Taking Responsibility for Your Profession

Taken from the Massage Therapy Body of Knowledge (MTBOK) Version 1.0

Section 210.8 Boundaries, Ethics and the Therapeutic Relationship


The quality of the therapeutic relationship is based on ethical behavior, clear boundaries and the therapist’s capacity to pay attention to his or her own body and mind. According to research, this quality impacts the central nervous system of the client. Consequently, this section begins with a research-based understanding of therapeutic relationships from the field of social neuroscience. Research in this field has highlighted the need for massage therapists to integrate information on the neurobiology of interpersonal relationships at a clinical level. This research includes much more clarity on the neurobiology of empathy, altruistic love and kindness. To facilitate that understanding, some additional detail has been added, both in this section and in the terminology section. This is a new paradigm evolving from the research literature on interpersonal relationships that affect every helping profession [35, 43, 44, 47, 74, 96].

Knowledge, skills and abilities relating to professional boundaries and ethics in relation to the development and maintenance of therapeutic relationships.


Therapeutic relationship

• Description and components.
• Therapist/client/patient interaction and communications.
- Differentiate between emotional and psychological processing (outside scope of practice for massage therapists) and handling emotions (in scope of practice).
- Understand that clear communication in the therapeutic relationship is important to successful health outcomes.
• Client/patient disclosure and confidentiality.
• Understand impact of therapist self disclosure on therapeutic relationship.
• Personal and professional boundaries.
• Professional boundary between massage therapy and psychotherapy.
• Trauma and shock.
- Understand that client/patients may hold stress, trauma and shock in their bodies and these can be sensed by the therapist [48, 50, 65, 66, 71, 87, 102].
• Dual relationships.
• Transference/countertransference.
• Psychological defense mechanisms.
• Empathy.
- Understand that empathy is generated in the brain and heart by mirror neurons in order for the therapist to feel what the client/patient is feeling.
- Understand that the therapist’s empathy develops the client/patient’s felt sense of being nurtured [18, 31, 32, 94, 99,100].
• Body language.
- Understand that body language, postures and body shapes, forms and tissue patterns may be expressions of psychological history coupled with chronic stress, trauma and experiences of shock in the past. Tissue work may or may not impact these expressions.
- Understand that when soft tissue does not respond to massage, the tension may be psychological or emotional in nature. Attempting to force this tissue to change may re-traumatize the client/patient [58, 68].
• Therapeutic environment.
• Self regulation.
- Understand that self regulation is modulated by two pathways. One pathway is from the body and heart to the brain via sensation and feeling (bottom up). The second pathway is from the brain to the body via cognitive thinking and memory (top down) [62, 110].
- Massage therapy strongly affects the first pathway, from the bottom up.
- Understand that the quality of attention is based on self-regulation utilizing three simultaneous neurological pathways: attunement, intersubjectivity and nurturing touch [72, 89, 90, 92, 93].
• Attunement
- Understand that a therapeutic relationship based on safety and trust includes the process of attunement [96, 97].
• Intersubjectivity
- Understand that the client/patient and the therapist co-regulate each other’s nervous systems and cardiovascular systems through resonance, which builds emotional coherence.
- Understand that each person in the therapeutic relationship is affecting the other’s nervous and cardiovascular systems equally.
- Understand that intersubjectivity involves the nervous systems of the client/patient and therapist seeking to remain oriented to the present rather than the past [6, 105, 106].
• Social Neuroscience
- Understand neurological self-regulation and integration of the mind-body has two components:
o Internal self-regulation through interoceptive (self) awareness of the body from the inside of it.
o Socially, in relationships, through exteroceptive processing with the special senses such as seeing, touching and hearing others.
- Know that the therapist is responsible for building and maintaining a therapeutic relationship in which normal self regulation can manifest [5, 17, 21, 22, 24-27, 78, 79, 86].
• Altruistic love and kindness
- Understand that nurturing touch stimulates the release of the hormone oxytocin and deepens the empathetic response in both the therapist and the client/patient.
- Understand that people who are suffering need compassion.
- Having a warm and generous affect seems to bring reassurance and joy to others.
- Understand that all human beings are of equal worth [37, 38, 75].


• Code of ethics.
• Ethical and legal considerations and ramifications of harassment, prejudice and discrimination in the workplace.
• Ethical challenges relating to personal beliefs and biases.
• Ethical challenges relating to misconduct of peers.

Sexual misconduct

• Definition.
• Misconduct by the client/patient or the therapist.
• Power differentials.
• Recognition and appropriate responses.
• Ethical and legal ramifications.
• Preventive measures – behavior, communications, policies, boundaries and presentation.

The mind, body and spirit connection

• Healing processes.
• Therapeutic processes.
- Understand that emotions may surface for a client/patient during a massage, that this is normal and that emotions are not harmful [10, 56].


Therapeutic relationship

• Therapist/client/patient interaction and communication.
- Demonstrate active listening and reflection.
- Actively acknowledge the client/patient as he/she speaks using soft eye contact, head nodding, sounds of recognition and/or words of recognition.
- Acknowledge emotions when they arise.
- Provide support for a client/patient experiencing an emotional release during a massage therapy session.
• Personal and professional boundaries.
- Demonstrate maintenance of boundaries while applying massage therapy.
- Demonstrate supporting client/patient while experiencing and/or expressing thoughts and feelings.
- Terminate, in a professional manner, a session when a client/patient violates and is unwilling to respect a therapist’s professional boundaries.
• Body language.
- Notice when soft tissue does not respond to massage.
- Move on to another area of the client’s/patient’s body if one area is unresponsive.
• Self regulation.
- Maintain a steady pace during the massage that can be integrated by the client/patient.
- Be able to refer to mental health professional when appropriate.
• Attunement.
- Use conscious breathing to center attention in the therapist’s body.
- When using deep or vigorous techniques, pause periodically and observe the client’s/patient’s breathing.
• Intersubjectivity.
- Regularly scan the whole body of the client/patient while in contact.
- Observe signs of the client’s/patient’s autonomic nervous system seeking homeostasis, such as skin color tone, breathing, shaking or trembling, eyes glazing, etc.
- Modulate input to the client/patient slowly while the autonomic nervous system is active.
- Understand that feeling awkward or making an occasional mistake during a session can be a normal aspect of the therapeutic relationship.


• Communicate with a fellow therapist about alleged or perceived unethical or illegal behavior(s).
• Follow proper reporting processes relating to unethical or illegal behavior of other therapists and other health care professionals.

Sexual misconduct

• Demonstrate awareness of how therapist’s body might touch client/patient and avoid incidental and/or inappropriate body contact.
• Do not sexualize communications or initiate or engage in sexualized or sexual contact with clients/patients regardless of who initiates.
• Communicate boundaries in appropriate professional manner without blaming or shaming the client/patient.


Therapeutic relationship

• Therapist/client/patient interaction and communications.
- Therapist periodically attends to own sensations while in contact with the client/patient, acknowledging and addressing them as appropriate.
- Therapist provides non-judgmental support.
- Therapist avoids probing questions that serve to elicit psychological or emotional information.
- Therapist avoids interpreting or giving advice regarding client’s personal issues.
- Therapist conveys a sense of dignity and respect, in both actions and words, towards clients/patients, colleagues and the profession.
- Therapist demonstrates consistent patience in dealing with others.
- Therapist demonstrates appropriate communications during a session by remaining focused on client’s/patient’s intentions, rather than unfocused conversation.
• Client disclosure and confidentiality.
- Safeguard the client’s/patient’s confidentiality unless information is released by client/patient or compelled by law.
• Personal and professional boundaries.
- Respect boundaries of client/patient.
- Respect professional boundaries of other health care providers involved in the client’s/patient’s care.
- Establish, communicate and maintain healthy professional boundaries.
• Boundary between massage therapy and psychotherapy.
- Be willing to not know the source or cause of a client’s/patient’s pain and suffering.
- Be thoroughly familiar and operate with a rigorous code of ethics.
• Dual relationships.
- Avoid situations that create conflicts of interest and dual relationships.
• Psychological defense mechanisms.
- Recognize client’s/patient’s psychological defense mechanisms and, when necessary, take appropriate steps to reduce adverse impact on the therapeutic relationship.
• Empathy
- Therapist periodically notices own sensations and feelings related to empathy and compassion.
• Therapeutic environment.
- Establish and maintain an environment of emotional safety and trust for the client/patient.
• Self regulation.
- Regularly sense both the therapist and the client/patient body systemically as one whole continuum of fluid, bone and membrane.
- Acknowledge (nonverbally) any personal feelings, such as fear and anxiety, during a massage and hold them as normal.
- Visualize the client/patient as one interconnected whole being during the massage.
- Maintain conscious awareness of the location of mental and physical attention while in relationship with the client/patient.
- Scan own body periodically in order to sense areas of tension and holding during a session and release when appropriate.
- Avoid judgment, withdrawal or psychological intervention when emotions surface for a client/patient.
- Stay present with client/patient, grounded and centered in self, when emotions surface for client/patient.
- Seek supervision if thoughts, feelings and emotions that come up for client/patient trigger personal history or a personal emotional process.
• Attunement.
- Stay mentally and emotionally present with the client/patient while working.
- Be aware of how attention moves periodically between the body-mind of the therapist and that of the client/patient.
- The therapist should be aware when attention is separated from self or client/patient for prolonged periods and regularly settle attention back into the therapist body.
- Be aware of impact of emotions on your ability to maintain a therapeutic relationship and perform massage therapy.
- Monitor the speed or tempo of own sensations, thoughts and feelings, slowing them down in order to achieve attunement.
- Regulate the tempo of the massage to build resonance and sustain it over time.
• Intersubjectivity.
- Therapist periodically focuses attention on his/her heart, respiration rate and visceral sensations as a part of interoceptive awareness.
- Therapist becomes aware of, acknowledges and releases, when appropriate, own mundane thoughts of the past or future while in contact with client/patient.
• Altruistic Loving Kindness.
- Periodically practice thoughts and feelings of loving kindness while in contact with the client/patient.


• Demonstrate ethical behaviors with clients/patients, peers and other professions.
• Operate under a professionally recognized code of ethics.
• Practice with competence and within the individual knowledge, skills and abilities and the legal limits of the massage therapy profession.
• Refrain from using substances that would interfere with the ability to provide safe and effective massage therapy and to make ethical decisions.
• Avoid circumstances and situations where the ability to make ethical decisions is impaired or made difficult.
• Do not discriminate against a client’s/patient’s race, color, religion, gender, sexual orientation, national origin, age, disability, handicap, health status, physical appearance (including size, shape and body art), marital status or veteran’s status.
• Represent credentials and training honestly.