Professional Boundaries, Continuing a Dialogue: Is It Time For A Change?

Update: 08/07/14. Subsequent to the post below, the therapist mentioned below was sentenced from 7-14 years in prison. A bit of investigative searching on your own will bring up the details of this case. The testimony was convincing enough to have this therapist, who was performing myofascial release, convicted of sexual assault on multiple female patients. What was most troubling was the wording, reported across multiple news sources, which must make one step back and re-assess our chosen modality, or at least how we approach it. Here is an excerpt:

"While they were lying prone on his massage table – sometimes with another person in the room – he would put his hands under their underwear or exercise clothing..."

I was taught, and continue to teach, a nearly identical hand placement as quoted above when it is indicated to perform a cross handed release/stretch on the sacrum, or if supine, across the lower region of the hip flexor (as it crossed the inguinal region). As MFR therapists, we may have done this a thousand times or more, all with nothing but positive effect on our clientele. I am posting this quote to reinforce the need for all of us to be crystal clear on our language, intent, and boundaries. While all accounts make it appear that this therapist grossly crossed a line of professional conduct, placing ourselves in a position where our motives and intent could be called into question should force all of us to revisit how we communicate with our patients. Myofascial release is a highly effective means of eliminating pain, but how we go about this may need addressing.

Myofascial release, as well as many types of manual therapy/massage, is traditionally performed on bare skin. Exceptions exist, for instance with most chair massage situation as well as in craniosacral therapy. The mindset in myofascial release was that skin-to-skin contact was necessary to assure a firm, non-slip contact with the skin/body of the patient. But, is it always necessary to have our hands directly on skin or can the same end result occur through clothing? I feel I can often be just as effective while working outside of clothing. It this worth trying, if for nothing but to avoid any type of confusion as to our motives and intents? Have you changed your treatment from how you were taught in any fashion, honoring your own boundaries? I have. I can perform a supine lumbosacral decompression without being on the skin of the sacrum and teach this as a viable option in my seminars. I no longer place my hand directly on the skin over the distal aspect of the iliopsoas region. Instead, I find the results are just as effective if I place one hand one the lower abdomen and the other on the upper thigh. Give it some thought; how can you modify your technique to minimize your liability and remain effective? How can you improve your verbal and non-verbal communication with your patients/clients to assure there is no ambiguity about what is being performed in the privacy of the treatment room? How can you minimize the chance of a court case like this happening to you?

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There is a court case that just concluded in Pennsylvania, one in which I know not of the therapist's true innocence or guilt. The therapist, who specializes in Myofascial Release,  was convicted of groping female clients. He claims that he was simply performing the normal duties of a therapist and treating the areas of the body that a myofascial release therapist normally touches. The court saw it differently and convicted him and he is now facing time in jail. 

This whole affair has made me reflect on the extreme care that I take every day to assure this does not happen to me. While many things are out of our control, as therapist's our ability to communicate our needs and intentions in a clear and concise manner is crucial. We routinely touch areas of the body that may not be a big deal to us, but may indeed push a patient's alarm button. I strive for open communication in my treatment room.

As myofascial release therapists, placing a hand on the bare sacrum or sternum is routine...for us. I have no issue with performing techniques that require handholds in these location such as these, even on a first visit, as long as my communication is clear and unambiguous.

"In order to provide proper traction to stretch the low back region, I would like to place my hand under your pelvis, directly on your sacrum. Are you clear with what I'm asking and are you OK with this?"

Sound awkward? It is much less awkward than a lawsuit.

I speak in these sorts of clear terms to my patients every day. If they show any sign of not understanding what I am asking or saying or seem at all ill-at-ease, I back off and figure out a workaround. I dress professionally, have proper lighting in my treatment room, speak to them clearly and unambiguously, and always get permission for what I am about to do. I clearly know and honor my professional boundaries as a physical therapist, knowing fully what I am and am not licensed to perform. If I am to work in an area that seems to make my patient uncomfortable, I ask them to sit up and I sit at a level lower than them and we discuss the issue at hand. Placing them in a lower (subordinate) position while you stand over them is not always the best approach.

Can this avoid every type of problem? No, but communicating your intentions clearly and gaining verbal permission goes a long way to assure you will work another day.

How do you present yourself to clients?

For Now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars