In Part One of “Keeping Clients Safe,” we discussed how to avoid injuring clients. In Part Two, we will look at another way we can protect clients by attending to their personal and emotional safety. A successful practice is one where all participants—clients and therapists—respect and value each other’s personal boundaries.

Cultivating sensitivity and trust is essential to keeping clients safe—especially as we are aware that many women and men have experienced physical or sexual trauma in their lives. According to the National Council on Behavioral Health, 70 percent of adults in the US have experienced some type of traumatic event. That’s equal to 223.4 million people, so it is highly likely you are working regularly with individuals who have experienced trauma.¹

This article outlines some clear guidelines and boundaries that will help create a safe, comfortable environment for clients, not just those for which trauma is a factor. Safety is built on trust and trust takes time to establish. Yet, trust can also be lost in an instant. It is worth taking the necessary time and care to establish a therapeutic environment that feels both safe and respectful.

Ask What the Client Wants

As always, ask questions before you begin each session—even with regular and returning clients. For example:

• “Where would you like me to work today?”

• “Is there anywhere you would like me to focus on in today’s session?”

• “Is there anywhere you do not want me to work on today?”

Additionally, when checking in with regular clients, be sure to ask: “Is anything different since the last time I saw you?”

Who’s in Charge?

During your intake, let the client know they are ultimately the one in charge. At any point during the session, they inherently have the right to tell you to stop a particular technique, revisit an area where they would like more attention paid, or adjust the level of pressure. To reaffirm your commitment to their boundaries and increase their sense of safety and trust, remind the client they always have agency over their own body. Honoring this integral aspect of the client-therapist relationship requires that you let go of your ego or any false notions of control.

Most clients know what they like and what they want, and they will communicate it clearly when given the chance. But always use your common sense and avoid inappropriate touch that might cross a boundary or exacerbate an injury. Also, be mindful to not injure yourself or disregard your own boundaries.

Pressure Level

As detailed in Part 1, be sure you know the type of session and the amount of pressure the client would like before you begin. Work gently as you start, and build in pressure based on the client’s expectations. If you find that a different pressure not initially requested might be more effective, always ask first before acting on impulse. Setting this intention reiterates that the client is in control of their own body and can accept or decline your suggestion. One method used to empower the client is a 1–5 pressure scale to communicate if you are using too much, too little, or just the right amount of pressure.

Privacy Boundaries

Always have the client change in private with the door closed or a curtain drawn. Do this even if the client says they don’t need privacy. Some clients will just walk in and start undressing without you saying anything. Stop them while you gather whatever information you need before the session starts; let them know you will leave the room, at which point they can change and get ready. This establishes a professional boundary.

In the massage industry, the stock phrase “Undress to your level of comfort” is used frequently but doesn’t mean much to a person receiving massage or bodywork for the first time. Be sure to follow up this statement with examples like: “Some people choose to leave their underwear on, and others remove it, while some take off their socks and some leave them on. Do whatever is comfortable for you.”

When you set or reassert a clear boundary, you again increase the client’s sense of safety and comfort. It’s especially important to have this conversation with a first-time client because it normalizes their choice with regard to disrobing. Some people feel it’s expected to remove all their clothing. If they don’t, some clients feel it will impact the session, or they will be viewed negatively. With all the sexual and physical trauma people (especially women) experience in our society, safety and trust can only be facilitated when the client is free to make choices without judgment.

Check in Frequently

Due to the inherent power differential, many clients have difficulty speaking up during a session when their expectations are not being met, they feel disappointed, or they don’t like what’s happening in the session. A client may fall silent or, worse, choose not to return without explanation.             In creating an atmosphere of ease and safety, remind clients that an open dialogue is welcome. Begin to cultivate this awareness during your intake by saying to the client: “Feel free to let me know at any point if you don’t like something or feel uncomfortable. If you notice an internal dialogue that questions what’s happening in the session, it’s time to say something. Remember, it’s your session, not mine, and I’m happy to listen and change what I’m doing.” A client’s comfort level in communicating openly with a therapist will vary based on their familial, social, cultural, and religious history.

Drape Securely

Secure draping is an important part of establishing safety. Sloppy or loose draping only makes the client feel uncomfortable and may create unnecessary issues for the therapist. As the client is naked (or almost naked) on your table, they have to feel confident the drape will not slip, fall off, or be compromised in any way. Their confidence level rises if the drape is positioned professionally, which means it is secured in the right place and only exposes the area on which you are currently working. Never work under the drape; this violates the implicit, agreed-upon boundary.

Working Sensitive Areas

Explicit permission is necessary before working on body regions that may be sensitive areas for your clients. Use the following tips for handling these delicate areas, while also maintaining client trust.

Buttocks

Permission from your client before engaging in work on the buttock region is necessary, especially the middle and lower buttock. Most spas have restrictions on working in this area, and some do not permit therapists to work on the gluteus muscles at all. Others have therapists work only on the superior part of the buttock or on top of the drape.

Conversely, many therapists who have an independent, private practice do work on the buttock area. There are important ligaments that are located at the medial and superior border of the gluteus muscles and others that are deep to the gluteus muscles. The gluteal cleft is the groove between the buttocks that runs from just below the sacrum and coccyx to the perineum.

If you work with clients who experience low-back and hip pain, working on the buttock can be an important area to treat, if done appropriately. Remember to always undrape the buttock one side at a time, and keep the gluteal cleft covered. Never place your fingers into the gluteal cleft.

Inner Upper Thigh

The inner upper thigh is a very personal and sensitive area. It is often associated with touching only in an intimate, sexual relationship. Therefore, I discourage working the inner upper thigh unless you work 3–4 inches below the groin.

There are exceptions, such as an injury to the adductor muscle tendon units in the upper thigh, where the client has explicitly requested treatment. However, only a therapist trained and confident in injury assessment and treatment work should honor that request.

In this type of session, assessment is crucial because a pain in the groin area might be coming from the low back. For example, an inflamed iliolumbar ligament or hip joint will often refer pain to the groin area. The therapist must be skilled in assessment and able to differentiate an adductor injury from other injuries that refer pain to that area. There are also a number of gynecological and urological issues that would refer pain to the upper inner thigh as well, but these are beyond the scope of the massage therapist.

Unless there is a specific injury or pain to address, it is recommended to avoid the inner upper thigh area. Working on the area is not necessary in a relaxation massage and often causes the majority of clients to tighten up.

Abdomen

The abdomen is also a very sensitive area for the majority of people. Many emotions and feelings are held in that part of the body. Working on the abdomen is often used as a gateway, along with the inner upper thigh and the pectoral muscles, therapists with sexual predatory tendencies who are testing how far they can go without meeting resistance. Therefore, some of the larger spa companies prohibit any work on the abdominal muscles. Additionally, launching into work on the abdomen without a specific request can create a scary, unsafe environment for the client.

There are certain instances where abdominal work can be very useful. Examples include working through the abdomen on the psoas muscle attachments to the spine, treating rectus abdominis muscle strains, and working on menstrual pain or alleviating constipation issues. Also, visceral manipulation techniques can be effective if the therapist has the appropriate training. Above all, abdominal work should only be performed with an explicit request or consent of the client.

Pectoral Muscles

In the Unites States, working the pectoral muscles of a female client can also be problematic. As an expert witness, I have seen many cases of sexual assault in a massage setting that start with the therapist working the upper pectorals and drifting onto the breast and beyond. In the oversexualized cultural context of the United States, massage of breast tissue is not recommended. In most states, in fact, breast massage is illegal.

In certain provinces of Canada, breast massage is an accepted technique. In massage school programs of 2,400-plus hours of training, breast massage is often taught and is performed regularly on clients where there is a good reason. These provinces’ regulations are clear and strict; for instance, the client must consent in writing each time a breast massage is performed.

Women with certain conditions can definitely benefit from pectoral work and (in some cases) work on, near, or under breast tissue. Cases of clogged milk ducts in nursing mothers, painful surgical scarring on the breast, and intercostal and lower pectoral muscle strains are instances where manual therapy treatment is effective.

In the United States, I suggest two ways of working on the pectoral muscles of a female client. One: Carefully drape one side of the chest with just the very upper pectoral muscle undraped on one side. Work the upper segment of the muscle, then redrape the client and undrape the other side to continue the work. Two: Work through the sheet or towel in small circular motions. Work the upper pectoral muscle with moderate pressure.

In my opinion, if we lived in a different, more evolved time, it would be acceptable and beneficial to work on parts of the breast tissue, but not in the current social climate in the United States.

Conclusion

Always treat the client and their body with sensitivity and respect—the very same way you would wish and expect to be treated. Always ask permission, and be especially aware and careful when you work on more sensitive and personal areas of the body. Provide a space that upholds client safety to cultivate trust and maintain boundaries. Remember, trust takes time to build, yet can be damaged in seconds. If you follow these guidelines, you will protect not only yourself and your clients, but also your employer and the massage industry as a whole.

Note

1. National Council for Behavioral Health, “How to Manage Trauma,” May 2013, www.thenationalcouncil.org/wp-content/uploads/2013/05/Trauma-infographic.pdf.