By Madeline Green, an Associate at Whitelaw Twining in Vancouver, British Columbia with contributions from articling student, Pegah Kenarsari
At some point during their career, most RMTs have had a family member or friend ask them for a massage. But what should an RMT do in this situation?
It is generally recommended that RMTs should not treat family members, friends or anyone else they have a close personal relationship with. The rationale behind this recommendation is the close nature of the personal relationship could impact the RMT’s ability to provide good-quality, clinically objective care.
A therapeutic relationship between a patient and an RMT is based on trust, respect and the patient’s best interests. Providing clinical care while having a close personal relationship with a client is problematic because it makes it difficult (or even impossible) for an RMT to establish and maintain boundaries that are appropriate to a therapeutic relationship.
There are times, however, when an RMT may think it is appropriate to treat someone with whom they have a personal relationship. Before scheduling an appointment, it is important that the RMT considers all relevant factors and takes all appropriate steps to ensure they act ethically and within appropriate boundaries. The best interests of the patient must always be paramount.
What is the Nature of the Personal Relationship?
The closer the personal relationship, the more difficult it will be to provide objective care and to establish and maintain boundaries. Therefore, before taking on a person they know as a client, an RMT must analyze the nature of the relationship. For example, is the person an acquaintance or close friend? In the case of an acquaintance, an RMT may be able to establish and maintain appropriate boundaries whereas, for a close friend, it may be impossible to take these steps.
In order to evaluate the nature of the personal relationship, an RMT should ask themselves questions such as:
- Do you consider your relationship to be close, involving elements of exclusivity, privacy or emotional intimacy?;
- Could your ability to recognize and act in the patient’s best interests be negatively impacted?;
- Could you be uncomfortable asking questions necessary to make a proper assessment?;
- Could your ability to be clinically objective be affected?;
- Could it be challenging to maintain patient confidentiality? and
- Could it be difficult to establish and maintain boundaries appropriate to the therapeutic relationship?
If the answer is “yes” to any of the above questions, the RMT should refrain from treating the individual.
Treating Close Friends or Family Must be Avoided
In British Columbia, there is currently no express prohibition on an RMT treating family members or friends. Instead, section 7 of the Boundaries Standard of Practice states:
An RMT avoids providing treatment to close friends or family members where possible, and, if such treatment is provided: (a) clearly communicates to the patient when the RMT is acting in a professional capacity; and (b) maintains relationship boundaries when acting in a professional capacity [emphasis added].
While treating a family member or friend is not expressly prohibited, RMTs must “avoid” such treatments “where possible”. Unfortunately, the Standards of Practice do not clarify what “where possible” means in this context. The CMTBC similarly has yet to publish a notice to the profession on this topic.
This lack of clarity increases the risk that an RMT – despite acting honestly and in good faith – could interpret the guidelines in a way that the CMTBC did not intend. Therefore, the safest approach is to wholly refrain from treating close friends or family members. Alternatively, the RMT must consider whether avoiding such treatment is “not possible.” For example, this exception may apply to an RMT who lives in a small community where no other viable healthcare provider is available.
If an RMT believes that it is not possible to avoid treating a family member or friend, they should consider consulting a CMTBC Practice Advisor and/or obtain a legal opinion before scheduling an appointment.
Conflict of Interest and Dual Relationships
When an RMT treats a family member or friend, there can be a conflict of interest. Therefore, in accordance with section 2 of the Code of Ethics, an RMT must recognize and disclose this real or potential conflict of interest and resolve it in the patient’s best interest.
The RMT must also recognize the dual relationship. As part of managing this dual relationship, the RMT must clearly communicate to the patient when the RMT is acting in a professional capacity and maintain relationship boundaries when acting in a professional capacity.
The above steps should be documented.
Professional Boundaries
Whenever an RMT knows a client outside the clinical environment, extra vigilance is needed to maintain boundaries. Confidentiality must be maintained inside and outside the practice, and RMTs must not violate client privacy.
To ensure that professional boundaries are appropriately maintained when treating a family member or a friend, RMTs should:
- Not treat any client with whom they have had a sexual / romantic relationship with, including their spouse;
- Recognize that it is always their responsibility to establish and maintain professional boundaries;
- Use professional judgment to determine whether and when to terminate a therapeutic relationship in accordance with the CMTBC Code of Ethics;
- Monitor the changing nature of their relationship and ensure that they do not enter into a close personal relationship with their client;
- Schedule treatments during normal business hours only;
- Do not perform treatments at a home-based clinic space;
- Refrain from giving gifts to the client or receiving gifts (including tips) except where professional objectivity or ability to act in the patient’s best interests will not be compromised; and
- Do not initiate non-therapeutic touch or hugging both inside and outside the clinical space and, before receiving non-therapeutic touch such as a hug, consider whether it would be appropriate, supportive and welcome.
The above list is not exhaustive. Ultimately, an RMT is responsible for ensuring that all boundaries are maintained. This is a continuing duty throughout the course of a therapeutic relationship.
Sexual Misconduct
The Code of Ethics defines sexual misconduct to include any form of physical contact of a sexual nature – both nonconsensual and consensual – between an RMT and a patient, whether or not this occurs in the course of treatment. This definition is broad enough to capture consensual pre-existing intimate relationships. As such, RMTs should not treat their current or former sexual / romantic partner, including their spouse.
Consent and Capacity
When an RMT has a pre-existing relationship with their patient, the RMT is at risk of not objectively evaluating consent and/or capacity. However, RMTs must ensure that the CMTBC Consent Standard of Practice are adhered to, including the requirement to obtain written consent. RMTs should revisit consent and capacity frequently. Collaborate with other healthcare professionals if necessary.
Record Keeping
When treating a family member or friend, an RMT is still bound by the usual ethical and legal requirements of record-keeping, consent, boundaries, privacy, confidentiality and security under the Personal Health Information Protection Act. RMTs are responsible for making every reasonable effort to ensure that the information contained in the Health Care Records and Other Records is current, accurate and complete.
Fees and Billing
Fees and billing practices must be transparent and in accordance with professional standards. To avoid a conflict of interest (real or perceived), RMTs should not charge for services provided to any dependent, such as a child, spouse or dependent parent.
Before billing a third-party insurance company, RMTs should consider whether treatment would be in accordance with the insurer’s Terms and Conditions and Provider Guidelines. If it would not be, the RMT should refrain from treating.
Conclusion
RMTs must carefully reflect on compliance with the CMTBC’s ethical and Practice Standards when deciding whether to treat a family member or a friend. If, after reviewing the CMTBC laws and standards, and after contemplating all of the considerations, an RMT is not confident they can maintain the Practice Standards while treating a family member or friend, they should refrain from doing so.
Although not within the scope of this article, it is also important that an RMT recognizes that the CMTBC’s legal and professional requirements may change over time. RMTs must also be aware of any updates to the law which may impact their analysis, for example the Health Professions and Occupations Act which received Royal Assent in November 2022 but is not yet in-force.
This article was written by Madeline Green, an Associate at Whitelaw Twining, in Vancouver, British Columbia. Should you have any legal or ethical issues relating to your massage therapy practice, we invite you to contact Madeline Green or to visit www.wt.ca.
Disclaimer: The information in this article does not, and is not intended to, constitute legal advice; instead, all information, content and materials available in this article are for general informational purposes only. Readers of this article should contact their legal counsel to obtain advice with respect to any particular legal matter.