To Treat or Not to Treat, That is the Question – Fear and Contraindication in Reflexology

imageI initially qualified in reflexology via one of the more overly cautious training bodies here in the U.K.  Realistically, if I had continued to adhere to the ‘rules’ I was initially asked to follow, I probably would not still be in practice today.  The list of contraindications promoted by the training provider doubled in size during my training – leaving frankly only the perfectly healthy individual open to freely access treatment.

A real deep fear of causing harm seems to exist in many of today’s reflexology practitioners.  In some cases this is initiated by the primary training body, and in other cases it can be attributed to a lack of practitioner experience, or self development.  Some training bodies unfortunately seem to spend a great deal of time concentrating on application and technique alone, and not nearly enough time (if any) promoting the concept of holistic back engineering, or indeed exploring why reflexology might be impacting clients so positively (collectively this encourages the concept of working with the whole person).  Nor do many training bodies promote an appropriate form of practitioner self development – one ultimately capable of instilling a heightened sense of practitioner self awareness, encouraging development of the internal supervisor.

Unfortunately without the promotion of such concepts, as our awareness develops regarding the power of reflexology to promote more balanced health and wellbeing (often without really understanding why that might be), practitioners can also find they remain fearful that same power may be capable of causing harm to clients.

Ethical Decision Making

Remaining mindful of the limitations existing within the reflexology package, and indeed in our own professional competencies, is of course entirely ethical, but how might practitioners best define exactly where those ethical boundaries lie?

The challenge for practitioners in ethical decision making is to balance our real and perceived fears and concerns against our knowledge and experience, ideally then arriving at a decision – or a state of being – where we feel comfortable in our ability to confidently meet the needs of our client.  A good rule when making an ethical decision is where no clear path is illuminated, one should take the path that causes least harm.  Put simply, if you are unsure, do not proceed.

Beneficence is an ethical principle most connected with applying therapeutic skills to help people. It relates to and might be defined as actions which are taken to benefit another.  In reflexology the duty of beneficence must be considered together with its converse duty – that of non-maleficence – which is the concept of ensuring no-one is hurt.  This principle should ensure that any risks involved are proportionate to the benefits.

Back Engineering Holistically – When Common Sense and Knowledge Say Yes

I was contacted by Sue, 31 weeks pregnant, diagnosed with Obstetric cholestasis (OC).  Obstetric cholestasis is a condition of the liver – specifically a reduced flow of bile from the bile ducts in the liver.  Liver enzymes, and in particular bile salts leak into the bloodstream causing the symptoms (severe itching across the body, but often most pronounced in the hands and feet, tiredness and emotional distress).  Fairly often women with OC are induced at 37 weeks gestation due to slight increased risk of stillbirth.  Sue was determined she did not wish to be induced.

Sue was under the care of a consultant obstetrician, and her bloods were being checked weekly.  I was certainly initially cautious about engaging, but after researching the condition I agreed to the work.  I know from experience reflexology can certainly promote better circulation – which in turn can support liver function, and I was also confident reflexology could help with my clients frustration and obvious distress.  I did however make it clear to Sue, if her bloods test results remained outside normal range at 36 weeks, she must follow her consultants advice regarding induction.

I did not ask for written or verbal permission from the consultant, or the GP.  In fact, I’m often a little perplexed by the concept a medical doctor might be expected to know more about the impact of reflexology than me – the professional practitioner, or indeed that they might welcome endless letters or phone calls from unsure, insecure complementary therapists.  Undoubtedly there are situations where it is in the clients best interests to inform the GP or consultant about the inclusion of reflexology, but that is not the same as asking for permission to proceed.

Sue and I agreed on a plan of action together.

  • imageI would administer reflexology twice weekly
  • Sue agreed to steep her feet in hot water and to body brush daily to further improve circulation.
  • Sue also agreed to start consuming an additive and preservative free diet, and to avoid tap water.
  • We discussed Sue’s feelings of frustration regarding the potential induction – an important element to cover because of the TCM link between liver energy and the emotions of anger and agitation.
  • Sue agreed to engage in more instances of self care –  including regular guided meditations, additional periods of rest, and trying to remain mindful of her emotional state.

Sue’s itching subsided within a week and by 36 weeks gestation all blood test results displayed within normal range.  Sue was able to experience the home birth she so desired at 41.5 weeks, supported by her medical team.

My initial fears regarding engaging with this particular client were reduced principally because of my existing A&P knowledge, and because of my confidence and trust in my therapeutic modality.  I researched the condition fully, applied that information to my A&P knowledge, and then to my knowledge of TCM, before arriving at a place where I felt confident to proceed.  I explained my rationale for engaging in the work, and Sue and I worked together to invoke change.

When Fear Says No

I received a telephone call from a gentleman in his early sixties, recently diagnosed with terminal lung cancer.  During our telephone conversation this potential client disclosed his decision to refuse all offered medical treatment – believing instead complementary medicine held the potential to cure him entirely of the disease.  As our conversation progressed I became aware of a huge weight of responsibility potentially being placed on my shoulders.  His expectation regarding desired outcome felt heavy to me, and I can clearly recall feeling very uncomfortable and unsure.

We talked for while and I tried hard to better manage his expectations regarding reflexology, whilst also encouraging him to consider re-engaging with his medical team.  He was understandably angry and distressed regarding his diagnosis and completely adamant medical type cancer treatment was just not for him.  In the end, because of his emotional state, I respectfully declined to administer reflexology – explaining the potential weight of responsibility he was asking me to carry alone was just too much.

The decision I made in this case was based on my own feelings – an awareness that my own inner supervisor was not feeling at all confident.  I was able to acknowledge my feelings and gut instinct, and from that place made my decision. This is the only client I have ever declined to work with.

Where Do The Boundaries Lie?

Of course there are times when practitioners need to be mindful regarding administering reflexology – for example, localised injury or infection, undiagnosed pain etc.  Certainly also the presence of certain medications require some additional consideration:

  • Blood thinners (anticoagulants) such a Warfarin and Heparin. Probably the most important group of medication to be aware of.  Only once INR (International Normalised Ratio) testing has confirmed the blood is clotting correctly should reflexology be administered.  Until such a time reflexology is strictly contraindicated.  A past history of clotting does not however contraindicate treatment.
  • Titrated medication such as Thyroxine. Titration helps the body adapt slowly to certain medications, often reducing common side effects  occurring when the individual first begins treatment.  Titration additionally allows the physician to find an optimal dose for the individual.  Whilst reflexology is not exclusively contraindicated in the presence of titrated medication, the practitioner should make the client aware of the potential impact of reflexology on the circulation, as this can mean bloods may need to be monitored more regularly by the GP.

There are also certain client groups requiring additional consideration, again however they are not entirely contraindicated:

  • Pregnancy Group
  • Sub-Fertility Group
  • Cancer Care Group
  • Palliative Care Group

Evolution did not sneak little danger points in the feet.  Reflexology works so much more subtly, on multi-dimensional levels, and always in line with the principles of homeostasis – returning to a place of balance and equilibrium.

Homeostasis: Noun

1. The tendency of a system especially the physiological system of higher animals, to maintain internal stability owing to the co-ordinated responses of its parts to any situation or stimulus that would tend to disturb its normal condition or function.

2. Psychology. A state of psychological equilibrium obtained when tension or a drive has been reduced or eliminated.

How to Build Confidence in Practice

The key elements required to build practitioner confidence are:

  • Practical Experience
  • Good Levels of Appropriate Knowledge
  • Reflective Practice
  • Practitioner Self Awareness and the Development of the Inner Supervisor
  • Peer Support and/or Professional Supervision
  • Continuing Professional Development

image‘Physician, Heal Thyself’

So now let us imagine you have researched your clients condition fully and are content you understand the A&P involved.  Perhaps you have asked for advice from a more experienced practitioner, or are fortunate enough to belong to a professional association where telephone advice is readily available, yet still find you feel unsure about proceeding? Why might this be?

Fear and anxiety are strong emotions indeed.  Sometimes we can be very aware of their presence, and at other times the feelings can be more sub-conscious in essence – and therefore more difficult to define.  Practitioner self development can help to bring some of these sub-conscious emotions to a more transparent level.  For many practitioners, engaging in reflective practice exercises and peer supervision, for example, can help with gaining more clarity regarding their fears.  In other cases the practitioner may benefit from engaging directly with a supportive counsellor or psychotherapist.

The Wounded Healer

There is an interesting phenomenon occurs in professions where empathy is required and encouraged.  Perhaps the best way to consider this phenomenon would be to enquire why you, the reader, trained as a reflexologist?  The theme in essence relates to the concept of the wounded healer.  Studies have demonstrated that in many cases individuals who have chosen to follow careers paths involving caring or helping as an element:

“often as children experienced loneliness, illness, bereavement or the need to look after others”  March-Smith (2005)

Researchers have suggested that with these children the ability to empathise often develops to such an advanced degree in childhood, that as adults these individuals can then somehow feel compelled to care for others and are therefore drawn towards more therapeutic professions.

“the presence of such a ‘wound’ in a healer gives them an excellent basis from which to understand and empathise with the wounds of clients.”  McLoud (1998)

Whilst certainly no assumption can be made that all complementary therapists possess such a inner wound, the concept does demonstrate the requirement for good levels of self awareness in all professional reflexology practitioners.
Practitioners more aware of their inner motivations, thoughts and feelings are often:
  • better able to understand and regulate their own emotional reactions
  • better able to engage in appropriate levels of self care
  • potentially in less danger of exhausting their own personal energy
  • better able to maintain appropriate professional boundaries and offer appropriate reflective responses
  • better able to remain connected within the clients unique frame of reference

Engaging with a supportive counsellor can feel like a wonderful journey of self exploration.  There is absolutely no requirement to present for counselling with a particular problem or issue – the only requirement is a genuine desire to understand oneself more intimately, and with more clarity.  Often increased levels of practitioner self-awareness can help to allay fears – helping us to grow in confidence and become more self directed and autonomous.

Summary

Every therapist is different.  It is what makes human beings so wonderful – our uniqueness.  There are some practitioners who will find their own rationale for practice and ethical decision making processes develop relatively easily, whilst for others the journey can be more bumpy and seem filled with caution and fear.  Our similarities as reflexologists lie in our desire to help others through the wonderfully therapeutic medium of reflexology.  Our passion and desire to help others however, should always be accompanied by the ability to listen to our own internal drives and narrative.

Practitioner self development, ethical decision making and the concept of contraindication are inter-connected and related. Next time you feel fearful of causing harm, try to follow that fear to its source – examine more closely where it is coming from and take steps to balance your fear through appropriate education.  All the very best therapists do.

References:
March-Smith, R. (2005). Counselling Skills for Complementary Therapists.  London: Open University Press
McLoud, J.  (1998). An Introduction to Counselling. Buckingham: Open University Press
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