Pearce
Boundaries are guidelines, rules, and limits that we create in relationships. Boundaries help determinereasonable, safe, and acceptable ways to interact with others. Professional boundaries in the therapeutic
relationship have also been called the “therapeutic frame.” Boundaries are based on our roles in relationships.
They delineate di4erences between you and your clients. Boundaries help clarify individual responsibilities and
de%ne expectations—what we expect and what others can expect from us. Boundaries must also be : exible and
some boundaries are negotiable as we will see in the “Location Boundaries” section.
Boundaries are part of all healthy relationships. The more aware we are and the more respect we have for
our own boundaries, the more we can recognize and respect the boundaries of others. Boundaries create a sense
of predictability. This predictability helps promote feelings of trust and safety. Good boundaries pave the way
to achieving fulfilling relationships, ones that embrace empathy, respect, trust, and congruency.
Boundaries have another important role: protection. Good boundaries help us from becoming manipulated or
enmeshed in relationships with others who do not have good boundaries. Unintentional or intentional neglect
or abuse is more likely in relationships without boundaries. Good boundaries create emotional separateness, a
sense of autonomy, and a safe place for the client's experience. Let us consider Chapter 11 of the Tao Te Ching
translated by Stephen Mitchell:
We join spokes together in a wheel,
but it is the center hole
that makes the wagon move.
We shape clay into a pot,
but it is the emptiness inside
that holds whatever we want.
We hammer wood for a house,
but it is the inner space
that makes it livable.
We work with being,
but non-being is what we use.
The irony is that good boundaries cannot be learned from a book. We have all experienced boundaries in the
past beginning in early childhood and these were role modeled to us by family and friends. Hopefully, they
were examples of good boundaries and healthy relationships. If so, we know how it feels to be with someone
who is clear and careful with boundaries. If not, the process of establishing and maintaining healthy boundaries
may be challenging. In these cases, consider approaching individuals who you feel have healthy boundaries and
ask them to be your mentors. A mental health counselor may also be helpful in exploring boundaries.
The analogy of a cell might be helpful when visualizing boundaries. Imagine that you are surrounded by a
semipermeable membrane. This membrane lets nutrients in and keeps toxic materials out. This membrane also
de%nes the cell's existence by separating it from other cells. Healthy cells also have an innate intelligence; it
knows it is a brain cell and that brain cells and liver cells are di4erent types. Another analogy of healthy
boundaries is an intact immune system, which helps to maintain the boundary of the body's unique
individuality, distinguishing what is me and removing what is not me.
Having good boundaries is one of the many gifts we give to our clients; a gift that is often unacknowledged.
Types of Boundaries
Within the general context of professional boundaries, there are speci%c boundaries regarding touch and ourphysical bodies, boundaries surrounding how we handle expressions of thoughts and feelings, boundaries about
how and when we provide our services, and boundaries about what and how we charge for our services. These
boundaries are important aspects of a professional practice as they support the therapeutic relationship and
demonstrate our commitment to quality client care.
Physical Boundaries
Physical boundaries provide a barrier between you and another person. They include your physical body and
your sense of personal space. Each person has a slightly di4erent amount of personal space that feels safe to
them. In American culture, the distance is approximately 3 feet. If we stand closer than the person's “comfort
zone,” it may feel invasive to them. Conversely, if we stand further away, it may feel like we are being distant.
Physical boundaries de%ne the who, when, where, how, and under what circumstances we feel safe with
touch. Touching without the person's consent is a boundary violation. Even with consent, touching that does not
feel good is a boundary violation.
Physical boundaries are : exible and adapt to di4erent situations. Although most Americans like to have 3 feet
around them, they allow people closer in certain situations. Have you ever noticed that when a line starts, say
at a movie theater, people tend to line themselves up a normal personal distance of a few feet apart? And as
the line grows longer, the distance between people gets smaller. Over time, we might %nd we are standing
within inches of the person in front of us, and it does not bother us. This is an example of boundaries being
In massage relationships, physical boundaries change quickly. We greet our clients in the waiting room while
standing a normal distance from them. We sit closer during the intake process. We stand next to them and touch
them during the massage. At this point, the physical boundary is literally skin to skin. Once the massage is
complete, we return to a more normal distance. Just because clients allow physical boundaries to shrink during
the massage does not mean that it would be appropriate to continue touching them after they are o4 the
massage table.
We establish physical boundaries during treatment planning as clients indicate areas that need focused
attention and areas that will be avoided (i.e., local contraindications). Others physical boundaries during the
massage include:
• Letting clients choose the level of disrobing for clients who want to remain partially or fully clothed and using
techniques that do not require skin lubricant
• How clients are draped
• How the drape is moved
• Refraining from working under a drape
• How deep an area is worked
• How long an area is worked
• Not touching clients inadvertently with your clothing or body parts not engaged with the massage (be careful
how you lean against the table)
• Obtaining consent before working on the abdominal, gluteal, pectoral regions
• Use of scents or aromatherapy
• Type of massage/bodywork you perform
• Making sure clients know they are empowered to speak up if they feel uncomfortable with anything
Some therapists like to hug clients on their arrival or their departure. But hugging also represents a physical
boundary. Some questions to consider are:
• How do you know you have permission to hug someone? Was it spoken? Unspoken?
• Who initiates the hug?
• How long does the hug last?
• What is the norm for your geographic area?
• What type of work setting are you in?• Do you hug only opposite gender clients? Same gender clients?
• Do you hug only attractive clients? Unattractive clients?
• Do you hug only young clients? Mature clients?
• What determines who you hug if you hug some clients and not others?
Answers to these questions will help you formulate your own hugging policy. Some therapists only hug clients
who request one and only with the door open. Other therapists do not hug any clients, stating that other health
care providers do not hug their clients. Whatever you choose, hugs should respect the client's physical boundary
and not be forced upon them.
How you handle hugs should be : exible and depend on circumstances. If you have had a long relationship
with a client and she is moving away, a hug might be appropriate to close the relationship. If a client had a
particularly di( cult week, became emotional on the table and asked for a hug, to not do so may seem unkind.
If you suspect there is any element of sexual attraction on the part of the client, hugging would be
inappropriate. Avoid hugging any client you feel a sexual attraction toward (see “Sexual Misconduct” section).
Intellectual Boundaries
Intellectual boundaries encompass our beliefs, thoughts, and ideas, as well as safeguard our self-esteem. When
others agree with us, we tend to feel safe, validated, and close to the like-minded person. Conversely, we may
feel vulnerable when someone disagrees with us. When the disagreeing person is an authority %gure, we may
feel especially vulnerable, perhaps reverting to how we felt when a grade school teacher scorned us when we
did not produce the “right” answer.
Do you show respect for intellectual boundaries? Do items in your o( ce challenge a client's beliefs? Posters,
calendars, or art prints that espouse your philosophy may o4end clients with di4erent beliefs. Even our choice
of art could be o4ensive if they depict nudity or sensuality. This is especially true with regards to political,
religious, or spiritual beliefs. We are violating intellectual boundaries if we impose our political, religious, or
spiritual beliefs on clients who do not share them.
Clients have their own unique ways of knowing and understanding. They have the right to choose what to
think and what to do (within the limits of the law), as well as to accept the consequences of their choices.
Keep this in mind when you o4er information to clients. Do you ask if they are interested in learning more
about a topic before you present to them? Is the information tailored to their needs and wants? We are
violating intellectual boundaries when we impose our beliefs about the latest fads of nutrition and exercise on
We also violate intellectual boundaries when we disregard a client's belief about their problem even if we do
not agree with or understand their belief. Imagine a client who is seeing you for shoulder pain, and they believe
that they had it because their mother and father both had shoulder pain. Or they believed it was because of
karmic punishment for past deeds. Or they believed it was because of an emotional imbalance. Or they believed
it was caused by a nutritional imbalance. All of these examples could be true according to various models of
health and healing. According to your training and evaluations, you %nd weak and restricted rotator cu4
muscles. To disregard the client's beliefs and insist you know what is causing the pain would be violating an
intellectual boundary. O4ering them your information “according to the model in which I work” would be
respecting both them and your own training.
Emotional Boundaries
Emotional boundaries help identify our own feelings and keep them separate from the feelings of others. When
we have good emotional boundaries, we help create an environment where clients feel safe and supported.
Clients will trust us if they feel they can share their emotions and not be judged; that we both understand them
and accept them for who they are and how they feel.
An emotional release is letting go or releasing suppressed emotions. When we have strong emotions and do
not express or process those emotions appropriately, we may suppress them. An example is a feeling of deep
grief over the death of a loved one. This feeling may be too painful to bear at the time, so it becomes
suppressed. Suppressed emotions may surface and %nd a way to express themselves during a massage session as
clients relax and in a safe environment.
The most common expression of emotions is crying. If clients begin to cry during a session, approach thesituation with complete acceptance. Support them with statements such as “Crying is normal,” “You are in a
safe place,” “I am comfortable with your tears.” Come up with statements that you are comfortable saying in
the situation. When clients %nish crying, help them acclimate to their surroundings with statements such as
“Take a few deep breaths,” and “Feel the massage table beneath you.” Again, %nd statements that you feel
comfortable saying.
When clients share their feelings, they demonstrate trust in the therapeutic relationship. To strengthen that
trust, we safeguard client information including their feelings. If a client has an emotional release during one
session, we refrain from mentioning it in subsequent sessions unless the client brings it up. There is an
exception to this rule. If the emotional release occurred during the massage, obtain consent before working on
the area that led to the emotional release. For example, if your client had an emotional release while massaging
the feet, ask permission before working on the feet during the next session. Be sure to avoid mentioning the
emotional release when you ask permission. This demonstrates respect for emotional boundaries.
Clients may feel vulnerable and exposed during an emotional release even while feeling safe with the
relationship. Recall a time you have cried unexpectedly in front of someone. How did you feel? Were you
concerned that the person would judge you, or think less of you?
When clients tell us about emotional concerns in their lives, we can help bring the focus back to the body by
questions such as, “Where do you feel that in your body?” or “Can you tell me what you notice in your body as
you say that?”
Anytime the focus of massage becomes more about the client's emotions and less about the client's body,
emotional boundaries have been crossed. There is mounting evidence to suggest that release-based cathartic
therapies may feel good at the time but have no lasting bene%ts for the client's health and well-being. Cathartic
emotional releases may serve to retraumatize clients. Massage therapists are not trained to di4erentiate
between emotional experiences that are helpful to clients and those that are harmful. A good guideline to follow
is “seek not, forbid not.”
Even if a therapist is cross-trained in a recognized form of body psychotherapy, a di4erent license is required
to practice the method. This will be discussed in the Chat Room Box entitled Dual Licensure and Dual Roles.
To reiterate, scope of practice does not allow massage therapists to:
• Persuade clients to share emotional content
• Process client emotions
• Delve for deeper held emotions
• Evoke emotional responses intentionally
Time Boundaries
Time boundaries provide guidelines for how we spend our time at work and help separate our professional time
from our personal time. Unlike personal relationships in which time is somewhat : exible, we have an
agreement with our clients regarding time. Clients essentially rent our time for the length of the session. The
massage session is often described as structured time. Time boundaries include: (1) Being ready when clients
arrive with music playing (if appropriate) and clean linens on the table. (2) Beginning and ending the session
on time. (3) Focusing on the client during the session and avoiding distracting activities such as talking or
texting on the phone or conversing with other clients in the waiting room.
When does the session o( cially begin? Some therapists believe the session begins at the start of the massage.
Other therapists believe it starts with the client intake. Whichever you chose, be sure to disclose this information
when obtaining consent for therapy. It would be confusing to clients who are paying for a 60-minute massage
and the hour actually consisted of a 15-minute intake and a 45-minute massage. It also shows disrespect for
time boundaries when we are inconsistent and a 1-hour massage lasts 60 minutes one session, 75 minutes the
next, and 50 minutes during another session.
Time boundaries also include the days of the week and times of the day you schedule appointments. Other
aspects of time boundaries are how you handle cancellations and no-shows. These situations violate time
boundaries and possibly impact financial boundaries.
Questions to consider are:
• What are your office hours?• Do you schedule appointments at different times? Under what circumstances? Do you charge extra for
afterhours or off-day appointments?
• What if clients arrive late?
• What if you are running late?
• Would you allow sessions to run over time? Under what circumstances? Would you ask permission if you wish
to extend the session time?
• What if clients arrive early and you are ready to begin their session? What if you are not ready to begin the
session on clients who arrive early?
• What is your cancellation policy? How far in advance do you expect clients to cancel? Do you charge the full
amount or partial amount for cancellations?
• What is your policy regarding no-shows? Do you charge the full amount or a partial amount for no-shows?
• What is your policy if clients cancel or do not show in cases of emergencies?
• What happens if you miss an appointment?
Location Boundaries
Location boundaries provide guidelines about where services are provided. Be sure your location projects
professionalism whether in a spa, clinic, home o( ce, or other location. Sometimes massage services are
provided at a client's residence or a residential care facility as a house call.
Many therapists work out of their homes. Ideally the client entrance and work area is separate from your
living area. If this is impossible, be sure your work areas are clutter-free and contain few or no personal items.
Be in compliance of any local zoning restrictions.
When doing a house call, be sure you know in advance about the space the client has designated for the
massage. Inquire about where you should park your vehicle. Be realistic about how far you can carry your
equipment and supplies. Be sure to have a policy in place for house calls with clients you do not know. This
might include contacting a third party and letting them know who the client is, where you will give the
massage, the time and length of the session, and that you will contact them upon your arrival and departure.
Because this policy example involves disclosing client information, the client must consent to this policy.
If you are giving a massage in a private residence or residential care facility, it is unlikely you will be able to
control the massage environment so be : exible. If visitors are present, introduce yourself and let them know
why you are there. Be willing to massage your client in a care facility room with visitors. If health care
providers are in the room or arrive during the massage, discuss with them how to best coordinate services. It
may be best to postpone the start of the massage or take a short break to give this time to the health care
providers. These decisions are shared, so discuss options with the other party. Again, be : exible. Keep in mind
that when providing services at the client's residence, there is an increased risk of becoming involved in the
client's private life. More vigilance is needed to maintain boundaries.
Public places or social events are inappropriate settings for massage. This standard applies to practicing
therapists and students. If you run into your friend Bob while shopping and he asks you to rub his sore neck,
you might reply, “I am shopping right now and can do a better job at my o( ce. Here is my business card.
Please contact me for an appointment.” This demonstrates good boundaries regarding both location and time;
in this case, your time off.
Also avoid giving professional opinions or advice during social events. You are held accountable for
professional advice given in all settings, including social settings. You may not have all the information needed
to formulate your opinion and might carelessly ill-advise current or potential clients. Instead, o4er a business
card and ask them to call you.
Financial Boundaries
Financial boundaries in therapeutic relationships involve issues of money. Therapeutic relationships are also
business relationships and money is an important part of our professional practice. Our time, focused attention,
and expertise are of value to clients. We o4er this in exchange for money. If you are uncomfortable with money
or have issues around money, it may affect how you establish and enforce financial boundaries.
Inform clients of your fee schedule, payment procedures, and policies such as how insu( cient fundstransactions are handled. Even if this information is given when clients schedule their initial appointment,
mention this information again when obtaining consent for therapy. Be sure to inform current clients in
advance when fees and payment policies change, perhaps by posting it in your office and on your website.
Some therapists have sliding fee scales, allowing clients to pay di4erent amounts depending upon the client's
ability. If you choose to use a sliding scale, be sure you have a method to keep track of what each client is
charged. Sliding scales can become a boundary issues when money gets in the way of therapists being fully
present in their therapeutic role. Imagine how you might feel if a client who was getting a discount came in all
excited about their upcoming Caribbean vacation or their new expensive car. What if you had not been on
vacation for a few years for financial reasons?
Financial boundaries include how you handle payment arrangements when receiving massage from fellow
therapists. Will you o4er and/or expect professional discounts? Will you trade for services? What if you charge
more for an hour than your fellow therapist? How will you address the di4erence in fees for the same time
spent, if at all? If you are trading services, when will trades be scheduled? What will happen if the therapist you
are trading with has scheduled the third session with you and you have only received one session from her? Will
you stop trading until the number of trades are equal? Or will you expect payment for the third session? Ideally,
these types of situations should be discussed beforehand and mutually agreed upon.
Dual Licensure and Dual Roles
A dually licensed massage therapist is someone who has a second professional license to practice in a
di4erent profession. For example, you could be a licensed massage therapist and a licensed professional
counselor. When this occurs, the person refrains from wearing two hats simultaneously. For example,
operating in the capacity of massage therapist, provide only those services within that scope of practice.
When operating as a di4erent professional, provide only those services within that particular scope of
Keep in mind that all professions have their independent codes of ethics. The code of ethics for a licensed
mental health counselor for example will be di4erent from the code of ethics for a massage therapist. The
profession with the strictest code of ethics prevails and becomes the standard of conduct in every therapeutic
Transference and Countertransference
Transference and countertransference occur in all relationships: therapeutic, personal, and professional.
Psychotherapists have long been taught about experiences of personalization that happen in therapy and
counseling. Sigmund Freud was the %rst to describe it. Even though massage therapists are not psychotherapists,
we encounter transference and countertransference and therefore should learn how to recognize them and
reduce their negative impact on the therapeutic relationship.
As you explore these concepts, remember that transference and countertransference in: uence relationships in
ways that, under certain conditions, may be helpful to the client. Transference and countertransference are, by
their nature, complex and interrelated. Therapists will remind clients of other people in their lives, past and
present. Clients will remind therapists of people in their own lives. Power di4erentials in the therapeutic
relationship play a role in amplifying the occurrence.
Transference occurs when clients transfer feelings, thoughts, and behavior they have for a signi%cant person in
their early life onto the therapist. The therapist assumes a more signi%cant role in the client's subconscious
mind. Transference may occur when needs not being met in the client's personal life are now being met in the
therapeutic setting by the therapist. This includes touch needs, the need for attention, listening, validation, and
During transference, the client begins to personalize the therapeutic relationship. Vulnerability may actually
facilitate transference as can unresolved past events. Instead of seeing you as a member of a profession
providing a service, the client sees you and relates to you as if you were a signi%cant person from their past.
Transference can produce powerful feelings of love (positive transference) or destructive hatred (negative
transference), both of which are based on misperceptions.For example, if you remind your client of her father, the client's perception of you may change which leads to
a change in behavior. Her behavior depends on the type of relationship she had with her father. Was it loving
and nurturing or %lled with violence and abandonment? During positive transference, she may bring you raisin
cookies that her father liked, do things her father expected, and want to be treated as a special daughter
“client,” such as spending extra time on her or scheduling appointments outside your normal o( ce hours. A
client experiencing positive transference is not likely to question your actions (even ones that deserve
questioning) and may invite you to lunch or ask questions that encourage a more personal relationship.
But when you do not reciprocate by treating her special, she may feel hurt or even angry. And if you happen
to make her feel special by preferential treatment, transference may continue and even intensify. After all, who
would not be willing to bend the rules for a client who brings us gifts and does favors for us, right? But our
deliberate reinforcement of transference serves to perpetuate the problem, distorts the true nature of the
therapeutic relationship, and removes the focus from the client's therapeutic goals.
Clients may develop a romantic infatuation toward the therapist. Clients bring a variety of feelings, including
pain, both physical and emotional, to the massage table. Therapists who unrealistically represent the epitome
of kindness, sensitivity, and warmth may inadvertently %ll the client's unmet emotional needs. It is not hard to
fathom clients wanting to be friends with their therapists. Therapists are, in most cases, kind, thoughtful, and
willing confidants; this type of person is perhaps missing in the client's life.
Keep in mind that you cannot control how clients think or how they feel. Learn to recognize when clients are
in transference and do not encourage it or lead clients to feel that their a4ection is reciprocated or that their
fantasies have a place in reality. Successful navigation requires maturity, integrity, and ethical professionalism.
Seek professional supervision when needed.
Countertransference is emotional reactions of the therapist toward the client and may occur from unmet
personal needs, unresolved emotional issues, or internal con: icts that are brought into the relationship
unconsciously. Countertransference can occur when we view clients as people from our past.
Countertransference runs counter, or in the opposite direction of, transference (therapist to client instead of
client to therapist).
Countertransference can occur if we cannot maintain professional boundaries or detach ourselves from
clients. Detachment is not thinking less of a client but rather thinking of a client less. Countertransference can
be caused by the attention gained from a client's transference. You may %nd yourself taking a personal interest
in a client or play along with and acting on a client's infatuation. Countertransference can also occur when the
client reminds you of someone signi%cant from your past and you start treating the client di4erently, perhaps
less professionally.
Countertransference can also occur when you see aspects of yourself in your clients. For example, your client
may be of the same age, recently divorced, or have children with ages similar to your children. Because of these
similarities, you may believe that the client will be best served by the same type of work or solutions that
helped you. Remember, both transference and countertransference involve seeing a person as someone else; not
who they truly are. Countertransference may prevent us from ascertaining a client's unique history and
therapeutic goals, therefore not acting in their best interest. Signs of countertransference are:
• Having intense feelings, positive or negative, toward a client
• Becoming angry or depressed when a client cancels an appointment
• Becoming impatient, angry, or depressed when a client is not progressing with treatment
• Being argumentative with a client
• Seeking to or becoming involved in a client's personal life
• Thinking excessively about the client between appointments
• Making excuses for a client's inappropriate behavior
• Giving a particular client additional time during appointments
• In extreme cases, romantic and sexual fantasizing
• Ignoring or relaxing professional boundaries
So what can you do if you %nd yourself suddenly in countertransference? Begin by taking a closer look atwhat might be causing it. Are your getting your personal needs met? If not, how can you begin doing so outside
the therapeutic relationship? Does your client remind you of someone signi%cant in your life? As stated
previously, self-awareness is vital to healthy boundaries and key to averting countertransference. If you fail to
identify reasons behind countertransference, this pattern may continue or repeat itself with other clients.
Consider seeking guidance from a trusted colleague or mental health counselor. This will help you identify areas
of unmet needs and develop appropriate ways of getting them met.
In some cases, it is best to terminate the therapeutic relationship and refer the client to someone else if
countertransference has become irrevocable. Use caution during termination of the relationship because the
client may feel rejected. Seek guidance from a trusted source before talking with the client if you are unsure
how to proceed and how to best serve your client's highest good.
Keep in mind that feelings are just feelings and are impermanent. And if you have an emotional or sexual
attraction to a client, this does not mean that something is wrong with you. It is normal. Just do not act on
those feelings. These feelings and infatuations typically have a short lifespan of a few hours or a few days.
Again, supervision can be helpful.
“A helping relationship is …….a relationship in which at least one of the parties has the intent of promoting the
growth, development, maturity, improved functioning, improved coping with life of the other….put another way, a
helping relationship might be defined as one in which one of the participants intends that there should come about,
in one or both parties, more appreciation of, more expression of, more functional use of the latent inner resources
of the individual.”
Carl Rogers
Boundary Management
Once boundaries are established, they need to be managed throughout the course of the therapeutic
relationship. De%ning the boundaries and consequences for crossing them should be outlined when we obtain
consent for therapy. This will reduce or eliminate misunderstandings. When boundaries are unclear or when we
continually bend or disregard them, we may be viewed as unprofessional, which can harm or even destroy the
It is helpful to remember that our role as massage therapist never goes away—our professional license does
not suddenly become suspended when we leave the o( ce. Even though we see our clients in professional
settings, we are still their massage therapists as we shop at the market, go to the movie theater, and attend our
children's school functions. When our clients see us in these settings, we must still exhibit professionalism.
To establish and maintain professional boundaries, it is important that we (1) be aware of the boundary, (2)
clarify the boundary, (3) meet our personal needs outside the therapeutic relationship, and (4) develop and
follow a treatment plan.
Crossing boundaries means that we are behaving unprofessionally and irresponsibly. Boundary violations
vary widely and range from mild inconsiderateness to the more serious sexual misconduct. You, the
professional, are held accountable for any negative consequences resulting from lack of boundary management.
Remember that professional boundaries extend from our clients to other massage therapists and health care
providers. Our responsibilities often include confronting a fellow therapist if we hear allegations of professional
misconduct. Steps to take in these instances are discussed later in the chapter.
Meet Personal Needs Outside the Therapeutic Relationship
Be sure you are taking care of your personal needs outside the therapeutic relationship. If you are not doing
this, you risk trying to get those needs met in the therapeutic relationship consciously or unconsciously. To
avoid this, conduct periodic self-evaluation of your personal needs and how those needs are being met. As you
inventory these, ask yourself if they are being met in appropriate ways; make any needed changes. We need to
be clear about our intentions, focusing on the client and putting his or her needs before our own. It is helpful to
devise a self-care plan. Information about identifying personal needs and appropriate ways to meet those needs
is located in Chapter 4. The therapeutic relationship is not a place to have personal needs met; doing so opens
the door for dual relationships, transference, and countertransference.
Develop and Follow a Treatment PlanOne way to manage boundaries is by developing and following a treatment plan. This plan also provides
guidance with professional boundaries. Because treatment plans have an intended outcome, our professional
activities are geared toward these outcomes; putting client goals before our personal needs. When determining
if an action is appropriate, ask yourself the following questions.
• Who benefits the most from the action?
• How would others perceive the action?
• Would I tell my colleagues about the action?
• Will the action cause confusion for the client about my role as a massage therapist?
• Will the client expect that all massage therapists do this? Will performing the action cause difficulties when
other therapists will not or cannot do the same?
We also must be clear about what our treatment methods can and cannot accomplish. In cases where the
client goals are beyond our scope of practice or beyond the limits of the therapeutic relationship, we must direct
the client elsewhere.
“When we work from a place of compassion, it is a place of non-judgment, non-comparison, without the need to
understand. With compassion we are not entrained in the drama of the client's story, we are just with them. This is
love, which resides in the heart.”
Fritz Frederick Smith
Client Abuse and Neglect
When any professional, whether a physician, attorney, minister, or massage therapist, does not recognize and
respect the rights and boundaries of clients, abuse or client neglect may result. The potential for harm exists in
all relationships in which there is an imbalance of power. In therapeutic relationships, the therapist has the
more powerful or authoritative position. The client has chosen to enter the relationship because we have
particular knowledge, skills, and abilities. The client may feel vulnerable both physically and emotionally
because he or she is usually lying down and draped, whereas we stand over them during the massage and
remain clothed. When someone removes his or her clothing, he or she may feel psychologically naked and
Neglect is improper treatment of someone due to carelessness or thoughtlessness. The client is harmed
because of action or inaction, but it is unintentional, accidental, and reckless. Neglect often comes from lack of
understanding of the importance of boundaries or lack of professional knowledge. An example of neglect is
mistaking a cyst for a trigger point. Another example is trying to counsel a client who is crying rather than
simply providing emotional support.
Abuse is also the improper treatment of someone but it is intentional and deliberate, often for personal gain
or benefit. Abuse can be physical, mental, emotional, financial, or sexual in nature.
Abuse and neglect harm clients and the therapeutic relationship. Abuse and neglect look the same on the
outside, but the internal experience or motivation behind the action is quite di4erent. Examples of abuse are
listed next.
Physical Abuse
Physical abuse means knowingly crossing a client's physical boundary. An example is intentionally ignoring the
client's request for lighter pressure because you believe that more pressure is better. If a client becomes bruised or
injured as a result of the physical abuse, you may be liable and the client may %le battery charges. If you
discover clients who bruise easily (e.g., taking platelet inhibitors, is an older adult, or inactive) you must discuss
the potential for bruising so clients can weigh risks and benefits of treatment to make informed decisions.
Financial Abuse
Financial abuse is intentionally taking advantage of a client's %nancial resources. This may mean charging
more than the standard rate because you know a client is in a higher income bracket. Accepting expensive gifts
from clients or accepting an invitation to use a client's vacation home for a long weekend can be %nancially
abusive. For more discussion on guidelines for accepting client tips and gifts, see Chapter 17.
Sexual AbuseSexual abuse may be physical, verbal, or nonverbal. Examples of sexual abuse range from verbal advances to
leaning your body against your client during the massage. For more discussion, see the “Dating Clients” section
and the “Sexual Misconduct” section.
Crossing Boundaries: Common Mistakes
The following is a list of the more common mistakes therapists make when they cross professional boundaries.
These are examples of both client abuse and client neglect. Being forewarned is being forearmed; therefore, by
exploration of these pitfalls, you can avoid them.
Lack of Proper Training and Experience
Avoid the weekend workshop warrior syndrome, which is you representing yourself as quali%ed in speci%c
techniques or methods without proper training and experience. Avoid taking one workshop in a new method
then promoting yourself as skilled in the new method without proper certi%cation. Doing this may harm your
client. While practice is necessary to hone a new skill, inform your client that you are learning a new method
and use caution in the interim between initial training and certification.
Disregarding Contraindications
Avoid working on clients with absolute contraindications. Check current textbooks such as the most recent
edition of Mosby’s Pathology for Massage Therapists to help you make this determination. This may be di( cult
if you work in a setting in which deviating from a routine or suggesting massage postponement is discouraged
(i.e., salon or day spa). Or perhaps you have an overwhelming urge to help the client with a contraindication
and believe the bene%ts of massage outweigh the risks. Be sure to discuss your reasons for massage
modi%cations or postponement with your client during treatment planning (see Chapter 10) and use a method
other than massage therapy. When clients need medical evaluations or services outside of your scope of
practice, refer them to an appropriate health care provider.
Comments about a Client's Body or Appearance
Because of the vulnerability clients may feel, comments made about their body or appearance have the
potential to impact them deeply. For example, telling clients that they are the “tightest person I have ever
worked on” may seem harmless, but they may take it to mean that something is wrong with them and it
becomes part of their self-de%nition. Clients who are dealing with depression or anxiety or recovering from
addictions such as eating disorders may be deeply a4ected by comments about their appearance. For example,
after hearing a compliment about their shoes, clients with low self-esteem may feel as if nothing else about
them was worth complimenting. These types of comments can traumatize the client and interfere with a client's
therapeutic progress. These comments could be misread as abusive or even seductive. Comments made about a
client's body or appearance is best avoided.
Asking Clients to be Your Friend
This issue is common enough to merit a lengthy discussion under the “Dual Relationships” section later in this
chapter. It is easier to maintain good boundaries when we avoid creating dual relationships. Dual relationships
occur when clients are also friends. Some of the dangers of dual relationships are client abuse and neglect,
transference, and countertransference (see appropriate sections in this chapter).
Playing Psychotherapist
Using techniques intended to evoke emotional release is another common mistake. Legal statutes do a good job
outlining our scope of practice. However, situations arise that can “muddy” the waters. We need solid and
impeccable boundaries regarding the types of service we o4er clients. When we play psychotherapist, we
endanger our clients both mentally and emotionally. Although the body and emotions cannot be completely
separated in their physiologic functioning, we must be absolutely sure that our treatments, advice, and focus
remain on the soft tissue of the body. We can recognize the imprint that the emotions make on body tissues, but
we should not use techniques that intentionally evoke emotional responses in clients, nor engage in exercises
whose primary purpose is to address the human psyche directly.
We also cross professional boundaries when we attempt to process emotional material that naturally surfaces
during a session. An academic degree and separate license are required to practice individual counseling orpsychotherapy. Additionally, playing psychotherapist shows disrespect for our clients and for mental health
professions. If clients need a referral to counselors or psychotherapists, have their contact information available
for distribution.
Conflict Resolution
A conflict is a situation in which one person feels that someone or something is keeping them from achieving
their goals and is incompatible with their needs and concerns. In the therapeutic relationship, con: icts can arise
when boundaries are vague or nonexistent and when expectations are not met. Examples of unmet expectations
include (1) not starting the massage on time, (2) not adequately addressing your clients' area of concern during
the massage, and (3) canceling your client's appointment for the third time this month.
Con: icts cannot be avoided. They can be viewed as evidence of collaboration and provide opportunities for
exploration. During con: ict, it is important to foster empathy by (1) recognizing your own emotions, (2)
paying attention to the client's emotional message, (3) being aware of your own unconscious message or what
you are saying with body language, and (4) being receptive to negative feedback and opportunities for growth.
As soon as possible, take action when a client is unhappy with the service being provided. Be willing to listen
carefully and sincerely to the complaint without interjecting opinions or becoming defensive. Once the client
has completely stated his or her position, consider asking, “What would you like for me to do?” Comply within
reason. It is also important to communicate with I messages instead of you messages. You messages can be
perceived as blaming clients for the con: ict. Instead of saying “You keep texting me when I have asked you not
to.” Say “I feel stressed when I get texts from anyone. I don't have a texting plan so they cost me money, and I
have no clear way of tracking texts, so am concerned I will not respond quickly.”
Take full responsibility for your own actions and communicate clearly about what you want and need. Pick
your battles carefully, asking yourself if this con: ict will matter in 5 years. If you or your client becomes angry,
take a break and calm down before resuming conflict resolution (Table 2-1).
Healthy and Unhealthy Conflict Resolution Strategies
Fight Trying to impose one's preferred solution Insisting, blaming, criticizing, accusing, shouting
on the other party
Submit Lower aspirations and settle for less than Giving in or giving up
one would have liked
Agreeing to simply end the conflict
Surrendering to what the other wants
Flee Choose to leave the scene of the conflict Ceasing to talk
Leaving physically, cognitively, and/or
Changing the topic
Freeze Choose to wait for the other's next move Waiting
Doing nothing
Problem Pursue alternatives that satisfy both sides; Talking, listening, gathering information,
solve develop a win-win strategy thinking, generating options, resolving
Sometimes, it is best to o4er dissatis%ed clients a refund or gift certi%cate, even if no negligence exists on
your part. Giving an immediate refund to a client without question may save you a mountain of aggravation
Conflicts of Interest: Selling Products+
A con ict of interest is a situation in which a therapist could exploit a relationship for personal gain. Remember
that trust is a characteristic of therapeutic relationships. Trust is important because clients are in the position of
vulnerability and therapists have the position of power. This is known as a power di4erential. Con: icts of
interests arise when we use the relationship to serve our interests rather than the client's. When determining
potential conflicts of interest, ask and answer honestly the question, “Whose interest am I really serving?”
One common scenario is selling products to clients. In this situation, we may be faced with choosing between
what is in our best interest and what is in the client's best interest. Can we be truly objective when we are
making a pro%t on the sale? Therein lays one possible problem. Even without direct monetary gain, a con: ict
may exist if we receive points leading to ful%llment of established work goals for career advancement and
Selling anything to clients other than professional services creates a dual relationship; you are t h e r a p i s t and
s a l e s p e r s o n. Dual relationships are often problematic. A power di4erential exists and we have in: uence in the
relationship. Is the client really free to refuse the o4er? Might the client purchase products just to please us or
do it to get us to like them more? Perhaps the sales pitch simply feels awkward to the client. This uncomfortable
feeling may lead clients to schedule their next massage with therapists who do not sell products.
Suppose clients have allergic reactions to the supplements or herbal cream you sold them. What would
happen if clients believed they did not gain the bene%ts you said to expect? How would these and similar issues
be handled? Be sure to consider these and other possibilities before selling products to your clients.
In some work settings, you may be expected to sell products. There are varying opinions in the profession as
to how to handle this situation. In some settings, the product is visible and you do not mention it unless asked.
In other settings, you may be expected to approach clients about purchasing products. Be sure to discuss product
sales with your employer and understand his or her expectations before accepting a position if it involves sales.
If possible have another employee, such as the receptionist, handle the actual sale. Be aware that any situation
that involves selling products to clients may put stress on the therapeutic relationship.
Dual Relationships
Dual relationships refer to situations when two or more di4erent relationships exist between clients and
therapists. There are several types of dual relationships, such as social, professional, business, communal, and
sexual. Social dual relationships include friendships and having clients who are also your “friend” on social
networking sites such as Facebook. Professional dual relationships occur when you socialize with colleagues such
as while attending or copresenting at continuing education classes, state conferences, or national conventions.
Business dual relationships include having clients who are also business partners or persons who provides
business support, such as legal or accounting services. Communal dual relationships occur when clients live in the
same community and you participate in the same activities at the same time. For example, you both belong to
the same church or synagogue or shop where your client works. Communal dual relationships are easier to
avoid in large cities where there are many stores and restaurants. However, in smaller communities, there are
fewer places for worship, business, and specialty shops so communal dual relationships are unavoidable. Sexual
dual relationships occur when you are involved sexually with clients. Sexual dual relationships are always
unethical and often illegal. This section addresses only nonsexual dual relationships. Sexual dual relationships,
or sexual misconduct, are addressed in the next section.
Good boundaries will help us manage dual relationships and keep the focus on our clients and client goals.
They also help us distinguish which role we are in. When we are in the role of therapist, be a therapist. When
we are in the role of friend, be a friend. When we are in the role of family member, be a family member. Our
professionalism and ability to focus on our clients may be thwarted when we enter into dual relationships with
It can be challenging to maintain boundaries when we have more than one role in a client's life. Treating all
clients equally is di( cult when some are friends and others are not. Boundaries become blurred, con: icts are
more complicated, and the potential for abuse and neglect is heightened. You cannot promise that entering into
dual relationships with clients will not a4ect the therapeutic relationship; no one can make that promise.
Remember that the therapeutic relationship is not a relationship of equals. A power di4erential exists, similar to
a parent-child or teacher-student. Each person in the therapeutic relationship has expectations. Our clients
expect us to perform our professional duties and responsibilities. We expect our clients to comply with thetreatment plan, keep their appointments, follow our o( ce policies, and pay for their treatments. When we
have additional roles with each other, such as a client who is also our accountant, a di4erent set of expectations
now exist.
Strangely, one of the reasons why we initiate dual relationships is because they are convenient. A potential
friend, accountant, or attorney is right in front of us. Or in the case of a friend, a potential client is right there.
Maintaining boundaries and preserving ethics is not the client's responsibility—it is ours. The power di4erential
makes it nearly impossible for a client's behavior to be unethical. And the professional is held accountable for
any negative consequences that arise from dual relationships.
Next, we will examine dual relationships with friends, family, and situations of dating clients.
The most common dual relationship is clients who are also friends. When clients are also friends, we assume
several di4erent roles in their lives. Being in a professional role exclusively is challenging when clients are also
friends. Imagine how hard it would be not to chat with friends during massage. Excessive self-disclosure creates
a di4erent atmosphere during the sessions. You and your client/friend may treat appointments as opportunities
to develop your friendship; sessions may become more social events than professional sessions. You may
become careless, not keeping your focus on the needs of your client/friend. Whose interest is being served now?
How do therapeutic relationships di4er from friendships? Friendships involve choice, mutuality (both parties
voluntarily enter the relationship), trust, pleasure (both parties enjoy the relationship), and reciprocity. In
friendships, the relationship is ideally 50/50 and a certain amount of give and take exists. You know as much
about your friend as he or she knows about you. You also support each other. In therapeutic relationships, you
know much more about your clients than they know about you. You support them and o4er them a professional
service. They do not emotionally or physically support you. Mutual familiarity is not common in therapeutic
relationships. A power di4erential exists and it is not an equal partnership. Therapeutic relationships involve
choice, mutuality, trust, and pleasure, but not reciprocity (Figure 2-4). Some therapeutic relationships feel close,
but they are not as intimate as friendships. Each party is receiving something of worth from the relationship,
but it is not equal or reciprocal. This is as it should be, and helps keep the safety of the therapeutic relationship
Nina McIntosh
Everybody studies ethics, right?
Today, ethics training is mandatory for massage students all across the country, and it feels impossible that
it could ever have been otherwise. There are all sorts of texts available that cover issues such as professional
boundaries, dual relationships, and projection. But as hard as it is to believe, in 1999 there was only one: The
Educated Heart by Nina McIntosh.
McIntosh was born and raised in Memphis, Tenn., in 1943, and lived there until heading to study
psychology at the Newcomb College of Tulane University. After a few years of employment in New Orleans,
she then continued her education, earning her Masters of Social Work (also from Tulane).
Armed with her freshly minted MSW, McIntosh moved to Denver and began working as a psychiatric socialworker. The experience was educational, but also distressing. She watched as the sta4 in the psychiatric
hospital where she worked set up extremely rigid personal boundaries between themselves and their
patients. They were discouraged from having physical contact with the patients, who were there because of
their mental health issues, not body-related illnesses. McIntosh became convinced that both the body and the
mind needed careful and compassionate attention, and that neglecting the body could only be detrimental to
mental health, even when ostensibly done in the name of professionalism. This experience began McIntosh's
lifelong fascination with appropriate boundaries in professional settings, as well as the importance of the
health-promoting role of touch.
Determined to explore this idea further, in 1978 McIntosh enrolled in the Boulder College of Massage
Therapy, and then went on to study at the Rolf Institute in Boulder, becoming a Certi%ed Rolfer. During her
career as a Rolfer, she traveled widely and settled for a while in California before returning to her hometown
of Memphis to care for her aging parents.
McIntosh's parents died in 1995, leaving her with the free time to write down her understandings about
professional boundaries in the massage therapy %eld, inspired by her experiences in psychology, social work,
and massage. This became The Educated Heart, which is still used in massage therapy schools today.
McIntosh moved to Asheville, N.C. in 2005. Although she retired from Rol%ng, McIntosh never stopped
thinking or writing about massage ethics, and remained an active member of the massage therapy
community for the rest of her life. Her popular ethics column in Massage and Bodywork, “The Heart of
Bodywork,” ran for nearly 10 years, and The Educated Heart %nally found a publisher in Lippincott Williams
& Wilkins, who published not only the second edition of the book in 2005, but also a third edition in 2010.
The book, which is still one of the best-selling ethics texts in the massage therapy community, is immediately
useful, easy to read, and occasionally hilarious, with its real-life stories about professional boundaries gone
wrong, and done right. If your brain is exhausted from too many anatomy exams, reading The Educated
Heart is the perfect way to %t some more studying into your life without it actually feeling like work. There is
a reason it is such a classic.
In 2009, McIntosh was diagnosed with amyotrophic lateral sclerosis, better known as Lou Gehrig disease.
As her physical health began a rapid decline, she maintained her sense of compassion and justice,
volunteering with her church, advocating for wheelchair accessibility, and befriending a man who had been
unjustly imprisoned for 15 years. She also kept up her wry sense of humor as her body failed her in an
increasing number of ways, eventually losing even the ability to speak.
In 2010, she was awarded the Aunty Margaret Humanitarian Award at the World Massage Festival in
Berea, Ky. She was too weak to attend the ceremony, and with typical humility said, “I don't think I'm much
of a humanitarian.” McIntosh died 1 month later, with joy and dignity. Her work lives on in her writings,
and her ethics classes are still taught by Laura Allen, fellow massage therapist, educator, and McIntosh's
personal friend.
What started out as a self-published book by one woman with a devotion to ethical bodywork has since
blossomed into a nationwide conversation about the ethics of professional touch.FIGURE 2-4 Friendships versus therapeutic relationships.
Besides, can we call what develops between clients and therapists a friendship? Nina McIntosh examines this
question in her book, Educated Heart. Do we go to our client's offices, remove our clothing, lie on their desks, get
a massage, and pay for their time? McIntosh also states that we typically do not show our clients what she calls
our lower selves, the part of us reserved for only those closest to us. Negative aspects of our lower selves include
our pettiness, neediness, jealousies, idiosyncrasies, and quirks. Ideally, we project our higher selves in
professional settings. Positive aspects of our higher selves include empathy, compassion, and altruistic loving
kindness. Because of this projection, clients often see only our higher selves.
Turning clients into friends may also interfere with our relationships with other clients. How would you feel if
your therapist Michael was friends with his client Mary and not with you? If not hurt, you may question his
professional boundaries.
Friends Who Become Clients
For therapeutic relationships to emerge from friendships, professional boundaries must be established, just as
with all clients. Both parties need to understand their individual roles and responsibilities. You, the therapist,
will provide a service for which your client/friend will pay a fee. During the session, keep the conversation and
focus on the client/friend.
In some cases, it is better if friends go to therapists with whom there is no previous relationship. Remember
that therapeutic relationships serve clients. Friends may not be willing or able to give you the authority you
deserve, receive full bene%t from sessions, or take your work seriously as they would with therapists who are
not also friends. Friends may expect special treatment, consciously or unconsciously. After all they are your
friend. Maintaining professional boundaries may become challenging. Will you feel comfortable charging
friends who violate cancellation policies? What if friends arrive late and expect a full session? What if friends
want to pay for a session next week instead of that day? Anytime we do not enforce our professional practices
we need to examine why. If we treat friends di4erently than clients—letting them play by a di4erent set of
rules, we are likely not serving them. This may indicate that we are not staying fully in our professional role.
Crossing some boundaries can make it easier to cross others.
Friends and Massage School
You will practice massage techniques on fellow students while in school. These sessions need to be treated with
the same respect and acknowledgement of their boundaries as you will treat sessions with future clients. This
means not talking with the students at the next table, not chatting about your pathology test the next day, and
not discussing your plans for the weekend. Stay focused on the client/student recognizing the power di4erentialthat exists for the time he or she is on your table.
Massage students also often practice on friends while in school. Let friends know that, after licensure, a fee
will be attached. If you know what the fee will be, let them know early so they will be prepared to pay the
requested fee at the appropriate time. This is also an opportunity to practice your role of therapist with
professional boundaries intact and to treat practice sessions as you would in professional settings.
Friends and Social Networking Sites
Social networking sites such as Facebook and MySpace have brought the complexities of dual relationships to a
new level. Now, it is easy for clients to know more about you including your likes, dislikes, relationship status,
and sometimes your personal schedule. Participation in this social environment can make boundary
management with our clients trickier. The Internet can be a tremendous boon for marketing and networking, as
long as we are cautious about what we post. It is best to regard social networking sites as an open public folder
in which its contents can be read by everyone. Chapter 17 has a more detailed discussion including digital
citizenship and self-re: ective questions to consider before posting content. These are found under Marketing ≫
Social Media.
Family Members
Maintaining professional boundaries is more challenging with family members, yet vitally important. It can be
a source of great joy to work with family, particularly when they are in pain or need our services. However,
there is a tendency to carry over any family dynamic into the therapeutic relationship. If there is a strain in the
familial relationship, there will likely be a strain in the therapeutic relationship. For example, if you have
always wanted your sister's approval, you may use massage as a way to gain it. This places unrealistic
expectations on the therapeutic relationship, removing the focus from your sister/client to your needs.
Other considerations are how appointments and fees are handled. When will you work on family? During
normal o( ce hours or only during your o4 time? How will you handle missed appointments? Will you charge
family members? If so, is this fee di4erent than you charge other clients? And if you work with one family
member and not another, will this negatively impact family dynamics? If so, how?
Elliot Greene in Psychology of the Body, further limits working with family members. Greene advises that if you
have been abused sexually, physically, or otherwise by a family member, then do not massage that person or
anyone else associated with the abuse. Greene points out that many people who have been abused deny or
minimize the abuse, and may not fully understand the implications and impact of touching these people.
Dating Clients
What if therapists and clients want to date each other and move the therapeutic relationship into a more
romantic or sexual relationship? National Certi%cation Board of Therapeutic Massage and Bodywork (NCBTMB)
Standards of Practice (Standard VI. A) require discontinuing the client-therapist relationship for a minimum of 6
months before initiating these kinds of relationships. This time period is a minimum and, in some cases, 6
months is not enough. There are some cases where no amount of time is adequate.
Issues that need consideration include: the length of time both parties were in the therapeutic relationship;
the level of client disclosure while in the relationship; and whether transference occurred and if the client still
sees you in an authoritative role. When the latter occurs, it may be di( cult for the client to see themselves as
an equal partner in the new relationship.
Compare the level of disclosure with a client who you have been seeing for 2 weeks for a hamstring tear and
a client you have been seeing weekly for 3 years, during which time he went through a divorce and lost a
parent. It is easy to imagine that the second client may have leaned on you more for emotional support. In fact,
you may be a major part of his support network. There may be signi%cant transference and no amount of time
will put the two of you on equal footing because of the deep bond your client experienced. This client may
always see you as his savior, even as you attempt to establish a di4erent role. He may enter into a romantic
relationship with you willingly, but later feel taken advantage of because of previous disclosure. No matter who
initiated the change in the relationship, if the client later feels harmed by it, licensing and certi%cation boards
will most often agree with the injured client and discipline the therapist.
The decision to date an ex-client should be considered carefully. Such situations can easily damage
relationships with other clients, and damage your reputation professionally. The best and safest decision is tonot become romantically or sexually involved with ex-clients.
Sexual Misconduct
Sexual misconduct is behavior used to obtain sexual grati%cation against another person's will or at their
expense. It includes sexual harassment, nonconsensual sexual contact, and any sexual activity between someone
in an authoritative role and a subordinate. According to NCBTMB, sexual activity includes verbal and nonverbal
behavior for the purpose of soliciting, receiving, or giving sexual grati%cation. Although therapeutic
relationships consist of a person in an authoritative role and a person in a subordinate role, other relationships
%t this description. These include health care providers and their patients, clergy and their congregants,
teachers and their students, and employers and their employees. If therapists introduce sex into professional
relationships, they abuse their position of authority. It exploits the trust the client has in us and takes advantage
of the client's vulnerability.
Sexual harassment is a type of sexual misconduct and consists of nonconsensual sexual advances, requests for
sexual favors, or other conduct of a sexual nature. Telling a client that you are sexually attracted to them is
sexual harassment. Sexual harassments can occur in the therapist's place of business or o4site. Both sexual
misconduct and sexual harassment may be found in a single episode or as persistent behavior.
Examples of sexual misconduct are (1) : irtatious behavior and comments made about a client's body or
clothing; (2) seductive or sexual gestures or expressions; (3) sexual innuendos or sexually provocative remarks;
(4) telling sexually-explicit jokes; (5) discussing sexual problems, sexual performance, sexual preferences, or
fantasies; (6) kissing a client; (7) unnecessary examination or treatments over female breasts or pelvic area; (8)
%lming a client without permission; (9) entering the room before clients are completely draped or dressed; (10)
failure to ensure proper draping; (11) o4ering sexual services to clients; (12) asking a client on a date; (13)
sexual self-arousal or stimulation in the presence of clients including rubbing part of your body against the
client's body or on the table; and (14) genital, oral, or anal sex with clients.
Sexual misconduct is of particular concern to the massage profession because touch is our primary therapeutic
tool and our methods often involve treatment on a client's bare skin. The sensual pleasure inherent in massage
is one of its greatest assets, but also one of its liabilities and can lead to situations of seduction and exploitation.
Because therapists are likely to deal with issues of sexuality, talking about them early is best done while in
school. Through talking about these issues, we obtain the know-how to make sound judgments and good
decisions. Class discussions are important as we learn from instructors and classmates' experiences. William
Greenberg, the former grievance chairman for the American Massage Therapy Association, states that
complaints %led against therapists for sexual misconduct have decreased recently. Greenberg attributes this
reduction to the fact that schools are giving more instruction on boundaries in general and sexual boundaries in
Negative Perception of Massage
Some people have negative perceptions about massage and believe it is a euphemism for prostitution. Much of
this illusion is perpetuated by movies, television shows, magazines, newspapers, the Internet, prostitutes, and
human tra( ckers who use the terms massage and massage parlor. In some parts of country, the terms massage
a n d massage therapist are listed side-by-side with the former often used to describe unlicensed individuals
o4ering adult entertainment and sexual services. Some media do not separate the two entities; for example, ads
featuring Tootsie's Tantric Massage or Candy's Erotic Massage are next to ads featuring legitimate massage
therapy services. This confuses consumers.
As massage therapy becomes mainstream and available everywhere from the airport to hospitals, the
negative perceptions will fade. However, it is important to address the subject, empowering students to
skillfully and respectfully respond to negative perceptions about massage, whether from potential clients or the
public at large.
Risk Management
There are a number of things that we can do to prevent sexual misconduct. This is called risk management and
includes identifying potential risks and taking precautionary steps to reduce their likelihood of occurring. An
ounce of prevention is worth a pound of cure. The potential for sexual misconduct is in every profession, notjust in massage. And even with proactive measures, closeness felt by a client may lead to misunderstandings
and false accusations.
Our touch may be misinterpreted. We are touching clients sometimes with the gentleness and attentiveness
that might be commonly shared with a lover. You may have clients who are survivors of sexual abuse. These
individuals may be hypersensitive to seduction and may misinterpret your touch. Conversely, some people with
abuse in their past dissociate (a kind of numbing both mentally and physically) and are unable to detect or stop
therapist's inappropriate behavior because they feel they were unable to stop it from happening before.
Therapists who are survivors themselves may not realize that they are being sexually inappropriate with a
As with other professions, most complaints are against male therapists and men are more at risk for being
accused of sexual misconduct. Although every therapist should be watchful and alert with regard to sexual
boundaries, male therapists need to take extra precautions. Ways to reduce the risk of sexual misconduct are:
• Avoid terms of endearment (e.g., honey, sweetie) because they may be misread by clients.
• Avoid words in ads such as release, available anytime, open 24 hours, my place or yours, total relaxation, complete
relaxation, full service, full body massage, and happy endings.
• Note the demeanor, tone of voice, and language used when booking new clients. Note any discomfort you are
feeling. Be leery of clients who ask about the age of the therapist or distinct features such as hair color.
• Avoid sexual signals you may be sending inadvertently, such as wearing tight or revealing clothing. When you
start dressing for work as though you are going on a date, you are asking for trouble.
• Avoid working on a client if you cannot put your feelings of sexual attraction aside.
• Realize problems associated with a home office. Leading clients through your home to the bedroom (now
treatment room) can make clients feel uneasy and may give mixed messages.
• Be aware of body contact during the massage. Pay attention to the way you lean into your client's body. Be
conscious of what part of your body touches the client during massage techniques including joint mobilizations
and stretches.
• Screen clients carefully and use special consideration with out-calls. Perhaps accept out-call requests with
clients who have been referred by someone you know and trust.
• Obtain separate written consent before starting the session when working on or near female breasts is
clinically indicated. Work should be conducted over the drape. It is strongly recommended that only female
therapists work on female breasts. If male therapists are massaging female breasts, ask another female to be
present in the room. Know and adhere to your state's laws regarding female breast massage. Provide this
service only if you have specific training in this work.
Massage and Sexual Responses
Sexual activity has no place in the therapeutic relationship. However, you or your client may experience a
sexual response to touch. Su Fox points out in her book entitled Relating to Clients that sexuality is a biologic
fact, rooted in our brains, neural pathways, and hormones. Sexual response or arousal is a neurologic and
reflexive response that happens to all of us. Fox says that just like our mouth waters in response to the sight and
smell of certain foods, certain people will trigger neural circuits and the rush of hormones that spell sexual
arousal. Men who are concerned about getting an erection during massage are quite aware of this response.
This is not sexual misconduct. Acting on a sexual response is sexual misconduct.
Sexual responses such as erections can occur naturally from the massage and be triggered by sights, sounds,
smells, and without actually thinking sexual thoughts. Sexual response can occur as the body releases tension
held elsewhere in the body. And sometimes more is going on—it can be the client is intentionally sexualizing
the massage. Your response to these situations will depend on many factors.
If you feel that the erection is just a re: ex response (we are not suggesting this is easy to determine), you can
simply ignore it. You can ask questions to distract the client from thoughts or feelings or sensations leading up
to the erection. For example, “Tell me about your mother?” or “What type of work did your father do when you
were a child?” Even if you do not know his parents, you can ask. Referencing parents often reduces erections
caused by reflexes.
Or you can ask him to roll over and continue the massage. Be sure to avoid any areas that might restimulatethis response, such as the lower abdomen, inner thighs, and lumbosacral region.
If your client has an erection followed by inappropriate behavior, he is likely sexualizing the massage.
Behavior ranges from subtle to overt and includes noises such as moaning, repetitive movements of the pelvis,
touching his pelvis or penis, or removing some or all the drape. Inappropriate behavior includes
sexuallysuggestive comments, questions, or jokes; touching you; or positioning you for sexual activity.
If you have discussed how these situations will be addressed when obtaining consent for therapy (see Chapter
10), proceed with those actions, such as terminating the session (see Terminating a Session section). If measures
taken for these situations were not discussed previously, consider removing your hands from the client, stepping
back and toward the door, and saying something like “I do not like the way in which you are behaving
(talking). If you do not stop immediately, I will end this session.” If he agrees to stop, you may continue with
the massage if you feel comfortable. However, if you feel uncomfortable or if he makes excuses about his
behavior or tries to minimize your reaction, it is best to terminate the session. You have the right to refuse
massage to a client who makes you feel uncomfortable, unsafe, or continues to sexualize the massage.
Terminating a Session
It is rare that you will terminate a session because of inappropriate behavior, but you need a protocol to use
when the need arises. This decision should not be taken lightly. Once the decision has been made, it must be
carried out. Here are some guidelines:
• Remove your hands from the client; step back and toward the door.
• Tell the client that the massage is over.
• Inform the client that you will wait outside while he or she gets dressed.
• Avoid answering questions until the client is dressed and has stepped out of the massage room.
• If the circumstances leading to the session are extreme, or if you are alone and become frightened, lock
yourself in a room until the client has left or call 911 and stay on the telephone until the client leaves.
Document the events that led to the decision to terminate the session. Be sure to document statements
verbatim and describe the situation in detail. This information can be used should the situation become libelous.
If you feel fearful as a result of the session termination, some form of intervention should be taken such as
filing a police report. Also, file a police report if you feel sexually harassed or stalked by the client.
Sexual Misconduct and Professional Liability Insurance
Professional liability policies do not cover damages resulting from sexual misconduct.
Sexual Misconduct by Colleagues
Every massage therapist should contemplate possible consequences of inappropriate behavior, particularly
sexual misconduct. If a therapist intentionally or unintentionally violates a client sexually, the client's
realization of what happened rarely occurs during the session. Only after the massage does the client re: ect on
the events and inappropriate behavior of the therapist. Many acts of sexual misconduct go unaddressed. The
violated client may be silent and blame themselves for what happened.
If we hear allegations of a colleague who engaged in sexual misconduct, we have a professional responsibility
to take action. The %rst step is to speak to the therapist and let him or her know the nature of the allegation. If
your colleague con%rms the allegation and wishes to change the inappropriate behavior, suggest that he or she
seek professional help and refer the client to another therapist.
If you cannot speak to your colleague directly, or if your colleague does not recognize the problem, speak to
his or her supervisor. Be sure to document your concerns and include a description of the event that suggested
the boundary violation. The next step may be to %le the report with the proper authorities. This is often the
state board that regulates licensure and professional affiliations of which the therapist is a member.
In many states, there is “duty to report” sexual misconduct by other therapists. If we have %rsthand
knowledge (i.e., witnessed it ourselves or told to us by the o4ending therapist), we are required to %le a report
with the state licensing board. If we fail to do so, we are in violation of the law. If allegations are second-hand
or obtained by hearsay (i.e., learned from other persons such as the client) our role is to encourage the
client/victim to %le a report. Licensing boards and professional organizations are most able to act when theyhave a complaint %led by the victim. Some boards and organizations do allow anonymous complaints, but these
are not as strong as ones filed by victims, and are harder to take action on.
Therapists who are not concerned or are indi4erent about the damage caused by their sexual misconduct must
be stopped. Behind sexual misconduct lies a blatant disregard of ethics, morals, and disregard for the entire
profession of massage therapy. There is no excuse for sexual misconduct. Remember that the therapist is always
responsible and liable for his or her actions, even if the client initiates the situation.
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Activities and Assessments
Matching One
Place the letter of the answer next to the number of the term or phrase that best describes it.
A. Abuse
B. Congruency
C. Boundaries
D. Confidentiality
E. Countertransference
F. Disclosure
G. Dual relationships
H. Empathy
I. Neglect
J. Respect
K. Sexual misconduct
L. Transference
_____1. Emotional reactions of the therapist toward the client; may occur from unmet personal needs,
unresolved emotional issues, or internal conflicts that are brought into the relationship unconsciously
_____2. External presentation of words and actions that coincide with the internal world of thoughts and
_____3. Sexual activity between someone in an authoritative role and a subordinate
_____4. Guidelines, rules, and limits that we create in relationships to identify what are reasonable, safe, and
acceptable ways to interact with others
_____5. Transfer of client's feelings, thoughts, and behavior that they have for a significant person in their life
onto the therapist
_____6. Act of keeping information private or secret
_____7. Situations when two or more different relationships exist between clients and therapists
_____8. Treating someone with value and consideration
_____9. Intentional and deliberate improper treatment of someone for personal gain or benefit
_____10. Client sharing his or her personal information
_____11. Ability to understand the unique world of another
_____12. Unintentional improper treatment of someone for personal gain or benefit
Matching Two
Place the letter of the answer next to the number of the term or phrase that best describes it.
A. Attunement
B. Conflicts
C. Emotional boundariesD. Emotional release
E. Financial boundaries
F. Intellectual boundaries
G. Professionalism
H. Risk management
I. Sexual activity
J. Sexual harassment
K. Therapeutic relationship
L. Unconditional positive regard
_____1. Relationship between therapists and clients in which therapists provide services that benefit clients
_____2. Boundaries that encompass our beliefs, thoughts, and ideas as well as safeguard our self-esteem
_____3. Boundaries that protect feelings and separate our feelings from the feelings of others
_____4. Identifying potential risks and taking precautionary steps to reduce their likelihood of occurring
_____5. Verbal and nonverbal behavior for the purpose of soliciting, receiving, or giving sexual gratification
_____6. Situations in which one person feels that someone or something is keeping them from achieving their
goals and is incompatible with their needs and concerns
_____7. Acceptance of another regardless of what that person says or does
_____8. Experience of connectedness shared between two people
_____9. A form of sexual misconduct that consists of nonconsensual sexual advances, requests for sexual
favors, or other conduct of a sexual nature
_____10. Boundary that includes letting your clients know upfront about fees and forms of payment you
_____11. Adherence to a set of values and obligations, formally agreed-upon codes of conduct, and reasonable
expectations of clients, colleagues, and co-workers
_____12. Letting go or releasing suppressed emotions
Think about It
Professional Dual Relationships
Alice has been your accountant for 7 years. Two years ago, she needed help with a sti4 shoulder. Alice was so
pleased with the other bene%ts of massage therapy that she now receives weekly massages by you. Her standing
appointing is Thursday at 4 PM. On Monday, you receive a letter from the IRS stating that a mistake was made
on your last year's tax returns and you have overpaid by $800. How do you handle this situation?
Got Boundaries?
Do you have good boundaries? Well, do you? Take the quiz and %nd out how you rank at making decisions in
difficult relationship situations. Visit http://www.boundariesbooks.com/boundaries-quiz/.
Do you feel the quiz ranked you accurately? Why or why not? Post your re: ections on an Internet-based
discussion board monitored by your instructor. State why you feel this is the most important guideline.
NCBTMB's Code of Ethics
Given the complexity of therapeutic relationships, how can they be managed ethically? NCBTMB's Code of
Ethics give us guidelines and supports professional judgment (http://www.ncbtmb.org/code-ethics). Visit their
webpage that lists the code of ethics. After reading them, select the one you feel is most important and state
why you feel this way.<
C H A P T E R 3
Tools of the Trade
“The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty.”
—Winston Churchill
Learning Objectives
After completing this chapter, the student should be able to:
1. Define massage table features and state how to care for table fabrics.
2. Discuss massage table and massage chair accessories, such as face rests and bolsters.
3. Discuss massage linens, massage lubricants, and safe ways to dispense them.
4. State supplies and furnishings for a massage room and the importance of a safe, barrier-free work environment.
Your career as a massage therapist depends not only on your education, knowledge, skills, and the experience you will acquire, but also on
your ability to use wisely the tools of the trade. While no one will deny that your “hands” are your most important tool, you will most likely
use additional tools such as a massage table, a massage chair, and related accessories, such as linens and lubricants. The environment of your
massage room is also an important aspect of treatment because certain colors stimulate the nervous system while others soothe.
In this chapter, we will open up your toolbox and examine each instrument. Practical suggestions are included to assist you in decision
making when choosing equipment and accessories or when designing your massage space. We will also discuss equipment maintenance, as
well as when and how to disinfect equipment surfaces. Lastly, we will look at safety considerations for your massage equipment and your
massage room.
But first, let us examine massage tables.
Massage Tables
A massage table is what the therapist uses to position the client to receive massage. The massage table is likely the most important
professional purchase you will make (it is second only to your massage education in importance). Think of it as an investment that will last
you most of your career. If fact, your table will likely outlast the car you are now driving so choose your table wisely.
The most popular massage tables are portable tables and account for approximately 95% of all sales by table manufacturers, with prices
ranging from $200 to $600. Portable massage tables are hinged in the middle to be folded in half and carried (Figure 3-1), resembling an
oversized suitcase. The primary advantage of portable massage tables is convenience and relative ease when they must be transported from
one location to the next. However, portable tables from reputable companies are as strong and sturdy as stationary tables.
FIGURE 3-1 Portable massage table.
Selecting a Table Manufacturer
You must feel totally con8dent in your equipment. It will most likely be a major expenditure, especially when purchased with accessories.
Make every effort to obtain professional-grade equipment for the comfort, safety, and security for both you and your clients.
Purchasing equipment from a reputable, well-established manufacturer is important for several reasons. First, these manufacturers tend to
provide great customer service. Next, these manufacturers o er a trial period and, if you are not satis8ed, will refund your money once the
equipment is returned. Third, they o er superior warranties, usually 5 years and longer. Last, if the table is to be sold as previously-owned,
products from reputable manufacturers will hold their value and will bring a higher resale price.
There is no national standard for determining weight ratings for massage tables or chairs. When looking for a strong, safe, and reliable
massage table or chair, you must rely on the weight ratings provided by individual manufacturers. The more reputable the manufacturer is,<
the more you can trust their weight ratings. As with most things in life, you get what you pay for and:
“The bitterness of poor quality remains long after the sweetness of low price is forgotten.”
Benjamin Franklin
Two more things to mention; o -brand massage table or chair packages purchased by department stores and membership shopping clubs
may seem like a good deal at the time, but you may have di? culty locating the manufacturer when a problem arises. And remember; plan to
have your equipment for a very long time (in most cases, 10+ years). If you want to replace a broken face rest frame or purchase a new
accessory, such as an arm shelf, single accessory purchase may not be an option. When dealing with reputable manufacturers, you can
purchase replacement parts or accessories more quickly and easily.
Find out where on earth the products sold by the manufacturer are produced. In general, products made in the United States have superior
construction and better overall quality than those in other countries where manufacturing standards are not as stringent.
Massage Table Features
Most manufacturers offer several table options, such as width, height, frame material, padding, and fabric. Let us examine table features.
Most massage tables sold are between 28 and 33 inches wide. In many cases, portable table width is a personal preference and depends on
many factors such as (1) the size of the massage room, (2) the therapist's height, (3) the type of clients frequently served such as pregnant
clients who need to be in a side-lying position, and (4) how often the table is transported (shorter therapists may 8nd it easier to transport
narrower tables).
E ective body mechanics use leverage when delivering deep pressure techniques. The closer you are to your client's body, the more
leverage you have in the vertical plane. Wider tables may create a situation where it may be more difficult to apply deep pressure if the client
is far from the edge of the table.
On the other hand, narrow tables often make large-framed clients feel uneasy because their arms hang o the table's edge, especially when
lying supine (face up).
Hey Salvo, What Are Your Favorite Table Specs?
My table is 33 inches wide with a super deluxe table pad (4 inch). Wider tables more easily accommodate clients with special needs (try
doing a side-lying massage on a pregnant woman in her eighth month on a 28-inch table). Also, as I age, I 8nd myself using the extra
width to “perch” myself on the table while I massage. The super soft padding is preferred by the majority of clients and provides
comfortable prone, or face down, positioning in cases of breast tenderness (a frequent female client complaint). A soft table pad also
allows me to easily work beneath the client (I slip my hand between the client's back and the tabletop). This technique is best used while I
sit on a stool (my favorite accessory).
The height range is usually between 22 and 34 inches. Adjustment is achieved, usually in 1-inch increments, by lengthening or shortening the
four table legs. Aluminum table legs are made of nested tubes and adjustments can be made quickly by pushing in a spring-loaded button and
adjusting the leg length longer or shorter. Wooden table legs are made in two sections held together by a tongue and groove system and one
or two bolts. Height adjustments to wooden tables require unscrewing the knob(s), repositioning the table leg, and rescrewing the knob(s) to
secure the leg. See Chapter 7 for height suggestions.
Most massage tables are either 72 or 73 inches long. Most therapists use face rests and bolsters; a face rest adds 10 to 12 inches to table
length and 6- or 8-inch-high bolsters will reduce the client's length when placed behind the knees or in front of the ankles. A 6-foot or taller
client will have ample length when lying on your table.
Table frames, as well as its understructure, provide table support. These are typically made of wood, aluminum, or a combination of the two
materials. Portable tables that are predominantly wood tend to weigh more when compared with metal tables.
Petite therapists might purchase aluminum-frame tables because they are lighter and easier to transport. Aluminum tables also have the
advantage of quicker leg adjustments as mentioned previously. Although some therapists rarely change table height, clients' girth varies
enough to make leg adjustability a consideration. This circumstance is especially true when working on the fourth, 8fth, or sixth client of the
day, when energy conservation and proper body mechanics (or lack thereof) become a major concern.
If you ask clients what they remember most about being on your massage table, they will often mention table padding. It should be very
comfortable, adapting to and supporting your client's body. When selecting table padding, consider its density, loft, and durability. Let us
examine these areas.
Most foam pads are divided into three grades of density: light, medium, and high. High-density generally has better memory, or ability of the
foam pad to return to its original height after being compressed. Most high-quality tables use several foam densities (medium- to high-density
foam) as they are more durable and last longer.
Foam thickness, or loft, typically ranges from 1.5 (8rm) to 4 inches (ultra-plush). Therapists who use deep-pressure techniques often like