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1994-Two-FacesI have come to realize through recent interactions with my fellow educators and many Massage Therapists that not all massage therapy schools teach the management of dual roles or dual relationships. Hopefully this article will get into the hands of someone who has not been introduced to these important concepts, and it can help them avoid unnecessary and painful ethical dilemmas. In the end, this is ONLY an article, and if you know nothing of these concepts or wish to know more it’s time to grab some books and take some classes.

First let me start by clarifying that I am not a psychology expert. I am a massage therapy expert. I know enough about dual roles, boundaries, and the management of those to keep my clients, my students, and myself clear (most of the time) of the emotional and mental confusion, pain and destruction that can arise from unconscious engagement in multidimensional relationships.

For this article to work, I think it best to review or introduce many of the terms I will be using:

Boundaries – An emotional and/or physical limit in a relationship. Establishing healthy boundaries is a key skill in the helping professions and serve as good protection against problematic dual relationships.

Counter-transference – The feelings that a therapist develops toward one’s client, and which may be similar to or parallel the relationship patterns experienced by the client or therapist with other people and in other settings. When these feelings are especially strong, misunderstood, or ignored, they may lead to problems in the professional and therapeutic relationship. .

Dual Relationship – When you have more than one type of relationship with the same individual. This could be a professional relationship (the person is your client) and a personal relationship (the person is a friend whom you like to meet for coffee), could be multiple professional relationships (the person is a client, and is a building contractor who did painting and repairs on your office). Though not all dual relationships are automatically a problem, managing dual relationships is a professional skill and responsibility.

Ethics – The study of moral principles and appropriate conduct that may be applied to individuals, professions, or groups.

Ethical Dilemma – Occurs when two or more principles are in conflict, and regardless of your choice, something of value is compromised. Dilemmas can arise from a conflict between duties and rights.

Multidimensional relationships – Overlapping relationships in which therapist and client share an alliance, in addition to the therapeutic relationship. Multidimensional relationships suggest a more complex interweaving of roles.

Power Differential: The role difference between expert and client that results in a vulnerability on the part of the client.

Scope of Practice – Procedures, rules, regulations, and processes that are defined by a state or federal governing or licensing board for certain professions in order to ensure that those professionals are operating ethically, competently, legally, and with proper education, training, and certifications.

Transference – The feelings that a client develops toward one’s therapist, and which may be similar to or parallel the relationship patterns experienced by the client or therapist with other people and in other settings. When these feelings are especially strong, misunderstood, or ignored, they may lead to problems in the professional and therapeutic relationship

Now that we have covered that, let’s further explore DUAL ROLE, also known as “dual relationships”, “multidimensional relationships” or “multiple roles”. It’s all basically the same thing, the only thing that changes the term is the number of hats you are wearing in ONE relationship with ONE person. In other words, you would be in a dual or multiple relationship/role if you are in more than one relationship/role with the same person. Here are some examples:

  • You have a Sister. You start to massage her as a professional massage therapist.
  • You have a housekeeper. You start to massage him as a professional massage therapist.
  • You have a massage therapy client. You decide to watch football games with him as a friend.
  • You have a student. They become your accountant, and then start to date your son.
  • You have a massage therapy client. You go to church with him. You start to date.

Hopefully from my examples, you can imagine how easy and natural it is to enter into dual relationships or dual roles with others, and how as human beings it only makes sense that as we get to know someone, we see the benefits in the exploration of how we can serve each other’s needs in multiple ways. Right?

Not so fast…YOU decided to become a professional Massage Therapist, and now everything changes for you if you want to be an ethical and professional one.

It has been proven time and time again by health care and non-health care professionals outside of Massage Therapy that these multi-relationships can and do lead to major strife as well as business sabotage. Massage Therapists and Bodyworkers have figured this out too, and I have personally had a lot of difficulty managing dual roles as a professional massage therapist and massage therapy educator. I strongly suggest that if you are a sensible massage therapist you too will struggle with the management of dual roles. Managing dual roles should be something that becomes reflex for Massage Therapists. Not that we should do it unconsciously, but it should be something that we focus on the management of similarly to the way we make sure that our linens are clean, and our nails are filed. It is a professional courtesy and, as far as I’m concerned, a professional responsibility.

WHY IT GETS MESSY? There are a multitude of reasons dual roles can and do go wrong, and many I don’t claim to understand so I will just point to the reason that is most obvious to me. Confusion with boundaries and power differentials. Every role we are in with the people in our lives often contain an unspoken but usually known collection of complex cultural boundaries and power differentials. When you have multiple roles happening simultaneously the boundaries and power agreements between the two people in the original relationship become overlapped and blurry. Confusion, miscommunication, and assumption can often lead to someone feeling hurt or angry and overall damage to the relationship. There is also the potential to have your business reputation negatively impacted by a dual role gone bad.

HOW TO MANAGE? The best way I have found to manage dual roles is to first stay mindful so I am aware when it is happening. Once I realize I am on the threshold of a dual role I will strongly consider the pros and cons of the dual role. If I decide to enter into, or to reject the dual role, I will thoughtfully communicate with the other person as authentically and clearly as I can about what we are going to change, or are not going to change with our already established relationship. Finally, if I have decided to enter into the dual role, I will get consent from the other party, move forward, and I will continue to be as mindful as possible and be careful not to step into any of the blurry problems inherent in dual role management. Here is an example of how that can play out.

  • My sister wants a massage.
  • I consider if I want to massage my sister, and if I think I can hold the space necessary to provide a professional session for her.
  • I decide to give my sister the massage.
  • At the intake interview, I clearly let my sister know that we are entering into a dual role, and for the next hour I will be her massage therapist and that I am there to serve her as if she were any other client.
  • I receive her consent.
  • If I don’t feel I can serve my sister’s best interest, I will let her know that I would feel more comfortable with her receiving from my colleague and refer her. I would take the time to educate and explain to my sister so she does not feel rejected by me.

TYPES OF DUAL ROLES: I always tell my students that they WILL manage dual-roles and the FEWER they have to manage the better. Figuring out the type of dual role you are considering the management of is the first step.

Yellow Flag: I explain to my students that the only dual roles you want to manage are those occurring with the people you are in some kind of personal or professional relationship with prior to providing massage therapy. In other words, they are in your life in a significant role before you became their massage therapist. These are easier to manage when the role they were in with you was in the past, such as they WERE your realtor, or they WERE your daughter’s soccer coach in high school. Still, the therapist must strongly consider is it worth the risk of damage to the pre-existing relationship to work with this person? It may simply be a better idea to refer them to another excellent massage therapist.

Red Flag: The dual relationships to avoid at all costs are those that start to develop with someone who is your client. For those people who end up in your life because they came to you from the beginning for massage therapy I recommend you do everything you can to keep them in that role only, and forever. Will there be exceptions to the rule? Of course, but these exceptions should be incredibly rare and thoughtfully entered into for the health of both of you. This might be a good time to bring in a Mentor help you figure it all out.

Random Flags: Things are not always black and white. One day you may be at work and your boss gets on the table. One day your mother in law wants a session. One day you go to a birthday party and realize your best friend’s brother is your client. One day (hopefully once out of the 20,000 massages you give in your career) the love of your life shows up in your practice. One day you are teaching a class and one of your new students was at a party you were at last week. Always have positive intent, be professional, do what you know is right and call your mentor for advice. If you don’t have a mentor, get one.

PROFESSIONAL REPRESENTATION AND SELF SABOTAGE: If your client invites you to their Holiday party, go as their Massage Therapist, do not “let your hair down” and do take your business cards. Be introduced as their Massage Therapist, do not obnoxiously market yourself, keep your visit brief and stay in your professional integrity the entire time. DO avoid entering into personalized relationships with the people intimately involved in any way with your clients. You do not want to drink or smoke a joint or sexy dance with your client or have your client witness any of these behaviors at their party. You can still be your authentic self, but be your PROFESSIONAL, authentic self.

Consider this; How much time, money, and energy directly and indirectly have you invested in finding and retaining this client? If you want to throw all of that away, go ahead and get your unprofessional sexy dance on down at the Christmas party.

There are enough people on this planet for you to have plenty of friends, and plenty of clients, and not blend them. Compartmentalize your personal people and your professional people. This is a lot harder to do when you live in a very small town. You have an ethical responsibility to do so. If you did not know this and don’t agree to this you may want to do a bit of soul searching on this one.

PEOPLE GET HURT. REMEMBER…DO NO HARM: There are plenty of people in this world to be your friends. I highly recommend you don’t feed off of your clients to meet your emotional, mental and physical needs. If you are doing that, it’s time to take a big step back, do a personal inventory and figure out why you became a massage therapist to begin with. Some sort of professional mental/emotional support is always recommended to navigate these confusing and psychologically challenging situations. We are human. We all want community, camaraderie and love, however for us to serve our clients’ needs we must have iron clad boundaries as massage therapists, honor the vulnerability our clients bring to us and practice professional skills at all times. If you have not been ethically managing dual roles professionally, now is the time to put that tool in your tool belt and use it as often as the need arises.

MANAGING DUAL ROLES WITH TRADES: Many massage therapists enjoy the great benefit of trading services for other professional services. These dual roles are usually easier to manage than dual roles that have the element of a personalized relationship. These are relatively easy to manage because the relationship will not normally bleed over into your personal life. Here are some trades that are usually pretty easy to negotiate the professional dual roles

  • Massage Therapist and Accountant
  • Massage Therapist and Dentist
  • Massage Therapist and Hairdresser
  • Massage Therapist and Tree Trimmer
  • Massage Therapist and Massage Therapist

These professional trades are more difficult to manage because there is either a power differential, or the professional is serving you in your personal life and home.

  • Massage Therapist and House sitter
  • Massage Therapist and Babysitter
  • Massage Therapist and Pet Sitter
  • Massage Therapist and Tenant

Be super creative with this trade:

  • Massage Therapist and Psychotherapist or mental health care worker.

This trade must be managed in a way that continues to honor the power differential, the boundaries and the professional roles involved. I recommend you provide your mental/emotional health care provider with gift certificates they can share with a completely neutral party.

MANAGING CLIENTS CONFUSION AND TRANSFERENCE – Let’s say your client is experiencing transference with you. They see you as a person they want to have as a friend. They ask you to go to the movies with them and then dinner on Friday. How do you honor this person, retain them as a client, have them not feel rejected and avoid entering into the dual role? Authentic, compassionate, professional, and courageous communication! However you would sincerely let them know, and in a forth coming way that you do not socialize with your clients as it has a negative impact on the therapeutic relationship. That’s how! If you need more tips on how to have these difficult conversations you may want to role play with a colleague, talk to a mentor, or read more about this very normal professional action that massage therapists have to engage in often.

ENDING A THERAPEUTIC RELATIONSHIP IN ORDER TO TRANSITION INTO A PERSONALIZED RELATIONSHIP What if you determine for whatever reason that the professional relationship you have with your client would better serve your life personally. You WANT that client to be your friend. You WANT to date that client, and you feel STRONGLY that this is where the relationship must naturally evolve. The most ethical thing for you to do is to communicate in an authentic and honest manner with the client and let them know that you need to end the therapeutic relationship. Once you have done that it is strongly encouraged that there be a “cool down” period. For romantic interests the cool down period is at least 6 months. This is to insure that the power differential is not a predetermining factor of the personalized relationship and that this attraction is not based solely on unhealthy transference/counter-transference or the client/therapists power differential. If you ever decide to make this move, I certainly hope you were not delusional. Please note: There are some state laws which have a longer “cool down” period with up to two years being reported as the longest limitation.

IDEAS FOR EDUCATORS AND MENTORS: If you have been a mentor or an instructor of a massage therapy student and wish to personalize that relationship, my advice is DON’T do it. EVEN after the educational commitment is over. Many will not agree with me on this and that is fine. This has been my choice and I’ve learned from my own mistakes after years of being an educator and trying to be friends with former students. It was confusing for everyone and so now and for many years I have decided to hold space for my students into the future in the event they need further mentorship or continuing education with me. Is this difficult? Of course it is! Is it worth it? YES! Are there exceptions to the rule? Indeed, but again, I think it should be an extremely rare exception and not a regular practice to engage in a personal relationship with someone who has counted on you to hold a professional boundary for them. In these rare circumstances, if the connection desired is that of a romantic nature, it is my strong opinion that there should be an extensive cooling off period that meets and far exceeds the 6 month rule between a therapist and a client.

IN CLOSING Nothing and nobody is perfect but we have to do our best. We are Massage Therapists, and we either did or did not receive an education on the psychological, mental, emotional ramifications of our work. Even if we did, it was scant to none so for the best of our clients and for ourselves let’s continue to study and learn more about these subtle yet powerful aspects of our work so that we can serve the public to the best of our abilities. Let’s all be absolutely sure to know that critical boundary which defines where our work ends when it comes to our scope of practice. In the end, your best tool to turn to time and again is the cultivation of mindfulness in your practice! This will insure you are aware of, and thoughtfully processing challenging events as they present themselves to you.

I highly recommend that every massage therapist and massage therapy educator be familiar with the content of these two books.

  •  The Ethics of Touch by Cherie M. Sohnen-Moe, Ben E. Benjamin
  • The Educated Heart by Nina McIntosh
Jill Kristin Berkana

Jill K. Berkana LMT Founder/Director Berkana Institute of Massage Therapy and Bodywork Passionista