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Billing and Coding for Moxibustion
Q: I am trying to locate a code for cupping and moxibustion, and have had various fellow acupuncturists indicate that they bill using the existing codes for heat, 97010 hot packs or 97026 infra-red for moxa and 97016 vasopneumatic device for cupping.
Diet, Nutrition and the Context of Risk (Part 1)
Food and supplement safety is a topic that often comes up when I speak to chiropractors for CE relicensing, even when it is not the advertised subject.
Ethics: The Glue That Holds Us Together
Kudos to the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) for creating a code of ethics for the nationwide profession and for deciding to make courses in ethics a requirement for certification renewal.
The Clinical Versatility of Milk Thistle (Part 2)
Evidence is growing that the silymarin complex of flavonolignans from milk thistle can impact serum ferritin and iron overload in various clinical circumstances.
Taking Another Step Toward a Secure Future
In 2008, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) released a literature review on chiropractic care for low back disorders.
East Meets West
Gung Hay Fat Choi. Welcome to the year of the Monkey. There will be fireworks for both January and February this year. What great celebrations.
Chiropractic Around the World: WFC Country Reports December 2015
The following country updates are reprinted with permission from the December 2015 World Federation of Chiropractic (WFC) Quarterly World Report. Information is excepted for space and edited to DC-specific style guidelines.
Yo San University Helps Make LA Communities Healthier
An element of healthcare training often overlooked is the residual benefit to communities served by Acupuncture and Oriental Medicine (AOM) schools nationwide.
The Roots of Insomnia
One of the most common clinical presentations is insomnia. Next to digestive disorders, sleep disorders are one of the most common complaints the clinician will encounter in daily practice.
Integrative Medicine Can Shape the Profession
As the AOM profession struggles to define the role of "integrative" medicine within their practices their schools and organizations, students, faculty, alumni and administrators at schools wrestle with discussions of how much, where, how, and what to "integrate."
Treating Pain: The Hypermobile Coccyx
When I write about the coccyx, I recognize that I am talking about a relatively small subset of patients. When I write for Dynamic Chiropractic, I am trying to reach 60,000 chiropractors.
Enhancing Performance in Cross-Fit Athletes
Cross-fitness centers are expanding in number and increasing in popularity. To remain relevant to this growing portion of society, practitioners need to learn about the exercises and injuries common to this group.
From Antiquity to Modernity: Huang Qin Tang at Yale Medical School, Part 1
Traditional Chinese medicine is a coherent medical system with several unique characteristics: it originated almost 3,000 years ago; in its area of origin, it has been practiced without interruption since its inception.
Asking the Insurance Rep the Right Questions
One of the first or last questions a potential patient often asks is: "Do you take insurance?" An ill-informed or optimistic, "yes" can result in delayed or non-payment. Instead, just say: "Let me check if you are eligible first."
Percussion Therapy: An Experiment
My study of qi began more than 20 years ago — long before my study of TCM, points or pathways. It all started with an awareness in my hands and physical manifestations in the way of blockages while working on clients.
Forgotten Options for Musculoskeletal Health
Challenges with musculoskeletal health are of tremendous concern for many people today.
Is There a Neurological Basis and Correction for Macular Degeneration?
Macular degeneration, aka AMD (age-related macular degeneration), is a common eye disease and a leading cause of blindness in people age 50 years and older, according to the National Institutes of Health National Eye Institute.
Changing the Cultural View of Medicine
Many hospitals in the U.S. are incorporating integrative clinics that include Traditional Chinese Medicine. Cleveland Clinic has led the charge for adding a traditional Chinese herbal medicine clinic to their existing acupuncture program.
How to Humanize Your Content to Create Stronger Relationships
Content marketing is about building relationships, whether that is through updates on social media, offers on your website, blog posts, email campaigns, or even printed material. Now days a business needs to make a human connection.
The MRI: What to Do With the Results
As I wrote in my previous article on this topic, it is my goal for you, the doctor, to be an expert in interpreting MRI images yourself; and to be able to independently make decisions based upon a combination of clinical presentations and findings, followed by the MRI images.
Lab Rats (Roaming the Streets)
The title of this article is an accurate description of American consumers (regardless of age) in the modern era.
RAND Study Recruiting DCs
Dr. Ian Coulter, RAND / Samueli chair for integrative medicine and senior health policy researcher for the RAND Corporation, has issued a call for participation, recruiting doctors of chiropractic for a practice-based research study that will examine "the impact of evidence, outcomes, costs and patient preferences on the choice of treatment for chronic low back pain and neck pain."
Do Doctors Lie to Patients? (Do You Lie to Yours?)
In a previous column ["When Patients Lie (Bribe or Flatter)," Oct. 1, 2015], I discussed the issue of patients lying to doctors, and the many reasons why this can occur.
Interprofessionalism: What it Means and Why You Should Care
Interprofessionalism in education and in practice is a growing trend across health care in the United States. The idea that team-based care and collaborative practice can improve health care has been around more than 50 years.
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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