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Acupuncture's Essential Role
Acupuncture should play a more prominent role in U.S. healthcare during and after this post-Affordable Care Act era when chronic care and population health management are key concerns for all healthcare providers.
Dealing with a Pain in the Butt
The patient came into my office with the classic antalgic stoop. She was bent over almost to ninety degrees, leaning on her husband for support and staggering to walk. She had been under supportive care for a long time, but this new pain scared her.
Acupuncture Earns BLS Unique Code
The United States Bureau of Labor Statistics recently announced that acupuncturists will have their own unique occupational code in the 2018 BLS Handbook. The new Standard Occupational Code (SOC) is 29-1291, will be included in the next edition of the BLS Occupational Handbook, which will be published in 2018.
Case Study: 2-Year-Old Suffering From Urinary Reflux
A19-month-old female child presented to my office for treatment. Her mother reported the child had been diagnosed with urinary reflux and associated urinary tract infections, recurrent bouts of otitis media and inability to sleep.
HVLA Technique: Addressing Myths
In the annals of chiropractic history and literature, and in the imagination of the public, there is one manual adjusting technique that can produce a wide range of responses, both from patients and casual observers.
Comparing Costs of Care: DCs, MDs or PTs - Who Costs More?
In a health care era where evidence is increasingly the benchmark for insurance coverage, patient care and even cultural authority, we get plenty of it courtesy of a retrospective cost analysis spanning 10 years, more than 660,000 "covered lives" and nearly 7.5 million claims from Blue Cross Blue Shield of North Carolina.
Six Things Every Chiropractor Should Know About Opioids
An increase in addictions and deaths due to opioids has raised significant concern and media attention. We offer this brief overview on this important public health problem for the practicing chiropractor.
NBCE Fumbles Computerized Testing Process
Imagine being a student again, about to take one of the four tests required to become a doctor of chiropractic. You've studied almost nonstop for the past few weeks. You can feel your anxiety level rise as you sit down in front of the computer screen.
The Lung Official
The Lung is known as the "Official Who Receives the Pure Chi From the Heavens." The act of breathing in, known as inspiration, brings oxygen into the body from the atmosphere. Each exhalation or expiration removes and releases carbon dioxide, a waste product of the body, into the atmosphere.
We Get Letters & Email
Our Medicare Challenges Aren't an Education Issue; Passion to Succeed: More Pivotal Than GPA?
University of Bridgeport Acupuncture Students Make Rounds at Sisters of Notre Dame
Nuns are not stereotypical acupuncture patients, Dr. Jennifer Brett acknowledges with a laugh. But then again, acupuncture has gone mainstream, just like cappuccinos and recycling. "It's changed a lot from the '70s and '80s," said Brett.
Concerns Regarding CDC Guidelines for Pain Management
In response to the epidemic rates of opioid and heroin addiction, the Centers for Disease Control and Prevention (CDC) set new guidelines for physicians regarding treatment for pain.
Letter to the Editor
On December 7, 1999, the U.S. FDA reclassified the status of acupuncture needles from class III (investigative devices subject to investigative device exemptions...) to class II (special controls).
Putting POLITE Into Practice
First came the acronym RICE (Rest, Ice, Compression, Elevation), which eventually became PRICE (Protect, Rest, Ice, Compression, Elevation). Then in 2015, we started hearing POLICE (Protect, Optimal Loading, Ice, Compression, Elevation).
The Drug Epidemic: Are You Guilty, Too?
Attention-deficit / hyperactivity disorder (ADHD) has become epidemic among children in the United States. According to the Centers for Disease Control and Prevention (CDC), the percentage of school-aged children diagnosed with ADHD has grown from 7.8 percent in 2003 to 11.0 percent in 2011.
Why We Need to Fix the Mechanoreceptors (Part 2)
The muscle spindle, a particular type of mechanoreceptor, is located deep within the muscle belly, encapsulated in fascia made up of intrafusal fibers, all within the extrafusal muscle fibers.
Forward Head Carriage and the Feet: What's the Connection? (Pt. 2)
Clinical evaluation of standing posture using relatively low-tech tools has been confirmed as valid and reliable by several studies. The original device used to evaluate posture was the plumb line, which served as a reference line for the effects of gravity on body alignment.
Infertility: Managing Irregular Menses
Infertility is an area where Chinese medicine is particularly helpful. In the main, in women below the age of 38 without organic disturbance, the success rate using TCM (Traditional Chinese Medicine) should exceed 85%.
Physical Examination in an Evidence-Based World
I have always had a fascination with physical examination procedures, particularly orthopedic tests. The origin of my fascination began just after graduation when I began the chiropractic orthopedics program.
Patience vs. Patients
How long have you been in practice? I began my journey more than 20 years ago and opened my first acupuncture clinic in 2008. Just like you, I've learned a lot over the years. Recently, I sat in an interview and was asked what made me successful.
The Most Important Vitamin You've Never Heard Of: K2
Imagine if one in every three patients who walked through your door was afflicted with a debilitating, yet completely preventable and treatable disease.
News in Brief
F4CP MEmbership Milestone Reached; ICA Challenging New California Vaccine Law; TCC Names New President; New Provost at UWS.
CE Regulations Are Hurting Chiropractic
During my 35 years in the chiropractic profession, I have been forced to attend available continuing-education programs that were occasionally incredibly beneficial, but frequently not worth my time.
Sacroiliac Joint Fusion: Where's the Wisdom?
We should be very skeptical of the purportedly less invasive version of the already defrocked sacroiliac fusion surgery, "minimally invasive" sacroiliac joint fusion; and concerned this procedure simply represents the device manufacturer's attempt to find yet another new market.
September, 2010, Vol. 10, Issue 09
When a Client Crosses the Line
By Cherie Sohnen-Moe
The sexual assault allegations against Al Gore has elicited much commentary about clients crossing the line sexually. Regardless of the veracity of this particular claim, it is an important topic to explore in-depth.Some clients may "test the waters" about sexual services, while others blatantly cross the line. Massage practitioners must know how to appropriately deal with those situations.
A sexual boundary can be challenged physically, verbally or both. Many factors influence the impact this behavior has on a practitioner, such as the length of time the practitioner has been working, the practitioner's ability to manage boundaries, the practitioner's history of abuse, the setting in which the boundary challenge occurs, and the client's prominence.
Boundary Crossings vs Boundary Violations
Boundaries are contextual because they can change depending on the situation. Behavior that is deemed appropriate at one time may be highly offensive in another setting. A boundary crossing is a transgression that may or may not be experienced as harmful. Often it is a minute difference in degree that makes an action shift from being considered a boundary crossing to a violation. It is also relative: what is a mere boundary crossing to one person may be a major violation to another. A boundary violation is a harmful transgression of a boundary. Differentiating a boundary crossing from a violation needs to be done on a case-by-case basis taking into account the context and facts of the situation.
For instance, just because a male client has an erection doesn't necessarily mean that he has any intention of sexual misconduct. Men experience erections even when they are not necessarily emotionally desirous of sex (e.g. when they need to urinate). Touch, itself, on any part of the body can stimulate a physiological response that results in a partial or complete erection. In a therapeutic setting spontaneous erections are often uncomfortable for practitioners and clients. The difficulty lies in that many practitioners (both men and women) are uncomfortable or fearful when a client has an erectile response during a session.
Both male and female practitioners often either ignore or overreact to an erectile response, becoming passive or aggressive with the client in discussing the condition. Each of these responses puts the practitioner in a vulnerable position. If a practitioner is verbally aggressive about the erection or hurts the client physically to quell the erection, the practitioner is abusing the client. Worse, many practitioners learn in school to discourage erections by "pressing hard on certain points." There are more respectful, clear and safe ways to deal with erections in men and arousal in women, which we will discuss.
With a sexually inappropriate client the number and intensity of behaviors usually escalate. What starts out as "innocent" boundary crossings can easily become violations. Clients might tell a sexual joke, ask overly personal questions, talk about their other massage experiences (with innuendos of sexual interactions), discuss their sexuality, or repeatedly expose themselves (accidentally removing the draping). One or two episodes may be an accident, poor boundaries, or a lapse in judgement. Or this could be a prelude to a boundary violation. While these actions may truly be innocuous, they should not be ignored, particularly when combined with other verbal or nonverbal requests or innuendos.
It may be helpful to distinguish the context surrounding the behavior. What were the client's verbal and physical cues? Did the client watch to see the practitioner's reaction? Are the behaviors increasing in frequency or intensity?
If a client (male or female) is obviously sexually aroused, and shows no signs of discomfort or embarrassment through verbal and nonverbal cues, it's usually not necessary to talk to the client about the arousal. Sometimes a simple action of moving to a different part of the body is all that's needed. However, if the practitioner feels uncomfortable or the client displays other verbal or nonverbal behaviors that could indicate sexual intent, ensure safety by obtaining sufficient information to discern the intent--whether it is merely a physiological response to touch or part of sexual desire. Identifying sexual arousal in a woman can be difficult, yet practitioners also need to keep good boundaries with their female clients. Documented cases exist where female clients have crossed the line.
Actions to Take
The first thing to do when a client crosses the line is to break physical contact. If possible make eye contact. Make sure the client is properly covered. Stand in a relaxed yet grounded manner and use a firm voice. Maintain safety. If the client's behavior feels intimidating do not stay too close to the table and position yourself so that you have easy access to your exit door. Leave immediately if the client actively threatens you.
Talk with the client. Describe the inappropriate behavior, ask the client for feedback (this helps to clarify the client's intent), and set (or reset) your boundaries and requirements. The steps taken totally depend on the client's responses. For example:
Practitioner: This is the second time that you've moved in such a way that caused the draping to improperly expose your body. Can you tell me about it?
Potential Client Responses:
Corresponding Practitioner Responses:
If the client agrees to your request, the session can continue. If not, the session should be terminated. Sometimes after going through all the above steps, a client's intent is still unclear. If that's the case, tell the client that you will continue this session but will stop if s/he behaves in any way that does not work for you.
Keep in mind that your safety is of primary importance. Sometimes the most appropriate action to take is to end the session immediately without going through the above steps. Store your belongings (including a cell phone) in an easily accessible place in case you need to make a hasty escape. If you feel threatened, leave the room and call the appropriate authorities. If you are in a spa or clinic, then go directly to the front desk. If you are in a private office, leave the building. If you are doing an outcall session, leave the premises--you can return later, accompanied by someone, for your equipment and supplies.
Document the Incident
Always document incidents of sexual boundary crossings and violations, even if the incident was resolved through conversation. Describe what happened, what you did to address the matter, and the client's response. This is for your protection just in case the client decides to lodge a complaint against you. This might seem bizarre, but consider that if a client is willing to cross sexual boundaries, who knows what else that person might do. There are cases where massage practitioners have been accused of sexual misconduct when in reality the client acted inappropriately. The practitioner refused to provide the requested sexual services and the rebuffed client complained to management that the practitioner made a sexual proposition.
Healthy boundaries are vital to managing sexual boundary crossings and violations. Sometimes strong boundaries can help prevent the "testing of the waters" from escalating into a sexual violation. Other times healthy boundaries include knowing when to leave.
One of the best ways to develop boundary skills in this area is to role-play scenarios. This is particularly important if you have a history of sexual abuse as practicing can help you avoid going into a dissociated state and "freezing."
Work through a variety of situations from the flirtatious client, to the client who makes questionable comments, to the client who asks inappropriate questions, to the sexually aroused client, to the client who is attempting sexual congress. If you are a student, this should be part of your training. If you are no longer a student, get together with colleagues and role-play. The more you practice dealing with these situations, the more adept you will be if they occur.
Next time, we will explore prevention techniques and ways to desexualize the touch experience.
Editor's note to readers: Tell us of your experiences in dealing with clients who have crossed the line. Let us know what happened, how you handled the situation and/or what you wish you would have done. Your letters and e-mails will be reviewed for possible publication in Massage Today print and online editions. If you would prefer to be left "anonymous," please indicate this in your letter. E-mail us at or mail to Massage Today, 5406 Bolsa Avenue, Huntington Beach CA 92649.
Click here for previous articles by Cherie Sohnen-Moe.
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