Discerning Disclosure

Sharing Client Information

By Terrie Yardle-Nohr
[Ethics and Etiquette]

Are your clients disclosing too little information about their health? Are some disclosing too much about their personal lives? In each of these situations, what are the responsibilities of the massage therapist? It can be challenging to know what to do.

The term disclosure refers to sharing or revealing information between clients, therapists, and other health-care professionals. First and foremost, therapists expect clients to disclose all health-related information when doing an initial intake and interview. But how many times have you been performing a massage and come across a scar, sign, or symptom that could be a concerning pathology that wasn’t revealed during intake?

Although you’ve interviewed the client, she may say she simply forgot, or did not feel it was relevant. This can be both frustrating and potentially dangerous, because this manifestation may contraindicate massage. Therapists are forced to decide whether or not to proceed or end the session or treatment plan.

Client Non-Disclosure

Clients may not disclose information for one of the following reasons:

• They forget.

• They do not understand that certain information can be relevant.

• They do not feel comfortable revealing the information.

• The intake form doesn’t provide enough space for thorough answers or the interview process feels rushed.

Clients can forget certain aspects about their health that therapists feel are relevant to treatment. A client complaining of neck pain may not understand the relevance of an accident and injury that occurred years ago. Information may surface during the session because the client suddenly remembers as a therapist is working in a particular area. A situation such as this creates a good opportunity to educate the client on how all of this information interrelates. Many times the client begins to see the connection with symptoms she has had for years and can begin to understand more fully about the injury.

Our expectations as therapists are the result of knowing clients’ health histories. Therapists need information to assess the type of work that needs to be done, or whether massage can be performed at all. Helping clients understand the importance of this information is paramount. Asking a question such as “Are you under a doctor’s care?” may be answered no, even though the client is currently taking medication. Rephrasing the question to “When was your last visit to the doctor?” may help you obtain more information. This could be followed up with what the visit was for, the diagnosis, and medications that may have been prescribed. Including questions that can reveal more is a great way to obtain the information a therapist feels is important. We cannot assume clients will know what information their massage therapist needs.

To treat or not to treat

As doctors are referring more of their patients to massage therapists for treatment, it is important for medical professionals to know about the possible side effects or contraindications for massage. Many therapists have taken the time to talk with doctors who are referring clients or have sent information concerning possible contraindications. Therapists can be challenged with a client for whom a doctor has recommended or prescribed massage. If the therapist knows that a doctor has recommended a client with a contraindicated condition, should a treatment still be performed? It would not be ethical or good business to knowingly treat a client just because she has been referred. In some states, the massage therapy laws state a therapist can refuse to treat for any reasonable cause.

If a therapist chooses to not treat a client because of a condition, it would be helpful to send the referring doctor a note, thanking him for the referral and letting him know that the patient was not treated and explain why. An example of this would be a client who has recently had a stroke and feels achy. The doctor may feel that a deep-tissue massage would make him feel better, but the client is on a high dose of blood thinners that may make massage contraindicated. There may be alternative modalities that can be performed, but a deep-tissue massage may harm the client. Educating medical professionals and clients is good business for everyone. The client is not harmed, the doctor now knows that massage is contraindicated for this condition, and they both know about your concern for the client’s well-being.

  There may also be times when further investigation needs to be done about a syndrome or condition. Does a therapist refuse to treat or stop a session if he is unsure about a condition? This is a hard question to answer and a therapist will need to make a decision based on how this could impact the client and therapist. Most therapists have been placed in this situation at least one time in their career. Therapists who work in a medical setting may be faced with these challenges more often. It is best to fully evaluate the situation by asking yourself the following questions:

• Do I have enough information to assess proper treatment for this client?

• Could massage therapy be detrimental to the client’s health?

• Do I feel comfortable treating this client?

From an ethical point of view, the decision to treat or not treat a client comes down to the comfort level of the therapist. A therapist may be processing a great deal of information in her head, going back to information she learned in school, or remembers reading in a textbook and a quick decision may be difficult to make. Be sure to have resources available to look up information. You may also be able to call a mentor to help you decide the best course of action. Turning a client away without a valid reason is not good business. However, treating a client who has a contradindicated condition is not wise or safe.

Therapists can ask that a client return a health history form before the first visit. (Send the forms by mail with a letter welcoming the client to your practice or make your intake and health history forms available for download from your website.) This will give the therapist time to investigate anything that seems potentially dangerous. Unfortunately, many therapists do not have this capability and only have a short time to spend with clients prior to the session. Putting together a health history form that asks the right questions can assist a therapist in helping clients disclose important information.

Client comfort levels

Clients may not feel comfortable revealing health information. A client may have a condition that he or she perceives as embarrassing. So, how can a therapist convey that all health information is important in order to provide competent treatment? Therapists can put together an information sheet for clients to read and sign stating the importance of the information they are asking for and at the same time assure the client on the confidentiality of this information. It is the responsibility of each massage therapist to be clear on the ethics of confidentiality of each client. Therapists will unknowingly treat clients with various conditions. If clients choose to not reveal information about their health, the therapist could be at risk. A part of every health history form should have a statement that in some way states that the client has disclosed all known health information. This could help protect the therapist should something happen to the client during the massage.

  It is also important for all business owners to be clear about the ethics of confidentiality at all times. It is very important to educate all staff members in facilities that employ massage therapists. Staff members need to understand the confidential nature of the information they have on hand. Protecting clients and their information should be foremost in any business. The importance of obtaining relevant information, along with protecting this information, is an important aspect of a good business.

personal information

Clients may also disclose personal information that may or may not be relevant to the session and treatment plan. If a client reveals that something is going on in her life that is causing a great deal of stress, this could be relevant as to why a person’s muscles are tight. Educating the client on the affects of stress on the body is acceptable, but offering advice about personal issues is crossing an ethical boundary. It is beyond the scope of practice for a therapist to enter this personal arena with a client. The focus of a session should be the client, their physical issues, and the type of treatment that would positively affect those issues.

It can be easy to get caught up in the personal lives of a client, especially when you feel you may be able to help in some way. It is a therapist’s natural instinct as a caretaker to help a client. Most therapists have had clients who begin to cry, feel sad, or tense up while receiving a massage. This can be due to the physical connection that emotions play on the human body.

Massage therapists have to find an appropriate place to draw the boundary line with clients when it comes to personal issues. This should be done without the client even being aware it is happening. A gentle reminder to return to working on the area of concern by focusing on breathing techniques can help take a client out of that moment. Simply saying how sorry you are that something bad has happened to the client acknowledges the event, but does not get into the personal situation. Asking questions or offering advice is out of the scope of practice for a therapist, unless you are trained and credentialed in the mental health profession. This is challenging because massage therapists nurture clients in so many good and effective ways. The pain relief and relaxation have such a positive effect on the emotional well-being of clients that massage therapists often need to bring the focus back to providing the client’s treatment. It is very easy for a therapist to get distracted by listening and getting emotionally involved in what the client is saying.

If a therapist begins to feel the client’s anger or hurt, this should be a warning sign that she is beginning to get involved. This is not a bad thing as long as the therapist is aware that this is happening and knows not to pursue his thoughts, feelings, or the need to know more information about the situation with the client. This information can help therapists understand more about the client’s condition or symptoms and can help bring about a treatment plan that will be effective and nurturing.

Clients may also reveal information that can be reason to recommend further treatment or help from other parties. If a client is suffering from depression, a referral to a counselor, psychologist, or psychiatrist may be in order. This should be done gently so as not to offend the client. If a therapist does not have the resources for referral, call other therapists or a mentor and ask for help. A therapist should try and build a good network of counseling services; other medical professionals such as doctors, chiropractors, and nutritionists; and other massage therapists who may offer alternative treatments. The well-being of the client should be foremost in any therapist’s mind. Referring does not mean a client will be lost, it simply means the therapist is acting ethically for the well-being of the client.

get the Right Info

Clients can neglect to reveal information or reveal too much information for effective treatment. Finding the balance of the information that is needed is the responsibility of the massage therapist. Although challenging, there are no guarantees you will obtain all the information that is needed. Asking the right questions, along with understanding the information that is obtained, will help therapists make wise and educated choices toward appropriate treatments. The physical work that is done on a client can help with some emotional issues. Knowing the right time for help from others is equally important. Sometimes being only a part of a client’s journey to well-being is the ethical and right thing to do.

 Terrie Yardley-Nohr, LMT, has been a massage therapist for 18 years, working both in private practice and medical settings. She began teaching massage techniques and ethics 12 years ago and became program manager at Allied College in St. Louis, Missouri, nine years ago. She is the author of Ethics for Massage Therapists (Lippincott Williams & Wilkins, 2006). Contact her at TYardleyNohr@alliedcollege.edu.