The Ethics of Touch
The following is the first of three excerpts that will be published in Massage & Bodywork from the newly released book, The Ethics of Touch, by Ben Benjamin and Cherie Sohnen-Moe. (SMA Inc., Tucson, Ariz., 2003.)

Ethical Principles
The topic of ethics can often be confusing, difficult and at times downright baffling. Although debated by philosophers for millennia, agreeing upon what is “good” and “bad” remains difficult. So much depends on the situation. Not all ethical breaches are gross violations of conduct; much unethical behavior is subtle. Furthermore, being ethical is not limited simply to knowing and following ethical codes, laws and regulations. Ethical behavior also involves striving to bring the highest values into one’s work and aspiring to do one’s best in all interactions: doing the right thing in the right manner for the right reasons and with the right attitude. Tom Peters, acclaimed author of In Search of Excellence,1 sums it up like this: “High ethical standards — business or otherwise — are, above all, about treating people decently. To me (as a person, business person and business owner) that means respect for a person’s privacy, dignity, opinions and natural desire to grow; and people’s respect for (and by) co-workers.”2

For somatic practitioners ethics can be especially complex as they encounter ethical issues and dilemmas that do not always have simple, apparent solutions. In many cases practitioners may inadvertently act unethically because they have not considered the relevant issues. Expanding their grasp of ethical principles helps practitioners understand the impact of their behavior on clients and provides the knowledge and tools to act appropriately. The overall purpose of ethics is to guide professional practitioners so that clients’ welfare remains the first priority.

Self-Accountability
In essence, self-accountability is the cornerstone of ethics. It is about who you are and what you do when no one’s watching you. When you have a well-developed sense of self-accountability you are honest with yourself, and you are answerable and fully responsible for what you say and do at all times. You have the ability to look beyond the immediate moment to consider all the consequences and know if you are willing to accept them. You have personal ethics. As individuals it is our capacity for self-accountability that keeps us functioning ethically and responsibly.

Personal ethics is the precursor to professional ethics: you are not likely to be more ethical in your professional life than you are in your personal life. As the saying goes, “No matter where you go, there you are.” In other words, you are most likely dishonest in your business affairs if you are dishonest in your personal life. Likewise, if you cannot keep the secret of a friend, your client’s confidentiality is at risk.

A Practical Application for Professionals
Forethought and understanding help practitioners avoid a myriad of problems throughout their careers. Awareness of these potential issues and careful consideration assist healthcare professionals to avoid thoughtless errors in judgment. Below are a sampling of actions and behaviors generally considered unethical by professional codes of ethics.

Practicing Beyond Scope of Practice: Doing spinal adjustments, massage or counseling without appropriate training.
Sexual Misconduct: Watching a client undress or hugging a client in a sexual way.
Misrepresentation of Educational Status: Calling yourself a craniosacral therapist after taking a three-hour workshop.
Financial Impropriety: Charging a cash-paying client a different fee than an insurance-paying client.
Exploiting the Power Differential: Asking a stock broker for financial tips during a treatment.
Misleading Claims of Curative Abilities: Telling a client you guarantee her pain will be gone in two sessions.
Accessibility: Refusing to adapt your office (or making some reasonable accommodation) for those with physical challenges.
Bigotry: Refusing to work on someone due to race, religion, size or sexual orientation.
Inappropriate Advertising: Using a provocative picture in advertising; presenting misleading qualifications.
Dual Relationships: Dating a client.
Violation of Laws: Practicing out of your home when it is not permitted by law.
Confidentiality: Name-dropping famous clients; telling a spouse details about his partner’s session.
Contraindications: Treating a client when you are sick/infectious; ignoring signs of conditions that preclude physical contact.
Informed Consent: Working on a minor without parental knowledge; treating someone’s injury without permission.

Values Clarification
A satisfying and balanced life occurs when your values are in synchrony with the way you lead your life and run your business. Invest the time in exploring your values. After all, they are the major conscious and unconscious influences on the decisions you make throughout your life. Many conflicts in one’s life, both professional and personal, arise because there is a clash of values either within oneself or among others. (See “Core Values Assessment,” page 70.)

Core Psychological Concepts
To behave responsibly and ethically, every practitioner must intimately understand a number of core psychological concepts. A lack of psychological savvy is no longer a valid excuse for inappropriate behavior. These basic concepts are essential for all practitioners to understand. Practitioners must have a thorough understanding of the meaning of: the therapeutic relationship; power differential; transference; countertransference; projection; repression; and denial. These concepts create the bedrock of ethical decision-making and responsible behavior in all professional and (as a bonus) personal relationships.

The Therapeutic Relationship
The major elements in a therapeutic relationship are: there is a client-centered, fiduciary relationship; the time together is structured; each person has a clear role; the environment is safe; and there is a power differential.

Client-Centered
The therapeutic relationship is a very special kind of relationship and is often referred to as client-centered. Client-centered means that every action that the practitioner takes is in the service of the client’s needs and not the practitioner’s needs. Trouble often begins when the practitioner takes an action just because she feels like it and not because it is therapeutically necessary. Client-centered also means that the client has a voice in the process and must agree to the course of treatment for it to proceed. In the client-centered relationship the client has the right to expect that the practitioner always acts in the client’s best interest. When this occurs the client feels safe and attended. The client-centered relationship considers the client as a partner who shares decision-making power. In The Power of Touch, Phyllis K. Davis, Ph.D., describes a list of the characteristics of an “effective healer” that includes being motivated by the needs of the client.4 She emphasizes that creating a space for a supportive and nurturing environment begins with the practitioner’s commitment to personal and professional excellence. In this environment, overall health improves and enables everyone the practitioner touches to make a fuller connection with their lives.

Fiduciary Relationship
All healthcare practitioners have a fiduciary relationship with their clients. Fiduciary is a term that’s applied to a professional in whom a client places his trust. The client is putting his well-being in the hands of the practitioner and there’s an implicit contract that the practitioner places the client’s interests above and before the practitioner’s. Protecting and maintaining the boundaries of professional relationships is the responsibility of the professional even if the client requests or instructs the professional to behave otherwise. When a professional deviates from standard practice, which is sometimes necessary and useful to individualize care for a particular client, the fiduciary principle and the client-centered approach remain as the guiding parameters of care. The practitioner/client relationship and the treatment choices must be continually monitored. Also, because somatic practitioners are in positions of power relative to their clients, the law holds them to a higher standard of behavior than in business relationships with a lower level of a power differential.

Structure
Other elements of the therapeutic relationship are that the time spent together is limited and structured. The client comes for a session each week, or some other time interval, for a specific type of treatment. Within a prescribed time frame certain expected activities occur. Each person has a clearly defined role in these interactions. The client comes for help and the practitioner is there to help the client.

Safety
The client has the right to expect that the emotional and physical environment is safe and does not include inappropriate personal comments or sexual advances.

Power Differential
It is difficult to understand the therapeutic relationship between client and practitioner without comprehending the dynamics of power in a therapeutic relationship. There is a natural power differential in many but not all relationships: between parent and child; between teacher and student; between employer and employee; and of course between healthcare practitioner and client. A parent, teacher, employer or healthcare practitioner has the more powerful position. They are the authority figures whose actions, by virtue of their role, directly affect the well-being of the other. The child, the student, the employee and the client are in the more vulnerable position. In theory, and in ethical practice, the power differential exists for the purpose of bringing benefit to these more vulnerable individuals: the child’s well-being should be enhanced by the parent’s care; the employee should benefit from the employer’s management.

The power differential is inherent in any therapeutic relationship. There is an implicit acknowledgment that the practitioner has more knowledge in this area than the client. In the healthcare field the power differential is amplified by the physical aspects of practice. The client takes a position — usually lying or sitting — in which he allows the practitioner access to his body. The practitioner positions herself within the client’s physical space, often leaning over the client. Furthermore, in many professions the client is partially or fully unclothed. Although draping is used for privacy, the psychological effect of the unclothed client and the clothed practitioner increases the imbalance of power. Finally, as the practitioner’s hands make physical contact with the client’s body, the client’s physical safety is literally in the practitioner’s hands.

The Practitioner’s Role
The power differential in a relationship such as this requires consideration of two questions. The first seems obvious: How is the person with more power (in this case, the practitioner) handling that power?

The person who holds the power in the relationship may be tempted to misuse that power. The practitioner could take advantage of clients physically, emotionally, financially or professionally. Resentment usually brews when a client is put in an awkward position. Consider the following examples:

• A practitioner is treating a client who happens to be a lawyer and asks, “Since I have you here, could you just answer this quick little question I have about my divorce?”
• A practitioner who is running in a charity race solicits sponsorship during a session.
• During a session the client begins talking about an executive whom the practitioner has wanted to meet and the practitioner asks for a personal introduction.

To maintain an ethical practice, the person in power must regularly say “no” to something she could easily get and must instead choose to pay special attention
to the needs of the person with less power. The practitioner must consciously decide to maintain the integrity of the client’s boundaries in a situation where the client has significantly relaxed those boundaries.

Clients frequently test boundaries by offering things that may be inappropriate. For instance a client suggests that he tells you about some exciting new stock options while receiving a treatment or a client volunteers to take your computer home to repair it because he sees you are having trouble with it.

The Client’s Role
The second question is not so obvious: How is the person with less power responding to the other’s use of power?
The answer to this second question may be difficult to determine because of the explicit power dynamics in professional helping relationships. It is the practitioner’s responsibility to be aware of how the power differential may be affecting the client’s ability to raise concerns.

Consider this: The increased perception of the power differential in a hands-on session puts the client in a highly vulnerable position. The client feels less free to defend against intrusions or to question unexpected behavior by the practitioner. The client may feel uncomfortable about raising concerns, complaining about the treatment process or making requests. The client may find it difficult to say “no” or to question the practitioner’s behavior, even if the client feels uncomfortable or mistreated. The client may even refrain from communicating anything that could possibly be construed as negative for fear of reprisal or loss.

An active business woman has received massage twice monthly from the same massage therapist for over two years. She recently began having sharp pains in the big toe of her right foot. On one occasion, she mentioned the pain to the practitioner at the beginning of the session in hopes that the therapist would spend some time vigorously working the area. As the massage proceeded, the practitioner moved through the foot area rather quickly.

Disappointed, the client debated about asking the massage therapist to go back to the toe area. She couldn’t understand why it was so difficult to ask. After some thought she realized she felt vulnerable lying naked on the table having someone standing over her, touching her body (even though she was covered by a sheet). And asking someone to do something to her (especially on a big toe) might seem silly. She might be imposing, or maybe the practitioner would become upset since it was close to the end of the session. She did not want to appear needy or self-centered.

Finally, the client muttered in a very unsure, childlike tone, “Um, ah, do you think, I mean, would it be OK, could you, um, work on that toe that hurts?” The practitioner’s response? “Sure!”

In this case, even though the client and practitioner had worked together for a couple of years, the client became hesitant to make a request out of a sense of vulnerability, a fear of appearing foolish and concerns over possibly upsetting the practitioner. The psychological effects of the power differential in this case remained unperceived until a need arose requiring the client to make a request. And even after recognizing the effects, the client still asked as a child would for something she is not quite sure she should have.

Because of this psychological dimension, a growing trend in the healthcare world is to encourage clients to take an active role in the decision-making process of their healthcare. This is the way most somatic practitioners interact with their clients. Getting clients to take responsibility is not always easy. Unfortunately, it is difficult to reprogram a lifetime of “the doctor knows best.” Realize that even though you may be doing your best to foster an atmosphere of equality, the power differential always exists on some level in a therapeutic relationship.

Just the Beginning...
Ethics is an exciting, vital field of study for all professionals. Life is more fulfilling and satisfying if we live with honor and integrity in all our relationships and business dealings. Clarifying your values and understanding core psychological concepts is the first phase in developing a solid ethical foundation. The next steps include: expanding your abilities to resolve ethical dilemmas; learning to better manage boundaries; enhancing communication skills; improving your practice management capabilities; setting up a support system; and learning to effectively work with special populations. Running an ethical practice takes a life-long commitment to self-evaluation and exploration. We are delighted to join you on this journey.

References
1 Peters, T.J. and Waterman, R.H. In Search of Excellence. New York: Harper & Row; 1982.
2 Peters, T.J. Ethics is an everyday, lifetime endeavor. The Arizona Daily Star. 1989 Sept 26.
3 Peale, N.V. and Blanchard, K. The Power of Ethical Management. New York: William Morrow and Company, Inc.; 1988. 30-31.
4 Davis, P.K. The Power of Touch. Carlsbad, Calif.: Hay House, Inc.; 1999.173-174.

Ben Benjamin holds a doctorate in education and sports medicine. He is the founder and president of the Muscular Therapy Institute in Cambridge, Mass., and has been in private practice for 40 years. He can be contacted at ben@mtti.com. Cherie Sohnen-Moe is a business coach, international workshop leader and business owner since 1978. She was in private practice for many years as a massage practitioner and holistic health educator. She can be contacted at cherie@sohnen-moe.com.

To order The Ethics of Touch, call 800/786-4774 or visit www.sohnen-moe.com.

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