Name have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's name.
Massage Therapist, Mr E
A Report by the Deputy Health and Disability Commissioner
Parties involved
Ms A Consumer and complainant
Ms B Ms A's friend
Mrs C Ms A's manager
Ms D Mr E's business partner
Mr E Provider/Massage Therapist
Complaint
On 31 August 2006, the Commissioner received a complaint from Ms A, aged 25 years, about the massage provided by Mr E on 22 August 2006. The following issue was identified for investigation:
The appropriateness of the care provided to Ms A by massage therapist Mr E.
An investigation was commenced on 22 September 2006.
Information reviewed
Information from:
- Ms A
- Mr E
- Ms B
- Mrs C
- Ms D, Mr E's business partner
Independent expert advice was obtained from remedial massage therapist Barry Vautier.
Information gathered during investigation
Mr E
Mr E and his business partner, Ms D, advertise as massage therapists. Mr E stated that the business is operated mainly by Ms D, who has a New Zealand Qualification Authority (NZQA) Certificate in Relaxation Massage. Mr E has no formal qualifications in massage but said that he has watched DVDs and read textbooks on the subject. Prior to his massage of Ms A, Mr E had massaged one male client and, with Ms D, had provided a couples massage.
Massage booking
Ms A booked a one-hour appointment by telephone with Mr E for 22 August 2006. She said that she has regular massage to help her manage fibromyalgia,[1] as light massage helps to relieve her muscle and joint pain. Ms A said that when she booked her appointment, Mr E told her that Ms D was "busy" and that whoever was available on the day of her appointment would perform the massage. Mr E said that Ms A did not state her preference for who should massage her. He also said that when Ms A made her booking he thought he informed her that Ms D was unwell.
22 August 2006
On the day of her appointment, Ms A was greeted by Mr E and led to the massage room. Ms A said she thought there was a smell of alcohol on Mr E's breath; Mr E said he had just used a mouthwash. Mr E provided Ms A's massage, as Ms D was "crook for over a week … couldn't even talk" and she could "hardly move out of her chair". Ms D said that she had had diarrhoea, which had come on suddenly and lasted for a couple of days.
Mr E gave Ms A a single-sided form on which to provide her medical history and personal details. She wrote that she suffered from fibromyalgia and joint pains, and had undergone knee surgery. Ms A said that Mr E did not read the form, and it was placed on a desk in the massage room. However, Mr E stated that he read the form and asked Ms A when her knee injury had occurred.
Ms A said that Mr E told her to get undressed, but he was not clear about the clothing she should remove. Consequently, Ms A decided to remove all of her clothes. She stated that she removed her underpants, because she believed that this area would remain draped by the towel at all times.
Mr E stated:
"If a female wishes for her back to be massaged then it is practicable for her to remove her bra. Underwear is optional … I prefer clients to leave them on as this area isn't massaged in a Relaxation session."
Mr E said that while Ms A undressed he left the room to wash his hands prior to the massage. He then went to ask Ms D about fibromyalgia, as he did not know what this condition was. She was unwell but on the business premises at this time and asked Mr E to fetch a reference book from the office. She looked up the condition and advised Mr E to provide Ms A with a light, relaxing massage. Mr E said that he did not discuss the matter further as he believed a light massage would get the blood flowing, and this would be beneficial for Ms A.
Back massage
Mr E said that when he returned to the massage room, he knocked on the door and called out before entering the room. However, Ms A said that she had only just settled herself on her front on the massage table and covered herself with the towel, when Mr E re-entered the massage room without warning.
Ms A said there was a brief, general discussion about the massage and that she informed Mr E that she was "sore all over", and wanted only a gentle massage. Mr E agreed to provide a light massage. Ms A stated that Mr E did not explain or discuss with her what he was going to do, and he appeared nervous and slightly awkward. She asked him whether he had any training in massage, and he told her that he was "two units behind [Ms D]". Mr E denied that he said this, and stated that he told Ms A that he had been trained in massage by Ms D. Ms A stated that other than this conversation, Mr E said little during the massage.
Mr E stated that first he massaged Ms A's back, then her neck, shoulders, feet and legs, using light massage strokes to warm up her muscles, and then stronger strokes to stretch, knead, roll and compress the tissue.
Ms A said that when Mr E began to massage her legs, the towel was not tucked under her, but placed over the areas not being massaged, leaving a leg and buttock area exposed. Mr E denied this, saying that he placed the towel over the leg, and then tucked it under the same leg to cover the area he was not working on. Ms A also stated that Mr E massaged her buttocks, then below and around the buttock area and her upper thighs, and that his hands were too close to her genitals when he massaged her upper thighs. Mr E denied that he massaged too high on her thigh, but thinks Ms A may have gained the impression that her buttocks and upper thigh were being massaged as the thigh muscles stretch to the buttock area.
Mr E completed massaging Ms A's back and then asked her to turn over. Ms A said that Mr E did not hold up the towel to screen her from his view, and she was unable to turn over without exposing herself. Mr E strongly disagreed with Ms A on this point. He said that he clearly remembers holding up the towel for her in a way that allowed her to turn over with complete privacy.
Massage of front
Ms A then lay on her back, fully covered by the towel. In this position, she said she was aware of where the towel was placed during the course of the massage.
Mr E said that when he massaged Ms A's front he worked up from her feet, to her legs, her hands, arms, shoulders and neck and that she was covered by the towel from her upper chest to above her knees. Ms A stated that again Mr E massaged too high up on her inner thigh, and that the towel did not fully cover her pubic area. She was not comfortable with this, but did not say anything at the time. Mr E agreed that he massaged Ms A's inner thigh, but said that she did not give him any indication that she was uncomfortable with what he was doing.
Ms A said that Mr E told her he would massage her stomach. She added that Mr E pulled the towel down to her pubic area, exposing her front, and used his hands, fingertips, elbows and arms to massage her. She stated that Mr E's waist was pressing against her, and described him as leaning his body over her and using long, sweeping strokes to massage her stomach and breasts. Ms A said that Mr E then stood directly behind her head and rubbed her forehead. She understood this to mean that Mr E was finishing her massage. However, she said that he then moved back to her side, and again began to massage her stomach and breasts with his arms and hands, and asked, "How was that then?" He then ended the massage.
Mr E denied massaging Ms A's stomach and breasts, and said that Ms A's breasts and pubic area were covered at all times. He stated that he finished Ms A's massage by rubbing her neck, shoulders and upper chest area, and that when he massaged her neck, he stood side-on to the table, as this was more comfortable for him. He explained that in this position, he could have been leaning across Ms A, and may have brushed against her breasts with his arm or elbow. However, Mr E also said in interview that when he completed the massage he was standing behind Ms A's head and massaging her neck. He said that he told her he had finished and that he hoped she had enjoyed the massage.
Conclusion of massage
Mr E said that he then left the room to wash the wax off his hands, have a drink of water, and allow Ms A to get dressed. Ms A said she attempted to dress quickly, but Mr E returned to the room before she had finished. She was still putting on her socks and boots when Mr E entered the room without knocking. In contrast, Mr E said that he did knock before entering, and that Ms A told him to come in.
Mr E said that Ms A appeared "quite chirpy" and thanked him for the massage. He said that she indicated she would be interested in receiving a further massage but she did not book a follow-up appointment with him.
Ms A admitted that she had not told Mr E the truth, and had informed him that it had been a "fantastic" massage. She said that she was confused about what had happened and felt partly responsible as she did not take more immediate action to stop the massage and leave. Ms A said that at the end of the massage she wanted to leave the premises as soon as possible, so that she could reflect and make sense of what had occurred.
Later events
That evening, Ms A spoke with a friend, Ms B. Ms B stated that Ms A described the massage as bizarre, saying that it was unlike any other massage she had received. Ms B recalled that Ms A told her that Mr E had massaged her high on her thigh areas, had massaged her breasts, and had told her to book any further massages with him and not Ms D.
Ms A's manager, Mrs C, spoke with Ms A about this massage three to four days after it had taken place. Mrs C stated that Ms A told her that Mr E had massaged her in places that he should not have. Ms A had indicated to Mrs C the area on her breasts that Mr E had massaged. Mrs C said that Ms A was angry with herself because she did not challenge Mr E at the time, or ask him to stop the massage because she was uncomfortable with what he was doing.
Mr E
Mr E stated that he does not intend to provide further massages for female clients. He said that he was sorry that Ms A felt the way she did, and he would have preferred her to have told him at the time that there was a problem. Ms D informed this Office that she and Mr E have closed down the massage business and no longer provide massage.
Responses to provisional opinion
Mr E stated in response to the provisional opinion:
"I'm very sorry that you felt this way as it was not my intention to make you feel uncomfortable. This situation won't be happening again, as I won't be put in this position ever again.
Please accept my sincere apology."
Ms A responded to the provisional opinion and remains concerned that Mr E's account of what occurred during the massage is so different from hers.
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
Right 4
Right to Services of an Appropriate Standard
…
(2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Right 6
Right to be Fully Informed
…
(2) Before making a choice or giving consent, every consumer has a right to the information that a reasonable consumer, in that consumer's circumstances, needs to make an informed choice or give informed consent.
Right 7
Right to Make an Informed Choice and Give Informed Consent
(1) Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.
Opinion
This report is the opinion of Tania Thomas, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
Opinion: Breach - Mr E
Introduction
I am satisfied that the massage provided by Mr E to Ms A was a "health service". Therefore, in accordance with the definition in section 2 of the Health and Disability Commissioner Act 1994 (the Act), I consider Mr E to be a health care provider under section 3(k) of the Act.
Mr E advertised himself as a massage therapist, although he has acknowledged that he is not a registered health care provider, and lacks formal qualifications in massage. However, in my opinion, the public in general would expect that any person calling him- or herself a massage therapist would have professional competence in this area. Massage New Zealand (MNZ) is the professional body overseeing the standards of practice of registered massage therapists, and its Code of Ethics guides the professional standards expected of a massage therapist in New Zealand. I view MNZ's Code of Ethics as setting the basic criteria for providing a reasonable standard of practice and care when a massage therapist conducts a therapeutic massage, even if the provider is not a member of this body. I therefore consider it appropriate to assess the services Mr E provided Ms A against the standards set out in MNZ's Code of Ethics.
According to Right 4(2) of the Code of Health and Disability Services Consumers' Rights (the Code), Ms A was entitled to receive massage services from Mr E that complied with professional, ethical, and other standards. Right 6(2) of the Code required Mr E to provide information that would enable Ms A to make an informed choice or give informed consent. Right 7(1) states that Mr E could provide massage services to Ms A only if she had given informed consent.
Appropriate Standards
Scope of practice
Ms A said that she asked Mr E about his training in massage, and Mr E told her that he was "two units" behind Ms D. Mr E denied this and said he informed Ms A that he had been trained by Ms D. If Mr E's account is to be accepted, in my view his response still did not provide Ms A with sufficient information to establish Mr E's limited experience and lack of formal massage qualifications. If Mr E had informed Ms A that he had no formal qualifications, had previously massaged only one client - and never a female client - Ms A would have had the information she required to decide whether to proceed with the massage.
Assessment
This was Ms A's first appointment with this clinic. My expert advisor, massage therapist Mr Barry Vautier,[2] notes that, at the first appointment, a massage therapist is expected to compile an appropriate client history and identify any significant medical condition that could influence the proposed course of treatment. Although Mr E stated that he discussed treatment of Ms A's fibromyalgia with Ms D before he started Ms A's massage, he did not discuss with her what Ms D had advised.
Overall, I am concerned that Mr E did not sufficiently understand fibromyalgia, or any other medical condition, and its affect on a client's health. In addition, Mr E had insufficient experience to know when it would have been appropriate to refer someone with a medical condition to a qualified massage practitioner or other relevant health care provider.
Massage
Ms A and Mr E have provided very different accounts of what occurred during the massage. Ms A said that when she lay on her front, Mr E massaged both of her buttocks and high on her upper thighs, with his hand close to her genital area. Mr E has denied this.
Ms A states that when she lay on her back, Mr E massaged her stomach, breasts and high up on her inner thighs, close to her genital area, and used his fingers, hands, elbows, and arms to deliver his massage strokes. Ms A also said that Mr E leant over her with his waist pressing against her. Mr E has also denied this, saying that he massaged only Ms A's feet, legs, hands, arms, armpits, shoulders, and upper chest area, and then finished by massaging her neck. Mr E has categorically denied that he massaged Ms A's stomach or breasts, or that her front or pubic area was ever exposed during the second part of the massage.
In these circumstances, where there is a significant difference between the versions of events provided by the two parties, it is difficult for me to ascertain exactly what occurred. However, I do not believe that there is any advantage to Ms A in making a formal complaint about Mr E's massage. And, importantly, Ms A's description is supported by the accounts from Ms B and Mrs C. Having considered the available evidence, on the balance of probabilities I believe that it is more likely that the massage occurred as described by Ms A.
It is apparent to me from the description provided by both parties that Ms A's massage was of a particularly poor standard, reflected Mr E's lack of training, qualification and experience, and was below the minimum professional standards. Accordingly, Mr E breached Right 4(2) of the Code.
Informed consent
Mr Vautier has outlined the areas of the body, such as the stomach, upper inner thigh and parts of the breast area, that require consent from the client before a massage is commenced. There is no evidence that Mr E sought Ms A's consent to massage these areas. By not explaining what is involved in the massage, a provider runs the risk of making the consumer feel very uncomfortable, or it being misconstrued as having sexual connotations. Accordingly, Mr E breached Right 6(2) of the Code. In addition, as he proceeded with the massage without obtaining Ms A's informed consent, Mr E breached Right 7(1) of the Code.
Other matters
Ms A said that Mr E entered the massage room twice without knocking. The first time was shortly after she had undressed in preparation for the massage, and the second was while she dressed following completion of the massage. Mr E disputes this and stated that he not only knocked on the door, but that he also called out before entering the room. Mr Vautier advised that "a practitioner should explain clearly to the client the protocol around leaving the room for the client to undress and dress". Mr E may wish to consider whether he allowed sufficient time for Ms A to comfortably complete either the removal or putting back on of her clothing.
Ms A was naked throughout the massage, and she stated that her breasts, pubic region, and parts of her buttocks were inadequately covered during the massage. She also stated that she was exposed when she turned over onto her back halfway through the massage as she was inadequately covered. Mr E disputes this. He stated that Ms A was covered at all times, including when she turned over.
Mr Vautier advised that clients should be given clear instructions about draping, "to ensure that private areas of the [client's] body are securely covered for their dignity". Mr E may wish to consider whether he should have given Ms A clearer instructions as to what clothing to remove, and whether he could have provided Ms A with clearer instructions about draping.
Ms D has informed me that neither she nor Mr E provide massage any longer.
Recommendation
I recommend that Mr E does not offer massage services without completing training to at least the level of the NZQA Certificate of Massage.
Follow-up action
A copy of this report, with details identifying the parties removed, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Independent advice to Commissioner
The following expert advice was obtained from remedial massage therapist Barry Vautier. Mr Vautier has a Diploma in Therapeutic Massage, a Naturopath Diploma (specialising in remedial body therapies) and a Post Graduate Diploma of Herbal Medicine. Mr Vautier is the current President of Massage New Zealand, a member of the Society of Naturopaths, and a member of the New Zealand Natural Health Practitioners Accreditation Board.
"I have been asked to provide an opinion on case number06/12937/ML, and have read and agree to follow the Commissioner's Guidelines for Independent Advisors.
[At this point Mr Vautier notes the questions asked of him, and these are repeated in the advice. They have been omitted for the sake of brevity. The page and line numbers used by Mr Vautier, relevant to the information provided for him to review, have been replaced with ellipses.]
Information reviewed
Source: Health and Disability Commissioner:
(1) Email of complaint to Commissioner (pages 1-2).
(2) Notification letters (pages 3-7).
(3) Advertising material (pages 8-10).
(4) Telephone interviews with [Ms B], [Mrs C] and [Ms A] (pages 11-15).
(5) Transcript of interview with [Ms A] (pages 16-48).
(6) [Mr E's] response to Deputy Commissioner (pages 49-52).
(7) Transcript of interview with [Mr E] (pages 53-86).
(8) Follow-up interview with [Mr E] (page 87).
Summary
In my opinion [Mr E] did not provide [Ms A] with an appropriate standard of care.
1. The following standards of practice have been applied:
a. Industry standards as taught by massage schools in New Zealand.
b. Educational standards as per the NZQA unit standards for the certificate of relaxation massage.
c. Standards as defined by the Code of Ethics of Massage New Zealand.
d. Various Acts of Parliament.
2. The standards of massage practice of [Mr E] were overall not well complied with.
3. Inadequate information was provided by [Mr E] to [Ms A] prior to her massage.
4. [Mr E] obtained an inadequate medical history from [Ms A].
5. [Mr E's] advice to [Ms A] about removing her clothes and draping was unclear and unprofessional.
6. The massage techniques [Ms A] experienced and the parts of her body massaged were inappropriate leaving her feeling vulnerable and disempowered to speak up. The techniques [Mr E] described in treating [Ms A] were at variance with what she experienced.
7. In my professional opinion [Mr E] did not provide [Ms A] with an appropriate massage, based on the evidence presented. Other massage providers would view [Mr E's] conduct with severe disapproval.
In my opinion, the lack of massage experience and training of [Mr E] was borne out by the inadequate professional language and communication with Ms A. There was a lack of medical screening, information gathering, physical assessment and session planning. The written records lacked detail. Instructions to [Ms A] were unclear. Informed consent was lacking throughout the massage. Basic massage principles, particularly around draping, privacy and stroke application left [Ms A] vulnerable. Post massage advice and care were missing.
I believe that [Mr E] failed in a major way to provide an appropriate standard of care to [Ms A] based on the evidence provided, some of which is subject to conjecture and denied by [Mr E].
Most massage therapists trained to a certificate level of massage would view the conduct of [Mr E] with severe disapproval.
Body of the Report
1. In my opinion [Mr E] did not provide [Ms A] with an appropriate standard of care, based on the data provided by the written and verbal submissions.
2. Standards of practice overview.
There are two main levels of professional massage practice in New Zealand as defined by the professional Association of Massage New Zealand (MNZ) and by the NZQA unit standards of massage.
The two levels are:
National Certificate of Massage. (Level 4 - approx 47 credits - about 500 hours of training).
National Diploma of Massage. (Level 5 - approx 120 credits - about 1200 hours of training).
Most massage schools in New Zealand teach to these standards or equivalent.
In considering the case of [Mr E] I have compared the evidence presented against the NZQA National Certificate of massage
The following are some general standards which apply in New Zealand to the Certificate level of massage:
a. Industry standards for the theory and practice of massage as taught by massage schools in New Zealand, especially those teaching to the NZQA unit standards as applied to the certificate level of massage (See appendix (1)).
b. Educational standards as per the NZQA unit standards for the certificate of massage.
The scope of practice applies to giving a relaxation massage to healthy individuals. A practitioner at this level of training would be expected to screen the client for health concerns, and depending on the severity of the condition, get consent from another qualified health professional for any medical conditions presented. In some cases the client would be referred to another health practitioner for assessment and/or treatment. In this case the client reported fibromyalgia, joint pains, and knee surgery:
a. Standards as defined by the code of ethics of Massage New Zealand.
(See appendix (2)).
b. Ethics and legalities of massage. Scope of practice massage.
(See appendix (3) - New Zealand College of Massage training manual pp9-13).
Various Acts of parliament including:
- Health Practitioners' Competence Assurance Act (2003);
- Health and Disability Commissioners Act (1994) and the Code of Health and Disability Services Consumers' Rights (the Code);
- Consumer Guarantees Act;
- Privacy Act;
- Occupational Safety and Health Act;
- Human Rights Act;
- Fair trading Act; and
- Local body by-laws.
3. The standards of massage practice of [Mr E] were overall not well complied with.
In considering whether the standards of massage practice by [Mr E] were complied with, I have chosen the NZQA certificate level of massage training as it is the foundation level of massage practice in New Zealand. Points 3 to 8 of the expert advice required are covered by the following text.
I have considered the performance criteria for standards of practice under the following headings with comments on [Mr E's] performance:
1. Environment;
2. Information gathering and Goal setting (Verbal and written screening). See appendix (iii);
3. Physical assessment and session planning;
4. Massage principles;
5. Application of strokes and techniques;
6. Post-massage advice;
7. Professional presentation; and
8. Communication and language skills.
1. Environment
Performance criteria for standards of practice:
Includes temperature, ventilation, lighting, safe and hygienic equipment - massage table, bolsters, pillows, creams / waxes / oils.
Comment on [Mr E's] performance:
Not enough information given from the material presented to comment on, although the client had to go through the private part of the [premises] to use the bathroom. The massage room didn't appear to have any seating as [Ms A] sat on the 'couch' (massage table) to fill out the screening form. …
2. Information gathering and goal setting. (Verbal and written screening)
Performance criteria for standards of practice:
The massage practitioner should:
Clearly introduce him/herself;
Explain clearly to the client their scope of practice from the outset. Preferably at the time of booking by phone;
Establish client-based goals for this session including areas to be massaged, pressure, duration, based on the location of soft tissue pain or discomfort;
Obtain treatment goals with the client;
Be aware of any loss of movement / function;
Check for any existing medical conditions / injuries / current medical treatment / medication;
Check for any previous or current treatment / diagnosis;
Establish what medication the client is currently taking to assess safely of massage in order to apply modifications to the massage;
Check for any contraindications and thus modifications to safely perform the massage;
Consider the severity and duration of any condition. Are there any effects of these that need to be considered for the massage;
Find out about any previous massage experience in particular related to this condition;
Establish with the client any body areas not to be touched / massaged;
Confer with client around the type of massage they want and set a goal for the massage including: areas to be massaged, depth, speed, duration, possible outcome;
Explain to the client what to expect from the massage.
Comment on [Mr E's] performance:
Inadequate information was provided by [Mr E] to [Ms A] prior to her massage. (Summary point 4)
[Mr E] was unclear with [Ms A] about what sort of massage he gave and what his experience and qualifications were. [Mr E's] screening form lacks detail. (See appendix (4) of a typical screening form with a simple first appointment record).
[Mr E] did not obtain an adequate client history as indicated by his verbal and written evidence on his screening form. No case notes were presented showing what he had discovered or what massage he had applied to what areas of the body.
[Mr E] obtained an inadequate medical history from [Ms A]. (Summary point 5)
His history taking seemed to gloss over [Ms A's] condition with insufficient questioning of her levels of pain or discomfort due to her fibromyalgia. [Mr E] seemed unfamiliar with this medical condition and should have sought more information before proceeding to ensure his client's safety. He claimed he consulted [Ms D] about the fibromyalgia while [Ms A] was getting undressed for the massage. ([Ms A] however claimed in her verbal evidence that she thought no one else was [on the premises], until she heard someone [arrive] later in the massage). …
[Mr E] claims in his written evidence that he verbally asked about how long ago the knee surgery was and about possible allergies to the lubricant, but this was not corroborated by [Ms A]. [Ms A] claims [Mr E] did not consult about the nature of her massage until she was on the table. …
3. Physical assessment and session planning
Performance criteria for standards of practice:
Generally it would be expected at the certificate level of training for the massage practitioner to palpate the client prior to the massage to ascertain where pain or discomfort was on the body and what appropriate massage would be conducted in consultation with the client. A massage practitioner would also be expected to bilaterally compare one side of the body with another.
Comment on [Mr E's] performance:
[Mr E] does not appear to have considered any physical assessment of his client and thus did not indicate any findings and hence discuss a proposed treatment plan.
4. Massage principles
Performance criteria for standards of practice:
These include: Clear instructions and practice around positioning, cushioning and meeting the client's needs for privacy and comfort in whatever position.
Draping should be done with client dignity and privacy and should adhere to the following four main principles:
1) Provides warmth to the client;
2) Provides dignity to the client;
3) Defines the area being massaged (the rest of the body should be covered); and
4) Massage should not be performed under draping or clothing.
Clients should receive clear instructions as to what clothing to remove as necessary for the massage. Practitioners must get informed consent from the client about clothing removal. In most cases clients are advised to leave their 'knickers' (briefs, underpants, jock straps) ON. The reason for this is to ensure a client's dignity, provide a foundation to tuck draping into, and to help protect the client and practitioner against possible allegations of misconduct. Clients should be given clear instructions about draping to ensure that private areas of the body are securely covered for their dignity.
Client comfort should be considered and bolsters/pillows used as necessary. Repositioning (e.g. from prone to supine) the client, needs to be done with clear instructions on safety, with guidance during the manoeuvre, and adhering to the draping considerations such that the client's body is not exposed to the practitioner.
The practitioner should establish a feedback system where the client is in control over the pressure, speed and type of massage given. Regularly conferring with the client during the massage around depth (pressure), speed, and comfort gives confidence to the client. Explanations should be given to the client about what to expect next in the massage, as the practitioner moves from one area of the body to another. The client should be made aware of what strokes are being performed and why. Explanations should be given to the client if there is a variation to the goals of the massage and gaining consent to vary them.
The practitioner should explain clearly to the client the protocol around leaving the room for the client to undress and dress. They may need to assist the client off the table at the end of the massage or clearly explain how to get off the table unassisted.
Clarity needs to be made about when the massage has ended, and an explanation given to the client about protocol of leaving them to get dressed, and knocking on the door before entering.
Comment on [Mr E's] performance:
[Mr E's] advice to [Ms A] about removing her clothes and draping was unclear and unprofessional. (Summary point 6)
Instructions were unclear as [Ms A] expressed doubt as to how much clothing to remove and how to turn over from face down (prone position) to face up (supine position) and also how to get the client onto and off the table with dignity and safety. … Although there appeared to be some conferring with [Ms A] around what clothing to remove, she stated that [Mr E] seemed 'slightly nervous and awkward'. [Ms A] felt pressurised to remove all her clothing which would tend to suggest that she felt uncomfortable from the start. She stated that [Mr E] did not knock before entering the room either at the start, … or at the end of the massage. This [is] not best practice, as this does not allow time for the client to undress and dress without the anxiety of a practitioner coming in before the client is ready.
According to her written evidence, [Mr E] did consult [Ms A] about 'how strongly' he should massage, and in general terms where on her body, but he did not speak a great deal during the massage which would indicate he did not confer about pressure, speed, stroke application and comfort as the massage progressed.
Of concern was [Mr E's] inadequate draping technique when [Ms A] turned over, as reported by her. 'He just stood there watching'. … She felt exposed when supine (face up) with her abdomen, breasts and pubic region exposed. There is no statement from [Ms A] that she was ever 'tucked in' to secure the draping and her dignity. Had she left her underpants on, [Mr E] would have had a secure place to tuck the draping and provide dignity.
It is not unusual for a client to receive buttock massage, but with good diagonal draping only one buttock needs to be exposed at a time, and not both as in this case.
Also of concern is [Ms A] reporting that [Mr E's] waist line was pressing into her. This contravenes good practice of not allowing other body parts to come into contact with the client, other than the hands/arms.
It is not normal practice to carry out breast massage on a female without informed consent, or without a good therapeutic requirement (eg, lymphatic drainage). It is usually not advisable for a male therapist to massage a female's breast due to the potential risk of it being misconstrued as sexual harassment or misconduct. [Mr E] denies massaging [Ms A's] breasts, belly and buttocks. …
It is not normal professional practice to expose a female from the waist up in the supine (face up) position … . [Ms A] felt 'groped' in her verbal statement … . She felt his arms and hands massaging the top half of her body and her pubic region was exposed. It is possible she felt so traumatised that she couldn't speak.
Almost anywhere on the body may be massaged by client consent, except the genitalia and nipples. Cautionary areas for massage include endangerment sites on the body. These may be massaged but with specific techniques usually out of scope of the relaxation massage therapist. These are areas where nerves and blood vessels pass closely to the surface of the body and may be damaged by massage: They include: front of the (anterior) neck, under the arm pits, anterior elbow, anterior wrists, the groin, inner thighs and behind the knees.
Hence it is not normal to massage the upper inner thigh area of a client without informed consent. [Ms A] felt uncomfortable with the strokes [Mr E] applied to her inner thigh.
[Ms A] thought [Mr E] was about to finish the massage, when he was massaging her temples. A client would rightfully expect to have their front covered at this point but she was left exposed from her pubic hair up. He then went back to her abdomen and breasts which is when she stated in the verbal interview that 'I needed to get out of there' … . Normally a massage follows a certain sequence and to return to an area without consultation is inappropriate and possibly disempowering of a client.
5. Application of strokes and techniques.
Performance criteria for standards of practice:
In general warming up strokes should be applied with effleurage and petrissage with a progression of pressure and applied from a general, to a specific, and then back to a general area of the body. Usually once an area of the body is completed it is not revisited. Clients should be consulted around pressure for any changes of stroke, depth, speed or location on the body to ensure their safety and massage needs are met.
Comment on [Mr E's] performance:
The massage techniques [Ms A] experienced and the parts of her body massaged were inappropriate leaving her feeling vulnerable and disempowered to speak up. The techniques [Mr E] described in treating [Ms A] were at variance with what she stated as her experience. (Summary point 7)
The way [Ms A] describes the strokes … gives the impression that he was giving her a sensual massage. His quietness during the massage suggests there was insufficient consultation about the pressure, speed, depth and location of his strokes. Although the massage seemed to progress from one area to another, he revisited the stomach and breasts.
[Mr E's] statements in section 'F' confirm that he applied the standard strokes of effleurage and petrissage but deny that he massaged too high on [Ms A's] inner thigh, on her buttocks and her breasts and stomach. [Mr E] denies massaging [Ms A's] 'belly' and breasts. … .
6. Post massage advice
Performance criteria for standards of practice:
Ensuring client has water available to drink at the end of the massage;
Checking with the client about how he/she feels at the end of the massage;
Giving the client clear post massage instructions about the possible effects of the massage; and
Discuss any ongoing treatment, home care advice, or client referral.
Comment on [Mr E's] performance:
There appeared to be no post care advice from [Mr E]. [Ms A] 'needed to be out of there' and was unable to speak honestly at the end, … . There was some promotional material presented to [Ms A]. No water was offered to the client at the end of the massage, which is a common practice for most massage practitioners, as massage has a dehydrating effect on the tissues, and water helps to 'flush wastes out of the body'.
7. Professional presentation
Performance criteria for standards of practice:
Self hygiene principles apply. Clothing should be appropriate. Clean short fingernails. Body odours and breathe unobtrusive.
Comment on [Mr E's] performance:
[Ms A] stated she smelt alcohol on [Mr E's] breath, … though no other evidence was apparent of his possible drinking. Under no circumstances should a practitioner give a massage while under the influence of alcohol or drugs.
8. Communication and language skills
Performance criteria for standards of practice:
A practitioner should use language supportive to the client and the massage profession including:
Clear verbal instructions throughout the massage. Check that a client understands the instructions. Check for client comfort throughout the massage. Respond to the client's verbal and non-verbal feedback - considering changes of skin temperature, colour, body tension, relaxation, body movements, breathing patterns and facial responses.
Comment on [Mr E's] performance:
Inadequate professional language and communication seems to be the hallmark of this massage with [Ms A]. [Ms A] did not have informed consent throughout the massage. There are many discrepancies in the description between the two, of what happened in this massage which would suggest a failure of communication. [Mr E] did not give clear instructions, as [Ms A] seemed confused as to what clothes to remove and felt unable to speak her mind when she was uncomfortable.
[Mr E] does not seem to have picked up on the non-verbal clues from [Ms A] that she was uncomfortable with his massage. She stated … that she kept her eyes tightly shut.
It is not unusual for a client to experience disempowerment when an unsatisfying massage occurs. Most clients find it difficult to give negative feedback during or after an inadequate massage especially if rapport with their practitioner is not established.
In my opinion, [Ms A] was very disempowered by [Mr E's] lack of effective professional language. She was unable to state her discomfort. She said 'but if I felt like if I said it out loud, it would be worse ... well, I'm naked in his house…'
…
In my professional opinion [Mr E] did not provide [Ms A] with an appropriate massage, based on the evidence presented. Other massage providers would view [Mr E's] conduct with severe disapproval. (Summary point 8)
Additional comments of the care provided by [Mr E].
Some questions remain unanswered which apply to [Mr E's] practice.
Do [Mr E] and [Ms D] display a Code of Ethics at [the] clinic?
Do [Mr E] and [Ms D] belong to a professional massage association?
Do [Mr E] and [Ms D] have a complaints procedure displayed in a visible place and pointed out to clients?
Does [Mr E] have a referral network for sending clients on who are outside his scope of practice?[3]
Other points to consider:
[Mr E] and [Ms D's] business advertising lacks detail around the qualifications, professional membership and type of massage clients may expect;
It is unclear what professional training [Mr E] has been getting, and to what standard;
Learning massage from watching a DVD is inadequate. [Mr E] couldn't state where the training DVD came from … ;
Massaging couples together in the same room is unusual and may cause ethical and interpersonal boundary problems;
He doesn't have an appointment book … ;
Record keeping was lacking. Are records kept in a secure location? and
No log book of phone calls received as stated in the interview with [Mr E].
Appendices attached
(1) NZQA unit standards and assessment requirements as applies to the theory and practice of massage for the Certificate of Relaxation Massage.
(2) Code of Ethics Massage New Zealand.
(3) Ethics and legalities of Massage. pp 9-14 New Zealand College of Massage (NZCM) training manual 2006.
(4) Sample history screening form. - NZCM Certificate of Relaxation Massage.
Appendix 1 [see pdf document for scanned image]
Appendix 2 [see pdf document for scanned image]
Appendix 3 [see pdf document for scanned image]
Appendix 4 [see pdf document for scanned image]
[1] Fibromyalgia: A disorder, the cause of which is unknown, characterised by fatigue, muscle pain and stiffness of joints.
[2] Mr Vautier's advice follows the Opinion.
[3] Commissioner's note: [Ms D] has stated that they do not belong to a registered body, do not display a Code of Ethics, do not have a visible formal complaints process and do not have a referral system for clients assessed as being outside of their scope of practice. Bookings are recorded in a diary. They do not keep a client record for massages.