September 5, 2025 • 53 mins
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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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Eric (00:11):
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-basedmassage therapy.
In today's episode, we welcomeSarah MacAulay, who is a massage
therapist from Nova Scotia, andSarah is going to be presenting
at my upcoming Knowledge Summit, which is an online conference
(00:32):
specifically for massagetherapists, and that's going to
be on Sunday, October 5th.
She's going to be presenting atopic called A Closer Look at
Dual Relationships in Researchand Practice.
So today we're going to talkabout this with Sarah, as well
as many other things.
So thank you for being here andI hope you enjoy this episode.
Welcome Sarah.
(00:53):
Thank you for being here today.
How are you?
Sarah (00:56):
I'm doing great.
Thank you so much for having mehere today.
Eric (00:59):
You're very welcome, your first ever podcast.
Sarah (01:01):
Yes, first ever.
Eric (01:03):
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 bitwhere are you?
Sarah (01:12):
I am in a place maybe not too many people have heard
about before, but I'm in alittle tiny town called Stewyatt
in Nova Scotia, so out on theEast Coast.
It's a beautiful little town, asmall rural community, and,
yeah, I've been living here forabout 12 years now, and I grew
up in Halifax, so people aremore familiar with Halifax, of
course, but I moved here after Ibecame a massage therapist.
Eric (01:35):
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 somany times over zoom and phone
calls and stuff and we've had somany meetings.
But I can't.
I honestly couldn't rememberhow we connected in the first
place.
Sarah (01:52):
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 lookingfor an article, something online
, probably around 2017, 2018.
And I came across one of yourarticles on your blog about
(02:14):
education reform, I thinksomething like that, and I loved
it, and I'm the type of personthat writes emails to people and
I love their work and I mighthave reached out just through an
email and then maybe thingskept happening after that.
I'm just think I could.
Eric (02:30):
I can't quite remember, but that might have been where
something like that does makesense, because that the first
article I ever wrote and put outthere was called a time.
It's time for curriculum changein massage therapy that was it
something like that yeah, mightbe a couple words, different
steps and I wrote that initiallyfor a colleague of mine, jamie
(02:50):
Johnson, who I used to do apodcast with because he had a
website, and he said, hey, doyou want to do this thing for me
?
I thought, yeah, and I was sopassionate I still am but at the
time I was just fresh into kindof getting like finding my
voice and getting stuff outthere and I wrote that for his
site and then, probably a yearlater, I created my own website
which no longer exists, butericperviscom was my old website
(03:14):
, so if you go to that old oneit'll take you to my new one
right now, which is the cebecom,but I put it on there.
it was the first article I puton that site and it I don't
can't remember how many reads.
I had nothing, but that thingwas getting hundreds and
hundreds of reads per month andvisits and it was really popular
and it got published in acouple different professional
(03:37):
magazines.
I think even as far as ways.
New Zealand had it and I thinkanother one in Canada, I can't
remember which one.
One of them, maybe MassageToday or Massage something,
might have taken it on too andit got published, and so that
was a really popular one.
Sarah (03:50):
Yeah, it was great and it was interesting because it came
to me at a time when I wasreally needing it and really
ready for it, because, leadingup to, I guess, 2018 to 2019, I
was really.
I needed to get back intoschool, I needed a challenge, I
needed something new, I neededsomething new and that was what
I was feeling at that time.
I felt we need more substance.
(04:11):
Higher education isn't a verygood goal for massage therapists
.
We should be doing this.
And it really spoke to a lot ofthe things I was thinking about
at that time.
It just said reinforced me andgave me that sort of push to
apply to go back to university,which I did end up doing in 2019
.
Eric (04:25):
That's awesome.
I didn't know that.
Sarah (04:26):
Yeah, yeah.
Eric (04:27):
That's fantastic, it's so funny when you do podcasts or
you do blogs or you have contentout there.
You never really know how it'sgoing to resonate with people,
and so it's always reallyencouraging to hear that, oh,
it's resonated with you and ithelped to inspire you to do
something else.
As we're talking off air,sometimes you don't always hear
the good stuff.
Sarah (04:48):
Yeah, that's what I love to write to people and tell them
how much I love the work.
I started doing that years ago.
But I just so deeply appreciatea piece, a book or an article
that resonates with me or thatchanges me, because I just I
love reading and I think authorsneed to hear that.
And there was another piece ofthat time by Monica Noy, who I
know you know very well, and shehad written a piece for Massage
(05:11):
and Fitness magazine aboutcritical thinking.
And I wrote to her too and Isaid I just love this piece.
It is exactly what I needed tohear and it was another one of
those pieces that keptpropelling me in that direction
of going back to school andlearning more and thinking about
my thinking and all thosethings.
And so they were really like,when you write a piece like that
, you don't know who it's goingto reach, but oftentimes you
(05:31):
might not ever hear about it,which is too bad, but it does
reach people and it does impactthem in big ways, because it did
impact me in a big way, that'sawesome Monica's great.
Eric (05:41):
That's awesome Monica's great.
Her and I, around that time wewere teaching.
We taught a course together acouple times yeah in Toronto and
I think maybe two or threetimes.
We did a course there togetherand it was funny if I think back
now to how we thought at thetime, like we were.
Like this is we're just goingto change the world.
Everyone's going to, everyone'sgoing to learn this stuff and
(06:02):
they're going to be bettercritical thinkers and be more up
to date with the content.
We're going to get rid of thepseudoscience and you have these
hopes and dreams and I stilllike to think that, but I'm more
of a realist now, understandingthat it's not that easy.
Sarah (06:18):
It's a long road.
Eric (06:19):
It's a long road.
We're trying to change aculture.
We're trying to change anentire society and belief system
for a profession and I thinkthat is where where the hiccup
is that we know that evidenceand research doesn't change
(06:40):
people.
People don't react or don'tengage with things logically.
They engage with thingsemotionally.
Yeah, and over the years,trying to challenge the status
quo with, here's some I'm goingto say less wrong information,
because you never want to saythese are facts, but they're
less wrong than what wecurrently know.
Some people are like I don'tcare, that doesn't change, I'm
(07:01):
still going to go.
And some people will be like,oh, let me think about that.
But yeah, all percentage andand.
But if you went and try toappeal to someone's emotions,
you can get and say everythingyou think you know is wrong.
This is all hot garbage.
Sarah (07:16):
Yeah.
Eric (07:16):
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 goingto be further ingrained in my
beliefs and I'm not really surewhat the magic solution is.
Sarah (07:36):
I don't know.
Patience, keep planting thoseseeds.
I think it's just a slow thingthat you need to keep believing
in.
It's hard because you think youmight want to give up on those
things too, but it is a slowthing and if you can hang in
there, you do get to see thefruits of your labor at some
(07:57):
point.
Yeah, or more.
Eric (07:59):
I'm not giving up.
Sarah (08:01):
Don't give up.
Please don't give up.
Eric (08:02):
I like doing this stuff too much and yeah sometimes I
try to be like, oh, I'm going todo something else, and I think
no, because I really enjoy doingwhat I do and being able to
connect with people likeyourself, like across the
country is across the world,awesome, fantastic.
This kind of goes like into theconversation about today and
what we're going to talk to talka little bit more is your topic
(08:24):
of dual relationships yeahresearch practice, because this
is something that there's a lotof belief yes there's a lot of
kind of traditions that you'repushing against yeah and, and I
guess the thing that I reallywant to explore today with you
(08:48):
is that I want you just to tellus a little bit more about what
is a dual relationship and tellus a little bit about some of
the key things that we shouldunderstand.
Sarah (09:03):
Yeah, I talk about this because I live this experience
every day, living in a ruralcommunity, so it's been
something I've been working withand living with for the past 12
years or so.
A dual relationship is onewhere your professional
relationship overlaps in one ormany ways with your patients.
In a small town like where Ilive, I know all of my patients
(09:27):
and it's on the spectrum ofmaybe they're my friend or maybe
we volunteer on a committeetogether or our children go to
school together, but there's alevel of knowledge there and we
are, so our lives areintertwined and they overlap a
lot.
It's not just a little bit,it's every day.
In our ethics courses we learnthat dual relationships are
(09:51):
inappropriate and unethical andincredibly difficult to manage,
will inevitably lead to harm forthe patient and potentially for
the provider too, and that thebest advice is really just to
avoid them.
And that's great if you live ina highly populated area.
(10:13):
But even in a highly populatedarea, you're still going to find
tight-knit communities wheredual relationships are just
going to happen or they're goingto be preferred.
That just doesn't work for aperson working in a small
community or think about themore remote you are,
geographically isolated it's nothappening.
You're definitely treating yourfamily and friends and places
like this.
I want to make a point that I'mnot talking about sexual dual
relationships at all here.
It's just dual relationshipswith socially true business,
(10:38):
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 aboutand this is one reason why I
was so happy to invite you topresent on this topic to the
knowledge summit was becauseyou'd recently were working on a
paper.
Yeah, yes, yeah.
I thought this is such afantastic thing because, yeah,
what are you supposed to do?
Not?
Every rmt across the countrylives in an urban environment
(11:06):
where they have that luxury ofsaying yeah this is I can't
treat you.
Sarah (11:12):
Yeah, go see my colleague , or whatever, you just not.
Eric (11:16):
So let's use you as an example, Sarah.
So in Stuiak, what's thepopulation?
Sarah (11:20):
The 2021 census put us at 1500 people and I looked up
online recently.
We're estimated to be about1,800 right now in 2025.
We had a bit of a populationboom over COVID.
A lot of people were moving tothe country and, yeah, we
actually had, yeah, quite a fewpeople move here, but so it's
not a lot of people.
Eric (11:41):
Yeah, that's silly, that's a 20% population.
Sarah (11:44):
It was the highest in our province.
It was unprecedented actually,and there's a pause on building
and stuff here because we justdon't have the infrastructure
for it Of course.
Yeah, and it put all the pricesof the housing up, of course,
and everything is just superunaffordable here.
And we moved here because wewanted a country life, a quieter
life, and it was affordable.
But we couldn't afford to movehere now at all.
(12:06):
Oh wow, it's better everywhereyeah.
Eric (12:08):
It's like that too in Victoria, where I am.
Yeah, I don't know.
It'd be impossible for usunless you're very wealthy for
an average person to buy thattraditional single-family home.
Sarah (12:19):
Yeah, so it's a good thing we love our house because
we're not salivating.
Eric (12:25):
That's a thing, isn't it?
Sarah (12:26):
so yeah, so it's regressing here, but with so
there's 1500, maybe 1800 peoplethere yeah now and you probably
know, or friends with a huge agood number of them, because not
only am I friends with people,my husband's friends with people
, my children are friends withpeople, my husband's friends
with people, my children arefriends with people.
So this brings a lot of peopleinto your life and I'm not like
(12:50):
a super, a bit of a hermit.
This is different for everybodytoo, depending on how social
you are and how going andinvolved in your community,
that's going to look differentfor everybody.
So for me, who's a bit of amore reserved person, but I do
volunteer quite a bit within thecommunity, I really believe in
that and I enjoy that.
I might have less sort offriends or connections, but I
(13:14):
overlap in some way witheverybody that I treat in here.
There's just going to be thatit might change in a year from
now, depending on how our liveschange as our children grow and
as new things happen, and that'snot static either.
Eric (13:31):
But it just makes sense, if you stay long enough, that
you're going to make newconnections, new friends new
people are going to enter yourlife and ethically you're not
supposed to treat.
So what are you supposed to do?
Yeah, so you were saying thatit's basically the ethics
teaches us that these dualrelationships are wrong.
We learned that in massageschool.
Sarah (13:53):
Yeah.
Eric (13:55):
And I'm assuming MTANs yeah, has rules.
Do they have rules aboutrelationships?
Sarah (14:03):
Yeah, yeah, we have it.
There's a lot of things thatkind of progressed along the way
of me thinking and writing anddoing everything about this, but
one thing that changed in 2021or 2022 was that our code of
ethics changed and the phraseavoid dual relationships became
part of our principle three ofdo no harm, and that was not in
(14:27):
our past iteration of our codeof ethics, so this was a new
thing and it was also brought upin a practice standard around
boundaries.
And I understand why it's therebecause it's within our.
It's our ethical teachings.
It's to protect the patient.
I'm all for not causing anyharm the patient I'm all for not
(14:48):
causing any harm.
But there is no context for thatand this is a province where
most of us live in a smallcommunity outside of Halifax,
and even in Halifax, it's notthat big of a city that you're
not going to have some overlaprate.
You know what I mean To seethat and to know what it points
back to.
When you go back and you lookat whatever ethics text you were
brought up on, there is somediscussion around it being a
(15:08):
very poor choice.
You're probably not going to beable to know how to manage it.
It isn't compatible withpatient-centered care.
These are not the experiencesthat I'm having in this context
at all.
I'm having excellentexperiences, and I had to teach
myself how to do it because,since our best advice is to
avoid it, we're not teachingpeople how to do it, so that's a
(15:33):
problem.
Eric (15:34):
That's a huge problem, and it's if we look at the kind of
traditional ways that societyhas done about things that you
shouldn't be doing.
Well, just avoid it.
It's like this abstinenceapproach.
Sarah (15:47):
That's exactly what it is .
Eric (15:48):
It's an abstinence shift and has that ever worked for
anything?
It doesn't work for drugs oralcohol, 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 thathumans can do.
The abstence approach justavoid it doesn't work very well.
But what seems to work well andI'm this is I guess there's a
(16:09):
question for you but iseducation right?
People are educated about acertain topic, the they can then
make informed decisions.
They can make informeddecisions about should I smoke?
Why?
I know the risks, I know theharms, I know no benefit, but
just saying no, don't do thisthing.
It doesn't work.
Sarah (16:30):
Yep, that's right.
Eric (16:31):
Why would that approach be any different in a dual
relationship?
Sarah (16:35):
It drives me crazy here.
I'm just always so shocked thatthis hasn't been talked about a
lot before and I think probablyone 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 thisas a value or principle within
codes of ethics and standards ofpractice.
But when I finally, when thatwording came up in our own code
(17:00):
of ethics, it just was the kindof the last straw for me.
I was like I could handle itbefore I could rationalize it
because I was always coming backand forth with it.
Oh, some days I feel like I getnegative feedback about it from
peers who just don't understand.
But I can rationalize it and Ican live with it and I'm no end
doing the right thing.
But when I saw it in our code ofethics that's when I saw it,
(17:22):
and also because I was in schoolat the time and in the sort of
mode of critical thinking anddoing research and writing a lot
which was so beneficial at thetime, I was like, oh my God,
this has to be happeningeverywhere else, in every other
health profession.
Are they writing about it?
And yes, they were.
They've been writing about itfor decades.
I, immediately upon accessingand reading like one of the
(17:46):
first papers around dualrelationships.
I just felt seen and understoodand supported for the first
time ever and it was wonderful.
Eric (17:58):
Your experience was validated.
Sarah (18:00):
It was so validated Like, oh, everybody else is feeling
this.
Everybody else feels likethere's not enough education,
that their practice iscompletely misunderstood, it's
not valued, that the things thatwe're doing here every day.
Every day, we're really workinghard to check our biases, to
(18:21):
make sure our patients are safe,to just really care for them in
the best way, and this isechoed throughout nursing and
medicine and social work,psychology, all the health
professions.
And to see that other peopleworking in small spaces were
feeling the same way, I felt itwas great and I said, yeah, I
(18:42):
need to do something with this.
Eric (18:44):
I think it's great.
So why don't you tell us alittle bit about, go into as
much detail as you want aboutthe research and practice with
other healthcare professions,and how are they what's the word
?
Negotiating or working withdual relationships?
Sarah (18:59):
That's a great word because a lot of that
negotiating comes up.
A lot we negotiate the dualrelationship, the overlap and
the amount of overlap that wehave and that we're comfortable
with our patients, like on anongoing basis.
And this is happening in everyother area of health care.
And because there's thisconsistent message of there's
not enough education oracceptance of these
(19:21):
relationships, it's said inother areas of healthcare avoid
them, they're dangerous,whatever, unethical.
So because there's a lack ofeducation, healthcare providers
are coming up with their ownways and they're all ways that I
do it and it's not that they'redifficult, really it's honesty
and communication and caring andtalking and having an ongoing
(19:44):
conversation and saying when anew patient comes in and I know
them, I just say I just want tomake sure that you're
comfortable with the amount ofoverlap that we have here in
this community.
I'm always here for an openconversation.
If anything makes you feeluncomfortable, let's just talk
about it.
Just being human, Human, andthat comes up so much in the
research.
That and all this research thatI've read.
(20:04):
Pretty much all of it is fromthe provider perspective.
So of course the patientperspective is really important
too and there's a knowledgeabout that and hopefully
there'll be more of that done,and but it's just.
They want to see these rulesand guidelines and values be
more human, less fear-based,less based in suspicion.
(20:25):
You know of what you're doingwrong and everything, and of
course things do go wrongsometimes.
So for the most part, we'regood, we care, we're in
healthcare because we care aboutpeople.
Being in a community with people, that does not make you care
less.
It makes you maybe evenarguably care more because
you're going out there in thecommunity and you're going to be
seeing the next day and you'regoing to see your patients and
(20:48):
you're going to be like, well,there's.
Maybe you don't talk about itout loud, you don't want to risk
the confidentiality, but youhave just a different.
I don't know, it just feelsdifferent because you're seeing
the people that you, that youtreat, and you're happy to see
them when they're doing well,and if they're not doing well,
then you're accessible andyou're right there and you can
deal with that too.
But it's not.
It's funny that the argumentthere's an argument that it is
(21:09):
incongruent with or compoundedwith, patient-centered care,
because it actually improvespatient-centered care and that's
been brought up in theliterature that it's a good
thing that it doesn't diminishthat at all.
So it enhances the therapeuticrelationship.
When you do have a different,deeper knowledge of your patient
(21:30):
you might have depending on howlong you've been in the
community, you have a historythat you know of the person and
that can be a positive thing ifused in the right way.
So there's these benefits thatyou don't read about, that are
out there, that do exist.
The literature that we have inour texts is really just around
the risk and the harm and itreally scared to bring the
(21:51):
benefit in, and I suppose that'sunderstandable because we don't
want to hurt anybody.
So that's the boundary and thatis understandable.
But there is a lot of researchout there now and I think it
would be good to look at thatwhen people go to rewrite these
chapters.
Eric (22:06):
You said that there's an argument that a dual
relationship againstpatient-centered care.
What's the argument about theharms or the problems that dual
relationship?
There's some obvious ones whichI think anybody should be able
to identify.
There's some obvious ones whichI think anybody should be able
to identify.
But what are some of thearguments that you see in the
literature about this is notsomething you shouldn't do,
(22:27):
because of what are they worriedabout?
Sarah (22:30):
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 reallyfamiliar with Pavas and Fitches
and Lauren Allen's book andBenjamin and Moe's.
So those are the four that I'mdrawing a lot from because
they're really well known.
They're all about ethics.
They're really not aboutanything else, they're all about
(22:51):
professionalism and what comesup in those would be around it
being a conflict of interest.
But not only that.
It's stated in some of thebooks that it's an automatic
boundary violation or boundarycrossing.
Whether you're doing your bestor not, it's perceived as,
(23:15):
because it's perceived asunethical, you're just crossing
the line, it's just, and thatyou're not, probably not aware.
You might not be aware ifyou'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 objectivityas a clinician is diminished so
that it isn't near possible tobe objective.
So that's where you're not ableto provide that
patient-centered care, becauseyou can't make a good clinical
(23:35):
decision, because you're tooimpacted maybe by the emotional
relationship you might have withthis person or other things
going on.
But I would argue that is nothappening at all, and from the
research that I've read fromother areas of healthcare, it's
the same sort of story there.
But are we fighting sort of allthose things?
In any relationship that we'rein, regardless if we know the
(23:59):
person or not, they're coming inwith their own unique story.
Anything that they say couldmake us feel emotionally charged
, more or less.
We all have our own backgroundsand history and our job is to
treat each patient with respectand care and to listen respect
(24:27):
and care and to listen, and norelationship is devoid of
emotion.
And then putting up thoseboundaries really strict sort of
professional boundaries can beseen by some people, no matter
what context you're in, as youbeing cold and uncared too.
Eric (24:38):
That's the thing that I find has happened in our
profession.
I speak more about BC becausethat's who I am, but there's
over the years, there's almostbeen this mechanistic approach
If someone starts talking aboutemotions or life or problems,
we're supposed to just redirectthem back towards.
Why are you here?
Sarah (24:56):
Yeah.
Eric (24:57):
I remember a couple of years ago we had to do or
college had to make us do someonline course and for the life
of me I can't remember what theheck it was about, but I
remember that was one of thethings that they talked about.
There was this person came in Ithink they had shoulder pain
and they were talking about.
They started going off topicand the right answer for the
therapist was try to redirectthem back to their shoulder.
Sarah (25:18):
Yeah, but not treating the human not treating the human
, not treating the person infront of you that might need to
say they need to tell you theirstory.
Eric (25:28):
Yeah, no, I totally and I think a lot of it.
I think a lot of the worriesthat 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 hugeassumption here, so I could
(25:49):
totally be wrong, but I'massuming that there's the
regulators are worried thatwe're going to step out of our
scope of practice If we don'tjust focus on, like, the joint
or the tissue or the or, and westart focusing on the human yeah
, now I would say that I don'tagree.
I think their worry is.
I there is.
(26:09):
I could see how there's a worrythere, but I think you're,
there's more things to beworried about than than that way
more things to worry about inthe profession.
But moving the focus away fromtreating the human to me seems
unethical.
Sarah (26:25):
Yeah, it does Even of ethics.
Eric (26:27):
The ethical is we should do no harm.
Sarah (26:29):
Yeah.
Eric (26:29):
And we should have informed consent.
Sarah (26:32):
Yeah.
Eric (26:32):
Key ones and there's other ones, obviously.
Those are the key ones that Ialways come back to, and then
you have to treat the person.
You have to treat the human.
So if you have a dualrelationship, so using that as
an example, someone comes in andyou're the only person in that
town that could potentially helpthem with whatever's going on,
why would you say no?
Sarah (26:54):
That's the worst thing you could do.
Eric (26:56):
Exactly.
That's not patient-centeredcare, that's not in their best
interest and that's potentiallydoing harm.
So by saying you can't have adual relationship when you are
maybe the only person in thetown, that's not ethical.
Sarah (27:10):
That's not ethical Not at all.
I remember when I first movedhere and I was practicing in the
city for a year and a half orso before I moved here.
I'm not really cluing in thatmoving to a small town was going
to put me in the position ofjust being in the middle of all
these dual relationships, and Ihadn't had that experience yet.
And I remember thinking, if Isay no, that's wrong, it's a
(27:35):
barrier to accessing care.
People have the right to accesscare in their own community if
it's available, and so thatalways struck me as a really big
problem.
But I remember talking toanother massage therapist the
only other one who was in townat the time and I said how do
you do this?
Like our books say we can, andit just feels so wrong.
(27:59):
And she just said you just doit, you just do it because you
have to, but you just do yourbest.
And I said, okay, I'll just gowith this.
And it's always been a goodexperience because it's always
been led with honesty andintegrity and all those things
that you would want in anyinteraction.
And that's what, in theresearch too, is that all these
(28:20):
healthcare providers have theirown way of interacting with
people and everybody might be alittle bit different, but it's
just based on talking, likesaying, this is the situation
that we're in, are youcomfortable with it?
And more times than not theperson wants to be in that the
patient chooses it.
The patient's very comfortableknowing you.
(28:41):
It actually provides them witha foundation of trust because
they know you already.
And trust is so important andit takes time to build up, but
when you're actually seeing aprovider that you know or you're
getting to know that trust isalready there.
And we know from some researchin massage therapy that
psychological and physicalmassage therapy, that that
(29:05):
psychological and physical thetrust kind of helps relax us and
can help us have betteroutcomes in our treatment.
And that's like a yeah, ofcourse it is, but it does.
It does work really well, it's.
We need to move away from thisfear and suspicion and embrace
that this is happeningeverywhere and we shouldn't be
hiding from this conversation.
One thing that I've seenrepeated in the research is that
(29:29):
, like health, ethics in generalhas a lot they could be
learning from understandingpeople who work in small spaces
and whether it's in a rural orremote area or a tight-knit
community within an urbancommunity within an urban area.
There's a lot of great stuffthat you could be learning about
these complex relationships, ofhow they're managed, and how
(29:53):
they're managed well Becausethere's no epidemic of harm or
it would be shut down.
Eric (30:01):
So one of the questions I had is when they talk about,
you're saying there's this riskof harm and having a dual
relationship is bad, but isthere any evidence to show that
these dual relationshipsactually are causing harm?
Sarah (30:14):
In massage therapy?
There's absolutely none,because we have no ethical
research, no research on ethicalissues at all.
Really, in massage therapy andoutside of massage therapy it's
stated that it's greatlyoverstated the risk of harm.
There's always a risk of harm,but there's no.
(30:34):
It's not what people think itis.
I think we were talking youwere saying traditional ethics
and values and stuff, and it'sfunny because that comes up a
lot in the research.
I read this great book I read itand re-read it by Christy
Simpson and Fiona McDonald,called Rethinking Real Health
Ethics and their argument isthey talk a lot about ethics
(30:57):
beyond what we need to knowabout because it's for health
care, but on nurses andphysicians and everything need
to know about, because it's forhealth care, but on nurses and
physicians and everything, butthey talk about traditional
ideas around avoiding dualrelationships.
These ideas came into being inurban institutions decades ago,
based on what was the norm inurban institutions You're
(31:17):
primarily providing a treatmentto strangers and it just became
a gold standard of care, notreally based on any other
context or really anything.
And this has been perpetuated,this idea.
So they call this principleurban-centric and other authors
have called it a Western orEurocentric ideal.
(31:38):
This is from the perspective ofthe First Nations author, which
I read about when she wasspeaking to her work as an
educator and a psychologist inher remote First Nation
community.
She came up against the problemof having to abide by this
principle of avoiding dualrelationships, which is
completely incompatible withwhere she works.
And this is Tanya Dama ofDubuque, who wrote an
(31:59):
autoethnography about this in2023.
And I highly recommend peoplelooking her up and reading that
paper.
It was fantastic.
It really spoke to me.
I liked that she was writingabout her own experience, but
it's an incompatible value.
It really doesn't work outsideof a place where you're just
going to be with strangers allday.
Eric (32:21):
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 isjust the way things are it's
(32:41):
just the way things are becauseit'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 areason yep give me a reason say
so.
We use dual relationships as anexample.
They're bad, they're're wrong.
I can understand that there'srisks.
Sarah (33:01):
Yep.
Eric (33:02):
But telling people to just abstain.
Sarah (33:06):
Yeah, exactly.
Eric (33:07):
Avoid them completely, otherwise you are bad.
You are a bad human, you're abad therapist.
It's not a good enough answer,a good enough solution.
There's got to be a bettersolution, and I'm sure there is
better ones.
I'm sure.
There is yeah, If you couldrewrite the ethics rather than
say avoid, what could you changeit with?
(33:28):
And how would you make RMTsbetter at dual relationship
handling?
Sarah (33:43):
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 informedconsent, all of these things.
It's not there's nothingdifferent or secret or anything
like that.
It's respect and honesty andcreating boundaries together and
understanding that there thereneeds to be boundaries.
But, yeah, creating thattogether, that a lot in the
research that these boundariesare co-created with patients in
(34:07):
small communities.
It's interesting because insome of the texts, like in
Benjamin and Sonnenmoll and theEthics of Touch, they know like
they have a pretty clear bigchapter on dual relationships.
So it's pretty, it's reallygood.
But they do note that in ruralareas or small areas it's you're
going to come across them morethan in urban areas, but I never
(34:29):
see anyone make the point.
Then how can something thatseems so wrong and you're
telling us we probably don'tknow if we're doing it right, we
might not be mature enough todo it, we might, we're
definitely going to, it's goingto be hard or confusing at some
point.
How can something that is sowrong here have to happen?
(34:50):
Still, what does that make mypractice look like?
Am I just an unethical badpractitioner because I'm out in
the middle of nowhere doingwhatever I want, and it's just.
That's just just fine too.
I don't understand that.
I can't reconcile that.
Eric (35:06):
And with this thing, this is really interesting to me,
because this is a topic that Idon't I've never heard anybody
out of profession talk aboutbefore.
Sarah (35:12):
Beauty robotic.
Eric (35:13):
Not in this context.
Sarah (35:15):
Heard, not like this at all, Like I really haven't,
you're right.
Eric (35:22):
I commend you for that and for working on and hopefully
getting a paper published soonon it me.
What you said, though, isbasically respect, honesty
creating boundaries.
This is something that couldeasily be incorporated into
massage therapy education yeahwe take all those pd courses.
No matter where you go to schoolin the country, there's always
pd courses and I think most ofus would agree a lot of that PD
content is not very helpful.
(35:42):
No, and it's better utilizedthe time.
Yeah, positive there, positivelanguage why could you not have
a day, or use this as a lessonor two on managing dual
relationships?
Sarah (35:56):
Yeah, and I hope somewhere out there in some
school this is happeningdepending on, because we know
the education is so variable andwho knows who your teacher is
and what their personalexperiences are.
So I hope people are talkingabout it.
I know I personally didn't geta good, a positive conversation
about dual relationships when Iwent to school, but yeah, it
(36:17):
shouldn't be hard to incorporate.
And, with all of the researchthat's been published, bring a
couple of papers in when you'retalking about if you're still
teaching from texts that haven't, in their next edition, updated
any of this information basedon research.
Bring a few of these pieces inand get people to critically
(36:38):
think about it.
Read it.
It has to be required reading asfar as I'm concerned, because
there are so many of us that aregoing out there and moving into
a small community or we're in atight knit community, in an
urban area or in a ruralcommunity and we had.
We're scared and we feelothered because when you try to
talk about it to people thatdon't understand, they give you
(36:58):
a side eye and say you're doingsomething very wrong.
You got to stop doing.
That, from our perspective, isyou don't understand.
This is not the way that we'retaught this.
It's actually.
I'm having a very positiveexperience, and so are my
patients, and we're doing thisvery well and it's very healthy
and there are boundaries andthere are confidentiality and
(37:20):
it's actually not that hard tomanage.
What's hard to manage is goingback and reading those books and
you're what an unethical personyou are for doing something
that you have to do.
That's hard to manage.
Eric (37:32):
Yeah, you basically feel guilty for doing.
Sarah (37:34):
You feel guilty all the time.
And when I, when I read thebook rethinking real health
ethics, I did what I always doand contacted the authors and
said thank.
I read the book Rethinking RealHealth at Bix, I did what I
always do and contacted theauthors and said thank you for
this book.
This book took an immenseweight off of my shoulders as a
provider and I read this back inprobably 2022.
And, to my great luck, one ofthe authors, chrissy Simpson,
(37:54):
works at Dalhousie Universityand has been able to talk with
her on several occasions abouther work.
I mean, I've said to her a fewtimes I just can't tell you I
didn't realize how heavy thatweight was on me over the years
where I was doing my very bestand always checking in but still
to go back, any sort ofguidance that I wanted to seek
(38:16):
was just around the negativityand the wrongness of being in a
dual relationship and that washarmful.
And it is harmful and that's areason.
One of the many reasons why weneed to have a research-informed
and evidence-informedconversation about this is
because it does cause harm tothe patient and to the provider.
(38:37):
When you work in a small space,you want to feel comfortable
integrating into that space.
There are people that I, orparticipants that I've read of
in the research, that theyreally struggle with.
What is the level ofintegration that I'm allowed to
have in my community?
I want to feel free to join aclub and to go to church and go
(38:58):
to a community center and go toa town council meeting, but you
really feel limited and we arealready in an isolated
profession, a very isolatedprofession, and this is just
even further isolating.
So that's a big problem, Ithink and I've felt that.
Eric (39:15):
One thing that I don't think is talked about enough in
the profession is the isolationof it A lot of it, Even if
you're working in a busy clinic.
I've worked in a busy clinicfor part of 12, 15 years,
something like that.
It was still very isolatingbecause you're alone with
somebody, so I couldn't imaginethe isolation of just profession
(39:36):
.
Sarah (39:37):
Yeah.
Eric (39:37):
It's weird because you're with people all day, but it's
isolating, but it's different.
Yeah, different People arealways thinking they're massage
therapists.
They understand what we'retalking about.
Yeah, they do.
Adding to that, compoundingthat with an isolation of having
to avoid those relationships ina small community, a small
space, would just it wouldprobably, I imagine, make you
just not even want to work orjust do something completely
(39:58):
different.
It just gets you out of theprofession.
Sarah (40:00):
I've been through that too, the do.
I want to do this Because I am.
I like having standards and Ilike having something to measure
myself against.
You know what I mean.
And when you don't see yourpractice environment reflected
in those standards, it's reallydifficult.
And that is reflectedthroughout the research as well.
And when I heard that, when Iread that in these papers and
(40:24):
this book, I was like wow,that's what I've been going
through.
This has been hard because ofthis and I like to be a part of
my community and when I havekids we have we do a lot here.
My relationships with mypatients and with everybody.
They overlap in so many ways.
Not only that, like when you'rein a small space, you're out
(40:46):
there.
You need each other.
I need these people too,because they have skills that I
don't have, or we help eachother in other ways.
In Simpson McDonald's bookRethinking Real Health Ethics is
the argument aroundvulnerability and power, and
they say that this exchange ofvulnerability between patient
(41:08):
and provider.
Like I'm in a vulnerableposition with my patients
sometimes because they knowthings I don't know.
They have skills I don't havethat I have to seek out.
I'm a service seeker sometimes,so that switches back and forth
and that can actually help toseek out.
I'm a service seeker sometimes,so that switches back and forth
and that can actually help tobalance out that issue of
vulnerability, which I justfound so interesting.
They critique traditional healthethics from a feminist
(41:30):
perspective, theory,philosophical perspective, which
is interesting because theyreally take into account context
and relationships and the powerand balance between, like,
urban and rural, and it's notsomething I knew really anything
about until I read this book,but I am really.
I love learning about that.
This was something I neverlearned in our obviously in our
(41:53):
ethics course, but it's a greatway to describe or to think
about what's going on here isthere's a lot more and
relationships matter and ourconnection to people here matter
and it does play a part in howwe choose health care providers
and and things like that, sothat it's yeah, they go pretty
deep into that too and it wasvery enlightening these are
topics and conversations need tobe had they really are and
(42:17):
because really, what is massage?
it's's relationships firstreally.
Eric (42:21):
It's really all.
It's what it comes down to.
Sarah (42:23):
Yeah.
Eric (42:24):
Your relationship with the person in front of you is, I
would say is more important thanskill with your hands, your
technique.
Sarah (42:33):
Yep.
Another argument is that itcomes up in our books town
gossip and things like that.
There's gossip everywhere.
You're just being professionaleverywhere.
You just be a professional.
You don't need to engage in it,you don't need to agree with
anything at all.
Everybody that comes throughhere gets treated as if they're
the most important person I'veseen in this day.
(42:53):
I genuinely care and want togive them what they need and
what they're looking for, andthat's attending to, that's
patient-centered care, that'sattending to their values and
seeing them as a whole personand treating them as a whole
person and it's just.
It just none of it really addsup in my experience and I know
many people have many differentexperiences and I'm not saying
(43:13):
that people don't have negativeexperiences, because we all do
at some point but I think thevast majority of them are
probably going really well.
Things are going really wellfor people and we're just not
really comfortable talking aboutit because we're scared we're
going to get in trouble.
We're scared we're going to getthe side eye, and I've had all
of that and even when I startedtalking about this more and more
with people who really didn'tunderstand, it was very
(43:35):
uncomfortable, but I had tostand my ground because I said
how can this be wrong?
I've been doing this and thereare hundreds of thousands of
people just in Canada that areworking in small communities,
that are doing this right now.
They want to, they have to.
It's going great.
Eric (43:51):
And how have those responses been when you've had
those conversations?
Sarah (43:55):
Actually as long as in the conversations I've had when
I've really just not backed downand said what about this or
what about that, and they'veactually gone pretty well.
But I've only been comfortabledoing that now because I have
the confidence for reading theliterature outside of our
(44:16):
profession.
That's given me the confidencebecause I was never really able
to do that before.
Eric (44:29):
Yeah, that's a big thing to take away too.
Is that when you know a topicso well, you could have good
conversations with people aboutit?
Yeah, know a topic only alittle bit.
It's hard to have a real andlike you can't really have an
engaging conversations with mebecause you know you're not so
small, so I engagingconversation with me because
you're so small.
So I think it's great thatyou're having those
conversations.
Have you had theseconversations with your
association?
Sarah (44:50):
Yeah, I have, because I do a lot of volunteer work with
the association and some of thefirst conversations about this
that came up with colleaguesthere, some of the first
conversations about this thatcame up with colleagues there,
and it eventually sparked me towant to create like a guideline
for people working in dualrelationships, which we do have
(45:10):
now, and it at least, at thevery least, it acknowledges that
dual relationships arehappening and that we recognize
that now.
But I think as time goes on wecan do a lot more to make that a
more friendly and supportive.
But at this moment it is thereand it is acknowledging that
dual relationships happen andjust gives a little checklist of
(45:33):
how to work within that, fromour sort of ideas around ethical
values and standards andcommunication and things like
that.
But that gives me comfort toknow that's there, because
before we had nothing like thatand we needed it and I'd like to
see that everywhere.
When you look to this, say,physiotherapy, like the
(45:54):
Physiotherapy Association I'velooked at a lot of them across
the country colleges andassociations, and there's some
that will have maybe like alittle booklet on the
therapeutic relationship andthere'll be like a little blurb
in there.
Just be more careful when you'rein a rural community treating
friends and family, nothing morethan that.
Usually there's a big call toaction for ethical guidelines to
(46:28):
be informed by these othercontexts that people are working
in and that people need to feelsupported in working in and
within medicine and nursing andphysiotherapy.
There is an issue, too, aroundretention, like retaining these
very valuable health careproviders in rural spaces.
In rural spaces, they reallyneed to feel that they're not
doing anything wrong, becausethat can lead to burnout and it
can lead to people leaving whenalready there's not enough
people working out in thesecommunities, all these isolated
(46:50):
places, and that's not a goodthing.
Eric (46:54):
Yeah, the last thing you want to do is put people away.
Yeah, particularly when theserelationships are unavoidable.
Sarah (47:00):
They're normal and expected.
That's the thing too.
It's funny when you ask when Ifirst started working, it was
talking about this with peopleNot that everybody has this
general knowledge anyway, butthey're like I don't care that,
I know you, I'm happy that Iknow you, this is awesome.
I'm so glad Like I know you, Itrust you, I feel so comfortable
with you.
I don't want to go see anybodyelse and this is echoed
(47:24):
throughout the research as wellis it's expected, it's normal,
it's inevitable.
Dual relationships are alreadypart of normal health care
service.
They're already there, Beenthere forever.
Eric (47:37):
And it's not going to go away.
Sarah (47:39):
Go away.
No, been there forever and it'snot going to go away.
Eric (47:40):
Away, my thought I live in an urban area and it's huge
victoria.
I think the greater area isprobably just shy of 450 000.
But I've grew up here I can'tgo anywhere without having,
without knowing someone, or likeI have a two.
It drives my kids crazy.
But I got like a two degrees ofseparation or less, or or like I
(48:00):
know you or I swear, no morethan two, two degrees of
separation and I will knowsomebody whether it's soccer,
which has been a big part of mylife, whether it's through work,
whether it's through university, whether it's through high
school, whether it was throughfriends or friends of friends,
whatever it just you can't avoidit.
You can practice.
(48:22):
I would say a large, noteverybody, but a large
percentage of people that I hadin my when I had a full-time
practice were people that I knewor knew me from somebody else.
So there, there's always gonnabe.
Sarah (48:32):
You can't really separate that no, and here in Nova
Scotia we have like maybe amillion people now.
We knew I didn't grow up inthis community, which adds
another layer to dualrelationships because I'm not
treating my family.
I don't have family here, but alot of people that grew up here
the other massage therapiststhere's a few they're treating
family that we expect that theyare.
But if you grew up in thecommunity that you're servicing,
(48:55):
you're going to be treatingyour family.
But even in Halifax it's not ahuge city it's going to happen
at some point.
Just knowing that these ideasare outdated, they're not
helpful, they're not useful andthey are hurtful and they do
need to change.
It's an uncomfortable topicbecause we're made to feel that
(49:15):
being unethical when we're toldthat what we're doing is wrong
and eventually going to lead tosome sort of harm.
I haven't found that yet.
Eric (49:22):
These conversations are important, as I said, and I
think if we don't have them,then nothing's going to happen.
Sarah (49:28):
Nothing's going to happen , and that's the thing too, and
I'm always inspired by that.
This is talking about thesethings and putting these ideas
out there.
It's supposed to happen.
This is a natural and healthypart of engaging in your
profession.
It might be uncomfortable to doat first and I know I've gone
through a lot of feelings aroundthat, but this is helpful and
people need to hear this and weall need to share our stories.
(49:50):
There was a narrative reviewthat came out in 2023 by Sumer
and Arnold and they did a reviewof the literature and gave a
little schema fordecision-making around engaging
in dual relationships, and oneof the things was to reflect on
your challenges and successesand to share your stories with
(50:11):
people and to help other people,and that really you want to
support other people that are inthese positions.
We need to support each other.
We need to talk about this andneed to know that we're not
encouraging each other to do ourbest.
Eric (50:26):
Yeah, so when you're doing your presentation in October,
is there any other any specifickey things that you're going to
hit?
Sarah (50:32):
I'm working on the presentation now.
I think what I want to do ispick out a few key pieces of
research that really didsomething for me and just do a
bit of a deep dive into what thefindings were and just talk
about that from my perspectivetoo.
That where I'm going with itright now is and then give good
reference notes for everybody atthe end of it to do their own
(50:53):
reading and their own thinking.
But really it's to open up theconversation and to say let's
start talking about this andsupporting each other and see if
we can bring some change to theideas and the culture around
this and introduce theliterature, the body of
literature that's out there.
And yeah, I guess just seewhere it goes from there.
(51:15):
But it will.
I will be looking at a lot ofthese papers more in depth and
talking more to the specificsettlement, which I think would
be good.
Yeah.
Eric (51:23):
Fantastic, I'm excited.
Yeah, I think it'll be greatand, at the very least, these
conversations are starting.
Sarah (51:30):
Yeah, they're starting.
Eric (51:31):
Hopefully this will lead to others asking similar
questions or having theseconversations, and it's like you
said at the very beginning youfound me because of an article I
wrote back in 2016.
And conversations happenbecause of those, and sometimes
that might inspire some positivechange, and so hopefully this
will be something similar foryou.
Sarah (51:52):
I hope so too.
There's a lot that can be donehere, and the books that we have
are the great texts they justneed, like any other, you can
pick any other topic in them.
And well, this really isn'tmaybe how it is now, and we need
to evolve a little bit.
And that's the goal with beingon that professional trajectory
is not staying stagnant, toevolve and to bring new ideas in
(52:12):
and to recognize that there area lot of different ways of
doing things that areappropriate.
Eric (52:17):
So, yeah, that's a perfect way to end it, Sarah.
Sarah (52:22):
Well, great.
Eric (52:22):
Thank you very much for being here and we'll talk soon.
Sarah (52:25):
Well, thank you so much, Eric.
Talk soon.
Eric (52:27):
Thank you for listening.
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(52:52):
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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-basedmassage therapy.
In today's episode, we welcomeSarah MacAulay, who is a massage
therapist from Nova Scotia, andSarah is going to be presenting
at my upcoming Knowledge Summit, which is an online conference
(00:32):
specifically for massagetherapists, and that's going to
be on Sunday, October 5th.
She's going to be presenting atopic called A Closer Look at
Dual Relationships in Researchand Practice.
So today we're going to talkabout this with Sarah, as well
as many other things.
So thank you for being here andI hope you enjoy this episode.
Welcome Sarah.
(00:53):
Thank you for being here today.
How are you?
Sarah (00:56):
I'm doing great.
Thank you so much for having mehere today.
Eric (00:59):
You're very welcome, your first ever podcast.
Sarah (01:01):
Yes, first ever.
Eric (01:03):
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 bitwhere are you?
Sarah (01:12):
I am in a place maybe not too many people have heard
about before, but I'm in alittle tiny town called Stewyatt
in Nova Scotia, so out on theEast Coast.
It's a beautiful little town, asmall rural community, and,
yeah, I've been living here forabout 12 years now, and I grew
up in Halifax, so people aremore familiar with Halifax, of
course, but I moved here after Ibecame a massage therapist.
Eric (01:35):
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 somany times over zoom and phone
calls and stuff and we've had somany meetings.
But I can't.
I honestly couldn't rememberhow we connected in the first
place.
Sarah (01:52):
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 lookingfor an article, something online
, probably around 2017, 2018.
And I came across one of yourarticles on your blog about
(02:14):
education reform, I thinksomething like that, and I loved
it, and I'm the type of personthat writes emails to people and
I love their work and I mighthave reached out just through an
email and then maybe thingskept happening after that.
I'm just think I could.
Eric (02:30):
I can't quite remember, but that might have been where
something like that does makesense, because that the first
article I ever wrote and put outthere was called a time.
It's time for curriculum changein massage therapy that was it
something like that yeah, mightbe a couple words, different
steps and I wrote that initiallyfor a colleague of mine, jamie
(02:50):
Johnson, who I used to do apodcast with because he had a
website, and he said, hey, doyou want to do this thing for me
?
I thought, yeah, and I was sopassionate I still am but at the
time I was just fresh into kindof getting like finding my
voice and getting stuff outthere and I wrote that for his
site and then, probably a yearlater, I created my own website
which no longer exists, butericperviscom was my old website
(03:14):
, so if you go to that old oneit'll take you to my new one
right now, which is the cebecom,but I put it on there.
it was the first article I puton that site and it I don't
can't remember how many reads.
I had nothing, but that thingwas getting hundreds and
hundreds of reads per month andvisits and it was really popular
and it got published in acouple different professional
(03:37):
magazines.
I think even as far as ways.
New Zealand had it and I thinkanother one in Canada, I can't
remember which one.
One of them, maybe MassageToday or Massage something,
might have taken it on too andit got published, and so that
was a really popular one.
Sarah (03:50):
Yeah, it was great and it was interesting because it came
to me at a time when I wasreally needing it and really
ready for it, because, leadingup to, I guess, 2018 to 2019, I
was really.
I needed to get back intoschool, I needed a challenge, I
needed something new, I neededsomething new and that was what
I was feeling at that time.
I felt we need more substance.
(04:11):
Higher education isn't a verygood goal for massage therapists
.
We should be doing this.
And it really spoke to a lot ofthe things I was thinking about
at that time.
It just said reinforced me andgave me that sort of push to
apply to go back to university,which I did end up doing in 2019
.
Eric (04:25):
That's awesome.
I didn't know that.
Sarah (04:26):
Yeah, yeah.
Eric (04:27):
That's fantastic, it's so funny when you do podcasts or
you do blogs or you have contentout there.
You never really know how it'sgoing to resonate with people,
and so it's always reallyencouraging to hear that, oh,
it's resonated with you and ithelped to inspire you to do
something else.
As we're talking off air,sometimes you don't always hear
the good stuff.
Sarah (04:48):
Yeah, that's what I love to write to people and tell them
how much I love the work.
I started doing that years ago.
But I just so deeply appreciatea piece, a book or an article
that resonates with me or thatchanges me, because I just I
love reading and I think authorsneed to hear that.
And there was another piece ofthat time by Monica Noy, who I
know you know very well, and shehad written a piece for Massage
(05:11):
and Fitness magazine aboutcritical thinking.
And I wrote to her too and Isaid I just love this piece.
It is exactly what I needed tohear and it was another one of
those pieces that keptpropelling me in that direction
of going back to school andlearning more and thinking about
my thinking and all thosethings.
And so they were really like,when you write a piece like that
, you don't know who it's goingto reach, but oftentimes you
(05:31):
might not ever hear about it,which is too bad, but it does
reach people and it does impactthem in big ways, because it did
impact me in a big way, that'sawesome Monica's great.
Eric (05:41):
That's awesome Monica's great.
Her and I, around that time wewere teaching.
We taught a course together acouple times yeah in Toronto and
I think maybe two or threetimes.
We did a course there togetherand it was funny if I think back
now to how we thought at thetime, like we were.
Like this is we're just goingto change the world.
Everyone's going to, everyone'sgoing to learn this stuff and
(06:02):
they're going to be bettercritical thinkers and be more up
to date with the content.
We're going to get rid of thepseudoscience and you have these
hopes and dreams and I stilllike to think that, but I'm more
of a realist now, understandingthat it's not that easy.
Sarah (06:18):
It's a long road.
Eric (06:19):
It's a long road.
We're trying to change aculture.
We're trying to change anentire society and belief system
for a profession and I thinkthat is where where the hiccup
is that we know that evidenceand research doesn't change
(06:40):
people.
People don't react or don'tengage with things logically.
They engage with thingsemotionally.
Yeah, and over the years,trying to challenge the status
quo with, here's some I'm goingto say less wrong information,
because you never want to saythese are facts, but they're
less wrong than what wecurrently know.
Some people are like I don'tcare, that doesn't change, I'm
(07:01):
still going to go.
And some people will be like,oh, let me think about that.
But yeah, all percentage andand.
But if you went and try toappeal to someone's emotions,
you can get and say everythingyou think you know is wrong.
This is all hot garbage.
Sarah (07:16):
Yeah.
Eric (07:16):
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 goingto be further ingrained in my
beliefs and I'm not really surewhat the magic solution is.
Sarah (07:36):
I don't know.
Patience, keep planting thoseseeds.
I think it's just a slow thingthat you need to keep believing
in.
It's hard because you think youmight want to give up on those
things too, but it is a slowthing and if you can hang in
there, you do get to see thefruits of your labor at some
(07:57):
point.
Yeah, or more.
Eric (07:59):
I'm not giving up.
Sarah (08:01):
Don't give up.
Please don't give up.
Eric (08:02):
I like doing this stuff too much and yeah sometimes I
try to be like, oh, I'm going todo something else, and I think
no, because I really enjoy doingwhat I do and being able to
connect with people likeyourself, like across the
country is across the world,awesome, fantastic.
This kind of goes like into theconversation about today and
what we're going to talk to talka little bit more is your topic
(08:24):
of dual relationships yeahresearch practice, because this
is something that there's a lotof belief yes there's a lot of
kind of traditions that you'repushing against yeah and, and I
guess the thing that I reallywant to explore today with you
(08:48):
is that I want you just to tellus a little bit more about what
is a dual relationship and tellus a little bit about some of
the key things that we shouldunderstand.
Sarah (09:03):
Yeah, I talk about this because I live this experience
every day, living in a ruralcommunity, so it's been
something I've been working withand living with for the past 12
years or so.
A dual relationship is onewhere your professional
relationship overlaps in one ormany ways with your patients.
In a small town like where Ilive, I know all of my patients
(09:27):
and it's on the spectrum ofmaybe they're my friend or maybe
we volunteer on a committeetogether or our children go to
school together, but there's alevel of knowledge there and we
are, so our lives areintertwined and they overlap a
lot.
It's not just a little bit,it's every day.
In our ethics courses we learnthat dual relationships are
(09:51):
inappropriate and unethical andincredibly difficult to manage,
will inevitably lead to harm forthe patient and potentially for
the provider too, and that thebest advice is really just to
avoid them.
And that's great if you live ina highly populated area.
(10:13):
But even in a highly populatedarea, you're still going to find
tight-knit communities wheredual relationships are just
going to happen or they're goingto be preferred.
That just doesn't work for aperson working in a small
community or think about themore remote you are,
geographically isolated it's nothappening.
You're definitely treating yourfamily and friends and places
like this.
I want to make a point that I'mnot talking about sexual dual
relationships at all here.
It's just dual relationshipswith socially true business,
(10:38):
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 aboutand this is one reason why I
was so happy to invite you topresent on this topic to the
knowledge summit was becauseyou'd recently were working on a
paper.
Yeah, yes, yeah.
I thought this is such afantastic thing because, yeah,
what are you supposed to do?
Not?
Every rmt across the countrylives in an urban environment
(11:06):
where they have that luxury ofsaying yeah this is I can't
treat you.
Sarah (11:12):
Yeah, go see my colleague , or whatever, you just not.
Eric (11:16):
So let's use you as an example, Sarah.
So in Stuiak, what's thepopulation?
Sarah (11:20):
The 2021 census put us at 1500 people and I looked up
online recently.
We're estimated to be about1,800 right now in 2025.
We had a bit of a populationboom over COVID.
A lot of people were moving tothe country and, yeah, we
actually had, yeah, quite a fewpeople move here, but so it's
not a lot of people.
Eric (11:41):
Yeah, that's silly, that's a 20% population.
Sarah (11:44):
It was the highest in our province.
It was unprecedented actually,and there's a pause on building
and stuff here because we justdon't have the infrastructure
for it Of course.
Yeah, and it put all the pricesof the housing up, of course,
and everything is just superunaffordable here.
And we moved here because wewanted a country life, a quieter
life, and it was affordable.
But we couldn't afford to movehere now at all.
(12:06):
Oh wow, it's better everywhereyeah.
Eric (12:08):
It's like that too in Victoria, where I am.
Yeah, I don't know.
It'd be impossible for usunless you're very wealthy for
an average person to buy thattraditional single-family home.
Sarah (12:19):
Yeah, so it's a good thing we love our house because
we're not salivating.
Eric (12:25):
That's a thing, isn't it?
Sarah (12:26):
so yeah, so it's regressing here, but with so
there's 1500, maybe 1800 peoplethere yeah now and you probably
know, or friends with a huge agood number of them, because not
only am I friends with people,my husband's friends with people
, my children are friends withpeople, my husband's friends
with people, my children arefriends with people.
So this brings a lot of peopleinto your life and I'm not like
(12:50):
a super, a bit of a hermit.
This is different for everybodytoo, depending on how social
you are and how going andinvolved in your community,
that's going to look differentfor everybody.
So for me, who's a bit of amore reserved person, but I do
volunteer quite a bit within thecommunity, I really believe in
that and I enjoy that.
I might have less sort offriends or connections, but I
(13:14):
overlap in some way witheverybody that I treat in here.
There's just going to be thatit might change in a year from
now, depending on how our liveschange as our children grow and
as new things happen, and that'snot static either.
Eric (13:31):
But it just makes sense, if you stay long enough, that
you're going to make newconnections, new friends new
people are going to enter yourlife and ethically you're not
supposed to treat.
So what are you supposed to do?
Yeah, so you were saying thatit's basically the ethics
teaches us that these dualrelationships are wrong.
We learned that in massageschool.
Sarah (13:53):
Yeah.
Eric (13:55):
And I'm assuming MTANs yeah, has rules.
Do they have rules aboutrelationships?
Sarah (14:03):
Yeah, yeah, we have it.
There's a lot of things thatkind of progressed along the way
of me thinking and writing anddoing everything about this, but
one thing that changed in 2021or 2022 was that our code of
ethics changed and the phraseavoid dual relationships became
part of our principle three ofdo no harm, and that was not in
(14:27):
our past iteration of our codeof ethics, so this was a new
thing and it was also brought upin a practice standard around
boundaries.
And I understand why it's therebecause it's within our.
It's our ethical teachings.
It's to protect the patient.
I'm all for not causing anyharm the patient I'm all for not
(14:48):
causing any harm.
But there is no context for thatand this is a province where
most of us live in a smallcommunity outside of Halifax,
and even in Halifax, it's notthat big of a city that you're
not going to have some overlaprate.
You know what I mean To seethat and to know what it points
back to.
When you go back and you lookat whatever ethics text you were
brought up on, there is somediscussion around it being a
(15:08):
very poor choice.
You're probably not going to beable to know how to manage it.
It isn't compatible withpatient-centered care.
These are not the experiencesthat I'm having in this context
at all.
I'm having excellentexperiences, and I had to teach
myself how to do it because,since our best advice is to
avoid it, we're not teachingpeople how to do it, so that's a
(15:33):
problem.
Eric (15:34):
That's a huge problem, and it's if we look at the kind of
traditional ways that societyhas done about things that you
shouldn't be doing.
Well, just avoid it.
It's like this abstinenceapproach.
Sarah (15:47):
That's exactly what it is .
Eric (15:48):
It's an abstinence shift and has that ever worked for
anything?
It doesn't work for drugs oralcohol, 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 thathumans can do.
The abstence approach justavoid it doesn't work very well.
But what seems to work well andI'm this is I guess there's a
(16:09):
question for you but iseducation right?
People are educated about acertain topic, the they can then
make informed decisions.
They can make informeddecisions about should I smoke?
Why?
I know the risks, I know theharms, I know no benefit, but
just saying no, don't do thisthing.
It doesn't work.
Sarah (16:30):
Yep, that's right.
Eric (16:31):
Why would that approach be any different in a dual
relationship?
Sarah (16:35):
It drives me crazy here.
I'm just always so shocked thatthis hasn't been talked about a
lot before and I think probablyone 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 thisas a value or principle within
codes of ethics and standards ofpractice.
But when I finally, when thatwording came up in our own code
(17:00):
of ethics, it just was the kindof the last straw for me.
I was like I could handle itbefore I could rationalize it
because I was always coming backand forth with it.
Oh, some days I feel like I getnegative feedback about it from
peers who just don't understand.
But I can rationalize it and Ican live with it and I'm no end
doing the right thing.
But when I saw it in our code ofethics that's when I saw it,
(17:22):
and also because I was in schoolat the time and in the sort of
mode of critical thinking anddoing research and writing a lot
which was so beneficial at thetime, I was like, oh my God,
this has to be happeningeverywhere else, in every other
health profession.
Are they writing about it?
And yes, they were.
They've been writing about itfor decades.
I, immediately upon accessingand reading like one of the
(17:46):
first papers around dualrelationships.
I just felt seen and understoodand supported for the first
time ever and it was wonderful.
Eric (17:58):
Your experience was validated.
Sarah (18:00):
It was so validated Like, oh, everybody else is feeling
this.
Everybody else feels likethere's not enough education,
that their practice iscompletely misunderstood, it's
not valued, that the things thatwe're doing here every day.
Every day, we're really workinghard to check our biases, to
(18:21):
make sure our patients are safe,to just really care for them in
the best way, and this isechoed throughout nursing and
medicine and social work,psychology, all the health
professions.
And to see that other peopleworking in small spaces were
feeling the same way, I felt itwas great and I said, yeah, I
(18:42):
need to do something with this.
Eric (18:44):
I think it's great.
So why don't you tell us alittle bit about, go into as
much detail as you want aboutthe research and practice with
other healthcare professions,and how are they what's the word
?
Negotiating or working withdual relationships?
Sarah (18:59):
That's a great word because a lot of that
negotiating comes up.
A lot we negotiate the dualrelationship, the overlap and
the amount of overlap that wehave and that we're comfortable
with our patients, like on anongoing basis.
And this is happening in everyother area of health care.
And because there's thisconsistent message of there's
not enough education oracceptance of these
(19:21):
relationships, it's said inother areas of healthcare avoid
them, they're dangerous,whatever, unethical.
So because there's a lack ofeducation, healthcare providers
are coming up with their ownways and they're all ways that I
do it and it's not that they'redifficult, really it's honesty
and communication and caring andtalking and having an ongoing
(19:44):
conversation and saying when anew patient comes in and I know
them, I just say I just want tomake sure that you're
comfortable with the amount ofoverlap that we have here in
this community.
I'm always here for an openconversation.
If anything makes you feeluncomfortable, let's just talk
about it.
Just being human, Human, andthat comes up so much in the
research.
That and all this research thatI've read.
(20:04):
Pretty much all of it is fromthe provider perspective.
So of course the patientperspective is really important
too and there's a knowledgeabout that and hopefully
there'll be more of that done,and but it's just.
They want to see these rulesand guidelines and values be
more human, less fear-based,less based in suspicion.
(20:25):
You know of what you're doingwrong and everything, and of
course things do go wrongsometimes.
So for the most part, we'regood, we care, we're in
healthcare because we care aboutpeople.
Being in a community with people, that does not make you care
less.
It makes you maybe evenarguably care more because
you're going out there in thecommunity and you're going to be
seeing the next day and you'regoing to see your patients and
(20:48):
you're going to be like, well,there's.
Maybe you don't talk about itout loud, you don't want to risk
the confidentiality, but youhave just a different.
I don't know, it just feelsdifferent because you're seeing
the people that you, that youtreat, and you're happy to see
them when they're doing well,and if they're not doing well,
then you're accessible andyou're right there and you can
deal with that too.
But it's not.
It's funny that the argumentthere's an argument that it is
(21:09):
incongruent with or compoundedwith, patient-centered care,
because it actually improvespatient-centered care and that's
been brought up in theliterature that it's a good
thing that it doesn't diminishthat at all.
So it enhances the therapeuticrelationship.
When you do have a different,deeper knowledge of your patient
(21:30):
you might have depending on howlong you've been in the
community, you have a historythat you know of the person and
that can be a positive thing ifused in the right way.
So there's these benefits thatyou don't read about, that are
out there, that do exist.
The literature that we have inour texts is really just around
the risk and the harm and itreally scared to bring the
(21:51):
benefit in, and I suppose that'sunderstandable because we don't
want to hurt anybody.
So that's the boundary and thatis understandable.
But there is a lot of researchout there now and I think it
would be good to look at thatwhen people go to rewrite these
chapters.
Eric (22:06):
You said that there's an argument that a dual
relationship againstpatient-centered care.
What's the argument about theharms or the problems that dual
relationship?
There's some obvious ones whichI think anybody should be able
to identify.
There's some obvious ones whichI think anybody should be able
to identify.
But what are some of thearguments that you see in the
literature about this is notsomething you shouldn't do,
(22:27):
because of what are they worriedabout?
Sarah (22:30):
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 reallyfamiliar with Pavas and Fitches
and Lauren Allen's book andBenjamin and Moe's.
So those are the four that I'mdrawing a lot from because
they're really well known.
They're all about ethics.
They're really not aboutanything else, they're all about
(22:51):
professionalism and what comesup in those would be around it
being a conflict of interest.
But not only that.
It's stated in some of thebooks that it's an automatic
boundary violation or boundarycrossing.
Whether you're doing your bestor not, it's perceived as,
(23:15):
because it's perceived asunethical, you're just crossing
the line, it's just, and thatyou're not, probably not aware.
You might not be aware ifyou'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 objectivityas a clinician is diminished so
that it isn't near possible tobe objective.
So that's where you're not ableto provide that
patient-centered care, becauseyou can't make a good clinical
(23:35):
decision, because you're tooimpacted maybe by the emotional
relationship you might have withthis person or other things
going on.
But I would argue that is nothappening at all, and from the
research that I've read fromother areas of healthcare, it's
the same sort of story there.
But are we fighting sort of allthose things?
In any relationship that we'rein, regardless if we know the
(23:59):
person or not, they're coming inwith their own unique story.
Anything that they say couldmake us feel emotionally charged
, more or less.
We all have our own backgroundsand history and our job is to
treat each patient with respectand care and to listen respect
(24:27):
and care and to listen, and norelationship is devoid of
emotion.
And then putting up thoseboundaries really strict sort of
professional boundaries can beseen by some people, no matter
what context you're in, as youbeing cold and uncared too.
Eric (24:38):
That's the thing that I find has happened in our
profession.
I speak more about BC becausethat's who I am, but there's
over the years, there's almostbeen this mechanistic approach
If someone starts talking aboutemotions or life or problems,
we're supposed to just redirectthem back towards.
Why are you here?
Sarah (24:56):
Yeah.
Eric (24:57):
I remember a couple of years ago we had to do or
college had to make us do someonline course and for the life
of me I can't remember what theheck it was about, but I
remember that was one of thethings that they talked about.
There was this person came in Ithink they had shoulder pain
and they were talking about.
They started going off topicand the right answer for the
therapist was try to redirectthem back to their shoulder.
Sarah (25:18):
Yeah, but not treating the human not treating the human
, not treating the person infront of you that might need to
say they need to tell you theirstory.
Eric (25:28):
Yeah, no, I totally and I think a lot of it.
I think a lot of the worriesthat 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 hugeassumption here, so I could
(25:49):
totally be wrong, but I'massuming that there's the
regulators are worried thatwe're going to step out of our
scope of practice If we don'tjust focus on, like, the joint
or the tissue or the or, and westart focusing on the human yeah
, now I would say that I don'tagree.
I think their worry is.
I there is.
(26:09):
I could see how there's a worrythere, but I think you're,
there's more things to beworried about than than that way
more things to worry about inthe profession.
But moving the focus away fromtreating the human to me seems
unethical.
Sarah (26:25):
Yeah, it does Even of ethics.
Eric (26:27):
The ethical is we should do no harm.
Sarah (26:29):
Yeah.
Eric (26:29):
And we should have informed consent.
Sarah (26:32):
Yeah.
Eric (26:32):
Key ones and there's other ones, obviously.
Those are the key ones that Ialways come back to, and then
you have to treat the person.
You have to treat the human.
So if you have a dualrelationship, so using that as
an example, someone comes in andyou're the only person in that
town that could potentially helpthem with whatever's going on,
why would you say no?
Sarah (26:54):
That's the worst thing you could do.
Eric (26:56):
Exactly.
That's not patient-centeredcare, that's not in their best
interest and that's potentiallydoing harm.
So by saying you can't have adual relationship when you are
maybe the only person in thetown, that's not ethical.
Sarah (27:10):
That's not ethical Not at all.
I remember when I first movedhere and I was practicing in the
city for a year and a half orso before I moved here.
I'm not really cluing in thatmoving to a small town was going
to put me in the position ofjust being in the middle of all
these dual relationships, and Ihadn't had that experience yet.
And I remember thinking, if Isay no, that's wrong, it's a
(27:35):
barrier to accessing care.
People have the right to accesscare in their own community if
it's available, and so thatalways struck me as a really big
problem.
But I remember talking toanother massage therapist the
only other one who was in townat the time and I said how do
you do this?
Like our books say we can, andit just feels so wrong.
(27:59):
And she just said you just doit, you just do it because you
have to, but you just do yourbest.
And I said, okay, I'll just gowith this.
And it's always been a goodexperience because it's always
been led with honesty andintegrity and all those things
that you would want in anyinteraction.
And that's what, in theresearch too, is that all these
(28:20):
healthcare providers have theirown way of interacting with
people and everybody might be alittle bit different, but it's
just based on talking, likesaying, this is the situation
that we're in, are youcomfortable with it?
And more times than not theperson wants to be in that the
patient chooses it.
The patient's very comfortableknowing you.
(28:41):
It actually provides them witha foundation of trust because
they know you already.
And trust is so important andit takes time to build up, but
when you're actually seeing aprovider that you know or you're
getting to know that trust isalready there.
And we know from some researchin massage therapy that
psychological and physicalmassage therapy, that that
(29:05):
psychological and physical thetrust kind of helps relax us and
can help us have betteroutcomes in our treatment.
And that's like a yeah, ofcourse it is, but it does.
It does work really well, it's.
We need to move away from thisfear and suspicion and embrace
that this is happeningeverywhere and we shouldn't be
hiding from this conversation.
One thing that I've seenrepeated in the research is that
(29:29):
, like health, ethics in generalhas a lot they could be
learning from understandingpeople who work in small spaces
and whether it's in a rural orremote area or a tight-knit
community within an urbancommunity within an urban area.
There's a lot of great stuffthat you could be learning about
these complex relationships, ofhow they're managed, and how
(29:53):
they're managed well Becausethere's no epidemic of harm or
it would be shut down.
Eric (30:01):
So one of the questions I had is when they talk about,
you're saying there's this riskof harm and having a dual
relationship is bad, but isthere any evidence to show that
these dual relationshipsactually are causing harm?
Sarah (30:14):
In massage therapy?
There's absolutely none,because we have no ethical
research, no research on ethicalissues at all.
Really, in massage therapy andoutside of massage therapy it's
stated that it's greatlyoverstated the risk of harm.
There's always a risk of harm,but there's no.
(30:34):
It's not what people think itis.
I think we were talking youwere saying traditional ethics
and values and stuff, and it'sfunny because that comes up a
lot in the research.
I read this great book I read itand re-read it by Christy
Simpson and Fiona McDonald,called Rethinking Real Health
Ethics and their argument isthey talk a lot about ethics
(30:57):
beyond what we need to knowabout because it's for health
care, but on nurses andphysicians and everything need
to know about, because it's forhealth care, but on nurses and
physicians and everything, butthey talk about traditional
ideas around avoiding dualrelationships.
These ideas came into being inurban institutions decades ago,
based on what was the norm inurban institutions You're
(31:17):
primarily providing a treatmentto strangers and it just became
a gold standard of care, notreally based on any other
context or really anything.
And this has been perpetuated,this idea.
So they call this principleurban-centric and other authors
have called it a Western orEurocentric ideal.
(31:38):
This is from the perspective ofthe First Nations author, which
I read about when she wasspeaking to her work as an
educator and a psychologist inher remote First Nation
community.
She came up against the problemof having to abide by this
principle of avoiding dualrelationships, which is
completely incompatible withwhere she works.
And this is Tanya Dama ofDubuque, who wrote an
(31:59):
autoethnography about this in2023.
And I highly recommend peoplelooking her up and reading that
paper.
It was fantastic.
It really spoke to me.
I liked that she was writingabout her own experience, but
it's an incompatible value.
It really doesn't work outsideof a place where you're just
going to be with strangers allday.
Eric (32:21):
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 isjust the way things are it's
(32:41):
just the way things are becauseit'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 areason yep give me a reason say
so.
We use dual relationships as anexample.
They're bad, they're're wrong.
I can understand that there'srisks.
Sarah (33:01):
Yep.
Eric (33:02):
But telling people to just abstain.
Sarah (33:06):
Yeah, exactly.
Eric (33:07):
Avoid them completely, otherwise you are bad.
You are a bad human, you're abad therapist.
It's not a good enough answer,a good enough solution.
There's got to be a bettersolution, and I'm sure there is
better ones.
I'm sure.
There is yeah, If you couldrewrite the ethics rather than
say avoid, what could you changeit with?
(33:28):
And how would you make RMTsbetter at dual relationship
handling?
Sarah (33:43):
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 informedconsent, all of these things.
It's not there's nothingdifferent or secret or anything
like that.
It's respect and honesty andcreating boundaries together and
understanding that there thereneeds to be boundaries.
But, yeah, creating thattogether, that a lot in the
research that these boundariesare co-created with patients in
(34:07):
small communities.
It's interesting because insome of the texts, like in
Benjamin and Sonnenmoll and theEthics of Touch, they know like
they have a pretty clear bigchapter on dual relationships.
So it's pretty, it's reallygood.
But they do note that in ruralareas or small areas it's you're
going to come across them morethan in urban areas, but I never
(34:29):
see anyone make the point.
Then how can something thatseems so wrong and you're
telling us we probably don'tknow if we're doing it right, we
might not be mature enough todo it, we might, we're
definitely going to, it's goingto be hard or confusing at some
point.
How can something that is sowrong here have to happen?
(34:50):
Still, what does that make mypractice look like?
Am I just an unethical badpractitioner because I'm out in
the middle of nowhere doingwhatever I want, and it's just.
That's just just fine too.
I don't understand that.
I can't reconcile that.
Eric (35:06):
And with this thing, this is really interesting to me,
because this is a topic that Idon't I've never heard anybody
out of profession talk aboutbefore.
Sarah (35:12):
Beauty robotic.
Eric (35:13):
Not in this context.
Sarah (35:15):
Heard, not like this at all, Like I really haven't,
you're right.
Eric (35:22):
I commend you for that and for working on and hopefully
getting a paper published soonon it me.
What you said, though, isbasically respect, honesty
creating boundaries.
This is something that couldeasily be incorporated into
massage therapy education yeahwe take all those pd courses.
No matter where you go to schoolin the country, there's always
pd courses and I think most ofus would agree a lot of that PD
content is not very helpful.
(35:42):
No, and it's better utilizedthe time.
Yeah, positive there, positivelanguage why could you not have
a day, or use this as a lessonor two on managing dual
relationships?
Sarah (35:56):
Yeah, and I hope somewhere out there in some
school this is happeningdepending on, because we know
the education is so variable andwho knows who your teacher is
and what their personalexperiences are.
So I hope people are talkingabout it.
I know I personally didn't geta good, a positive conversation
about dual relationships when Iwent to school, but yeah, it
(36:17):
shouldn't be hard to incorporate.
And, with all of the researchthat's been published, bring a
couple of papers in when you'retalking about if you're still
teaching from texts that haven't, in their next edition, updated
any of this information basedon research.
Bring a few of these pieces inand get people to critically
(36:38):
think about it.
Read it.
It has to be required reading asfar as I'm concerned, because
there are so many of us that aregoing out there and moving into
a small community or we're in atight knit community, in an
urban area or in a ruralcommunity and we had.
We're scared and we feelothered because when you try to
talk about it to people thatdon't understand, they give you
(36:58):
a side eye and say you're doingsomething very wrong.
You got to stop doing.
That, from our perspective, isyou don't understand.
This is not the way that we'retaught this.
It's actually.
I'm having a very positiveexperience, and so are my
patients, and we're doing thisvery well and it's very healthy
and there are boundaries andthere are confidentiality and
(37:20):
it's actually not that hard tomanage.
What's hard to manage is goingback and reading those books and
you're what an unethical personyou are for doing something
that you have to do.
That's hard to manage.
Eric (37:32):
Yeah, you basically feel guilty for doing.
Sarah (37:34):
You feel guilty all the time.
And when I, when I read thebook rethinking real health
ethics, I did what I always doand contacted the authors and
said thank.
I read the book Rethinking RealHealth at Bix, I did what I
always do and contacted theauthors and said thank you for
this book.
This book took an immenseweight off of my shoulders as a
provider and I read this back inprobably 2022.
And, to my great luck, one ofthe authors, chrissy Simpson,
(37:54):
works at Dalhousie Universityand has been able to talk with
her on several occasions abouther work.
I mean, I've said to her a fewtimes I just can't tell you I
didn't realize how heavy thatweight was on me over the years
where I was doing my very bestand always checking in but still
to go back, any sort ofguidance that I wanted to seek
(38:16):
was just around the negativityand the wrongness of being in a
dual relationship and that washarmful.
And it is harmful and that's areason.
One of the many reasons why weneed to have a research-informed
and evidence-informedconversation about this is
because it does cause harm tothe patient and to the provider.
(38:37):
When you work in a small space,you want to feel comfortable
integrating into that space.
There are people that I, orparticipants that I've read of
in the research, that theyreally struggle with.
What is the level ofintegration that I'm allowed to
have in my community?
I want to feel free to join aclub and to go to church and go
(38:58):
to a community center and go toa town council meeting, but you
really feel limited and we arealready in an isolated
profession, a very isolatedprofession, and this is just
even further isolating.
So that's a big problem, Ithink and I've felt that.
Eric (39:15):
One thing that I don't think is talked about enough in
the profession is the isolationof it A lot of it, Even if
you're working in a busy clinic.
I've worked in a busy clinicfor part of 12, 15 years,
something like that.
It was still very isolatingbecause you're alone with
somebody, so I couldn't imaginethe isolation of just profession
(39:36):
.
Sarah (39:37):
Yeah.
Eric (39:37):
It's weird because you're with people all day, but it's
isolating, but it's different.
Yeah, different People arealways thinking they're massage
therapists.
They understand what we'retalking about.
Yeah, they do.
Adding to that, compoundingthat with an isolation of having
to avoid those relationships ina small community, a small
space, would just it wouldprobably, I imagine, make you
just not even want to work orjust do something completely
(39:58):
different.
It just gets you out of theprofession.
Sarah (40:00):
I've been through that too, the do.
I want to do this Because I am.
I like having standards and Ilike having something to measure
myself against.
You know what I mean.
And when you don't see yourpractice environment reflected
in those standards, it's reallydifficult.
And that is reflectedthroughout the research as well.
And when I heard that, when Iread that in these papers and
(40:24):
this book, I was like wow,that's what I've been going
through.
This has been hard because ofthis and I like to be a part of
my community and when I havekids we have we do a lot here.
My relationships with mypatients and with everybody.
They overlap in so many ways.
Not only that, like when you'rein a small space, you're out
(40:46):
there.
You need each other.
I need these people too,because they have skills that I
don't have, or we help eachother in other ways.
In Simpson McDonald's bookRethinking Real Health Ethics is
the argument aroundvulnerability and power, and
they say that this exchange ofvulnerability between patient
(41:08):
and provider.
Like I'm in a vulnerableposition with my patients
sometimes because they knowthings I don't know.
They have skills I don't havethat I have to seek out.
I'm a service seeker sometimes,so that switches back and forth
and that can actually help toseek out.
I'm a service seeker sometimes,so that switches back and forth
and that can actually help tobalance out that issue of
vulnerability, which I justfound so interesting.
They critique traditional healthethics from a feminist
(41:30):
perspective, theory,philosophical perspective, which
is interesting because theyreally take into account context
and relationships and the powerand balance between, like,
urban and rural, and it's notsomething I knew really anything
about until I read this book,but I am really.
I love learning about that.
This was something I neverlearned in our obviously in our
(41:53):
ethics course, but it's a greatway to describe or to think
about what's going on here isthere's a lot more and
relationships matter and ourconnection to people here matter
and it does play a part in howwe choose health care providers
and and things like that, sothat it's yeah, they go pretty
deep into that too and it wasvery enlightening these are
topics and conversations need tobe had they really are and
(42:17):
because really, what is massage?
it's's relationships firstreally.
Eric (42:21):
It's really all.
It's what it comes down to.
Sarah (42:23):
Yeah.
Eric (42:24):
Your relationship with the person in front of you is, I
would say is more important thanskill with your hands, your
technique.
Sarah (42:33):
Yep.
Another argument is that itcomes up in our books town
gossip and things like that.
There's gossip everywhere.
You're just being professionaleverywhere.
You just be a professional.
You don't need to engage in it,you don't need to agree with
anything at all.
Everybody that comes throughhere gets treated as if they're
the most important person I'veseen in this day.
(42:53):
I genuinely care and want togive them what they need and
what they're looking for, andthat's attending to, that's
patient-centered care, that'sattending to their values and
seeing them as a whole personand treating them as a whole
person and it's just.
It just none of it really addsup in my experience and I know
many people have many differentexperiences and I'm not saying
(43:13):
that people don't have negativeexperiences, because we all do
at some point but I think thevast majority of them are
probably going really well.
Things are going really wellfor people and we're just not
really comfortable talking aboutit because we're scared we're
going to get in trouble.
We're scared we're going to getthe side eye, and I've had all
of that and even when I startedtalking about this more and more
with people who really didn'tunderstand, it was very
(43:35):
uncomfortable, but I had tostand my ground because I said
how can this be wrong?
I've been doing this and thereare hundreds of thousands of
people just in Canada that areworking in small communities,
that are doing this right now.
They want to, they have to.
It's going great.
Eric (43:51):
And how have those responses been when you've had
those conversations?
Sarah (43:55):
Actually as long as in the conversations I've had when
I've really just not backed downand said what about this or
what about that, and they'veactually gone pretty well.
But I've only been comfortabledoing that now because I have
the confidence for reading theliterature outside of our
(44:16):
profession.
That's given me the confidencebecause I was never really able
to do that before.
Eric (44:29):
Yeah, that's a big thing to take away too.
Is that when you know a topicso well, you could have good
conversations with people aboutit?
Yeah, know a topic only alittle bit.
It's hard to have a real andlike you can't really have an
engaging conversations with mebecause you know you're not so
small, so I engagingconversation with me because
you're so small.
So I think it's great thatyou're having those
conversations.
Have you had theseconversations with your
association?
Sarah (44:50):
Yeah, I have, because I do a lot of volunteer work with
the association and some of thefirst conversations about this
that came up with colleaguesthere, some of the first
conversations about this thatcame up with colleagues there,
and it eventually sparked me towant to create like a guideline
for people working in dualrelationships, which we do have
(45:10):
now, and it at least, at thevery least, it acknowledges that
dual relationships arehappening and that we recognize
that now.
But I think as time goes on wecan do a lot more to make that a
more friendly and supportive.
But at this moment it is thereand it is acknowledging that
dual relationships happen andjust gives a little checklist of
(45:33):
how to work within that, fromour sort of ideas around ethical
values and standards andcommunication and things like
that.
But that gives me comfort toknow that's there, because
before we had nothing like thatand we needed it and I'd like to
see that everywhere.
When you look to this, say,physiotherapy, like the
(45:54):
Physiotherapy Association I'velooked at a lot of them across
the country colleges andassociations, and there's some
that will have maybe like alittle booklet on the
therapeutic relationship andthere'll be like a little blurb
in there.
Just be more careful when you'rein a rural community treating
friends and family, nothing morethan that.
Usually there's a big call toaction for ethical guidelines to
(46:28):
be informed by these othercontexts that people are working
in and that people need to feelsupported in working in and
within medicine and nursing andphysiotherapy.
There is an issue, too, aroundretention, like retaining these
very valuable health careproviders in rural spaces.
In rural spaces, they reallyneed to feel that they're not
doing anything wrong, becausethat can lead to burnout and it
can lead to people leaving whenalready there's not enough
people working out in thesecommunities, all these isolated
(46:50):
places, and that's not a goodthing.
Eric (46:54):
Yeah, the last thing you want to do is put people away.
Yeah, particularly when theserelationships are unavoidable.
Sarah (47:00):
They're normal and expected.
That's the thing too.
It's funny when you ask when Ifirst started working, it was
talking about this with peopleNot that everybody has this
general knowledge anyway, butthey're like I don't care that,
I know you, I'm happy that Iknow you, this is awesome.
I'm so glad Like I know you, Itrust you, I feel so comfortable
with you.
I don't want to go see anybodyelse and this is echoed
(47:24):
throughout the research as wellis it's expected, it's normal,
it's inevitable.
Dual relationships are alreadypart of normal health care
service.
They're already there, Beenthere forever.
Eric (47:37):
And it's not going to go away.
Sarah (47:39):
Go away.
No, been there forever and it'snot going to go away.
Eric (47:40):
Away, my thought I live in an urban area and it's huge
victoria.
I think the greater area isprobably just shy of 450 000.
But I've grew up here I can'tgo anywhere without having,
without knowing someone, or likeI have a two.
It drives my kids crazy.
But I got like a two degrees ofseparation or less, or or like I
(48:00):
know you or I swear, no morethan two, two degrees of
separation and I will knowsomebody whether it's soccer,
which has been a big part of mylife, whether it's through work,
whether it's through university, whether it's through high
school, whether it was throughfriends or friends of friends,
whatever it just you can't avoidit.
You can practice.
(48:22):
I would say a large, noteverybody, but a large
percentage of people that I hadin my when I had a full-time
practice were people that I knewor knew me from somebody else.
So there, there's always gonnabe.
Sarah (48:32):
You can't really separate that no, and here in Nova
Scotia we have like maybe amillion people now.
We knew I didn't grow up inthis community, which adds
another layer to dualrelationships because I'm not
treating my family.
I don't have family here, but alot of people that grew up here
the other massage therapiststhere's a few they're treating
family that we expect that theyare.
But if you grew up in thecommunity that you're servicing,
(48:55):
you're going to be treatingyour family.
But even in Halifax it's not ahuge city it's going to happen
at some point.
Just knowing that these ideasare outdated, they're not
helpful, they're not useful andthey are hurtful and they do
need to change.
It's an uncomfortable topicbecause we're made to feel that
(49:15):
being unethical when we're toldthat what we're doing is wrong
and eventually going to lead tosome sort of harm.
I haven't found that yet.
Eric (49:22):
These conversations are important, as I said, and I
think if we don't have them,then nothing's going to happen.
Sarah (49:28):
Nothing's going to happen , and that's the thing too, and
I'm always inspired by that.
This is talking about thesethings and putting these ideas
out there.
It's supposed to happen.
This is a natural and healthypart of engaging in your
profession.
It might be uncomfortable to doat first and I know I've gone
through a lot of feelings aroundthat, but this is helpful and
people need to hear this and weall need to share our stories.
(49:50):
There was a narrative reviewthat came out in 2023 by Sumer
and Arnold and they did a reviewof the literature and gave a
little schema fordecision-making around engaging
in dual relationships, and oneof the things was to reflect on
your challenges and successesand to share your stories with
(50:11):
people and to help other people,and that really you want to
support other people that are inthese positions.
We need to support each other.
We need to talk about this andneed to know that we're not
encouraging each other to do ourbest.
Eric (50:26):
Yeah, so when you're doing your presentation in October,
is there any other any specifickey things that you're going to
hit?
Sarah (50:32):
I'm working on the presentation now.
I think what I want to do ispick out a few key pieces of
research that really didsomething for me and just do a
bit of a deep dive into what thefindings were and just talk
about that from my perspectivetoo.
That where I'm going with itright now is and then give good
reference notes for everybody atthe end of it to do their own
(50:53):
reading and their own thinking.
But really it's to open up theconversation and to say let's
start talking about this andsupporting each other and see if
we can bring some change to theideas and the culture around
this and introduce theliterature, the body of
literature that's out there.
And yeah, I guess just seewhere it goes from there.
(51:15):
But it will.
I will be looking at a lot ofthese papers more in depth and
talking more to the specificsettlement, which I think would
be good.
Yeah.
Eric (51:23):
Fantastic, I'm excited.
Yeah, I think it'll be greatand, at the very least, these
conversations are starting.
Sarah (51:30):
Yeah, they're starting.
Eric (51:31):
Hopefully this will lead to others asking similar
questions or having theseconversations, and it's like you
said at the very beginning youfound me because of an article I
wrote back in 2016.
And conversations happenbecause of those, and sometimes
that might inspire some positivechange, and so hopefully this
will be something similar foryou.
Sarah (51:52):
I hope so too.
There's a lot that can be donehere, and the books that we have
are the great texts they justneed, like any other, you can
pick any other topic in them.
And well, this really isn'tmaybe how it is now, and we need
to evolve a little bit.
And that's the goal with beingon that professional trajectory
is not staying stagnant, toevolve and to bring new ideas in
(52:12):
and to recognize that there area lot of different ways of
doing things that areappropriate.
Eric (52:17):
So, yeah, that's a perfect way to end it, Sarah.
Sarah (52:22):
Well, great.
Eric (52:22):
Thank you very much for being here and we'll talk soon.
Sarah (52:25):
Well, thank you so much, Eric.
Talk soon.
Eric (52:27):
Thank you for listening.
Please subscribe on yourfavorite podcast network so you
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(52:52):
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