A Touchy Subject

Nicolle Mitchell explores the ethics of touch, consent and boundaries as a modern therapist

WORDS Nicolle Mitchell

As professionals, we hold a power dynamic, and it’s crucial to take that responsibility seriously

Touch can be a powerful therapeutic intervention, but it can also be used unsafely, unprofessionally and compromise boundaries. What may feel therapeutic, appropriate and safe for one person may trigger a negative response in another. This is an initial exploration into some of the ethical considerations therapists need to employ to provide an inclusive, safe and person-centred service. Managing a client’s expectations, setting boundaries and allowing room for flexibility to truly meet a person where they are through therapeutic touch requires a broad range of skills, knowledge and understanding.

 

Setting Boundaries for Safety

Initial Consultations

Setting boundaries is important for building a trusting alliance before a treatment, preventing misunderstandings from the outset of your therapeutic relationship. This process begins with your client’s record card; whether you choose to have them complete it before treatment or opt to do it together over the phone, via video call or face-to-face, you begin to build a safe space for therapy. Personally, I prefer having potential clients complete forms before their treatment. This allows me to carefully review contra-indications, seek further input from other health care professionals if needed and consider how best to work with the client and their wider support system. I also send them a welcome email that manages my expectations in writing, outlining the treatment’s type and length, offering pre and post-treatment advice and providing a link to my terms and conditions – including my cancellation policy. However you choose to conduct consultations, it’s key to remain open and curious about your client’s expectations, clearly communicate the services you offer and agree on the goals for the therapy’s progression and expected outcomes. As with all relationships, you may need to remind clients of these boundaries in a professional manner to retain a safe therapeutic space where you both feel comfortable.

Continued Consent

Before beginning a treatment, it’s important to ensure a person feels a sense of complete bodily autonomy. I encourage my clients to let me know if they feel any discomfort at any point during the session. This includes aspects like the pressure applied, the massage style and the specific areas being addressed. It’s important that they understand they are in control of how they are touched, and that I work within my professional limitations guided by frameworks such as the Code of Conduct. In addition, it’s important to hold in mind relevant laws, such as the Equality Act 2010 and the Human Rights Act 1998, which safeguard both practitioners and clients, outlining rights in terms of how they are treated.

In Nina McIntosh’s book The Educated Heart, she states: “We owe our clients our care and attention. We may not connect with a person right away, but if we cannot imagine ever having a caring attitude toward a particular client, we shouldn’t work with him or her. We need to be on the alert for anything that interferes with our abilities to touch a client in a respectful, non-judgemental way. We are not just touching bodies – we’re touching spirits.” Given that this quote was first written in 1999, to be respectful of the current standards of inclusivity and non-judgmental language, as outlined in today’s Equality Act within the UK, I would apply this statement to individuals using pronouns such as him, her, or they.

 

Considerations of Touch

Maintaining Sexual Boundaries

As professionals, we must maintain clear sexual boundaries to retain trust and uphold our profession’s reputation. If a client compromises those boundaries and expresses sexual attraction, it is perfectly acceptable to discontinue treatments in a professional manner. Similarly, if we develop sexual feelings for a client, it is our responsibility not to act on them and to cease further treatments if we believe our feelings will impact our professional relationship. A useful framework called The Intervention Model by Daphne Chellos (Benjamin and Sohnen-Moe, 2014) can help navigate such sensitive situations assertively. Consideration should also be given to how we touch our clients off the table, if at all. If you have a high-touch background or are overly familiar, it could send mixed messages and blur boundaries.

We also need to be mindful of the sex or gender with which a client feels comfortable. Historically, some of my clients have shared discomfort with a therapist of the opposite sex or gender, or with the same sex or gender massaging them for different reasons, and some may choose same-sex practitioners to avoid sexual tension. Ultimately, a person needs to feel secure with their therapist, and therapists need to feel safe with their clients. Part of managing this involves conducting a risk assessment and undergoing training to take measures to keep ourselves safe too. After all, we need to feel comfortable about whom we touch; otherwise, we risk not being able to hold therapeutic space well and may inadvertently transfer anxiety onto our clients.

Addressing Intimate Areas and Accidents

If I intend to address tension in a more intimate area, such as the groin, I clearly communicate this during the consultation and during the treatment to ensure ongoing consent. For some clients, touching more intimate places may be inappropriate for a number of reasons. They may not be able to understand your intention, or it may trigger historical abuse.

Accidents happen, and sometimes, we may touch a person in a way that is deemed inappropriate during their treatment. This could include accidentally brushing against an intimate part of their body. Acknowledging and apologising immediately, along with offering to adjust draping to make them feel more secure, can help repair any temporary rupture in trust. Recording such incidents in your notes is a good safeguarding policy. Additionally, it is also worth considering how you touch a person in other ways during their treatment. For example, if you are leaning into someone with your belly, a client may find this disconcerting, even if your intention is to give them a sense of security. Communication is key, especially when introducing something different during a session or when it is the client’s first treatment.

Considering History and Trauma

Issues may arise during the consultation or treatment that highlight a need for sensitivity, particularly when someone discloses experiences such as sexual abuse, rape, assault, neglect, trauma-related stress or struggles with intimacy or eating issues. In such cases, I ask about any areas or types of touch to avoid, emphasising that preferences can be changed at any time, encouraging open communication. It’s key to remember that trauma survivors may experience triggers differently, and what may not be a trigger one day could be on another, depending on their current circumstances.

I also pay attention to non-verbal signs of discomfort, recognising that some individuals find it challenging to express themselves, especially if they have used compliance as a survival tactic. As professionals, we hold a power dynamic, and it’s crucial to take that responsibility seriously, never abusing our position. Regular check-ins, curiosity and a reminder that their comfort is paramount can encourage clients to provide necessary feedback for adjusting or stopping their treatment.

Breaks in the treatment are absolutely okay, as this honours your client’s bodily autonomy and pace. Similar considerations apply to people who have undergone operations, including transgender surgery. Ultimately, we are seeking permission to touch a person at every moment of their treatment, which is why we need to be constantly present.

Offering Further Support

We must always consider the limitations of our role. Collaborating with other professionals, who can provide therapeutic support in other ways, may be appropriate to help clients process or manage their trauma safely. Working with psychotherapists, counsellors or EMDR practitioners can be vital in helping a person’s healing journey. Sometimes, I recommend that clients discuss specific issues with their psychiatrist, acknowledging my lack of qualification in that aspect of their journey. Bodily held trauma can be navigated more effectively when therapists and clients work together.

A psychophysical model, pioneered by Robert Timms, PhD, a psychotherapist, and Patrick Connors, C.M.T., a massage therapist, illustrates the benefits of combining skills and insights to support the healing process. Timms stated: “Often I find clients are better able to make cognitive connections in psychotherapy sessions that follow bodywork sessions. In most cases, the client’s characteristic resistances are lowered, and she or he is more available for therapeutic insight.”

 

Inclusive Practice

Promoting Equality

Individuals with disabilities or additional care needs may understandably be sensitive to touch due to past encounters with ableist attitudes or a lack of involvement in their treatment and support. To ensure equality of access to our services, it’s essential to consider and address various needs. Simple steps, such as indicating wheelchair access in promotional materials, offering home visits or highlighting trauma-informed practices, contribute to an inclusive environment.

As therapists, it is our responsibility to clearly communicate our intentions and agree potential outcomes in a way the client can understand. This may involve completing additional training in communication approaches such as signing, learning augmentative and alternative communication or developing dementia friendly techniques. I encourage my clients to share any considerations to help them feel more at ease during treatments. In one instance, with an autistic child, even the placement of my oil bowl became a significant factor in creating a conducive and comfortable space for therapy.

Adapting Communication Methods

During a massage, I gently define the area of the client’s body about to be massaged using my hands. This approach is particularly reassuring for individuals with communication difficulties or sensitivity to touch. For example, applying gentle but firm pressure through a towel on a leg communicates my intention to address that specific area. I repeat this action when uncovering the leg, especially for clients who are particularly sensitive, autistic, live with dementia or rely on touch as their primary form of communication. I am always led by the client and, where appropriate, their carers or supporters.

In some instances, we may be treating a vulnerable person, including those whose capacity to verbally consent is partly or completely compromised, such as individuals with dementia. It’s essential to be aware of the signs and signals of non-verbal consent, pausing and validating any expressed distress by checking in with the client. When working with individuals with dementia, addressing agitation with reassurance, a calm demeanour and adapting our approach in line with the client’s wishes can be effective. Seeking input from family and caregivers who know the person well is valuable for understanding unique communication styles. Regardless of how a person communicates, consent must always be voluntary, never coerced and as informed as possible, presented in a way that the client understands best.

Cultural Considerations

Finally, we also need to consider cultural influences around touch when working with clients. Cultures, whether defined by geography, ability, sexuality, work or ideals, represent a collective of people sharing beliefs, behaviours, ideas, values or customs. While certain cultures may have general and historical contexts regarding touch, it is fundamental to treat each person as an individual. Generalisations about different cultures can lead to preconceptions and prejudice, especially considering the presence of subcultures within larger cultural groups.

The key is to remain open and curious about cultural differences, embracing diversity and fostering inclusivity in our practice. For me, what it always comes back to is the importance of building trust, requiring the flexibility to meet each person where they are, while maintaining consistency to convey safety. It’s also about withholding judgement, suspending preconceived ideas and being guided by our clients.

This foundation is created within a relationship, and, as with any healthy relationship, we need to be willing to learn from each other, have humanity when we get things wrong and the confidence to repair and agree on ways forward to ensure continued safety.

Our clients are the experts in their own experiences, often being our best teachers, directing our learning and enabling us to meet their needs more mindfully, creatively and professionally. To achieve this, it’s wise to remain curious, open-minded and to listen deeply with our ears, eyes, hearts, hands and conscience.

 

Bio: Nicolle Mitchell (MFHT) is a holistic therapist, based in Cornwall since 1998. Although she has a general practice where all are welcome, she specialises in treating people living with dementia, supports people living with cancer and enables people living with additional needs or trauma to enjoy massage. Find out more at thelittlemassageclinic.co.uk

 

For references, please visit fht.org.uk/magazine-references

References [In house]:

The Human Rights Act. (1998). [online] Available at: https://www.legislation.gov.uk/ukpga/1998/42/contents.

The Equality Act. (2010). [online] Available at: https://www.legislation.gov.uk/ukpga/2010/15/contents.

Benjamin, B.E. and Sohnen-Moe, C. (2014). The ethics of touch : the hands-on practitioner’s guide to creating a professional, safe, and enduring practice. Tuscon, Arizona: Sma, Sohnen Moe Associates, Inc.

Mcintosh, N. and Allen, L. (2017). Nina Mcintosh’s the educated heart : professional boundaries for massage therapists and bodyworkers. Philadelphia: Wolters Kluwer.