The Knowledge Summit Series Part 2: Dual Relationships in Massage Therapy with Sarah MacAulay

Sarah MacAulay, an RMT from Stewiacke, Nova Scotia, brings a fresh perspective on dual relationships in massage therapy, challenging the profession's traditional ethical guidelines that don't reflect rural practice realities. Living in a town of approximately 1,800 people, Sarah shares her journey of navigating professional relationships that inevitably overlap with personal ones, revealing how urban-centric ethics create unnecessary burdens for rural practitioners.

• Dual relationships occur when professional therapeutic relationships overlap with personal connections
• Traditional ethics teaching instructs therapists to "avoid dual relationships" without providing context for rural practitioners
• The abstinence approach to dual relationships is unrealistic in small communities where practitioners know most patients
• Research from other healthcare professions shows risks of dual relationships are often overstated
• Patients in small communities often prefer being treated by someone they know and trust
• The burden of reconciling practice reality with traditional ethics creates unnecessary guilt for rural practitioners
• Successful management of dual relationships involves honesty, communication, and co-created boundaries
• Current ethical frameworks derived from urban institutional settings don't translate to rural practice
• Practitioners need education on managing dual relationships rather than simply being told to avoid them
• Sarah is developing guidelines to support therapists navigating dual relationships in small communities

Join Sarah at the upcoming Knowledge Summit on Sunday, October 5th, where she'll present "A Closer Look at Dual Relationships in Research and Practice" – offering research-informed approaches for practitioners working in small communities.

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Chapters

• 0:00 Introduction to Sarah MacAulay
• 11:51 Understanding Dual Relationships in Practice
• 19:19 Ethics and Human-Centered Care
• 28:10 Research on Dual Relationships
• 37:15 Small Communities and Professional Boundaries
• 46:03 Creating Change in Professional Ethics
• 53:20 Closing Thoughts

Transcript

Eric: 0:11

Hello and welcome to the Massage Science Podcast. My name is Eric Purves. I'm an RMT course creator, continuing education provider and advocate for evidence-based massage therapy. In today's episode, we welcome Sarah MacAulay, who is a massage therapist from Nova Scotia, and Sarah is going to be presenting at my upcoming Knowledge Summit, which is an online conference specifically for massage therapists, and that's going to be on Sunday, October 5th. She's going to be presenting a topic called A Closer Look at Dual Relationships in Research and Practice. So today we're going to talk about this with Sarah, as well as many other things. So thank you for being here and I hope you enjoy this episode. Welcome Sarah. Thank you for being here today. How are you?

Sarah: 0:56

I'm doing great. Thank you so much for having me here today.

Eric: 0:59

You're very welcome, your first ever podcast.

Sarah: 1:01

Yes, first ever.

Eric: 1:03

Amazing Thanks for choosing me, or allowing me to have you view on my podcast. That's what I should say. So tell everybody a little bit where are you?

Sarah: 1:12

I am in a place maybe not too many people have heard about before, but I'm in a little tiny town called Stewyatt in Nova Scotia, so out on the East Coast. It's a beautiful little town, a small rural community, and, yeah, I've been living here for about 12 years now, and I grew up in Halifax, so people are more familiar with Halifax, of course, but I moved here after I became a massage therapist.

Eric: 1:35

One thing I was thinking of, actually before we planned this. I was thinking how do I know, like how do we know each each other because we've talked so many times over zoom and phone calls and stuff and we've had so many meetings. But I can't. I honestly couldn't remember how we connected in the first place.

Sarah: 1:52

I was thinking about this too, because this comes up in podcasts and things like this, and I remember the first time I heard of you was I was looking for an article, something online, probably around 2017, 2018. And I came across one of your articles on your blog about education reform, I think something like that, and I loved it, and I'm the type of person that writes emails to people and I love their work and I might have reached out just through an email and then maybe things kept happening after that. I'm just think I could.

Eric: 2:30

I can't quite remember, but that might have been where something like that does make sense, because that the first article I ever wrote and put out there was called a time.

Eric: 2:40

It's time for curriculum change in massage therapy that was it something like that yeah, might be a couple words, different steps and I wrote that initially for a colleague of mine, jamie Johnson, who I used to do a podcast with because he had a website, and he said, hey, do you want to do this thing for me? I thought, yeah, and I was so passionate I still am but at the time I was just fresh into kind of getting like finding my voice and getting stuff out there and I wrote that for his site and then, probably a year later, I created my own website which no longer exists, but ericperviscom was my old website, so if you go to that old one it'll take you to my new one right now, which is the cebecom, but I put it on there.

Eric: 3:19

it was the first article I put on that site and it I don't can't remember how many reads. I had nothing, but that thing was getting hundreds and hundreds of reads per month and visits and it was really popular and it got published in a couple different professional magazines.

Eric: 3:37

I think even as far as ways. New Zealand had it and I think another one in Canada, I can't remember which one. One of them, maybe Massage Today or Massage something, might have taken it on too and it got published, and so that was a really popular one.

Sarah: 3:50

Yeah, it was great and it was interesting because it came to me at a time when I was really needing it and really ready for it, because, leading up to, I guess, 2018 to 2019, I was really. I needed to get back into school, I needed a challenge, I needed something new, I needed something new and that was what I was feeling at that time. I felt we need more substance. Higher education isn't a very good goal for massage therapists. We should be doing this. And it really spoke to a lot of the things I was thinking about at that time. It just said reinforced me and gave me that sort of push to apply to go back to university, which I did end up doing in 2019.

Eric: 4:25

That's awesome. I didn't know that.

Sarah: 4:26

Yeah, yeah.

Eric: 4:27

That's fantastic, it's so funny when you do podcasts or you do blogs or you have content out there. You never really know how it's going to resonate with people, and so it's always really encouraging to hear that, oh, it's resonated with you and it helped to inspire you to do something else. As we're talking off air, sometimes you don't always hear the good stuff.

Sarah: 4:48

Yeah, that's what I love to write to people and tell them how much I love the work.

Sarah: 4:52

I started doing that years ago. But I just so deeply appreciate a piece, a book or an article that resonates with me or that changes me, because I just I love reading and I think authors need to hear that. And there was another piece of that time by Monica Noy, who I know you know very well, and she had written a piece for Massage and Fitness magazine about critical thinking. And I wrote to her too and I said I just love this piece. It is exactly what I needed to hear and it was another one of those pieces that kept propelling me in that direction of going back to school and learning more and thinking about my thinking and all those things. And so they were really like, when you write a piece like that, you don't know who it's going to reach, but oftentimes you might not ever hear about it, which is too bad, but it does reach people and it does impact them in big ways, because it did impact me in a big way, that's awesome Monica's great.

Eric: 5:41

That's awesome Monica's great. Her and I, around that time we were teaching.

Eric: 5:45

We taught a course together a couple times yeah in Toronto and I think maybe two or three times. We did a course there together and it was funny if I think back now to how we thought at the time, like we were. Like this is we're just going to change the world. Everyone's going to, everyone's going to learn this stuff and they're going to be better critical thinkers and be more up to date with the content. We're going to get rid of the pseudoscience and you have these hopes and dreams and I still like to think that, but I'm more of a realist now, understanding that it's not that easy.

Sarah: 6:18

It's a long road.

Eric: 6:19

It's a long road. We're trying to change a culture. We're trying to change an entire society and belief system for a profession and I think that is where where the hiccup is that we know that evidence and research doesn't change people. People don't react or don't engage with things logically. They engage with things emotionally. Yeah, and over the years, trying to challenge the status quo with, here's some I'm going to say less wrong information, because you never want to say these are facts, but they're less wrong than what we currently know. Some people are like I don't care, that doesn't change, I'm still going to go. And some people will be like, oh, let me think about that. But yeah, all percentage and and. But if you went and try to appeal to someone's emotions, you can get and say everything you think you know is wrong. This is all hot garbage.

Sarah: 7:16

Yeah.

Eric: 7:16

Well, some people are going to be like, oh what, I want to learn more about that, but you're going to have just as many people that are going to. It's going to backfire. They're going to say hold on, you're crazy, I hate you. I'm going to go and I'm going to be further ingrained in my beliefs and I'm not really sure what the magic solution is.

Sarah: 7:36

I don't know. Patience, keep planting those seeds. I think it's just a slow thing that you need to keep believing in. It's hard because you think you might want to give up on those things too, but it is a slow thing and if you can hang in there, you do get to see the fruits of your labor at some point. Yeah, or more.

Eric: 7:59

I'm not giving up.

Sarah: 8:01

Don't give up. Please don't give up.

Eric: 8:02

I like doing this stuff too much and yeah sometimes I try to be like, oh, I'm going to do something else, and I think no, because I really enjoy doing what I do and being able to connect with people like yourself, like across the country is across the world, awesome, fantastic.

Eric: 8:17

This kind of goes like into the conversation about today and what we're going to talk to talk a little bit more is your topic of dual relationships yeah research practice, because this is something that there's a lot of belief yes there's a lot of kind of traditions that you're pushing against yeah and, and I guess the thing that I really want to explore today with you is that I want you just to tell us a little bit more about what is a dual relationship and tell us a little bit about some of the key things that we should understand.

Sarah: 9:03

Yeah, I talk about this because I live this experience every day, living in a rural community, so it's been something I've been working with and living with for the past 12 years or so. A dual relationship is one where your professional relationship overlaps in one or many ways with your patients. In a small town like where I live, I know all of my patients and it's on the spectrum of maybe they're my friend or maybe we volunteer on a committee together or our children go to school together, but there's a level of knowledge there and we are, so our lives are intertwined and they overlap a lot. It's not just a little bit, it's every day.

Sarah: 9:45

In our ethics courses we learn that dual relationships are inappropriate and unethical and incredibly difficult to manage, will inevitably lead to harm for the patient and potentially for the provider too, and that the best advice is really just to avoid them. And that's great if you live in a highly populated area. But even in a highly populated area, you're still going to find tight-knit communities where dual relationships are just going to happen or they're going to be preferred. That just doesn't work for a person working in a small community or think about the more remote you are, geographically isolated it's not happening. You're definitely treating your family and friends and places like this. I want to make a point that I'm not talking about sexual dual relationships at all here. It's just dual relationships with socially true business, friends and family in particular, though, but that's a good distinction to make, so make so.

Eric: 10:43

Yeah, that's a little bit of an intro there and it's such an important thing to talk about and this is one reason why I was so happy to invite you to present on this topic to the knowledge summit was because you'd recently were working on a paper. Yeah, yes, yeah. I thought this is such a fantastic thing because, yeah, what are you supposed to do? Not? Every rmt across the country lives in an urban environment where they have that luxury of saying yeah this is I can't treat you.

Sarah: 11:56

Yeah, go see my colleague, or whatever, you just not.

Eric: 11:59

So let's use you as an example, Sarah. So in Stuiak, what's the population?

Sarah: 12:04

The 2021 census put us at 1500 people and I looked up online recently. We're estimated to be about 1,800 right now in 2025. We had a bit of a population boom over COVID. A lot of people were moving to the country and, yeah, we actually had, yeah, quite a few people move here, but so it's not a lot of people.

Eric: 12:25

Yeah, that's silly, that's a 20% population.

Sarah: 12:28

It was the highest in our province. It was unprecedented actually, and there's a pause on building and stuff here because we just don't have the infrastructure for it Of course. Yeah, and it put all the prices of the housing up, of course, and everything is just super unaffordable here. And we moved here because we wanted a country life, a quieter life, and it was affordable. But we couldn't afford to move here now at all. Oh wow, it's better everywhere yeah.

Eric: 12:52

It's like that too in Victoria, where I am. Yeah, I don't know. It'd be impossible for us unless you're very wealthy for an average person to buy that traditional single-family home.

Sarah: 13:03

Yeah, so it's a good thing we love our house because we're not salivating.

Eric: 13:09

That's a thing, isn't it?

Sarah: 13:10

so yeah, so it's regressing here, but with so there's 1500, maybe 1800 people there yeah now and you probably know, or friends with a huge a good number of them, because not only am I friends with people, my husband's friends with people, my children are friends with people, my husband's friends with people, my children are friends with people. So this brings a lot of people into your life and I'm not like a super, a bit of a hermit. This is different for everybody too, depending on how social you are and how going and involved in your community, that's going to look different for everybody. So for me, who's a bit of a more reserved person, but I do volunteer quite a bit within the community, I really believe in that and I enjoy that. I might have less sort of friends or connections, but I overlap in some way with everybody that I treat in here. There's just going to be that it might change in a year from now, depending on how our lives change as our children grow and as new things happen, and that's not static either.

Eric: 14:15

But it just makes sense, if you stay long enough, that you're going to make new connections, new friends new people are going to enter your life and ethically you're not supposed to treat. So what are you supposed to do? Yeah, so you were saying that it's basically the ethics teaches us that these dual relationships are wrong. We learned that in massage school.

Sarah: 14:37

Yeah.

Eric: 14:39

And I'm assuming MTANs yeah, has rules. Do they have rules about relationships?

Sarah: 14:47

Yeah, yeah, we have it. There's a lot of things that kind of progressed along the way of me thinking and writing and doing everything about this, but one thing that changed in 2021 or 2022 was that our code of ethics changed and the phrase avoid dual relationships became part of our principle three of do no harm, and that was not in our past iteration of our code of ethics, so this was a new thing and it was also brought up in a practice standard around boundaries. And I understand why it's there because it's within our. It's our ethical teachings. It's to protect the patient. I'm all for not causing any harm the patient I'm all for not causing any harm.

Sarah: 15:32

But there is no context for that and this is a province where most of us live in a small community outside of Halifax, and even in Halifax, it's not that big of a city that you're not going to have some overlap rate. You know what I mean To see that and to know what it points back to. When you go back and you look at whatever ethics text you were brought up on, there is some discussion around it being a very poor choice. You're probably not going to be able to know how to manage it. It isn't compatible with patient-centered care. These are not the experiences that I'm having in this context at all. I'm having excellent experiences, and I had to teach myself how to do it because, since our best advice is to avoid it, we're not teaching people how to do it, so that's a problem.

Eric: 16:18

That's a huge problem, and it's if we look at the kind of traditional ways that society has done about things that you shouldn't be doing. Well, just avoid it. It's like this abstinence approach.

Sarah: 16:31

That's exactly what it is.

Eric: 16:32

It's an abstinence shift and has that ever worked for anything? It doesn't work for drugs or alcohol, it doesn't work for smoking, it doesn't work for sex, it doesn't work for I don't know every kind of thing that humans can do. The abstence approach just avoid it doesn't work very well. But what seems to work well and I'm this is I guess there's a question for you but is education right? People are educated about a certain topic, the they can then make informed decisions. They can make informed decisions about should I smoke? Why? I know the risks, I know the harms, I know no benefit, but just saying no, don't do this thing. It doesn't work.

Sarah: 17:14

Yep, that's right.

Eric: 17:15

Why would that approach be any different in a dual relationship?

Sarah: 17:19

It drives me crazy here. I'm just always so shocked that this hasn't been talked about a lot before and I think probably one reason is that if you look to other areas in healthcare, it's still the norm to see this type of language and to see this as a value or principle within codes of ethics and standards of practice. But when I finally, when that wording came up in our own code of ethics, it just was the kind of the last straw for me. I was like I could handle it before I could rationalize it because I was always coming back and forth with it. Oh, some days I feel like I get negative feedback about it from peers who just don't understand. But I can rationalize it and I can live with it and I'm no end doing the right thing.

Sarah: 18:01

But when I saw it in our code of ethics that's when I saw it, and also because I was in school at the time and in the sort of mode of critical thinking and doing research and writing a lot which was so beneficial at the time, I was like, oh my God, this has to be happening everywhere else, in every other health profession. Are they writing about it? And yes, they were. They've been writing about it for decades. I, immediately upon accessing and reading like one of the first papers around dual relationships. I just felt seen and understood and supported for the first time ever and it was wonderful.

Eric: 18:42

Your experience was validated.

Sarah: 18:44

It was so validated Like, oh, everybody else is feeling this. Everybody else feels like there's not enough education, that their practice is completely misunderstood, it's not valued, that the things that we're doing here every day. Every day, we're really working hard to check our biases, to make sure our patients are safe, to just really care for them in the best way, and this is echoed throughout nursing and medicine and social work, psychology, all the health professions. And to see that other people working in small spaces were feeling the same way, I felt it was great and I said, yeah, I need to do something with this.

Eric: 19:28

I think it's great. So why don't you tell us a little bit about, go into as much detail as you want about the research and practice with other healthcare professions, and how are they what's the word? Negotiating or working with dual relationships?

Sarah: 19:43

That's a great word because a lot of that negotiating comes up. A lot we negotiate the dual relationship, the overlap and the amount of overlap that we have and that we're comfortable with our patients, like on an ongoing basis. And this is happening in every other area of health care. And because there's this consistent message of there's not enough education or acceptance of these relationships, it's said in other areas of healthcare avoid them, they're dangerous, whatever, unethical. So because there's a lack of education, healthcare providers are coming up with their own ways and they're all ways that I do it and it's not that they're difficult, really it's honesty and communication and caring and talking and having an ongoing conversation and saying when a new patient comes in and I know them, I just say I just want to make sure that you're comfortable with the amount of overlap that we have here in this community. I'm always here for an open conversation. If anything makes you feel uncomfortable, let's just talk about it.

Sarah: 20:42

Just being human, Human, and that comes up so much in the research. That and all this research that I've read. Pretty much all of it is from the provider perspective. So of course the patient perspective is really important too and there's a knowledge about that and hopefully there'll be more of that done, and but it's just. They want to see these rules and guidelines and values be more human, less fear-based, less based in suspicion. You know of what you're doing wrong and everything, and of course things do go wrong sometimes. So for the most part, we're good, we care, we're in healthcare because we care about people.

Sarah: 21:19

Being in a community with people, that does not make you care less. It makes you maybe even arguably care more because you're going out there in the community and you're going to be seeing the next day and you're going to see your patients and you're going to be like, well, there's. Maybe you don't talk about it out loud, you don't want to risk the confidentiality, but you have just a different. I don't know, it just feels different because you're seeing the people that you, that you treat, and you're happy to see them when they're doing well, and if they're not doing well, then you're accessible and you're right there and you can deal with that too. But it's not.

Sarah: 21:51

It's funny that the argument there's an argument that it is incongruent with or compounded with, patient-centered care, because it actually improves patient-centered care and that's been brought up in the literature that it's a good thing that it doesn't diminish that at all. So it enhances the therapeutic relationship. When you do have a different, deeper knowledge of your patient you might have depending on how long you've been in the community, you have a history that you know of the person and that can be a positive thing if used in the right way. So there's these benefits that you don't read about, that are out there, that do exist. The literature that we have in our texts is really just around the risk and the harm and it really scared to bring the benefit in, and I suppose that's understandable because we don't want to hurt anybody. So that's the boundary and that is understandable. But there is a lot of research out there now and I think it would be good to look at that when people go to rewrite these chapters.

Eric: 22:50

You said that there's an argument that a dual relationship against patient-centered care. What's the argument about the harms or the problems that dual relationship? There's some obvious ones which I think anybody should be able to identify. There's some obvious ones which I think anybody should be able to identify. But what are some of the arguments that you see in the literature about this is not something you shouldn't do, because of what are they worried about?

Sarah: 23:14

I've seen it's a conflict of interest Straight up. Some texts are, I'll say that, the few texts that I have gone through. There's four that we're really familiar with Pavas and Fitches and Lauren Allen's book and Benjamin and Moe's. So those are the four that I'm drawing a lot from because they're really well known. They're all about ethics. They're really not about anything else, they're all about professionalism and what comes up in those would be around it being a conflict of interest.

Sarah: 23:42

But not only that. It's stated in some of the books that it's an automatic boundary violation or boundary crossing. Whether you're doing your best or not, it's perceived as, because it's perceived as unethical, you're just crossing the line, it's just, and that you're not, probably not aware. You might not be aware if you're doing any harm, and that's a danger. Aware if you're doing any harm, and that's a danger. And also that your objectivity as a clinician is diminished so that it isn't near possible to be objective. So that's where you're not able to provide that patient-centered care, because you can't make a good clinical decision, because you're too impacted maybe by the emotional relationship you might have with this person or other things going on.

Sarah: 24:25

But I would argue that is not happening at all, and from the research that I've read from other areas of healthcare, it's the same sort of story there. But are we fighting sort of all those things? In any relationship that we're in, regardless if we know the person or not, they're coming in with their own unique story. Anything that they say could make us feel emotionally charged, more or less. We all have our own backgrounds and history and our job is to treat each patient with respect and care and to listen respect and care and to listen, and no relationship is devoid of emotion. And then putting up those boundaries really strict sort of professional boundaries can be seen by some people, no matter what context you're in, as you being cold and uncared too.

Eric: 25:22

That's the thing that I find has happened in our profession. I speak more about BC because that's who I am, but there's over the years, there's almost been this mechanistic approach If someone starts talking about emotions or life or problems, we're supposed to just redirect them back towards. Why are you here?

Sarah: 25:40

Yeah.

Eric: 25:41

I remember a couple of years ago we had to do or college had to make us do some online course and for the life of me I can't remember what the heck it was about, but I remember that was one of the things that they talked about. There was this person came in I think they had shoulder pain and they were talking about. They started going off topic and the right answer for the therapist was try to redirect them back to their shoulder.

Sarah: 26:02

Yeah, but not treating the human not treating the human, not treating the person in front of you that might need to say they need to tell you their story.

Eric: 26:12

Yeah, no, I totally and I think a lot of it. I think a lot of the worries that regulators have is because we are not as a profession, we're not educated or trained in a lot of these softer skills, which are actually harder skills, things like interviewing, listening and stuff. There's probably this is a huge assumption here, so I could totally be wrong, but I'm assuming that there's the regulators are worried that we're going to step out of our scope of practice If we don't just focus on, like, the joint or the tissue or the or, and we start focusing on the human yeah, now I would say that I don't agree.

Eric: 26:51

I think their worry is. I there is. I could see how there's a worry there, but I think you're, there's more things to be worried about than than that way more things to worry about in the profession. But moving the focus away from treating the human to me seems unethical.

Sarah: 27:09

Yeah, it does Even of ethics.

Eric: 27:11

The ethical is we should do no harm.

Sarah: 27:13

Yeah.

Eric: 27:13

And we should have informed consent.

Sarah: 27:16

Yeah.

Eric: 27:16

Key ones and there's other ones, obviously. Those are the key ones that I always come back to, and then you have to treat the person. You have to treat the human. So if you have a dual relationship, so using that as an example, someone comes in and you're the only person in that town that could potentially help them with whatever's going on, why would you say no?

Sarah: 27:38

That's the worst thing you could do.

Eric: 27:40

Exactly. That's not patient-centered care, that's not in their best interest and that's potentially doing harm. So by saying you can't have a dual relationship when you are maybe the only person in the town, that's not ethical.

Sarah: 27:54

That's not ethical Not at all. I remember when I first moved here and I was practicing in the city for a year and a half or so before I moved here. I'm not really cluing in that moving to a small town was going to put me in the position of just being in the middle of all these dual relationships, and I hadn't had that experience yet. And I remember thinking, if I say no, that's wrong, it's a barrier to accessing care. People have the right to access care in their own community if it's available, and so that always struck me as a really big problem. But I remember talking to another massage therapist the only other one who was in town at the time and I said how do you do this? Like our books say we can, and it just feels so wrong. And she just said you just do it, you just do it because you have to, but you just do your best. And I said, okay, I'll just go with this.

Sarah: 28:52

And it's always been a good experience because it's always been led with honesty and integrity and all those things that you would want in any interaction. And that's what, in the research too, is that all these healthcare providers have their own way of interacting with people and everybody might be a little bit different, but it's just based on talking, like saying, this is the situation that we're in, are you comfortable with it? And more times than not the person wants to be in that the patient chooses it. The patient's very comfortable knowing you. It actually provides them with a foundation of trust because they know you already. And trust is so important and it takes time to build up, but when you're actually seeing a provider that you know or you're getting to know that trust is already there.

Sarah: 29:40

And we know from some research in massage therapy that psychological and physical massage therapy, that that psychological and physical the trust kind of helps relax us and can help us have better outcomes in our treatment. And that's like a yeah, of course it is, but it does. It does work really well, it's. We need to move away from this fear and suspicion and embrace that this is happening everywhere and we shouldn't be hiding from this conversation. One thing that I've seen repeated in the research is that, like health, ethics in general has a lot they could be learning from understanding people who work in small spaces and whether it's in a rural or remote area or a tight-knit community within an urban community within an urban area. There's a lot of great stuff that you could be learning about these complex relationships, of how they're managed, and how they're managed well Because there's no epidemic of harm or it would be shut down.

Eric: 30:45

So one of the questions I had is when they talk about, you're saying there's this risk of harm and having a dual relationship is bad, but is there any evidence to show that these dual relationships actually are causing harm?

Sarah: 30:58

In massage therapy? There's absolutely none, because we have no ethical research, no research on ethical issues at all. Really, in massage therapy and outside of massage therapy it's stated that it's greatly overstated the risk of harm. There's always a risk of harm, but there's no. It's not what people think it is. I think we were talking you were saying traditional ethics and values and stuff, and it's funny because that comes up a lot in the research.

Sarah: 31:29

I read this great book I read it and re-read it by Christy Simpson and Fiona McDonald, called Rethinking Real Health Ethics and their argument is they talk a lot about ethics beyond what we need to know about because it's for health care, but on nurses and physicians and everything need to know about, because it's for health care, but on nurses and physicians and everything, but they talk about traditional ideas around avoiding dual relationships. These ideas came into being in urban institutions decades ago, based on what was the norm in urban institutions You're primarily providing a treatment to strangers and it just became a gold standard of care, not really based on any other context or really anything. And this has been perpetuated, this idea. So they call this principle urban-centric and other authors have called it a Western or Eurocentric ideal. This is from the perspective of the First Nations author, which I read about when she was speaking to her work as an educator and a psychologist in her remote First Nation community.

Sarah: 32:33

She came up against the problem of having to abide by this principle of avoiding dual relationships, which is completely incompatible with where she works. And this is Tanya Dama of Dubuque, who wrote an autoethnography about this in 2023. And I highly recommend people looking her up and reading that paper. It was fantastic. It really spoke to me. I liked that she was writing about her own experience, but it's an incompatible value. It really doesn't work outside of a place where you're just going to be with strangers all day.

Eric: 33:05

And that makes a lot of sense and that's so common. What we see in our profession, unfortunately, is that there's these histories, this beliefs, this culture, this traditions of massage therapy, and this is just the way things are it's just the way things are because it's always been done. But why, yeah, but why that's, and that's the way I've always been and that's why I am still. Is that why? Give me a reason? Yeah, just because it's not a reason yep give me a reason say so.

Eric: 33:39

We use dual relationships as an example. They're bad, they're're wrong. I can understand that there's risks.

Sarah: 33:45

Yep.

Eric: 33:46

But telling people to just abstain.

Sarah: 33:50

Yeah, exactly.

Eric: 33:51

Avoid them completely, otherwise you are bad. You are a bad human, you're a bad therapist. It's not a good enough answer, a good enough solution. There's got to be a better solution, and I'm sure there is better ones. I'm sure. There is yeah, If you could rewrite the ethics rather than say avoid, what could you change it with? And how would you make RMTs better at dual relationship handling?

Sarah: 34:27

Just using all the general principles of an interaction that you're having, like in a therapeutic relationship. You're asking for permission, you're being honest, you're listening, you're informed consent, all of these things. It's not there's nothing different or secret or anything like that. It's respect and honesty and creating boundaries together and understanding that there there needs to be boundaries. But, yeah, creating that together, that a lot in the research that these boundaries are co-created with patients in small communities. It's interesting because in some of the texts, like in Benjamin and Sonnenmoll and the Ethics of Touch, they know like they have a pretty clear big chapter on dual relationships. So it's pretty, it's really good. But they do note that in rural areas or small areas it's you're going to come across them more than in urban areas, but I never see anyone make the point.

Sarah: 35:16

Then how can something that seems so wrong and you're telling us we probably don't know if we're doing it right, we might not be mature enough to do it, we might, we're definitely going to, it's going to be hard or confusing at some point. How can something that is so wrong here have to happen? Still, what does that make my practice look like? Am I just an unethical bad practitioner because I'm out in the middle of nowhere doing whatever I want, and it's just. That's just just fine too. I don't understand that. I can't reconcile that.

Eric: 35:50

And with this thing, this is really interesting to me, because this is a topic that I don't I've never heard anybody out of profession talk about before.

Sarah: 35:56

Beauty robotic.

Eric: 35:57

Not in this context.

Sarah: 35:59

Heard, not like this at all, Like I really haven't, you're right.

Eric: 36:06

I commend you for that and for working on and hopefully getting a paper published soon on it me. What you said, though, is basically respect, honesty creating boundaries. This is something that could easily be incorporated into massage therapy education yeah we take all those pd courses.

Eric: 36:20

No matter where you go to school in the country, there's always pd courses and I think most of us would agree a lot of that PD content is not very helpful. No, and it's better utilized the time. Yeah, positive there, positive language why could you not have a day, or use this as a lesson or two on managing dual relationships?

Sarah: 36:40

Yeah, and I hope somewhere out there in some school this is happening depending on, because we know the education is so variable and who knows who your teacher is and what their personal experiences are. So I hope people are talking about it. I know I personally didn't get a good, a positive conversation about dual relationships when I went to school, but yeah, it shouldn't be hard to incorporate. And, with all of the research that's been published, bring a couple of papers in when you're talking about if you're still teaching from texts that haven't, in their next edition, updated any of this information based on research. Bring a few of these pieces in and get people to critically think about it. Read it.

Sarah: 37:24

It has to be required reading as far as I'm concerned, because there are so many of us that are going out there and moving into a small community or we're in a tight knit community, in an urban area or in a rural community and we had. We're scared and we feel othered because when you try to talk about it to people that don't understand, they give you a side eye and say you're doing something very wrong. You got to stop doing. That, from our perspective, is you don't understand. This is not the way that we're taught this. It's actually. I'm having a very positive experience, and so are my patients, and we're doing this very well and it's very healthy and there are boundaries and there are confidentiality and it's actually not that hard to manage. What's hard to manage is going back and reading those books and you're what an unethical person you are for doing something that you have to do. That's hard to manage.

Eric: 38:16

Yeah, you basically feel guilty for doing.

Sarah: 38:18

You feel guilty all the time. And when I, when I read the book rethinking real health ethics, I did what I always do and contacted the authors and said thank. I read the book Rethinking Real Health at Bix, I did what I always do and contacted the authors and said thank you for this book. This book took an immense weight off of my shoulders as a provider and I read this back in probably 2022. And, to my great luck, one of the authors, chrissy Simpson, works at Dalhousie University and has been able to talk with her on several occasions about her work. I mean, I've said to her a few times I just can't tell you I didn't realize how heavy that weight was on me over the years where I was doing my very best and always checking in but still to go back, any sort of guidance that I wanted to seek was just around the negativity and the wrongness of being in a dual relationship and that was harmful. And it is harmful and that's a reason.

Sarah: 39:10

One of the many reasons why we need to have a research-informed and evidence-informed conversation about this is because it does cause harm to the patient and to the provider. When you work in a small space, you want to feel comfortable integrating into that space. There are people that I, or participants that I've read of in the research, that they really struggle with. What is the level of integration that I'm allowed to have in my community? I want to feel free to join a club and to go to church and go to a community center and go to a town council meeting, but you really feel limited and we are already in an isolated profession, a very isolated profession, and this is just even further isolating. So that's a big problem, I think and I've felt that.

Eric: 39:59

One thing that I don't think is talked about enough in the profession is the isolation of it A lot of it, Even if you're working in a busy clinic. I've worked in a busy clinic for part of 12, 15 years, something like that. It was still very isolating because you're alone with somebody, so I couldn't imagine the isolation of just profession.

Sarah: 40:21

Yeah.

Eric: 40:21

It's weird because you're with people all day, but it's isolating, but it's different. Yeah, different People are always thinking they're massage therapists. They understand what we're talking about. Yeah, they do. Adding to that, compounding that with an isolation of having to avoid those relationships in a small community, a small space, would just it would probably, I imagine, make you just not even want to work or just do something completely different. It just gets you out of the profession.

Sarah: 40:44

I've been through that too, the do. I want to do this Because I am. I like having standards and I like having something to measure myself against. You know what I mean. And when you don't see your practice environment reflected in those standards, it's really difficult. And that is reflected throughout the research as well. And when I heard that, when I read that in these papers and this book, I was like wow, that's what I've been going through. This has been hard because of this and I like to be a part of my community and when I have kids we have we do a lot here.

Sarah: 41:21

My relationships with my patients and with everybody. They overlap in so many ways. Not only that, like when you're in a small space, you're out there. You need each other. I need these people too, because they have skills that I don't have, or we help each other in other ways.

Sarah: 41:39

In Simpson McDonald's book Rethinking Real Health Ethics is the argument around vulnerability and power, and they say that this exchange of vulnerability between patient and provider. Like I'm in a vulnerable position with my patients sometimes because they know things I don't know. They have skills I don't have that I have to seek out. I'm a service seeker sometimes, so that switches back and forth and that can actually help to seek out. I'm a service seeker sometimes, so that switches back and forth and that can actually help to balance out that issue of vulnerability, which I just found so interesting.

Sarah: 42:10

They critique traditional health ethics from a feminist perspective, theory, philosophical perspective, which is interesting because they really take into account context and relationships and the power and balance between, like, urban and rural, and it's not something I knew really anything about until I read this book, but I am really. I love learning about that. This was something I never learned in our obviously in our ethics course, but it's a great way to describe or to think about what's going on here is there's a lot more and relationships matter and our connection to people here matter and it does play a part in how we choose health care providers and and things like that, so that it's yeah, they go pretty deep into that too and it was very enlightening these are topics and conversations need to be had they really are and because really, what is massage?

Sarah: 43:02

it's's relationships first really.

Eric: 43:05

It's really all. It's what it comes down to.

Sarah: 43:07

Yeah.

Eric: 43:07

Your relationship with the person in front of you is, I would say is more important than skill with your hands, your technique.

Sarah: 43:16

Yep. Another argument is that it comes up in our books town gossip and things like that. There's gossip everywhere. You're just being professional everywhere. You just be a professional. You don't need to engage in it, you don't need to agree with anything at all.

Sarah: 43:30

Everybody that comes through here gets treated as if they're the most important person I've seen in this day.

Sarah: 43:37

I genuinely care and want to give them what they need and what they're looking for, and that's attending to, that's patient-centered care, that's attending to their values and seeing them as a whole person and treating them as a whole person and it's just.

Sarah: 43:52

It just none of it really adds up in my experience and I know many people have many different experiences and I'm not saying that people don't have negative experiences, because we all do at some point but I think the vast majority of them are probably going really well. Things are going really well for people and we're just not really comfortable talking about it because we're scared we're going to get in trouble. We're scared we're going to get the side eye, and I've had all of that and even when I started talking about this more and more with people who really didn't understand, it was very uncomfortable, but I had to stand my ground because I said how can this be wrong? I've been doing this and there are hundreds of thousands of people just in Canada that are working in small communities, that are doing this right now. They want to, they have to. It's going great.

Eric: 44:35

And how have those responses been when you've had those conversations?

Sarah: 44:39

Actually as long as in the conversations I've had when I've really just not backed down and said what about this or what about that, and they've actually gone pretty well. But I've only been comfortable doing that now because I have the confidence for reading the literature outside of our profession. That's given me the confidence because I was never really able to do that before.

Eric: 45:13

Yeah, that's a big thing to take away too. Is that when you know a topic so well, you could have good conversations with people about it? Yeah, know a topic only a little bit. It's hard to have a real and like you can't really have an engaging conversations with me because you know you're not so small, so I engaging conversation with me because you're so small. So I think it's great that you're having those conversations. Have you had these conversations with your association?

Sarah: 45:33

Yeah, I have, because I do a lot of volunteer work with the association and some of the first conversations about this that came up with colleagues there, some of the first conversations about this that came up with colleagues there, and it eventually sparked me to want to create like a guideline for people working in dual relationships, which we do have now, and it at least, at the very least, it acknowledges that dual relationships are happening and that we recognize that now. But I think as time goes on we can do a lot more to make that a more friendly and supportive. But at this moment it is there and it is acknowledging that dual relationships happen and just gives a little checklist of how to work within that, from our sort of ideas around ethical values and standards and communication and things like that. But that gives me comfort to know that's there, because before we had nothing like that and we needed it and I'd like to see that everywhere. When you look to this, say, physiotherapy, like the Physiotherapy Association I've looked at a lot of them across the country colleges and associations, and there's some that will have maybe like a little booklet on the therapeutic relationship and there'll be like a little blurb in there.

Sarah: 46:51

Just be more careful when you're in a rural community treating friends and family, nothing more than that. Usually there's a big call to action for ethical guidelines to be informed by these other contexts that people are working in and that people need to feel supported in working in and within medicine and nursing and physiotherapy. There is an issue, too, around retention, like retaining these very valuable health care providers in rural spaces. In rural spaces, they really need to feel that they're not doing anything wrong, because that can lead to burnout and it can lead to people leaving when already there's not enough people working out in these communities, all these isolated places, and that's not a good thing.

Eric: 47:38

Yeah, the last thing you want to do is put people away. Yeah, particularly when these relationships are unavoidable.

Sarah: 47:44

They're normal and expected. That's the thing too. It's funny when you ask when I first started working, it was talking about this with people Not that everybody has this general knowledge anyway, but they're like I don't care that, I know you, I'm happy that I know you, this is awesome. I'm so glad Like I know you, I trust you, I feel so comfortable with you. I don't want to go see anybody else and this is echoed throughout the research as well is it's expected, it's normal, it's inevitable. Dual relationships are already part of normal health care service. They're already there, Been there forever.

Eric: 48:21

And it's not going to go away.

Sarah: 48:22

Go away. No, been there forever and it's not going to go away.

Eric: 48:24

Away, my thought I live in an urban area and it's huge victoria. I think the greater area is probably just shy of 450 000. But I've grew up here I can't go anywhere without having, without knowing someone, or like I have a two. It drives my kids crazy.

Eric: 48:40

But I got like a two degrees of separation or less, or or like I know you or I swear, no more than two, two degrees of separation and I will know somebody whether it's soccer, which has been a big part of my life, whether it's through work, whether it's through university, whether it's through high school, whether it was through friends or friends of friends, whatever it just you can't avoid it. You can practice. I would say a large, not everybody, but a large percentage of people that I had in my when I had a full-time practice were people that I knew or knew me from somebody else. So there, there's always gonna be.

Sarah: 49:16

You can't really separate that no, and here in Nova Scotia we have like maybe a million people now. We knew I didn't grow up in this community, which adds another layer to dual relationships because I'm not treating my family. I don't have family here, but a lot of people that grew up here the other massage therapists there's a few they're treating family that we expect that they are. But if you grew up in the community that you're servicing, you're going to be treating your family. But even in Halifax it's not a huge city it's going to happen at some point. Just knowing that these ideas are outdated, they're not helpful, they're not useful and they are hurtful and they do need to change. It's an uncomfortable topic because we're made to feel that being unethical when we're told that what we're doing is wrong and eventually going to lead to some sort of harm. I haven't found that yet.

Eric: 50:06

These conversations are important, as I said, and I think if we don't have them, then nothing's going to happen.

Sarah: 50:12

Nothing's going to happen, and that's the thing too, and I'm always inspired by that. This is talking about these things and putting these ideas out there. It's supposed to happen. This is a natural and healthy part of engaging in your profession. It might be uncomfortable to do at first and I know I've gone through a lot of feelings around that, but this is helpful and people need to hear this and we all need to share our stories. There was a narrative review that came out in 2023 by Sumer and Arnold and they did a review of the literature and gave a little schema for decision-making around engaging in dual relationships, and one of the things was to reflect on your challenges and successes and to share your stories with people and to help other people, and that really you want to support other people that are in these positions. We need to support each other. We need to talk about this and need to know that we're not encouraging each other to do our best.

Eric: 51:10

Yeah, so when you're doing your presentation in October, is there any other any specific key things that you're going to hit?

Sarah: 51:16

I'm working on the presentation now. I think what I want to do is pick out a few key pieces of research that really did something for me and just do a bit of a deep dive into what the findings were and just talk about that from my perspective too. That where I'm going with it right now is and then give good reference notes for everybody at the end of it to do their own reading and their own thinking. But really it's to open up the conversation and to say let's start talking about this and supporting each other and see if we can bring some change to the ideas and the culture around this and introduce the literature, the body of literature that's out there. And yeah, I guess just see where it goes from there. But it will. I will be looking at a lot of these papers more in depth and talking more to the specific settlement, which I think would be good. Yeah.

Eric: 52:07

Fantastic, I'm excited. Yeah, I think it'll be great and, at the very least, these conversations are starting.

Sarah: 52:14

Yeah, they're starting.

Eric: 52:15

Hopefully this will lead to others asking similar questions or having these conversations, and it's like you said at the very beginning you found me because of an article I wrote back in 2016. And conversations happen because of those, and sometimes that might inspire some positive change, and so hopefully this will be something similar for you.

Sarah: 52:36

I hope so too. There's a lot that can be done here, and the books that we have are the great texts they just need, like any other, you can pick any other topic in them. And well, this really isn't maybe how it is now, and we need to evolve a little bit. And that's the goal with being on that professional trajectory is not staying stagnant, to evolve and to bring new ideas in and to recognize that there are a lot of different ways of doing things that are appropriate.

Eric: 53:01

So, yeah, that's a perfect way to end it, Sarah.

Sarah: 53:06

Well, great.

Eric: 53:06

Thank you very much for being here and we'll talk soon.

Sarah: 53:09

Well, thank you so much, Eric. Talk soon.

Eric: 53:11

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