PD200 Flashcards
therapeutic vs non-therapeutic touch
.
power differential via
standing
clothed
active role
in position of authority in treatment room
client
lying prone/supine
without clothes
allowing therapist to touch them
passive role
client description vs what they actually feel
.
clues about what client feels
affect
nonverbal behaviour
body language
posture
tone of voice
breathing rate
tension in tissues
responses to question/touch
affect
how emotional state is expressed through facial expression, tone of voice, body language
Albert Mehrabian research about how speaker’s message is interpreted
7% verbal messages
38% paraverbal messages (tone/pitch of voice)
55% nonverbal messages (gestures, facial expression, stance, etc.)
differences in patients
“Some differences are due to patient illness, personality, socioeconomic class, or education, but the most profound differences may be cultural.”
danger in (incorrectly) considering cultural differences
“The danger in considering cultural differences is that of stereotyping people.”
GENERALIZATION VS STEREOTYPE
First, it is important to distinguish between stereotypes and generalizations.
They may appear similar, but they function differently.
A stereotype is an ending point, and no effort is then made to ascertain whether it is appropriate to apply it to the person in question.
A generalization, on the other hand, serves as a starting point.”
generalization
“A generalization is a statement about common trends within a group, but with the recognition that further information is needed to ascertain whether a generalization applies to a particular person.
Therefore, it is just a beginning.
Because differences always exist between individuals, stemming from a variety of factors, such as, in the case of immigrants, the length of time they have spent in [a country]and their degree of assimilation, even generalizations may be inaccurate when applied to specific persons.”
low context vs high context cultures
(LOW)
german, swiss, scandinavian
american, english, canadian
french, spanish, italian
mexican, greek, arab
japanese, chinese
(HIGH)
low context
specific
detailed
precise
poorer @ decoding UNSPOKEN MESSAGES
& body language
high context
less direct
emphasis on human relations
more sensitive to non-verbal elements
& to feelings of others
most cultures
Most cultures fall between the extremes on the spectrum and share characteristics of both high and low context traits to varying degrees.
how therapeutic touch is perceived?
The therapist touches the client in nurturing and compassionate ways that may remind the client of childhood or other times when caregivers kept them safe.”
Or not, as physical touch can provoke anxiety in survivors of childhood abuse.
INAPPROPRIATE TOUCH AS RMT
1) Hostile or aggressive touch
2) Erotic or sexual touch
3) Body areas of touch sensitivity
if anger b/w client/therapist, best not to touch?
If you are angry with a client, it is best not to touch them
Alternately, if a client is angry with you, do not touch until the energy changes
The perception of holding power over another underlies this type of touch
paying attention to intent of touch
Constant attention must be paid to the appropriate understanding and interpretation of the feelings generated during professional touch;
pleasurable touch must not evolve into or become misinterpreted as erotic touch
which body areas are more sensitive?
orifices
ventral surfaces (esp breasts)
inappropriateness of touch?
Touch –
when? the way? w/ what intent?
what is anxiety?
Feel on edge, fretful, distressed.
Be nervous, unsettled.
Feel faint, dizzy, nauseous, clammy, or sweaty.
Hold breath or experience heart palpitations.
define low moods
Appear unhappy, blue, despairing, and sad.
Seem fatigued or exhausted.
Lack of motivation to the point of incapacity
Feelings of worthlessness or being overwhelmed by life.
Experience disruptions in personal relationships.
how RMT help patients with anxiety or depression?
Improving mood.
Facilitating parasympathetic response and decreasing resting muscle tension.
Deepening breath and awareness of breathing patterns.
Teaching clients to stay focused in the present.
key concepts (2)
boundaries & boundary-lessness
dual relationships
transference & countertransference
MT is
transaction
not a casual interaction
intimate space boundary
0.5 meter = intimate space
1.2 meter = personal space
3 meter = social space
beware of illusion of intimacy b/w therapist/patient
.
clear communication
Clear communication
Empathic yet firm
Leaving no doubt as to where a boundary lies
client who is uncommunicative
Non disclosure of information places the client at risk
Why might a patient be uncommunicative?
why uncommunicative?
The client does not feel comfortable sharing the information
The client does not think certain information is relevant
The client forgets to disclose something specific
why might client not disclose info?
“might have difficulty reading”
3 things therapist can do when they think client is giving incomplete or inaccurate information
1) verbally repeat questions on health form
2) reword questions
3) work conservatively/generally until it’s possible to get more information
what happens when therapist ignores their professional role?
When therapists ignore their professional role, they may:
Harm clients emotionally, psychologically, physically, financially.
Promote transference.
Ignore ethical responsibilities.
Become vulnerable to clients who wish to promote personal contact.
what happens when clients forget their roles?
When clients forget their roles, they may:
Confuse therapeutic touch with intimacy.
Assume that the therapist shares client feelings.
boundarylessness
Inappropriate or suggestive comments
Crude behavior
Attempts to control through guilt or intimidation
Offering advice outside of therapeutic role
Ignoring client cues
Exchanging treatments for personal favors
Breaking confidentiality
note terms, internal/external locus of control – in the context of massage
Internal or external locus of control
Family culture, schooling, religion, and personal experience with setting limits
Attitudes towards:
Intimacy, body image, and sexuality
Authority and discipline
types of boundaries permeable vs rigid
Permeable ——
Weak
Ignores massage therapy transaction
Does not challenge problematic behaviors
Personal sharing compromises care
types of boundaries permeable vs rigid (2)
Rigid ——
Allows no personal information, attitudes or feelings to be shared
Boundary is firm and cannot be penetrated
No acknowledgement of potential for exceptions
semi permeable boundary (3rd option, in b/w)
Firm but flexible boundary ——
Allows personal information to be shared if it is:
Ethical to do so
In the client’s best interest
power differential
Actively listen to client concerns while limiting advice-giving
Stick to professional role and scope of practice
what is the result of boundarylessness
Represents a violation of client-centered care
Poses significant risk to clients and therapists
components of a framework that supports boundaries
Separate personal/professional environments
Professional standard of hygiene
Predictable schedule
Availability limited to professional hours
Clearly communicated fee structure
Discounts and special relationships avoided
DUAL RELATIONSHIPS
Occur when two people share more than one type of relationship
Initial relationship foundational
For example, Friends who later became clients will always be FRIENDS first.
massage therapy during dual relationship
Do not confuse the therapeutic hour with personal time with a friend.
why do dual relationships put therapists in difficult position?
Divided loyalties and conflicts of interest —
Therapeutic responsibilities versus personal relationships
Unreasonable expectations for therapists —
Therapists must always respond therapeutically.
Personal conversations may conflict with therapeutic response.
confidential information risks
Conflict between professional role and personal relationship
No objectivity
Potential for misuse of confidential information
dual relationships and OBJECTIVITY
Dual relationships compromise objectivity.
The nature of the first relationship defines the nature of the second.
transference
Occurs when clients project feelings onto their therapist
Stems from personal experiences
responsibility for transference
Pay attention to signs of transference.
Transference is not about the therapist.
Responsibility for managing it always rests with therapist.
who is responsible for managing transference
Responsibility for managing it always rests with therapist.
risk of ignoring transference
Ignoring transference puts clients at risk.
Client feelings may intensify.
Client may feel permission to act out transference fantasies.
WHAT TO DO TO PREVENT TRANSFERENCE
DO’s
Begin and end treatments on time.
Establish and clarify boundaries.
Limit personal disclosures.
Respond empathically.
Seek peer supervision.
WHAT NOT TO DO (TO PREVENT TRANSFERENCE)
DON’Ts
Don’t provide extra time.
Don’t meet the client socially.
Don’t indulge in dual relationships.
Don’t ignore signs of transference.
counter-transference
Occurs when:
Therapists project feelings or associations onto clients
Clients remind them of other relationships
potential to ruin relationship
positive/negative counter-transference
Countertransference causes communication and boundary challenges.
Positive countertransference
Feelings of love and attraction toward client
Negative countertransference
Feelings of discomfort, dislike, or even hatred toward client
countertransference & peer supervision
Seek peer supervision to help:
Clarify feelings and reactions.
Create a strategy to address countertransference.
“I” statements to address transference/
“I feel … (description of emotion)
“when you … (specific description of behavior)
“I would appreciate if [you, we] could do this differently by …” (request for a change in behavior)
boundaries…
Describe a therapist’s limits to care
Remind clients that massage therapy is a transaction
Protect both clients and therapists
Minimize transference and countertransference
CLINIC FRAMEWORK
a framework that predictably outlines what clients may expect.
Hours of work
Fees
Location
Ethical commitment to practice
Clinical policies regarding:
Confidentiality
Privacy
Cancellation fees
business framework
Business cards
Your physical space
The first telephone contact
A website
Word of mouth referrals – what kind of people are talking about you?
Your fee structure, and how patients learn about it
The music you play
The length of your sessions; how you deal with lateness – your own, and that of your clients
…
about business cards
Having a business card shows you are serious about your business
People expect professionals to have business cards
Cards should be simple and eye catching
“a graphic or other image used by a Registrant …as a massage therapist should not suggest that some service is being provided other than massage therapy.” 78.3(1)
“shall be dignified and in good taste.”78.3 (1)(b)
professional work space
“Working out of an office rather than a home is generally more professional and will feel safer both to you and to your clients.”
“You don’t want your office space to look like a bedroom with a massage table in it.”
Practitioners need to avoid making their offices into displays of their personal beliefs-political, spiritual, or otherwise.
“Clients love coming into a room that’s all set up for them.’
when receptionists present
“For clients’ confidentiality , you need to have a way that they can leave a message that only you can access.” (phone)
SOCAN & music in public spaces (lobbies)
Society of composers authors and music publishers of Canada
SOCAN– the Society of Composers, Authors and Music Publishers of Canada – is a not-for-profit organization that represents the Canadian performing rights of millions of Canadian and international music creators and publishers.SOCANcollects license fees from businesses that use music and distributes the money as royalties to those who create music.SOCANoperates in accordance with tariffs certified by the Copyright Board of Canada.
In the case of a business such as a massage therapy clinic, the waiting room/reception area is considered public space and is therefore licensable and potentially subject to a yearlySOCAN fee, based on square footage. In a public area, music coming from a radio does not require a SOCANmusic license, but streamed/online radio requires a licence. The exception to this is if you subscribe to a music supplier that already submits license fees toSOCAN. If you’re not sure if your music provider is licensed withSOCAN, you can contactSOCANto inquire about your provider.
Change rooms and treatment rooms are considered private space and therefore are not licensable. In a private area, any music can be played without a license fromSOCAN.
talking to clients about money
Be careful about your tone (straight-forward, businesslike and confident, not apologetic nor punitive)
problem with bartering (services)
Lack of continuity of care
Lack of charting
Failure to remit required taxes (CRA – Treatment has value which is taxable)
What happens if something goes wrong?
risk of seeking professional services from a client
When you hire them for a commercial service, you create a situation where someone with whom you have a therapeutic relationship is now under contract to you in another context.
seeking professional services from a client?
Is there a potential to create vulnerability for your patient?
Are there risks in letting your patient into some aspect of your personal life?
What happens if there are issues with the work done by the patient who is now your web developer or photographer?
How will that change the therapeutic relationship?
What happens if you are not satisfied with their work?
Will it be awkward to discuss it with them? Or, provide them with a medically indicated treatment?
risks of accepting gifts/gratuities from clients (Yellow light)
A yellow light:
warning signs for boundary crossings
Accepting personal gifts/money from a client (other than the regular fee for your services) that could be perceived as an unfair benefit or unfair advantage by other clients and staff.
sensitively declining gratuity/gifts
If a registrant has decided not to accept a gratuity on the basis that doing so would violateCMTBCBylaws, he should inform the patient of his reasons for declining the gift in a professional manner.
Citing professional obligations and responsibilities may assist the patient in knowing that this is a professional requirement, not a personal rejection.
Boundaries – standards of practise (regarding gifts/tips)
“An Rmt:
10. refrains from giving gifts to patients or receiving gifts( including tips) from patients, except where the RMT’s objectivity or ability to act in the patient’s best interest will not be compromised.”
RMTBC & coupons
Is the use of discount coupons in health care appropriate?
The RMTBC believes that discount coupons in health care are not appropriate.
RMTBC & discounts
RMTBC guidelines do permit reduced fees on a patient-specific basis in order to enable access to those who are unable to benefit from our profession due to economic hardship or reduced income.
RMTBC & discounts for no reason
if the patient has no financial hardship, then discounting a treatment undermines the education and professionalism of RMTs in BC.
separate from body workers
We encourage RMTs to separate themselves from non-registered body workers who commonly use this type of marketing.
Jurisprudence meaning
Means the legislation, policies and procedures that apply to the practice of massage therapy in a jurisdiction(e.g. B.C.)including the governing statute, College/Board rules or bylaws, code of ethics and practice standard.
self-governing profession
In B.C., it means that RMTs have ——
A unique combination of knowledge and skills;
A commitment to duty above self-interest or personal gain; and
Independence from external interference in the affairs of the profession (self-government).
privilege of self regulation
Self regulation is a privilege delegated to a professional or occupational group by the Legislature only when it is clear that the public can best be served by regulating the profession or occupation.
social contract b/w profession & public
With any self- regulating profession , there is an implied “social contract” between the profession and the public.
social contract
the profession agrees to regulate its members in the best interests of the public.
In exchange, the public agrees to allow the profession to regulate itself instead of being regulated by the government.
when social contract?
The “social contract” is created when the government grants the profession self- regulating status through a legislative framework.
Health profession’s act (BC*****)
Massage therapy practice in British Columbia is regulated within a framework that starts with theHealth Professions Act,
but also includes regulations made under that Act, other provincial legislation applicable to health professionals, and CMTBC’s Bylaws, Code of Ethics, and Standards of Practice.
Health Professions General Regulation (FURTHER CLARIFICATION)
TheHealth Professions General Regulationprovides further clarification of theHealth Professions Act, including:
The prescribed periods for disposing ofcomplaints.
The standard form Oath of Office for Board members.
The reasons for refusing to disclose information contained in theregister.
Massage Therapists Regulation (BC)
TheMassage Therapists Regulationdefines what constitutes massage therapy, as well as:
Naming CMTBC as the regulatory college for massagetherapy.
Granting titles reserved for the exclusive use ofregistrants.
Placing restrictions on the practice of massagetherapy.
3 titles reserved for use by RMTs
a) massage therapist
b) registered massage therapist
c) massage practitioner
d) registered massage practitioner
what may registrant not do (based on HPA Massage therapists regulation)
a) prescribe administer drug/anaesthetic
b) treat recent fracture of bone
c) apply any form of medical electricity
d) move a joint of the spine beyond the limits the body can voluntarily achieve using high velocity, low amplitude thrusts
CMTBC one of
CMTBC is one of 20 health regulatory colleges in BC governed by theHealth Professions Act. The Act mandates the colleges to govern their registrants in the public interest. As outlined insection 16 (1) of the Act, it is the duty of a college:
To serve and protect the public.
To exercise its powers and discharge its responsibilities under all enactments in the publicinterest.
CMTBC bylaws do a number of things
Set out rules for governance and administration of the College
Define the requirements that RMTs must meet in areas such as registration renewal and quality assurance
Set out entry-to-practice requirements for applicants for initial registration, and
Establish fees.
code of ethics
TheCode of Ethicsoutlines the expectations for ethical massage therapypractice.
standards of practice
CMTBCStandards of Practicedefine the minimum level of expected performance for RMTs. CMTBC is continuing to develop new standards of practice, each of which will be posted when it is ready for comment on theProposed Standards of Practicepage.
HEALTH PROFESSIONS AND OCCUPATIONS ACT
(reform of HPA – eventually replaces HPA)
The HPOA came out of a very significant report conducted by an expert in the field of Health Regulation, Harry Cayton.
The HPOA does important things:
It takes a proactive approach to eliminating discrimination
It improves governance of regulatory colleges by moving to a merit and competency-based appointment process.
It creates a superintendent’s office to oversee the regulatory colleges.
It allows for more transparency and accountability to the public.
It is focused on keeping people safe.
HPOA MT will be combined with
Massage Therapists will be amalgamated with Chiropractors, Naturopaths, Traditional Chinese Medicine, and Acupuncture
HPOA received Royal Assent on November 24, 2022, and is to take place by June 28, 2024.
keep in mind
Keep in mind…
Confidentiality
Informed consent
Framework – keep it consistent!
PIPA FIPPA
Personal Information Protection Act
Freedom of Information and Protection of Privacy Act
Health Care Consent and Care Facilities Admissions Act
Obtaining informed consent to treatment
when obtaining informed consent
When therapists establish informed consent, they fully disclose the purpose and benefits of a treatment approach.
They discuss any potential problems that might arise, what parts of the body will be massaged and how the client will be draped.
Therapists empower clients to state any concerns or ask any questions.
Before proceeding with the treatment, the therapist explicitly asks the client for permission to begin.
confidentiality
Confidentiality: A commitment to keep private information from being shared with unauthorized individuals.
Maintaining confidentiality means restricting access to client information to authorized individuals and keeping information secret from everyone else.
In massage therapy, maintaining client confidentiality is a foundation of professional practice.
obtaining consent
theHealth Care (Consent) and Care Facility (Admission) Act
Infants Act.
Obtaining consent is both a professional obligation, as well as a legal obligation under two BC statutes
(theHealth Care (Consent) and Care Facility (Admission) Act
andInfants Act.
consent
Code of ethics
Section 9 of the College’sCode of Ethicsrequires RMTs to obtain informed consent for therapeutic services.
Under section 8 of the Code of Ethics, RMTs must provide complete and accurate information to enable the patient to make an informed decision regarding the need for, and nature of, therapeutic services.
consent
CMTBC standards of practice (consent)
The CMTBCstandard of practice on consentwent into effect January 15, 2019.
CMTBC’s Bylawsrequire RMTs to comply with the standard of practice on consent.
infants act
TheInfants Actsets out different requirements for obtaining consent from an “infant” or minor (legally defined as an individual under the age of 19 years).
While theInfants Actuses the term “infant” to describe all minors, it provides rules to determine who qualifies as “mature” minors and who are entitled to give consent to their own health care.
mature minors & consent
can, if ——
explained the nature, consequences
the patient understands these benefits and risks
efforts to determine that massage therapy … best interest
if one or more not met … cannot consent
infant’s medical information & PIPA
medical information must be kept confidential under thePersonal Information Protection Act(PIPA)
infant and age of consent to massage therapy
“ In other words, there is not set age whereby infants can consent to their own medical treatment.
Instead, registrants must use their own best judgement to determine when an infant is capable of providing consent.
PRIVACY & CONFIDENTIALITY
Privacy
Describes a client expectation:
Being free from observation
Client expects to undress in private
Confidentiality
Describes therapist action:
Maintaining client information and records securely
Ensuring that information may not be accessed without client consent
privacy vs confidentiality
privacy = PATIENT EXPECTATION
confidentiality = THERAPIST’S ACTION
informed about how their personal health information is used.
informed about how their personal health information is used.
obtain written authorization to share health information with third-party payers.
have the right to refuse to share their personal information.
using private information for marketing or personal gains
exploitation
against bylaws/laws
MEDICAL LEGAL
This is a factual summary of all the information available regarding the patient’s history.
It expressly does NOT contain any opinion from you with respect to the patients’ condition.
two types of medical legal reports
One is the long form for more complex cases. It includes a cover letter and then a report.
The short form has the report within the body of a formal business letter.
example of treatment + techniques
The treatment programme consisted of a progressive approach to return the patient to normal activities and optimal function.
Massage, ischemic pressure, contract relax, PNF, soft tissue manipulation, and cryotherapy were used to decrease spasm and pain.
Active and passive joint mobilization techniques were used to improve and restore ROM.
Cross fibre frictions were used to decrease fibrosis in left and right shoulders
Progressive exercise programme was demonstrated to increase ROM and strengthen in cervical, scapular and thoracic regions
Pendulum exercises for shoulders initially to increase ROM with progressive increase in intensity with light weights to strengthen shoulder muscles.
write reports within scope of practice and area of expertise – send reports to MD when necessary
In complex cases it is even more important to send medical reports to the patient’s M.D.
It is not our job to determine if a patient is malingering.
When preparing a report ensure that the contents conform to legal evidentiary requirements.
Opinions poorly written can result in embarrassing cross examination.
It is extremely important to confine yourself to your area of expertise. (Experience, training and education).
offering prognosis?
It is appropriate to offer a prognosis, as long as it is couched in such terms as:
“I have treated _______of patients over a __________ number of years exhibiting similar symptoms and have found that my patient’s symptoms and recovery are in line with their injury”.
Never offer an opinion on how the law should apply.
Your report should be objective and impartial.
