We recently received a question wanting know about any legal requirements for massage therapists to break confidentiality with clients when they reveal things like abuse (e.g., child, elder, partner, etc.), suicide threats or attempts, mental health issues, or crimes committed. Well, my first thought was, if there are legal requirements they are probably addressed under licensure.
So, since I’m licensed in the state of Arizona, I decided to check out the Arizona State Board of Massage Therapy website for statutes and rules. I found two areas related to this subject:
In Chapter 42 of the Arizona Revised Statutes, under Article 3 Regulation:
32-4253. Disciplinary action; grounds; definitions A. The following are grounds for disciplinary action: 16. Failing to adhere to the recognized standards and ethics of the massage therapy profession.
And in Title 4 of the Arizona Administrative Code Rules, under Chapter 15 Board of Massage Therapy:
R4-15-103. Ethical Standards Pursuant to A.R.S. § 32-4203(A)(6), the Board is adopting the following ethical standards, which a licensee is required to meet: 1. When a licensee agrees to provide massage therapy to a client, the licensee shall: g. Safeguard the confidentiality of all client information unless disclosure is requested by the client in writing, medically necessary, required by law, or necessary for the protection of the public;
I know, pretty vague, but I think we can work with this because it’s about ethics.
Standards of Ethics
Under Disciplinary Action, it suggests that we have to “adhere to the recognized standards of ethics of the massage therapy profession.” So I went to a few websites to explore the codes and standards published by some of our most recognized organizations:
NCBTMB Ethical Standard III: Confidentiality
Standard III(a): protect the confidentiality of the client’s identity and information in all conversations, advertisements, and any and all other matters unless disclosure of identifiable information is requested by the client in writing, is medically necessary, or is required by law;
3. Professional Relationships with Clients: 3.2 The Practitioner maintains appropriate professional standards of confidentiality.
7. Commitment to Confidentiality: I will keep client communication and information confidential and will not share client information without the client’s written consent, within the limits of the law. I will ensure every effort is made to respect a client’s right to privacy and provide an environment where personal health-related details cannot be overheard or seen by others.
It’s clear that I’m required to keep my interactions with clients confidential. Of course I am. But it looks like some disclosure may still be necessary, by law. The tricky part is that none of these sources define which disclosures the law may require me to make, exactly.
In The Ethics of Touch by Ben Benjamin and Cherie Sohnen-Moe, we are told: “Some reasons for breaking confidentiality include: there’s a clear and imminent danger to the client or another individual; a client discloses an intention to commit a crime; you suspect abuse or neglect of a child, an elderly person, or an incapacitated individual.” And since massage therapists have adopted many ethical standards similar psychologists over the years (due to similar one-on-one intimacy and power differentials), it makes sense that the law may require similar disclosures. Here’s what the American Psychological Association website says about confidentiality:
In some specific situations, psychologists can share information without the client’s written consent. Common exceptions are:
- Psychologists may disclose private information without consent in order to protect the patient or the public from serious harm — if, for example, a client discusses plans to attempt suicide or harm another person.
- Psychologists are required to report ongoing domestic violence, abuse or neglect of children, the elderly or people with disabilities. (However, if an adult discloses that he or she was abused as a child, the psychologist typically isn’t bound to report that abuse, unless there are other children continuing to be abused.)
- Psychologists may release information if they receive a court order. That might happen if a person’s mental health came into question during legal proceedings.
That gives me a little better idea of the critical issues we are dealing with here. I’m sure the legal requirements vary from state to state, region to region, and it may even depend on whether or not a massage practitioner is considered a healthcare provider in a particular state. But, it makes sense that I may be asked to disclose confidential information under certain circumstances.
The harder question for me is, when should I report something without being asked?
On the surface it seems simple: report to the authorities if someone is in danger. Period. But what about the domestic violence victim who won’t report it herself, or the child abuse victim without any bruises or other evidence? Will I be putting these people in more danger by sending the authorities to their house if nothing can be done? It’s not fair, but too often authorities say they cannot do anything about it if the alleged victim won’t press charges or if they cannot prove anything happened. These are the realities that make ethical dilemmas so hard sometimes.
I take confidentiality seriously. But, with the privilege of providing therapeutic touch comes great responsibility, especially to those who cannot speak for themselves. So, I probably shouldn’t worry so much about what the law requires, I should probably be more concerned with what’s the right thing to do.
The Bottom Line
Whether or not it makes me uncomfortable, I am obligated by my choice of profession (and frankly, because I’m a human being), to report anything that I believe puts someone in imminent danger—whether that’s me, the client, or anyone else.
Often doing the right thing means having to make those hard choices.
These are very dangerous boundary waters, indeed. As an Ethics teacher, I have always advised my students to think very carefully about the implications of breaking confidentiality when it comes to adults who might be victims of domestic abuse, talking about suicide, etc.
As massage therapists, we cannot, of course, give our clients advice on how to handle these issues, but what we can do is to make resources available to them. We need to let go of feeling responsible for “fixing” or improving these situations. By interfering, we can make things much worse. In the case of domestic violence, crisis intervention organizations often make available tear off slips and cards with their contact information. Having them available in the waiting room can give a person the confidentiality of taking one. The same is true for victims of sexual violence.
I have never had a client who has talked about self harm, but I know what I would do if this happened. At the end of the session, I would kindly and discreetly give the person contact information for a suicide hotline and suggest to them that if they needed somebody to talk to, they could call the number.
At the end of the day, we want to feel as if we’ve done all that we can to help our clients in crisis. We also need to acknowledge and respect that our clients are capable of making their own decisions whether we agree with them or not. We help our clients best by giving them information to an option with which they can turn to.
Pam, thank you so much for your contribution. Your examples of what you do are very, very helpful in considering these tricky boundaries. I especially appreciate, “We also need to acknowledge and respect that our clients are capable of making their own decisions whether we agree with them or not.” Thank you for that critical reminder.
Thank you for this important consideration to our work. I make it a habit to point out bruises, wounds, and scrapes to my clients. Often they explain, sometimes not. Generally I do this to bring bruises and such to their attention and to protect myself from any claim of harm. Document what you see! In one of my clients she came back to me and stated that she wouldn’t be seeing me for a while since she was headed to rehab. My comments on the bruises she had over the course of several months made her more aware that she had a problem (alcoholism). Thankfully she got the help she needed. I believe it is imparitive that we tread lightly and do not make assumptions in this area. Respecting our clients is important, by showing that we truly care about their health and welfare. This may come as simply asking questions, but not always expecting answers. Possibly having resources posted in our offices/bathrooms. Again I thank you. – Tamra
Great approach, Tamra. And you’re right, it is so important for us to respect and trust our clients. Thank you for your comment!
Another hypothetical situation: a client is coming to you for respite from an abusive domestic environment. They don’t tell you that explicitly, but maybe they show up with weird bruising or other pain symptoms. They become a repeat client, and your work with them ultimately gives them the impetus/confidence/wherewithal/whatever to make a decision on their own to change their environment.
If you make a report of suspected abuse to some authority without the client’s consent, especially when not legally required to do so, are you not inserting yourself into a situation inappropriately, albeit with good intent?
If something like this would come up in my practice, I would speak directly to the client about it first. This would let the client know that I have noticed something unusual, that I am concerned for their well-being, that I am willing to be a person they can trust to confide in, and that the decision is up to them re: how I can be of help to them.
At some point very early in this situation, I would also have to point out that in my position as an LMT, I have no authority to offer any expertise outside the scope of massage. I could refer them to available resources that could be of more direct assistance, but that is probably as much as I could do within the scope of my license. Given that people in abusive domestic situations are often intentionally socially isolated by their abuser, being an ally might be incredibly helpful, maybe more so than calling in the authorities without the client’s consent.
My view is informed from practicing in NY, where as far as I know, I’m not required to be a reporting agent. At least, this is what I was told in school. I’m not sure I could verify that one way or the other from my state’s massage profession page, though. If I were explicitly required to report suspected cases of abuse, I would necessarily have to approach this situation differently.
William, thank you for this! I think you are right on about speaking directly to the client and establishing yourself as an ally. What a gift that can be in so many subtle (and profound) ways.
This article led me to dig into the mandatory reporting requirements in New York. As of 2019, NYS massage therapists are not on the list of professions required to file reports of suspected abuse. The following site was helpful, if any NY readers want to also check this out:
http://www.nysmandatedreporter.org/MandatedReporters.aspx
Excellent, thank you!