Sexual Assault Prevention: Keeping Patients Safe from Sexual Predators Part 3
By Ben E. Benjamin, PhD
In previous articles of this series, I covered hiring processes, working with sensitive areas of the body, and company policies so that you can adhere to the safest standards of care in massage therapy. If you are interested in more detailed information or process templates, please email [email protected]. These templates will make it easier for you to do your job and provide the safest, most professional environment.
Suggested for a sidebar: For chiropractors who hire massage therapists, protecting your patients and business from inappropriate sexual behavior is paramount because it results in thousands of reports every year. These recommendations and guidelines come from someone with 20 years of experience as an expert witness, a PhD in sports medicine, and over 50 years of experience in the massage industry.
10. Training
Take the time to orient and train every new hire during onboarding and approximately every two or three months. As mentioned previously, training in ethical behavior is inconsistent in massage schools in the U.S. Since 2001, large corporations have purchased many of the best massage schools in the United States. They proceeded to cut most of the ethics, communication, and business skills courses to save money. Many new owners often let go of the most experienced teachers, the only ones capable of teaching the mentioned subjects, because they were paid at a higher rate. The corporate schools began to hire new graduates who had little experience teaching.
Don’t assume your new therapist learned everything they needed to know in their schooling. The previous standard of most professional schools was to train new teachers for six months to a year and then closely supervise them. This is no longer the benchmark.
Also, many skills need to be put into action through experience on the job, including ethics, boundaries, sexual assault prevention, reporting therapist or patient inappropriate behavior, dealing with difficult patients, attraction to patients, and dealing with sexual arousal. It is an investment to take the time to train each hire so that they adhere to your standards, provide work that is consistent with the services you offer, and to make sure they are part of a cohesive team. Training in ethical behavior, communication, and sexual issues that may occur are important. Training by video on these topics can be useful but only as a supplement to live robust training led by a skilled person who is knowledgeable about these issues.
Within the onboarding orientation, there should be in-person live training about boundaries, communication, sexuality, and ethics with explicit conversations and roleplays around a number of scenarios, including:
Recognizing and respecting boundaries
Power dynamics of the patient/therapist relationship
What to do if you are attracted to a patient
How to politely avoid dual relationships
How to respond if a patient asks you to engage in an activity outside the workplace (online or in real life)
The zero-tolerance policy for sexual comments, jokes, or actions
Responding to off-color jokes or sexual innuendo
Dealing with overly personal patient questions
Effective draping
Dealing with patients who don’t want a drape
Never working under the drape
Never working on the inner upper thigh more than three to four inches from the groin
Always allowing the patient to undress and dress in private (including how to make all patients comfortable with how much clothing they wish to remove)
Additional areas to note are:
How to handle patients who cross boundaries or behave inappropriately toward the therapist
How to write and file a report to the employer about an inappropriate patient behavior or interaction
How to report the inappropriate behavior of another therapist
Inappropriate behavior of another therapist may come to the attention of a therapist from a patient or in an interaction with a coworker. It is important to have a reporting and complaint process for patients and therapists so that they feel safe to speak up if inappropriate behavior occurs.
At the end of the initial orientation and training sessions, ask the therapist to sign a document that attests they have completed the orientation and have them take a challenging test to check their comprehension and understanding of the material. Do not assume they understood what you have taught.
Create a clearly written training manual that states the organization’s philosophy, values, policies, and procedures that apply to the practitioner. Not only does the manual outline the training given to new hires, but it will also serve as a reference tool during their time of employment. It is standard to include your stated policies regarding absences, lateness, dress code, cleanliness, room setup, and so forth. Also, expand the manual to explicitly state policies about:
Communicating with management
Resolving conflict
Giving and receiving feedback
Cultivating a patient-centered focus
Sexual misconduct and harassment
Areas of the body you never touch
Prohibiting dual relationships with patients
Never having sexual contact or making sexual comments or sexual innuendos.
For employee reference, the training manual should also include the roleplays performed during training on how to handle patients who are verbally or physically inappropriate with the therapist. By being direct and clear on all of these subjects, you set the tone for your new hires and existing employees.
(Roleplay template is available by email.)
11. Patient Education Brochure
Provide every patient with a printed or digital brochure that lets them know what to expect in the massage therapy session, what is expected of them, and how to recognize and respond to signs of inappropriate conduct. This documentation creates well-informed patients and serves as a safety valve and deterrent to those with unclear professional boundaries.
Patients don’t always know what to expect or what is acceptable behavior in a massage therapy session. This is especially true for patients new to massage. However, regular patients can also come across situations when they do not know how to appropriately react.
For therapists who may be unclear about boundaries, when a publication of this sort is given to every patient, it may also serve as a deterrent to know their patients are well-informed. If you put this patient brochure on your website instead of handing a paper brochure to the patient, it’s important to make sure they read it. Not everybody reads what is on the website. If the brochure is only on your website, ask each patient if they have read it. If not, hand them a printed copy or have them read it on a tablet at the office.
(A patient brochure template is available by email.)
12. Patient Surveys
Set up simple surveys to be automatically sent to every new patient after they receive a session from one of your therapists. Send the survey again every two to three months if they come for massage treatment regularly. A victim of sexual abuse often needs time and physical distance from the event to process it and decide to report an incident. The patient is often in shock and not thinking clearly.
These surveys are an effective method for spotting inappropriate behavior and boundary crossings before they escalate into sexual misconduct. Small boundary crossings and violations are often the precursors to gross sexual assault. The surveys should have an option for the patient to remain anonymous.
If an issue presents itself in the survey or there is a question about possible misconduct, there should be immediate follow-up with the therapist. For example, if they had loose, sloppy draping or asked inappropriate personal questions, follow-up training may be all that is needed. However, if a pattern of poor boundaries is spotted, or if the patient was inappropriately exposed (even momentarily) due to poor draping, the therapist should be put on probation and carefully monitored. If warranted, your business can begin an investigation of this therapist to gain further information. Investigations are best held by third-party professional investigators.
(Survey template is available by email.)
13. Complaint Process
There should be a clear and rigorous process for complaints about a patient’s or therapist’s behavior. It can help protect your patients, practitioners, and business. A transparent policy cultivates trust and establishes confidence that they are dealing with a practice with high ethical standards. Often, patients who are dissatisfied with some aspect of their treatment don’t directly express their concerns; they just stop coming. Encourage every complaint, regardless of how small it may seem, and follow up on it.
If the patient is inappropriate, the organization must support the therapist in terminating the session and banning that patient from their office. Conversely, an inappropriate therapist should be immediately suspended and investigated by the police, an independent company, or internally.
Surveys should be sent out immediately to all of that therapist’s patients over the past six months. Immediately arrange an interview with the reporting patient at their chosen location. If the allegations are found to be true and if the patient gives their permission, report the therapist to the police. The therapist should be terminated. Ethically and morally, the therapist should be reported to the massage therapy board, which would likely revoke their massage license.
In most cases that end up in court, there is often a pattern of small complaints before an instance of gross abuse. Therefore, having a safe, clear avenue for complaints to be voiced can prove itself invaluable since it can bypass a more grievous situation later. Having a robust complaint process will help discourage therapists with predatory tendencies who will be searching for an establishment with less rigorous checks and balances. There are investigative companies that will manage the complete complaint process for your office.
(More information about the complaint process is available by email.)
14. Mystery Shopper
If you choose to use a mystery shopper, careful selection, vetting, and training are crucial. The mystery shopper should have these qualities and qualifications:
A massage therapist with at least five years of experience; a massage therapy teacher with at least five years of experience; a massage therapist who has also been a communications teacher at a massage school; a teacher who has taught communication and ethics, including boundaries at a massage school; or a psychologist, social worker, counselor, or psychotherapist who has at least several years of experience as a massage patient.
An assertive person who has had regular massage, can set boundaries, and say no easily.
Emotionally mature person with a good sense of boundaries.
Where to find mystery shoppers:
Massage schools
Rape crisis centers
Small massage clinics
Local AMTA Chapters
(More information on mystery shoppers is available by email.)
15. Call Button
Installing a “call button” on the treatment table within easy reach gives the therapist and patient access to the front desk staff immediately in case of an emergency or a situation that requires an urgent response. A small button should be placed under the edge of the massage table, just where the patient’s hand rests.
At the start of each session, the therapist indicates the location and use of this “call button.” Within your training and training manual, provide instructions with sample phrases for the therapist to use, such as, “This call button is here to keep both of us safe if either of us wants or needs help.” This creates an immediate sense of safety for the patient and the therapist. The call button also works as a deterrent for any therapist to engage in inappropriate activity or any patient who has a tendency to violate the boundaries of a therapist.
Information about the call button and its purpose should be on the company’s website as well as having prominent signs in the treatment rooms. Call buttons can generally be installed at a reasonable price. Research has shown that the incidence of inappropriate touch is dramatically reduced when call buttons are installed, and complaints generally go down significantly.
(More information on call buttons is available by email.)
16. Investigations
Sexual assault investigations in a massage therapy setting require a unique set of skills and extensive training. Chiropractors or managers do not have those skills, often have an unconscious bias toward their employees, and are not trained investigators. There are firms with investigators experienced in trauma-informed investigative techniques that know how to minimize the retraumatization of victims. They understand that victims may be in shock for many days after an assault, that memory loss is common, and the reluctance of victims to come forward.
I recommend using third-party investigators. Professional investigators have usually worked for decades investigating cases of human trafficking and other sex crimes. I recommend Ulbrich-Scull Investigations or a company called Redirect.
(More information on investigations is available by email.)
In Conclusion
This may seem like a lot of work because it is a lot of work. Once these procedures are in place, they will help keep your patients and business safe and lawsuits less likely. If you wish to request any of the templates or want any additional information, please contact me at [email protected].
About the Author
Dr. Benjamin holds a PhD in Sports Medicine and has been an expert witness in cases of sexual assault in the massage and bodywork field since 2004. He is the coauthor of The Ethics of Touch, a textbook used in schools throughout North America to teach ethics and boundaries to massage therapists as well as other hands-on healthcare professionals. In 1974, Dr. Benjamin founded the Muscular Therapy Institute, a school he owned and directed for over 30 years. In the 1980s, he developed a 150-hour curriculum in ethics and communication skills for therapists in training. He has also taught courses in ethics, boundaries, and communication to somatic therapists for over 30 years. In addition to his work with pain and injury problems, he did much pioneering work in the areas of ethics and communication, including writing articles on professional, sexual, and business ethics.
