Massage Therapist: Professional Standards and Legal and Business Practices

Key Topics:
- Professional standards
- Legal practices
- Business practices
- Tips for answering questions on professional standards and legal and business practices

Professional standards and legal and business practices are the principles upon which your practice must be built. Appropriate operational standards and professional practices are vital. The choices you make and the business operations you follow form the very foundation of the your practice. Your goal should be to establish and maintain the most professional, safe, and trustworthy environment possible, so that both your client/therapist relationships and business will flourish.

The professional standards and legal and business practices questions on the massage therapy examinations cover a fairly broad range of topics. The focus of these questions varies by exam; however, some of the topics you should expect to encounter include the following:

- Business and strategic planning
- Ethical behavior and choices
- Federal and state laws pertaining to massage therapy
- Office management
- Patient confidentiality
- Professional boundaries
- Scope of practice
- Sexual misconduct
- The therapeutic relationship

For examination study, at a minimum, you should be able to do the following four things:

(1) recognize and discuss the standard parameters of ethical behavior and professional boundaries for massage therapists; (2) explain the nature of the therapeutic relationship between the therapist and the client; (3) identify basic federal and state laws applicable to your practice; and (4) describe core business practices concepts and strategies required for success. In addition, if you plan to take an NCE examination, you should also be able to recognize and describe the elements of the Code of Ethics and Standards of Practice published by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB).

The number of questions you will need to answer on professional standards and legal and business practices varies by exam. If you are taking the MBLEx, you will be required to answer a total of 125 questions; of these, about 13 percent, or around 16 questions, are on this topic. If you are taking the NCETMB, you will be required to answer a total of 160 questions; of these, about 12 percent, or around 15 questions, touch on this topic.

Professional Standards
Ethical Behavior
Ethics are defined as standards of conduct and moral judgment, or a system or code of morals. Ethics are important in any profession. However, due to the intimate nature of the client/therapist relationship, the making of ethical—or morally right—choices is critically important for massage therapists.

For your examination, you should understand what is meant by ethical behavior. You should also be familiar with a variety of the concepts related to ethics:
- Boundaries: Recognizing legal, professional, and personal boundaries
- Confidentiality: Understanding your obligation to protect client information
- Informed consent: Allowing the client to participate in treatment decisions
- Right of refusal: Allowing the client to stop treatment at any time
- Scope of practice: Recognizing the limits that apply to your practice (i.e., what you can and cannot do)

Code of Ethics
A code of ethics provides a blueprint for professional behavior that members of a profession are expected to follow. For bodyworkers, a code of ethics is designed to protect both the practitioner and the client by explicitly outlining expectations for behavior. For example, members of the American Massage Therapy Association (AMTA) are expected to follow the AMTA Code of Ethics; individuals certified by NCBTMB are expected to adhere to the NCBMTB Code of Ethics.

In general, agreeing to abide by a code of ethics means you
- are committed to providing the highest quality of professional care.
- are educated and qualified to render professional services.
- recognize the limitations of your discipline and refer clients when they are better served by other health-care professionals.
- provide treatment only when it is likely to be advantageous to the client.
- keep up with the profession and continue to grow your skills and knowledge.
- make ethical, nondiscriminatory decisions and conduct your practice with honesty and integrity.
- protect your clients by all means possible.
- respect the rights of your clients, recognize boundaries, and refuse to engage in inappropriate behaviors.

Ethical Violations
In most cases, the top ethical concern for massage therapists is sexual misconduct. Because massage therapy and bodywork involve physical contact with a client who may be unclothed, sexual feelings may arise in either the practitioner or the client. In the course of providing massage therapy or bodywork, it is critically important to avoid any form of sexual misconduct. Some approaches to avoiding sexual misconduct include wearing professional apparel, avoiding any sexual conversation or behavior, abstaining from engaging in a sexual relationship with a client, and observing the appropriate dressing regulations.
Not all ethical violations are so blatant as sexual misconduct. Some other tips for maintaining high ethical standards at your practice include giving clients a fair value for their money, refraining from cancelling appointments other than in the event of an emergency, and paying your bills in a timely manner.

Boundaries
A boundary is a delimiting point (a border or a limit). In professional practice, boundaries can be legal, professional, and personal.
- Legal boundaries are determined by a governing body. For massage therapists, legal boundaries are generally defined by your scope of practice, which is the outline of the things you are and are not allowed to do. Legal boundaries are generally determined by the governing body that regulates practices in your state.
- Professional boundaries are the rules that govern your professional behavior. Most professional organizations publish guidelines for members associated with that profession. For example, if you are certified by NCBTMB, you are expected to abide by the NCBMTB Code of Ethics and Standards of Practice. If you are a member of the American Massage Therapy Association (AMTA), you are expected to abide by the AMTA’s Code of Ethics and Standards of Practice. (And so on and so forth.) No matter your professional affiliation, however, you should expect to behave professionally around all clients at all times.
- Personal boundaries are one’s personal “safety zone.”

Confidentiality
A key ethical consideration for massage therapists and other health-care workers is confidentiality. As part of your practice, you will gain access to a considerable amount of information about clients. Under no circumstance should you disclose this information to nonprofessional parties.
In some cases, it may be necessary to share information about a client with a fellow therapist or with some other health-care provider (the client’s doctor, for example). Even under such circumstances, however, you need to make sure you have obtained the client’s consent to speak with that person.

Health Insurance Portability and Accountability Act (HIPAA)
Among the most important laws affecting massage therapy practices is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA laws were first introduced in 1996. HIPAA governs the privacy and security of personal health information. HIPAA grants clients/patients guaranteed access to their medical files and also governs the ways in which medical professionals may use that information. According to HIPAA, health-care providers are required to let their clients know how their personal information is secure. In addition, health-care providers are required to obtain the client’s express consent prior to sharing information with an insurance company, medical professionals, or other third parties. Careful observation of HIPAA laws is critical, as these regulations are taken very seriously and any violation may have severe consequences for your practice.

Informed Consent
Informed consent is defined as a client’s agreement to undergo treatment with a full understanding of all risks involved. Informed consent means the client is the one who makes the ultimate decision as to whether or not to pursue the treatment. In order to provide informed consent, the client must understand the treatment goals and purpose, benefits and risks, potential consequences, and the time and money involved. It is your responsibility to ensure that the client has this information.

Right of Refusal
The right of refusal works both ways. First, clients have the right to refuse treatment for any reason, at any time. That means if the client wishes you to stop treatment midway, you must honor that decision. Second, you have the right to refuse to treat a client for any reason (you might, for example, refuse to treat a client who presents with a contraindication, or one who appears to be under the influence of drugs or alcohol).

Scope of Practice
As already mentioned, another important consideration is your scope of practice. Due to its intimate nature, the massage profession has definite limitations, and you must never go beyond them.
In addition, you should avoid doing or saying anything beyond your level of training. For example, you will not diagnose conditions nor prescribe or suggest medications for clients. You should also refrain from performing procedures for which you are not appropriately trained, abstain from giving unsolicited or unqualified advice, and avoid asking clients invasive questions about their personal lives.

Standards of Practice
Standards of practice provide explicit guidance in how to present yourself and conduct your business. Standards of practice generally cover legal and ethical requirements, business practices, professionalism, roles and boundaries, sexual misconduct, and confidentiality.
If you become certified by NCBTMB, you agree to abide by the NCBTMB Standards of Practice. If you are a member of AMTA, you agree to abide by the AMTA Standards of Practice. Other organizations may have similar published standards, so that members are fully aware of expectations for behavior and professionalism.
In addition, some states may provide additional ethical standards to be followed.

Client/Therapist Relationship
The core element of any massage practice is the client/therapist relationship. Many of the concepts discussed here impact your ability to successfully forge relationships with your clients. For example, if a therapist fails to respect boundaries, maintain confidentiality, or stay within the bounds of professional practice, that therapist cannot really expect to build trusting relationships with clients. On the other hand, a therapist who acts in a trustworthy manner builds trustworthy relationships.
An important point to keep in mind is the power differential that exists in the client/therapist relationship. This power differential favors you, as you are considered the expert health-care professional in this situation; the client is seeking your advice and paying for your services. In addition, consider that your role involves standing fully clothed over a client who is generally in a prone position and some state of undress.
As you interact with each client, be vigilant about any unhealthy developments in your relationship. Some clients may become overly dependent on you to meet emotional needs, a phenomenon known as transference. This dependence often stems from unresolved issues relating to previous personal relationships. Countertransference is the opposite situation, in which you project your issues or conflicts onto the client. Both situations are unhealthy and you will need to be mindful to ensure they do not occur.
Another client/therapist relationship pitfall to avoid is taking on dual roles or dual relationships. Dual relationships occur when you enter into an additional relationship with a client while continuing to act as the client’s therapist. For example, if the client becomes a personal friend or gets involved with you on a business level (for example, if you barter services with each other), that is considered a dual role. Engaging in dual roles can be risky, because it becomes easier to cross boundaries.
Assuming an employer/employee relationship with a client when bartering your massage treatment services for some other form of service is risky because it can lead to complications surrounding the value of each person’s time and worth. As the therapist, it is your responsibility to maintain the proper boundaries in your relationship with the client, so you should avoid taking on any dual roles that might confuse this relationship.
Finally, becoming romantically involved with a client is the most dangerous dual role of all and should always be avoided. If you find yourself wishing to enter into a romantic relationship with a client, you should end the professional relationship and seek supervision or guidance before proceeding.

Communication
An important part of any job, but particularly one in which you interact with the public, is the ability to communicate well. For the massage therapist, this means really listening to your clients and taking cues from them (from what they say with words as well as what they say with nonverbal cues).
During a session, you may engage in conversation with a client who wishes to talk; however, if the client seems to be avoiding conversation, you should remain quiet and allow the client to relax. When you do converse with a client, be sure to keep the conversation professional and try to keep it focused on the massage and how the patient is feeling.

Interviewing Clients
Your primary communication goal before, during, and after a treatment is to build and maintain a good rapport with the client. The most important portion of communication between practitioner and client occurs when the two first meet. The client’s first impression of you is critical to the relationship. Therefore, when you enter the treatment room, be sure that your full attention is on the client and engage in conversation. Offer a caring handshake and address the client by his or her first name. Remember to make regular eye contact as you discuss the client’s condition and treatment, as this will serve to communicate your interest in the client. You can also communicate interest by acknowledging the client’s input during the conversation. You should also be sure that the client understands that you are committed to respecting his or her confidentiality. Finally, keep in mind that approaching your client from a humanistic point of view that focuses on the client’s needs, interests, and values can have a significant impact on the success of the communication and rapport-building process. Remember, for example, that each client is unique, possesses varying individual skills, and desires success.

Exercises: Professional Standards
Choose the option that best answers the question.

1. After developing a comprehensive, multifaceted treatment plan with a client, she decides that she wants to stop in the middle of the procedure. At this point you should (A) continue the procedure until the contract is fulfilled. (B) encourage the client to continue. (C) tell her that she will still have to pay the full price. (D) stop the procedure immediately.
Regardless of how much effort you and the client have put into developing a treatment plan, if the client asks you to stop treatment, you should stop immediately. This is known as the client’s right of refusal. The correct answer is (D).

2. You are interviewing a potential new client who was referred to you by her husband, who is an existing client. During the course of the interview, the client asks you a few questions about her husband’s treatment. How should you respond? (A) Answer her questions truthfully. (B) Give fabricated answers to protect the husband’s privacy. (C) Politely let her know you cannot share that information. (D) Scold her for prying into her husband’s business and ask her to leave.
Under no circumstances should you share personal information about a client, even when the party asking for that information is a close family member. The correct answer is (C).

Legal Practices
A wide variety of laws and legal regulations govern the operation of a massage therapy practice. Federal, state, and local governments all issue and enforce various laws that may impact your practice in some way. Strict observance of the laws is critical to operating a successful practice. Breaking or bending the law in any way can not only hurt your business, it can also cost you your practice and land you in serious legal jeopardy.
Government bodies at the federal, state, county, and municipal levels can all impact your particular practice.

Below are a few of the ways these bodies impact the profession in general.
- Federal government: The federal government grants certain organizations the authority to accredit massage therapy schools, which allows for the distribution of financial aid grants to students who attend such schools.
- State government: State governments frequently regulate the practice of massage therapy within the state. Others do not govern the practice of massage therapy at all.
- County government: County governments may regulate the practice of massage therapy in unincorporated areas not governed by municipal government. County governments may also be responsible for the enforcement of zoning and health regulations in these areas. Most importantly for massage therapy practices, county governments also keep records of business names and grant businesses the right to use them.
- Municipal government: Municipal (local) governments regulate business operations within their limits. In addition, municipal governments deal with health concerns as well as zoning and parking laws. Some municipal governments, particularly large city governments, may enact their own laws specifically regarding the practice of massage therapy or may even prohibit it.
Individuals who apply for a massage license may be subject to regulations pertaining to the licensure process. As per these requirements, you may need to present your employment history, references, a recent photo, fingerprints, and confirmation from a physician that you do not have any communicable diseases. In addition, as already discussed, you may be subject to specific rules in regards to required education.
Some municipal governments enact laws that regulate the physical properties of business establishments. Such laws are generally concerned with lighting, bathrooms, signage, health codes, and more.

Other requirements and restrictions established by these governments, such as dress codes, licensing fees, medical examinations, or background checks, may also apply.

Additional Legal Information
Other legal matters to keep in mind include the following:
- Business classification: As a business entity, you will need to register as a sole proprietorship, partnership, corporation, or some other form of business classification. Each classification includes specific tax requirements and legal responsibilities.
- Business licensing: Most municipal governments require businesses to be licensed. Local governments use these licenses as a record of local businesses and the goods and services they provide. Business licensure generates funds for the local treasury and helps to ensure that all zoning laws are being observed.
- Contractual relationship: Massage therapists enter into verbal and written contracts on a daily basis. Most commonly, this involves contracts between the practitioner and the client for services provided. This also involves contracts for services from third parties for various goods and services.
- Fictitious name statement: Business owners who make up a name for their business are required to submit that name to the county government. There may be a fee for this registration and you will probably have to make sure no other business already uses that name.
- Local taxes: Based on the regulations established by your municipal government, you may be required to pay local taxes on your business property, which means the value of your property will be assessed and you will pay a percentage of that value annually. You may also be subject to other forms of taxation, such as a sewer tax.
- Taxpayer identification number: Any business owner who hires employees, incorporates, or enters into a partnership must obtain a taxpayer identification number for tax purposes.
- Zoning law: Zoning laws dictate where you can and cannot operate a business within a municipality. Most municipal governments require certain types of businesses to be located in areas zoned for such businesses.

Not all massage regulations cover all forms of bodywork. In states where massage is regulated, each specific regulation either directly defines the forms of massage and bodywork meant to be included in that regulation, or else it indicates a broad definition of massage applies. In the case of those regulations with only a broad definition of massage, the decision as to whether the definition in question applies to a specific form of bodywork is usually left to the discretion of a special board or commission.

Exercises: Legal Practices
Choose the option that best answers the question.

1. HIPAA is primarily concerned with (A) certification. (B) privacy. (C) malpractice. (D) taxation.
HIPAA requires health-care providers to guard the personal information of clients/patients. The correct answer is (B).

2. The authority to accredit massage therapy schools is granted to certain organizations by which level of government? (A) Federal (B) State (C) County (D) Municipal
The federal government is responsible for granting certain organizations the authority to accredit massage therapy schools. The correct answer is (A).

Business Practices
Once you have earned your massage license, there are a wide variety of ways you can put your license to use. You may choose to work for someone else, or you may start your own business. Where the law allows, you may choose to work out of your home or open an office. You can also opt to work as a traveling massage therapist who practices at various sites as needed, or you might take a job at a hospital or other medical facility. Some massage therapists also work in spas, resorts, salons, or on cruise ships. However you choose to conduct business, it is important for you to have a fundamental understanding of both traditional business practices and the business of massage.

Business Concerns
Massage therapists who work for someone else are generally paid on a regular schedule and sometimes earn a percentage of the fees charged for their services. Employers provide all essential needs for the practice, handle taxes, and may provide added benefits, such as health insurance or vacation time.
Some massage therapists choose to work as independent contractors, which means working out of someone else’s office on agreed-upon terms, for a negotiated fee. As an independent contractor, you are considered self-employed, so you may have to provide your own materials and supplies. Your clients may be either referred to you or scheduled for you. You will also be responsible for paying your own taxes, including federal and state income tax, social security tax, and self-employment tax.
Massage therapists who own their business and/or employ others are usually subject to other types of taxes, such as state unemployment tax or sales tax, if they sell products through the business.
As with any job, when you agree to be an employee or independent contractor, you must be sure that the exact details of your agreement are clearly stated in writing. All of the responsibilities and expectations of both employee and employer should be outlined in advance of an agreement.

Business Plan
If you decide you want to start your own business, you should first prepare a business plan, which constitutes your vision for your business, what you expect to accomplish, and how you intend to get there. A traditional business plan includes estimated expenses, immediate goals, and a mission statement, which is a brief written explanation of the intent of your new business. Some prospective business owners look at the long-term potential and create five- and ten-year business plans.
When writing a business plan, consider everything from how to advertise to whether you will use a linen service. Your community’s Small Business Administration (SBA) or Chamber of Commerce can help you to determine all of the considerations at hand so that your business plan is thorough and complete.

Marketing Plan
One of the key components of any good business plan is a marketing plan. Marketing is based on four principal elements: product, place, price, promotion. When developing a marketing plan, think about the services your business will offer, where you will practice, the price points you will work in, and how you intend to promote your business.

Some of the many methods of marketing you may choose to pursue include:
- Advertising on the Internet, TV, radio, or in print
- Handing out business cards
- Listing in the phonebook/Yellow Pages
- Offering discounts/gift certificates
- Pinning fliers on bulletin boards
- Providing promotional massages
- Setting up a Web site
- Soliciting word-of-mouth recommendations

Business Recordkeeping
One of the most important aspects of running your own business involves business records. Whether you do your recordkeeping via computer or by hand, maintaining an accurate record of your income and expenses is vital. Keep in mind that every expense you incur can potentially be used as a tax deduction. Keep all of your business receipts as these are tangible documentation of your expenses. If you are audited by the IRS, such documentation will be critical.
If you think that you would not do a good job at recordkeeping, consider some alternatives. If you have the funding, you might invest in software or hire a bookkeeper to do the work.

Client Recordkeeping
Your client records are crucial for maintaining familiarity with clients and for tracking their progress. These records contain highly confidential personal and medical information as well as the history of your treatment. You will need to keep these records organized and safe. Consider investing in a fire-proof filing cabinet that locks.
Note that client records may be needed when billing insurance companies for services rendered.

Insurance
No massage therapy practice can afford to be without insurance. Insurance protects you and your business from various risks that could threaten your financial well-being. As you begin your new venture, there are a number of different types of insurance you will need to consider.
- Professional liability insurance: Professional liability insurance protects you against claims made by clients who allege that your professional negligence resulted in injury or damage to them. Most professional liability insurance provides defense coverage (meaning the insurance company will defend you against warranted lawsuits) as well as indemnity (meaning the insurance company will pay the judgment levied against you, up to the amount agreed upon in your policy). Claims generally not covered by professional liability policies include those dealing with sexual misconduct. Some insurance carriers may pay for your defense in the event of a sexual misconduct allegation, but none will cover the judgment. Professional liability coverage is complex. Many practitioners obtain professional liability insurance through one of the major professional massage organizations, such as the American Massage Therapy Association (AMTA) or Associated Bodywork and Massage Professionals (ABMP). Coverage can also be purchased independently.
- Business owners insurance: Business owners insurance (frequently called a business owner policy, or BOP) is designed to meet the needs of small business owners. It includes a combination of property and liability insurance which is designed to protect your property and equipment due to losses from events such as fire or theft. In addition, most business insurance covers liability claims from third parties, such as slip-and-fall claims. Some policies also provide time element coverage, which covers lost income and expenses if your practice needs to be closed due to a covered cause of loss. Business insurance is generally obtained through major insurance companies, via an insurance agent.
- Disability insurance: Disability insurance provides income in the event that you are unable to work for a period of time due to a covered injury or illness. Generally, you must be disabled for some period of time (several weeks to several months) before you can collect on such a policy. This type of insurance is often expensive and difficult to obtain. Your decision on whether to purchase disability insurance should be based on how much you rely on a continued income.
- Medical/health insurance: Many different types of health insurance policies are available, offering various degrees of coverage for a wide range in price. The most basic and inexpensive policies offer coverage for hospital costs. More comprehensive and costly policies may cover hospital visits, routine procedures, medications, and more. Medical insurance can be purchased individually or as part of a group policy. Many of the major professional associations offer some form of group medical insurance in which you can enroll at discounted prices.

Professional Networking
The relationships you build and maintain with other health-care professionals are an important factor in the potential success of your practice. First and foremost, building relationships with other health-care professionals can increase the number of referrals you receive. If local physicians, chiropractors, physical therapists, and others know you and trust your work, they are likely to refer their patients/clients to you. Similarly, such relationships give you comfort and trust when referring your clients to other types of providers.
In addition, it is important to maintain relationships with fellow massage therapists, especially those who specialize in modalities other than your own.

Employees
When an established practice is ready to grow, one of the most critical steps in the expansion process is hiring employees. Growing your staff will give you expanded ability to serve clients. However, employing others adds another level of complexity to your business. You must keep payroll records, withhold the proper taxes, prepare tax returns, buy workers compensation insurance, and more. If you reach this level in your business, it is important to remember that potential employees should be
- licensed and willing to follow the rules and regulations of your practice.
- ethical individuals who are willing to interact with clients courteously and professionally.
- hard working and willing to participate in continuing education and professional growth opportunities.
- self-motivated and honest.

Exercises: Business Practices
Choose the option that best answers the question.

1. The best way to prevent a financial crisis if your business is audited is to (A) hire an accountant. (B) store emergency funds separately. (C) keep all your business receipts. (D) purchase the right insurance.
The best way to prevent a financial crisis if your business is audited is to keep all your business receipts, as these receipts serve as physical documentation of your business transactions. Such documentation can be invaluable in this situation. The correct answer is (C).

2. A written document that outlines the purposes and goals of a new business is known as a (A) business plan. (B) mission statement. (C) letter of intent. (D) marketing plan.
A business plan is a written document outlining the purposes and goals of a new business. The correct answer is (A).

Tips for Answering Questions on Professional Standards and Legal and Business Practices
When answering test questions that deal with professional standards and legal and business practices, you may find it helpful to remember these tips.
- Read the questions carefully. Many professional standards and legal and business practices questions will present a brief scenario and ask you to indicate how you should proceed in that situation. Be sure to read each question carefully so that you fully understand exactly what is going on in each scenario. Misreading a scenario can lead you to an incorrect response.
- Take time to think critically. When you encounter a scenario-based question, carefully read the scenario and take a moment to think it over. Do not rush to select an answer. Many of these questions require common sense to answer correctly, so stop and think about the situation before you answer.
- Study the terminology. Many professional standards and legal and business practices questions will be based directly on specific terminology and concepts discussed above As you study, be sure to pay close attention to key terms. Understanding these concepts will go a long way toward improving your performance.
- Conduct your own research. Many of the business and legal concepts discussed in this guideare touched only briefly. To gain a better understanding, try researching them further using other resources. Topics such as taxes and insurance can be complex with local implications too specific to be covered in generalities. Look to appropriate outside sources for help.