The Somatic Arts and Sciences Institute

The Somatic Arts and Sciences Institute www.sasionline.com

12-Hours Continuing Education LMT Success Group Package

12 Hour LMT Success Group Package

This is a package of four (3 CE ho ur) NCBTMB Approved Courses, all compiled into one book to make it easier for you to look up the answers as you take the test. This package includes:

EPS001: Massage Therapy Roles and Boundaries

EPS002: Ethics in Massage Marketing

EPS003: Cultural Sensitivity for Massage Therapists

EPS004: Transference and Countertransference in Massage Therapy Table of Contents

Instructions…………………………………………………………………………………………………..……… 3

Educational Objectives……………………………………………………………………….………………….… 3

Section 1: Roles and Boundaries (NCBTMB Standard V)..………………………………………..……………4

Section 2: Ethics in Massage Marketing………………………………………………………………………..154

Section 3: Cultural Sensitivity for Massage Therapists………………………………………………….……295

Section 4: Transference and Countertransference in Massage Therapy……………………………..……476

Course Completion: Certificate of Completion and Transcript…………………………………………….…607

Course Evaluation and Errata.………………………………………………………………….……….………608

Help and Technical Support Line……………………………………………………………………….….……608

Bibliography (Sources)…………………………………………………………………………………………...609

2 Massage Therapy Roles and Boundaries

Instructions Thanks for downloading this Somatic Arts and Sciences continuing education course. Read the book, then take the quiz on our website. HINT: You may want to look at the quiz before you start reading, it’s very helpful to know what kind of questions are going to be asked.

Taking the quiz To take the quiz you can click the link on our website that appears below this book.

Target Audience This continuing education course has been designed to meet the educational needs of massage therapists.

Degree of Difficulty Beginner/Entry Level

Course Description This course will address a variety of ethical issues that might arise in the course of a Massage Therapist’s career. Therapists will review ethical standards for massage therapy, and an outline of appropriate roles and boundaries in a massage therapy are provided.

Educational Objectives Upon completion of this home study continuing education course, the massage practitioner should be able to:

Define Ethical boundaries as it applies to massage therapy. Identify proper strategies for ethical problem solving.

3 Section 1: Massage Therapy Roles and Boundaries

Chapter 1: An ethics primer This is an ethics course written specifically for massage therapists, so as you would expect we are going to spend quite a bit of time discussing the usual ethical issues and quandaries that one might expect in bodywork, specifically roles and boundaries, massage advertising, business practices, draping, sexual misconduct and all that stuff.

Don’t worry. We’ll get there. But first we need to review the basics.

Remember when you first started learning anatomy in massage school? The first thing you should have been taught is basic anatomical vocabulary. In order to learn the names, locations and functions of the muscles you first had to learn what words like “superior, inferior, and medial” meant.

Before you learned how to do the various strokes and techniques you were taught the words “effeurage, petrissage, and tapotement”. Without the words and their definitions the hands on lessons couldn’t be taught.

In all disciplines there is a foundation that must be laid before you can build a body of knowledge.

Ethics is no different, but unfortunately massage schools treat it like it is. For some reason massage schools tend to think that they can teach lessons on “ethics for massage therapists” without covering the basics of what ethics actually are-including the language used in making ethical decisions and rational thought.

I don’t want to just give you a long list of dos and don’ts for massage therapy and a rehash of the Standards of Practice. A simple Internet search for “ massage therapist arrested… ” should convince you that the standard teaching of ethics for massage therapists is not quite getting the job done 1. That being said, we are going to go a bit deeper into what ethics are really all about.

1 About 1,610,000 results on Google this afternoon for “massage therapist arrested”. Yes. One and a half million .

4 A basic ethics vocabulary The following theories and concepts (presented in alphabetical order for convenience) cover the basics of the study of ethics in western society.

Absolutism, moral Moral absolutism is an ethical view that certain actions are absolutely right or absolutely wrong , regardless of other circumstances such as their consequences or the intentions behind them 2.

Prostitution, for example, might be considered to be always immoral, even if the woman doing it believes she has a good reason (resorting to prostitution to buy food for her children). Moral absolutism stands in contrast to other categories of normative ethical theories such as consequentialism, which holds that the morality (right or wrong) of an act depends on the consequences of the act and relativism, which means that moral principles gain their validity through approval by the culture or the individual.

Act-intuitionism This is a theory of ethics that states that we should consult our moral intuition (conscience) in every situation to discover the morally right thing to do. Jiminy Cricket would approve.

Action-based theory This theory, brought to you by Immanuel Kant, one of the most influential men in the history of Western philosophy, is based on the idea that we should act properly by following moral rules, and we can judge other people based on how they act , not on whether they are “virtuous people.” In case the underlining wasn’t obvious enough, this theory is most concerned with how we act.

Actual duty Duty theories base morality on specific, foundational principles of obligation. These theories are sometimes called deontological, from the Greek word deon, or duty, in view of the foundational nature of our duty or obligation 3.

2 Pojman, L. P. : A Defense of Ethical Objectivism 3 Samuel Pufendorf, De officio hominis et civis juxta legem naturalem (1673), tr., The Whole Duty of Man according to the Law of Nature (London, 1691).

5 In the case of actual duty , it means that when you have two duties that are in conflict, the stronger one overrides the weaker one and that is the one you should do. For example, if you work in a spa you have a duty to massage clients for your employer. If a client is on the schedule for you to massage and they inform you that they have DVT (Deep Vein Thrombosis), which contraindicates massage, you also have a duty to protect the client by not doing the massage. Both of these are your duties, but protecting the client is a stronger duty-so it overrides the other one, that is your actual duty.

Act-utilitarianism Act utilitarianism is a theory of ethics that states that a person's act is morally right if and only if it produces at least as much happiness as any other act that the person could perform at that time 4.

To understand how this might apply to you, imagine that someone asks you to donate your time doing chair massages at an event to raise awareness for cancer patients. Unfortunately the event is scheduled for your day off, and you were going to spend that day watching reruns of old TV shows on Netflix, because that is what makes you happy.

So you have a choice, stay at home and make yourself happy, or work the charity event and probably make a lot of people happy. According to act utilitarianism theory, the morally right thing to do is the charity event, because that is the act that will generate the most happiness.

Agapeism Agapism is the belief that selfless love (or "agape") should be the ultimate value and that all other values are derived from it, or in other words, love is the most important thing. Theological agapism holds that our love of God is expressed by loving each other. In ethical arguments, agapism tells us that we should do the most loving thing in any situation, letting love determine our obligation rather than rules. Sweet, right?

Altruism Altruism is the opposite of selfishness. It is the principle of concern for the welfare of others. Pure altruism consists of sacrificing something for someone other than yourself (sacrificing time, money, energy or

4 Lyons, David. Forms and Limits of Utilitarianism . Oxford: Clarendon Press, 1965, p. vii.

6 possessions) with no expectation of any compensation or benefits, either direct, or indirect (e.g., receiving recognition for the act of giving). In ethics, altruism can refer to an ethical doctrine that claims that individuals are morally obliged to benefit others. Used in this sense, it is usually contrasted with egoism , which is defined as acting to the benefit of one's self. We’ll talk about the fun of egoism later.

Antirealism, moral Anti-realism is used to describe any position involving either the denial of an objective reality or the denial that verification-transcendent statements are either true or false. In the context of this ethics course, it is the belief that there are no moral facts .

Applied ethics This is a specific branch of ethics that deal with the thorny issues of our time, like abortion, cloning, premarital sex, capital punishment, euthanasia (assisted suicide), and civil disobedience. Thankfully, we will not be dealing with it in this course, even though it kind of sounds like the title.

Autonomy This one is particularly relevant to us as massage therapists because it is one of the four key principles that our Standards of Practice is based on, and a core concept in medical ethics. We will be talking about it in the next chapter. It is from the Greek for “selfrule,” self-directed freedom.

Cardinal virtues Once upon a time there was a man named Plato who just happened to live in ancient Greece at a time when ancient Greece wasn’t doing too well. It was a time of decline of the Greek aristocracy and Plato was discouraged by the "mob" (majority rule) and the "elite" (group of nobles). He felt that majority rule is irrational and dangerous. This is because the average person lacks wisdom and self-restraint, making decisions from emotional responses based on desire and sentiment. On the other hand, the elite aristocracy is cruel, self-centered and greedy. Much of Plato’s teaching was on ethics and virtue. He identified four cardinal virtues , which are wisdom, temperance, courage and justice 5 and one of is students, Aristotle, went on to expand those virtues into the ideas that shaped virtue and ethics in

5 The four cardinal virtues: prudence, justice, fortitude, temperance Josef Pieper University of Notre Dame Press, Mar 31, 1966

7 western culture to this day. You are going to be reading a lot about Aristotle and the idea of virtue later in this chapter.

Care-ethics The moral theory known as “the ethics of care” wants us to believe that there is moral significance in human relationships, especially those that promote the well-being of care-givers and care-receivers. It is often defined as a practice or virtue rather than an ethical theory as such, “care” involves maintaining the world of, and meeting the needs of, ourself and others.

Categorical imperative This is another very important term in the study of ethics that was given to us by the philosopher Immanuel Kant. A categorical imperative is a moral law that is unconditional or absolute for all people, the truth of which cannot be disputed, no matter what justification you come up with for doing so.

The idea behind the categorical imperative is that it is supposed to provide a way for you to evaluate moral actions and to make moral judgments. It is not a command to perform specific actions -- it does not say, "never steal", or "never run red lights". It is a formal mental procedure we can go through when making a decision to see what the moral/ethical choice is.

Let me break down the idea for you in a simple way.

An imperative is a command. Say your boss at the day spa tells you "Perform a hot stone massage on the client waiting in room B."

According to the philosopher Kant, this kind of a command is an abbreviation, because it doesn’t tell the entire story-which would be “Perform a hot stone massage on the client waiting in room B, so that he can pay for it and I can give you part of the money."

This is what Kant called a "hypothetical imperative" meaning that the command depends upon the goals to be fulfilled. Hypothetical imperatives are commands that apply only in particular circumstances, for particular people who happen to have these desires, and goals. In the example above, you are only obligated to obey the imperative if you are interested in the result, which is getting paid for doing the hot stone massage.

8 This is different from a categorical Imperative which is universal and impartial -- universal because all rational people, would act in precisely the same way, and impartial because their actions are not motivated by their own desires, but because they believe it is the right thing to do (or not do, if the imperative is a negative).

So in the above example, "Perform a hot stone massage on the client waiting in room B" is a hypothetical imperative, your choice to obey the imperative really only matters to you desire to get paid and not get fired.

When you go in to do the massage the client tells you that he just opened his own day spa and he really liked your massage and he would like for you to come and work for him. He also wants you to make copies of all of your boss’s client intake forms and bring them with you, so that he can make sure you have enough clientele to stay busy.

In this second example there is a categorical imperative, because what the man is asking you to do is to steal your employers’ client list. We know that it is a categorical imperative because we can submit it to the test of universality.

It’s like when you were a kid and you did something to another kid and a grown up asked you “how would you like it if someone did that to you?”

The grown up was trying to teach you a categorical Imperative , because in their eyes what you did was wrong, no matter what your excuse was for doing it.

In the example above, you can ask yourself “How would I feel if I owned a business and someone that worked for me left and took all of my clients with her?”

This helps us make moral and ethical decisions in the real world because every person who breaks a law or does something unethical generally feels justified in doing it, but that doesn’t make it right.

In the example above you might say “But those clients like my massage, and I’m the one doing the massage, so why shouldn’t I leave and take them?”

9 Keep in mind that categorical imperative is NOT a description of how everybody does behave, as an ethical theory; its purpose is to help people decide how they ought to behave.

A lot of people like to compare the categorical imperative to the Golden Rule , one of the foundational principles of Christianity that greatly influenced western ethics -“Do unto others as you would have them do unto you.”

Consequentialism (see also teleological ethics) You have probably heard the old saying "the ends justify the means", meaning that if a goal is morally important enough, any method of achieving it is acceptable. This is an extreme example of the idea of consequentialism 6.

Consequentialism is an ethical theory that states the consequences of one's actions are the ultimate basis for any judgment about the rightness or wrongness of actions . Thus, from a consequentialist standpoint, a morally right act (or omission from acting) is one that will produce a good outcome, or consequence.

To bring this into our realm, a Physical Therapist will often guide their patients through a series of exercises that are quite painful, knowing that the end result will be restoring the injured part of the body back to health and functionality. The Physical Therapist is not a sadist that enjoys inflicting pain on their patient, they just know that what they are doing will, in the end produce the best result for the patient.

Conventional ethical relativism (conventionalism) Remember earlier when you read about Moral absolutism, the idea that certain actions are absolutely right or absolutely wrong, regardless of other circumstances? Well conventionalism is a branch of relativism, which is the opposite of that.

6 Mizzoni, John. Ethics: The Basics. John Wiley & Sons

10 than it is morally fine to do. So all moral principles are justified by virtue of their cultural acceptance. Here is one example:

In the year 1922 many public beaches had laws that mandated a woman’s bathing suit couldn’t be further than 6 inches from the knee.

The bathing suit code is one example of conventionalism-at the time a woman showing too much skin was considered wrong, today we laugh when we see this.

Culture changes, and while we might like to think that it always changes for the better, the scary truth is that it doesn’t. This brings me to my second example of conventionalism: The Eugenics movement.

Eugenics was a social movement in the United States that believed we should be using science to improve the genetic features of human populations through selective breeding and forced sterilization of undesirable people. It was practiced in the United States many years before similar programs in Nazi Germany even started and the U.S. programs actually inspired the Nazis. Over 20,000 “inferior” people were forcibly sterilized in California alone 7.

It’s tempting to look at the madness of the Eugenics movement and say “the people of the past sure were ignorant”-but remember, this movement was, at the time, espoused by scientists and universities across the country 8 and the people that were fighting it then were called “ignorant” and “old fashioned”.

Deontology The word deontology is derived from the Greek words for duty (deon) and study of (logos). So basically it’s fair to say that deontology is duty-based

7 California had the most, sterilizing people against their will for decades after WWII. Curious about your state? http://www.uvm.edu/~lkaelber/eugenics 8 Blom, Philipp (2008). The Vertigo Years: Change and Culture in the West, 1900-1914. Toronto: McClelland & Stewart, Ltd. p. 334. ISBN 978- 0-7710-1630-1.

11 ethics. These are ethics that concerned with what people do, not with the consequences of their actions. It argues that you should:

Do the right thing, and do it because it's the right thing to do.

Don't do wrong things, because they are wrong.

With this form of ethics you can't justify an action by saying “the ends justify the means”-you have to avoid doing what’s wrong simply because it’s wrong and there is no justification for doing otherwise.

Duty-based ethics teaches that some acts are right or wrong because of the sorts of things they are, and people have a duty to act accordingly, regardless of the good or bad consequences that may be produced.

A deontologist is a person that lives in a world bound by moral rules, such as: It is wrong to kill innocent people. It is wrong to steal from other people. It is wrong to intentionally deceive people. It is right to keep your promises.

A person that follows duty-based ethics will do the right thing, even if it produces an unpleasant result. For example:

A large amount of your massage income is in cash and when you sat down to do your taxes you realized that if you didn’t claim that cash you would get a tax refund.

If you follow duty-based ethics you would report 100% of your taxable income, even if it meant you didn’t get a refund and ended up owing more money in taxes.

Descriptive morality Descriptive morality is the study of actual beliefs, customs, principles, and practices of people and cultures. This is usually the domain of historians, sociologists and anthropologists or other academics as they observe the codes of conduct and rules of behavior accepted as standards in any society or group. Because they see morality being expressed in different

12 ways in different cultures they tend to view morality as being a cultural phenomenon, like language and traditions, and not a “universal” system.

Divine command theory Divine command theory is an ethical theory that proposes that an action's status as morally good is equivalent to whether God commands it. The theory asserts that what is moral is determined by what God commands, and that to be moral is to follow his commands.

It’s important to point out that this is not unique to any one particular religion-all religion that believes in a higher power or powers share this concept-in fact it’s kind of difficult for a religion to function without it.

Egoism, ethical Ethical egoism is the theory that everyone should always do those things that will best serve his or her own best self-interest 9. It is the opposite of Altruism, which stresses the value of giving time, energy and money to help or serve others. Egoism basically says “I’m looking out for number one.” While it doesn’t necessarily mean the person wants to harm others, the welfare of others isn’t their concern.

Egoism, psychological Psychological egoism is the theory that we humans always do what we perceive to be in our own best self-interest . That means that even when we are doing something that looks like selfless charity, we are actually motivated by self-interest.

Psychological egoism states that when people choose to help the homeless, or work to stop climate change, etc, they do so ultimately because of the benefits that they themselves expect to obtain, directly or indirectly, from doing so. This benefit might be nothing more than a sense of self-satisfaction, or it might be social accolades or even financial benefits. The view of psychological egoism is that if you didn’t get the benefit, you would never do the “noble thing” that you did.

Empiricism Empiricism, from the Greek word empeiria, “experience” is a theory that states that knowledge comes only or primarily from sensory experience 10 .

9 Sanders, Steven M. Is egoism morally defensible? Philosophia. Springer Netherlands. Volume 18, Numbers 2–3 / July 1988 10 Ethics: Discovering Right and Wrong: 7th Edition by Louis P. Pojman

13 Empiricism emphasizes the role of experience and evidence, especially sensory experience, in the formation of ideas, over the notion of innate ideas or traditions; empiricists may argue however that traditions (or customs) arise due to relations of previous sense experiences.

Empiricism is a fundamental part of the scientific method that all hypotheses and theories must be tested against observations of the natural world rather than resting solely on intuition, or theory.

This is good for you to know as a massage therapist, because most forms of manual massage therapy were developed in the ancient world based on this same method of observance and experimentation. Classical Greek medicine, traditional Chinese medicine and Indian Ayurveda all had their origin in empirical thought, the early natural scientists, who observed the working of the body and its reaction to different stimuli.

Error theory Error theory is a form of moral nihilism, which we will discuss in more detail later. It is a view that all ethical propositions are false (or cannot be true) — that we are generally in error when we make any moral statement. Error theory is built on three principles:

1. There are no moral features in this world; nothing is right or wrong.

2. Therefore no moral judgments are true; however,

3. Our sincere moral judgments try, but always fail, to describe the moral features of things.

So Error Theory is the view that moral statements claim to report facts but such claims are in error and no moral claims are actually true 11 . In other words, there is no such thing as right or wrong. Personally I don’t know how these people stay out of jail.

11 D. Brink, "Moral Realism and the Skeptical Arguments from Disagreement and Queerness," Australasian Journal of Philosophy 62 (1984)

14 important for us massage therapists because people from different cultures view massage therapy, the human body and nudity in very different ways. In fact it’s so important you are going to be reading a lot more about it later in this course.

Fact–value distinction In ethics, the term Fact-value distinction refers to a distinction between what is and what ought to be .

What is are those things that can be discovered by science, philosophy, or reason.

What ought to be is a judgment agreed to by consensus, or believed to be objectively morally binding.

So you are probably thinking “Yeah…so what?”

In ethics the fact-value distinction represents a problem because it challenges us with the question “Are morals or ethics real?”

Facts are the elements of reality that make declarative sentences true. Take this statement for example:

“I got a massage today from my massage therapist.”

If that statement is true it is made true by the fact that a certain individual, the massage therapist, did something for me, namely give me a massage. If reality did not contain this fact (say, because I never went to the appointment, or the massage therapist double booked and couldn’t fit me in) the sentence would not be true.

A similar analysis can be made of any fact. Now here is where the problem comes in. Are there such things as moral facts ?

For example I can make the statement “It is wrong for a massage therapist to cheat on their taxes.”

What possible elements of reality would make that sentence true? It is certainly illegal for them to cheat on their taxes, but how do I prove that it is wrong? You see I can point to law books that say they need to pay their

15 taxes, but where do I point to prove something is morally wrong? This is what in ethics is called the fact–value distinction, or sometimes, the fact- value problem, and we have the philosopher David Hume to thank for it.

Hedonism, ethical The theory that pleasure is the only intrinsic positive value and that pain is the only negative intrinsic value. Basically, a hedonist is a person that strives to maximize net pleasure (pleasure minus pain).

Ethical hedonism is the idea that all people have the right to do everything in their power to achieve the greatest amount of pleasure possible to them. It is also the idea that every person’s pleasure should far surpass his or her amount of pain. Ethical hedonism as a philosophical discipline is believed to have been started by a student of Socrates, Aristippus of Cyrene. He held the idea that pleasure is the highest good. I’m guessing he was probably pretty popular and was invited to a lot of parties.

Heteronomy The term heteronomy refers to the condition of being under the domination of an outside authority, either human or divine. It applies to politics, law, religion, language, etc.

In our case, it would be the massage licensing boards of our states.

Hypothetical imperative The hypothetical imperative is the non-moral principle that proposes you obey an imperative (command, order, etc) not because it is good or right to do so, but because there is a motivation that follows directly from obeying. In the example used earlier for the categorical imperative, “Perform a hot stone massage on the client waiting in room B, so that he can pay for it and I can give you part of the money."

Hypothetical imperatives are commands that apply only in particular circumstances, for particular people who happen to have these desires, and goals.

Indeterminacy of translation Indeterminacy of translation is a theory proposed by philosopher W. V. Quine which suggests that languages are often so fundamentally different from each other that we cannot accurately translate concepts from one to

16 another; which would mean that each society’s moral principles depend on its unique linguistically grounded culture 12 .

Instrumental good A thing that is desirable because it is an effective means of attaining intrinsic goods . A good example of this would be money. Money has no value by itself; its only value is that it can be used to buy other things, things that do have value.

Intrinsic good An intrinsic good is something that has value just for what it is, unlike an Instrumental good (above). An example would be “Happiness”-which is good because of what it is, not because it can bring you something else.

Intuitionism Intuitionism is the theory that humans have a natural faculty that gives us an intuitive awareness of morality. For this to be true we have to believe that there are real objective moral truths that exist independently of human beings. In other words, even if there were no humans on earth, lying, cheating and stealing would still be wrong, because they are just wrong.

Intuitionism tells us that these truths are fundamental and can't be broken down into parts or defined by reference to anything except other moral truths. We human beings don’t make up these moral truths, but we instead become aware of them by using our minds in a particular, intuitive way .

Intuitionism is closely related to Act-intuitionism, which is the theory that we should consult our conscience in every situation to discover the morally right thing to do.

According to intuitionism, our minds enable us to discover the basic moral truths, and our everyday moral decision-making then involves thinking about the choices available and making moral judgments in an ordinary sort of way.

Metaethics Metaethics is the most abstract area of ethical study, so I am not going to spend a lot of time discussing it. Basically, instead of concentrating on

12 Willard Quine (2013). "Chapter 2: Translation and meaning". Word and Object (New ed.). MIT Press. pp. 23–72. ISBN 0262518317.

17 people’s actions and attitudes, metaethics attempts to describe the nature of good and bad and right and wrong. It asks the questions “Are good and bad inherent qualities, or do they depend on your point of view?” and “How can we know what is really right and wrong anyway?” These are time- consuming questions fit only for people that don’t have real jobs to go to, like college philosophy professors.

Moderate objectivism This is the theory that at least one objective moral principle exists and some core moral values are shared by all or most cultures. These objective principles are sometimes called “ prima facie principles ” which is a Latin term that means “on the face of” or “at first glance”-it refers to principles that are so important they override other principles.

According to W. D. Ross, a Scottish philosopher who was well known for his work in the realm of ethics, there are several prima facie principles that we can use to determine what our true duties ought to be 13 . A prima facie duty is a duty that is obligatory, meaning that when we have to decide between several different courses of action, the one that is most closely aligned with a prima facie duty is the one we are obligated to choose, it trumps all other duties or choices.

The prima facie duties identified by W.D. Ross are:

1. Fidelity. The duties of fidelity are our obligations to keep promises, honor contracts and not to willfully engage in deceptions.

2. Reparation. This is a duty to make up for the wrongs we do to others.

3. Gratitude. The duty of gratitude is a duty to be grateful for things you are given or things that are done on your behalf.

4. Non-injury. The duty of non-injury (also known as nonmaleficence, which you will see again in this course several times) is the duty not to harm others physically or psychologically.

Other ethical philosophers have added to the four prima facie principles originally listed by W.D. Ross. Some of those include:

13 Ross, W. D., 2002. The Right and the Good. Edited, with an Introduction, by Philip Stratton-Lake. New York: Oxford University Press; rpt. of original 1930 edition.

5. Harm-Prevention. Once again, this is the prima facie duty of a person to prevent harm to others from causes other than him- or herself.

6. Beneficence. The duty to do good to others: to foster their health, security, wisdom, moral goodness, or happiness. (Beneficence is another term you will be seeing again in this course-it’s kind of important).

7. Self-Improvement. The duty of self-improvement is our responsibility to promote our own good, and that good is defined as meaning health, security, wisdom, morality, and happiness.

8. Justice. The duty of justice requires that one act fairly, to do what is right by other people, which includes following laws that are good.

Natural law theory Natural law theory is a system of thought that proposes that laws are determined by nature , and so they are universal. This is important to us Americans because our founding fathers were big believers in Natural law theory and referenced it in both the Declaration of Independence and the Constitution of the United States.

Natural law refers to the use of reason to analyze human nature and to deduce binding rules of moral behavior from it.

For example, it’s natural for a person to want to own private property, so we can deduce that there should be laws protecting private property rights. It’s also natural for us to want to be paid for doing work, so it follows that we would pass laws that guarantee us the right to charge money for our services and to be paid.

It’s not natural for human beings to murder each other, so we have laws that prohibit that. That is how Natural law works, it is based on the idea that morality is a function of human nature and reason can discover valid moral principles by looking at the nature of humanity and society.

19 Naturalism Naturalism is the idea that only laws of nature (the physical world) exist and so our system of morality and ethics should be based on natural properties within the world, such as pleasure or satisfaction. It basically denies the existence of the spiritual or supernatural ideas.

Adherents of naturalism assert that natural laws are the rules that govern the structure and behavior of the universe and that the changing universe at every stage is a product of these laws 14 .

Naturalistic fallacy This is a problem ethical philosophers struggle with. Most ethical arguments revolve around what is “good”-but that changed when a philosopher named George Edward Moore published a book called Principia Ethica 15 , where he dropped this mind blowing notion that every philosopher before him was wrong to argue about what is good because there is no way to definitively define what “good” actually is.

I’m guessing he didn’t get invited to a lot of the philosophy professor’s mixers.

Negative responsibility This is the idea that we are not only responsible for the things we do, but we are also responsible for things we don’t do, or allow to happen 16 . A good example of this is the saying by the philosopher Edmund Burke:

“The only thing necessary for the triumph of evil is for good men to do nothing.”

To see this idea in our world, imagine that your massage client started having a heart attack at the beginning of your massage session. If you decide to take that moment to check your voicemail and send a few text messages instead of calling 911 and the man dies you had a negative responsibility. You didn’t kill the man, but you allowed him to die by doing nothing.

14 Papineau, David "Naturalism", in "The Stanford Encyclopedia of Philosophy" Papineau used the term "ontological" instead of "metaphysical." 15 George Edward Moore, Principia Ethica, Cambridge, Engl.: Cambridge UniversityPress, 1903. 16 Ethics: Discovering Right and Wrong: 7th Edition by Louis P. Pojman

20 Nihilism, moral Nihilism comes from the Latin word "nihil" -- which means, nothing. The moral nihilists assert that there isn’t any such thing as moral values, principles, or truths, so there is no point concerning yourself with them. A nihilists denies the existence of… A meaning to life in general (we're all just here by accident) Human destiny (I'm here for a reason) Moral principles (be honest, be kind, don't be violent, etc.) Moral values (life, honesty, freedom, etc.) Moral order of the universe (God)

So moral nihilists believe there are no moral facts, moral truths, and moral knowledge 17 .

Nonnaturalism As the name suggests, this theory is the opposite of naturalism. It suggests that moral values are grounded in non-natural facts about the world (facts that can’t be detected through scientific means).

Objectivism, moral Moral Objectivism is the view that what is right or wrong doesn’t depend on what you or anyone else thinks is right or wrong. In other words, 'moral facts' are like 'physical' facts in that what the facts are does not depend on what anyone thinks they are.

There are two main objectivist theories in ethics, both of which I have already written about:

Duty Based theories (see Deontology) that claim that what determines whether an act is morally right or wrong is the kind of act it is.

Consequentialist theories (see Consequentialism) that state what determines whether an act is right or wrong are the consequences of the act itself.

So basically a moral objectivist is a person that believes there are universal moral principles, valid for all people and cultures.

17 The nature of morality: an introduction to ethics Gilbert Harman Oxford University Press, 1977

Obligatory act This is an action that morality requires you to do. Throwing a life preserver to a drowning person, for example. This is in contrast to what ethicists call an “optional act”.

Optional act This is an act that is neither obligatory nor wrong to do. Ordering popcorn in a movie theater is an optional act. If you do it or don’t do it, it really has no bearing morally.

Overridingness This is a funny word that basically means that moral principles have a special authority that gives them more importance than other principles.

Practicability In the realm of ethics practicability refers to a view that believes moral principles must be workable for the average person and its rules should not lay a heavy burden on us when we follow them. The rule here is to do what is right in a sensible way.

Prima facie duty We mentioned this earlier, under moderate objectivism. A prima facie duty is a duty that is obligatory, meaning that when we have to decide between several different courses of action, the one that is most closely aligned with a prima facie duty is the one we are obligated to choose, it trumps all other duties or choices.

Problem of posterity In ethics the problem of posterity refers to the problem of determining what obligations we owe to future generations of people who do not yet exist.

It’s easy to say that this is only something politicians and history teachers should worry about, but it relates to massage therapists too. Every time your city or state passes a new law regulating (or deregulating) massage therapy it not only matters to you, but it also matters to the next generation of massage therapists coming after you.

A good example would be when I went to get my first massage license. I live in California, a state that does not have a state licensing board for

22 massage therapy-here every city and town regulates massage therapy on their own.

The city ordinance regarding massage therapy where I lived at the time had been written during a dark era in our industry. One of the requirements for me to get my license was a doctor’s note saying that I had no venereal diseases. The city ordinance also said that:

“it is unlawful for a man to leave his legal wife at a massage parlor or bathhouse to work.”

I wish I was making that up, but that was still on the books when I became a massage therapist. So please pay attention to the laws that are being passed regarding massage in your city and state and think about the massage therapists in the future.

Publicity No this isn’t about advertising. In ethics the term “Publicity” refers to a belief that moral principles must be made public in order to guide our actions, like giving advice, praise or blame. It also inspires others to see the example of the ethical life being led, so it would be counterproductive to keep your ethics a secret.

Rationalism Rationalism, in philosophical/ethical circles, is the view that regards reason (thought, logic, etc) as the chief source and test of knowledge. The rationalist believes that reality itself has an inherently logical structure and that a class of truths exists that the intellect can grasp directly.

Because of this, certain rational principles, especially in logic and mathematics, but also in ethics, are so fundamental that to deny them is to fall into contradiction. The rationalist’s confidence in reason and proof tends, therefore, to detract from his respect for other ways of knowing.

Realism, moral A moral realist believes that moral facts exist and are part of the fabric of the universe; they exist independently of whether we believe them or not. Like gravity, it exists and you can choose to not believe in gravity if you want to, but that doesn’t allow you to fly because it exists whether you believe in it or not.

The moral realist would say that “right” and “wrong” are like gravity. You can say they don’t exist, but that doesn’t change the fact that they do.

Relativism, ethical Remember when we looked at conventionalism, and I gave you the examples of the bathing suit codes and the eugenics movement? Well conventionalism is a branch of relativism.

Ethical relativism states that moral principles gain their validity only through approval by the culture or the individual.

Situationalism, ethical In Situationalism, also called situation ethics, right and wrong depend upon the situation at hand . There are no hard and fast moral laws to follow, just general guidelines that are flexible and fluid and can change on a case-by- case basis 18 .

In other words, a person who practices situation ethics approaches ethical problems with a general principle, like “do what’s fair for everyone involved” or “treat everyone the way you would want to be treated” and then they try to shape their decisions to get the best result in the situation, and the best result being whatever is closest to their general principle.

For example, a person applying situational ethics might believe that lying is not in the best interest of interpersonal communication and social integrity, but is justifiable if it means not hurting someone’s feelings, because sparing the feelings of other people is closer to their general principles than always telling the truth.

Social contract theory Social contract theory is another important concept for us Americans. Some of the famous philosophers that argued for this theory include Thomas Hobbes, John Locke and Jean-Jacques Rousseau-all of which were influential to the thinking of our founding fathers.

18 Joseph Fletcher, Naturalism, situation ethics and value theory, in Ethics at the Crossroads, 1995

24 Social contract theory is the idea that persons’ moral and/or political obligations are dependent upon a contract (agreement) among all the people in the society in which they live.

Basically it’s the idea that people collectively agree to behave morally and lawfully as a way to reduce social chaos and create peace. We are able to live in cities because people all agree to not murder, rape and steal from each other. Those that do these things are “breaking the social contract” and as a result are usually locked up away from the others.

One of the reasons why the founding fathers of our country liked this theory so much is that it places limits and responsibilities on political leaders. Social contract theory proposes that if a leader or elected representative isn’t doing what’s best for the people, a new leader or representative is needed-that’s part of the contract 19 . That would work great if we could just get the people to decide what works best.

Sociobiology This theory states that social structures and behavioral patterns are biologically based and explained by evolutionary theory. For example:

The hypothalamus and limbic system are entirely responsible for the emotions of hate, love, guilt, and fear 20 . Sociobiologists believe that since all of our emotions are simply caused by juices being squeezed out of glands the concepts of ethics and religion evolved under the pressure of natural selection. All of the purported benefits of ethics and religions, good will toward man, altruism, cooperation, mutual aid, etc. are all explainable in biological terms. Moral conduct aided the long-term survival of the human animal, so that is why we do it.

Solipsism, moral Solipsism is the philosophical idea that only your own mind is real. This is an extreme form of egoism, generally only encountered in sociopaths and other people that don’t fit in well with society. If you believe that you are the only person that is real, and everyone else in the world is just part of your dream, you are a solipsism. You might also be crazy and you should probably get that checked out-but you won’t because you don’t believe the doctor is real. Moving on.

19 Rousseau, Jean-Jacques. The Basic Political Writings. (Trans. Donald A. Cress) Hackett Publishing Company (1987). 20 Wilson, Edward O. (1975) Sociobiology: The New Synthesis, Harvard University Press, Cambridge, Massachusetts.

State of nature A war of all against all where there are no common ways of life, no enforced laws or moral rules, and no justice or injustice (Hobbes).

The state of nature is a concept in philosophy to denote the hypothetical conditions of what the lives of people might have been like before we all adopted the “social contract”.

We say it is hypothetical not just because there are no written records of what life was like before civilization (obviously), but because the earliest human remains found by anthropologists still show humans living in family groups, so it can be argued that there was some form of social contract even then, Others argue that many animals live in groups without a social contract and early humans were no different, the social contract did not come into effect until we had formal governments.

It’s an important concept in ethics and philosophy because some people argue that there are no rights in the state of nature, only freedoms, and it is the social contract that creates rights and obligations. In other versions the opposite occurs: the contract imposes restrictions upon individuals that curtail their natural rights.

Subjective ethical relativism (subjectivism) Subjectivism is the view that all moral principles are justified by virtue of their acceptance by the individual making the judgement . In other words, there is no such thing as right or wrong; just what I FEEL is right and wrong .

Supererogatory act Supererogation, from the Latin word super-erogare, means, “paying more than is due”, in ethics it is a term we use to describe an act that exceeds what reasonable morality requires. In other words, it goes “above and beyond the call of duty.”

Teleological ethics (consequentialism) Teleological ethics, like consequentialism, states that the center of value is the outcome or consequences of the act; if the consequences are good, then the action is right; if the consequences are bad, then the action is wrong.

Universalizability In ethics the concept of universalizability is part of the process we go through when using the categorical imperative (page 9) in decision- making.

The first formulation of the categorical imperative states that decision is universal and impartial -- universal because all rational people, would act in precisely the same way in the same situation.

Here’s an example:

You want to open a new massage business, so you are applying for a business loan from your bank. You are afraid that they will not loan you the money if you are truthful on the application. Is it okay to lie on the application?

If you are using the categorical imperative to make your decsion the first thing you would ask yourself is “Would everyone lie on the loan application?” or even better “What if everyone lied on their loan applications?”-the answer is of course no, not everyone lies on their loan application and if they did banks would stop lending money because they would quickly become insolvent due to the number of people refusing to pay back loans they couldn’t afford and should not have taken out in the first place.

This is universalizability, the concept that moral principles must apply to all people who are in a relevantly similar situation.

Verification principle The Verification principle, also known as the verifiability principle, is a philosophical doctrine holding that a statement is meaningful only if it 1. Is empirically verifiable (can be proven scientifically). 2. Is tautological (that word means that it is true by definition-i.e he got wet standing in the river is a tautological statement).

Vice The opposite of virtue, in ethics the term “vice” refers to a conditioned behavior, often habitual, that results in an act of moral wrongness.

27 Maybe you have noticed from watching crime dramas on TV that there is a special division of police departments that deal exclusively with “Vice” crimes.

Vice crimes are those that offend the morals of the community, such as prostitution and pornography. The responsibilities and duties of those who enforce laws against vice crimes include, but are not limited to conducting moderate to complex undercover surveillances and investigations which target prostitution, lewd public sex acts, adult entertainment, gambling and alcohol offenders in both city and county jurisdictions.

Here in California, law enforcement officers who deal with vice crimes often have other duties, they are, for example, responsible for conducting the background investigations on permit applicants of massage establishments, massage technicians , bingo establishments, card rooms and their employees and cabaret permits.

Virtue The opposite of vice, virtue is a trained behavioral disposition that results in a habitual act of moral goodness.

Virtue-based theories Another theory brought to you by Kant, this one suggest that we should acquire good character traits, not simply act according to moral rules, and morality involves being a virtuous person.

Virtue theory (virtue ethics) Virtue theory, or as it is sometimes called, “virtue ethics” is a broad family of theories that emphasize the importance of character and virtue in moral philosophy, elevating it above doing one’s duty or performing actions based on their intended consequences.

A person that practices virtue ethics would approach decision making by asking himself or herself “What would a virtuous person do in this situation?” and then do what they believe a virtuous person would do.

The ideas of virtue ethics go all the way back to the ancient Greeks, Aristotle in particular, who stated that a virtuous person is someone who has ideal character traits. These traits come from natural internal tendencies (the Greeks believed man was naturally good), which need to

28 be nurtured. Once these good tendencies were firmly established in a person they would guide his or her behavior through their entire life, and they would do good because it would be in their nature, not because of any potential reward for doing good or punishment for doing wrong.

Summary of terms Well that concludes the first half of our ethics primer, an introduction to basic terms that we use when discussing ethics. If you feel lost or overwhelmed don’t worry, we will be getting to the massage therapy specific applications very soon.

The second half of this chapter is an attempt to zero in on what exactly is “good” and “virtue” as it applies to us. As you already read, there are a lot of different theories of ethics out there, and all of you are on one of those paths, whether you know it or not.

That’s right. Some of you are moral absolutists, others are moral relativists, objectivists, consequentialists or even hedonists. Even if you have never stopped to consider what type of ethics you follow you are on an ethical path . Some of those paths can help you be a prosperous and successful massage therapist, while others make it dangerously easy to ignore rules and stray away from the standards of practice.

Virtue and Integrity What it means to Be Good Now this next part might be a little unpleasant to read (like the first part was a day at the carnival, right?) but it’s a necessary part of the ethics primer.

We spent the first 30 pages introducing you to a variety of ethical theories just to make you familiar with the terms-but those short introductions don’t help you to be a better person-just a better educated person.

So now we are going to dive a little deeper into Virtue Theory, because virtue and integrity are important parts of being an ethical person. In the following chapters we will focus on what it takes to be an ethical massage therapist .

If this sounds condescending I apologize. Believe me I assume that each and every one of you is already a person of impeccable character and moral fortitude, but we are required to study ethics for a reason (and the

29 reason why isn’t all bad, as you will see in the next chapter it’s actual an honor to be required to study ethics).

The theory of virtue ethics states that the most important part of living an ethical life is your personal commitment to being a good and virtuous person.

To fully grasp what that means we have to explore the concept of virtue in more detail. Virtue can be defined as good habits, behavioral traits that direct you towards doing what is good, for others and for you.

Where our concept of Virtue comes from Many cultures gave us philosophers that explored the ideas of ethics and virtue, as well as many religious traditions. In our western culture the ideas of virtue are traced back to ancient Greece.

Plato is one of the Greek philosophers that gets the credit for defining virtue for us, but it was one of his students, Aristotle, that made it popular. So popular in fact it was the dominant theory in Western ethical philosophy until at least the explosion of enlightenment thinkers in the 17th century. Aristotle believed that true virtue lies somewhere along a continuum between deficiency and excess — the so-called golden mean .

The 'golden mean' is the desirable middle ground between too much of something and not enough of something.

Take freedom for example.

If we have an excess of freedom we have anarchy, stealing, murder, rape, people doing whatever they want and that’s not good.

But if we have a deficiency of freedom we live under oppressive regulations and totalitarianism, and that’s not good either.

So virtue in government is giving us just the right amount of freedom, so that we can do what we want as long as it isn’t hurting others. That’s the ‘golden mean’ in government.

30 On a personal level you can take the virtue of courage. If you have too much courage you are likely to be reckless and overconfident. If you have too little courage you would be a coward and would never take risks.

Of course the idea of the ‘golden mean’ isn’t unique at all to western culture. Chinese philosophy produced a similar concept called the Doctrine of the Mean, and the great Confucius promoted it. Buddhist philosophy also includes the concept of the middle path, (moderation in all things) so this is an idea that is as deeply rooted in Eastern cultures as it is in our Western society.

There was only one area in which Aristotle argued against the idea of moderation and that was in the acquisition of knowledge. Ignorance is a deficiency of knowledge, but Artistotle stated that there was no such thing as an excess of knowledge, you can never have too much knowledge, and so the golden mean did not apply to what he called the virtue of “wisdom”.

(So if you were going to say that you have already read an excess of boring philosophical ethics you can forget about it, Aristotle was way ahead of you.) According to Aristotle, every virtue other than wisdom has both a deficiency and excess and wisdom lies in finding the optimal point between the two.

There were four virtues described by his teacher Plato; temperance, wisdom, courage and justice. Aristotle added a few more to the list in a series of writings called the Nicomachean Ethics (nobody knows why it’s called that, but Aristotle’s father and son were both named Nicomachus so they may have been inspired by his father or written for his son, or a little of both) 21 .

Some of the virtues are:

Generosity To Aristotle virtue lies in finding the balance between miserliness and extravagant giving/spending, which he called liberality.

21 Aristotle (1955). The Ethics of Aristotle: The Nichomachaen Ethics. (rev. ed.) (J. K. Thomson, trans.). New York: Viking. p. 104.

31 Greatness of soul An odd term to us modern people, to Aristotle this mean soul meant “ego” or what we would call self-esteem today. What you should seek here is a middle ground between vanity and unwarranted humility.

Temperance Another old-fashioned term you don’t see much anymore (unfortunately) the word temperance literally means “moderation” and in this case Aristotle is talking about things we consume and sensual pleasures. The balance between overindulgence and self-denial in food, alcohol, TV, sex, artificial tanning, etc.

Modesty An important one for us massage therapists I think, the virtue of modesty was to Aristotle the middle ground between bashfulness and shamelessness. We wouldn’t want clients that are so worried about removing garments they couldn’t enjoy a massage, but we also don’t want them strutting around our workplaces nude either.

Magnificence This is all about class, because the Greeks were, if nothing else, classy people. After all, that’s why we call it the classical period.

To Aristotle the virtue of Magnificence meant you were walking the middle path between being a petty person who is easily offended by everything or being a vulgar boor who offends everyone.

Courage The virtue of courage puts you in the middle of rashness (recklessness) and cowardice. This doesn’t just apply to physical danger, but as you will see in later examples courage applies to a great many ethical challenges. Remember earlier in this chapter when I mentioned the eugenics movement? Many college professors in this country supported it, would you have had the courage to tell them they were wrong and that their “science” was bogus?

Social Conduct According to Aristotle, there is a middle ground between obsequiousness (that means being a suck-up and fawning over someone) and the opposite, which is being cantankerousness (overtly unfriendly).

Honor Another old-fashioned term that many people today have no concept of. You might have been on the honor roll in your school, or been an honors graduate, but what does that mean? The American culture doesn’t obsess over honor the way other cultures do, (the ancient Greeks definitely did) and that is a shame, because it explains a lot about our society today.

Honor in this context is pride, not to be confused with Greatness of soul, which is self-esteem. Pride and self-esteem are not the same thing, you can have pride and no self-esteem, and you can have self-esteem and no pride.

Pride shows that you care about something. When you take pride in your work, it means you put a lot of thought and effort into it. Being an honors graduate is something to be proud of.

To have an excess of pride results in vanity, and a deficiency of pride is shame or disgrace.

Self-expression Aristotle believed that self-expression was a virtue (not surprising considering he was a philosopher and all they do is talk about what they think). An excess of Self-expression makes people boastful, and a deficiency makes them understated and timid.

Conversation Human interaction is important. Aristotle believed that too much conversation makes a person a buffoon or a gossip, and too little makes a person boorish (rude).

Indignation This isn’t something we typically think of when we are pondering “virtues” but Aristotle makes a good point. Indignation is what spurs into action when we know others are doing wrong, it’s our innate sense of justice.

Aristotle argued that too much indignation leads to envy and too little leads to spitefulness. The golden mean of indignation is what is typically referred to as “righteous” indignation-meaning that you are offended when you see some someone commit an act that you know is wrong.

According to Aristotle, these virtues aren’t rules to follow, they are states of being -you are either on the golden mean or you’re in excess or deficiency in one or more of the areas. This led to an important element of ethics- separating inclination form action.

Separating inclination form action We are all inclined to be honest, because nobody likes being lied to. It’s human nature. Aristotle believed (like most Greek philosophers) that humans want to be good because we are good at heart, but we don’t actually become good unless we make ourselves practice it.

So if your massage client accidentally drops money in your massage room while getting dressed and doesn’t notice you have a choice to say nothing and keep the money or to point it out to him or her and be honest. According to Aristotle, your inclination is to be honest and tell, but that’s not enough to make you virtuous, you have to actually do the action and speak up.

And not just once, but over and over again. Aristotle argued that in order to be a virtuous person you have to exercise the virtues repeatedly, at every opportunity to make it a habit. When it becomes a habit, and you do the right thing without even thinking about it, you have become a virtuous person.

Aristotle spent a lot of time teaching his pupils about habit forming because to him it was an important element of ethical conduct. Just doing the right thing once in a while, when you feel generous, doesn’t make you a virtuous person.

The cultivation of an ethical habit works both ways. If you repeatedly make dishonest or even selfish choices they will become a habit as well. When you have habits that are the opposite of virtuous it doesn’t stay private, and it will eventually start to have an impact on all facets of your life, both professional and personal.

Assess yourself In the example above, with the client dropping money in your massage room, what would be your first inclination, to be honest and tell them, or to keep it? According to Aristotle, the first thought that pops into your head

34 when you see that money is an indication of the habits you have been developing and shows what type of person you are, either virtuous or not.

Don’t despair if your first inclination is to keep the money-as long as you are now aware of it you can start practicing good virtues, and if you keep practicing them they will become second nature.

Virtues and Duties as Massage Therapists Massage therapists have had “Codes of Conduct, and Standards of Practice” for as long as there have been professional massage therapy organizations. We will discuss these later in this course, but for right now let me just say that these codes of Codes and Standards focus on behavior (usually the behaviors that they prohibit). In other words, codes of conduct and Standards of Practice are generally based on rules to follow, or Duties .

The aim of virtue ethics is to become a better person rather than simply to improve your behavior. Applying virtue ethics to your massage practice will help you make better choices, and as a result following the Codes of Conduct and Standards of Practice will be second nature.

Deontology and Standards of Practice If you are a licensed massage therapist you probably have a Standard of Practice, or Ethical Code of Conduct that somebody wants you to follow, and that somebody is usually whoever granted you your license.

Standards of Practice fall under the area of Deontological Ethics, which we introduced you to earlier in this chapter. In case you forgot already, the word deontology stems from the Greek word for “duty” or “obligation.”

Deontological Ethics states that a practical ethical theory has to include reasons for following it , they can’t just say, “do this because it’s right”-there has to be a justification of the theory’s rightness. In this case the justifications for ethical behavior stem from principles of obligation, or duty, and the rights of others.

With the deontological ethical theories, behaviors are inherently right or wrong, and individuals are morally obligated to act only in right ways.

Deontologists believe that following rules have an important place in our decision-making process and when it comes to professional people such as

35 ourselves, Standards of Practice and Ethical Codes of Conduct are duties that we have a moral obligation to follow.

In both virtue ethics and deontological ethics, the consequences of doing the right thing (i.e. acting morally) are not the most important factor in making ethical decisions. I am going to repeat that, because it’s important.

The consequences of doing the right thing are not the most important factor in making ethical decisions.

The most important thing with virtue ethics and deontological ethics (duty ethics) is acting from virtue or one’s duty; the consequences of action or inaction are of less or little significance . The reason why this is important is because people will often fail to do the right thing if there is little or no consequence, especially consequence to themselves.

To illustrate this point, let’s go back to the example of the massage client dropping money in your massage room, but let’s add that the client is known to you, a regular. You know that this client is short on funds because they talk during their massage and one of the stressors they talk about is having too many bills to pay.

There is now an obvious negative consequence to your client if you decided to keep the money.

According to both the virtue and deontological theories of ethics this consequence shouldn’t matter to you. Why? Let’s change the example a little bit.

Let’s say the client is still known to you and is a regular, but instead of being someone who is tight on funds he or she is an investment banker that makes a lot of money, and you know that because they talk during their massages and they tell you all about how much money they make.

Now the consequence of you keeping the money is not as negative to your client, in fact, you can rationalize that they wouldn’t even miss it. You might even go so far as to say that it was karma…

36 What just happened? When you start looking at the consequence of the choice instead of the inherent rightness or wrongness of the choice itself it becomes easier to do the wrong thing, which is of course to keep the money-because it’s not yours.

You see the choice didn’t change; it still comes down to telling your client that they dropped some money or being quiet and keeping it.

If you would keep the rich clients money, but return the poor clients money you are making a decision that is not based on the rightness or wrongness of the act.

This is why the consequences of the decision should not be the determining factor if you are trying to be a virtuous and ethical person; it’s the act that matters, not why you do it (or don’t do it).

Stripping away the consequences and focusing on the act itself is hard to do sometimes (actually it’s hard to do A LOT of times). That is why Immanuel Kant gave us the categorical imperative .

Using Kant’s categorical imperative I’m sure you remember the concept of the categorical imperative; it’s a method of determining whether an action is right or wrong by identifying the principle for the action and then asking yourself if that principle can be applied universally.

So for our example of the client dropping money in your massage room, you can ask yourself “Would it be okay if everyone decided to keep the money that they saw someone else drop?”

When we say “everyone” that means whether the client is rich or poor doesn’t matter. When we apply the choice universally it doesn’t matter if it’s a wealthy and spoiled dot-com billionaire or a widow on a fixed income-if it’s not right for both than it’s not right for either.

Another way to apply this is to say, “What if you were the client and it was your money that was dropped?” I’m willing to bet you would want the massage therapist to tell you that you dropped your money. This is how the

37 categorical imperative works-it takes away the distracting factors and gets right to the right or wrong of the action itself.

The categorical imperative is a way for you to see if the principle of a proposed action is morally acceptable. When you use the categorical imperative to determine if your actions are ethical and morally acceptable it means that you are: Doing the ethical thing when your action would be the right thing for anyone in the same position to do .

Treating all people as an intrinsic good and not an instrumental good (meaning that the people have value themselves, they are not valuable because of what they can do for you).

According to Kant, you are using the categorical imperative right if you are imagining that your conduct is establishing a universal law that governs others in similar circumstances 22 .

In other words, if you decide to keep the money your massage client dropped than you are establishing a universal law that means anyone else in the same position would be right to keep the money-and that includes when it’s a poor widow on a fixed income dropping the money.

The Power of Moral Universalism The concept of moral universalism, the idea that some actions are always right or wrong, has its foundation in the categorical imperative and has had a strong influence on western society.

The evil of eugenics was defeated because moral universalists were able to successfully argue that certain behaviors are inherently right or wrong, regardless of the current cultural climate. It didn’t matter that college professors and certain very vocal scientists thought it was a good idea to sterilize people against their will to “improve the gene pool”-it could never be considered moral under Moral Universalism and the test of the categorical imperative.

22 Paton, H. J., 1947, The Categorical Imperative: A Study in Kant's Moral Philosophy. London: Hutchinson's University Library.

38 The ethics of Immanuel Kant classifies some actions as universally unethical or immoral based on the logic of the categorical imperative. Some of those universally “wrong” behaviors are:

Lying and deliberate deception When we first introduced the idea of the categorical imperative we used the example of lying on a loan application from the bank. We were able to deduce, using the idea of the universal law, that it would be wrong to lie on the application, because if everybody did that the banks would either stop making loans (causing critical damage to the economy because many businesses need those loans) or they would go bankrupt from all the loans that were given to people that couldn’t pay it back (also damaging the economy).

Honesty has to be a universal law, because if it wasn’t nobody would accept promises from anyone, if they bothered to make promises at all. Deceptions of all types, including lying, violate the categorical imperative because they can’t logically become universal laws that govern everyone.

Stealing Like deception above, society can’t function if everyone helped himself or herself to everyone else’s property. Since people can’t consent to having their property stolen (if they consented it would be lent or given, not stolen) stealing represents a violation of the victim’s rights. You are not just taking a thing, you’re taking the persons ability to use the thing, to sell it, or to give it to someone else.

That’s why stealing is morally wrong, regardless of a persons personal views about property ownership.

Laziness Immanuel Kant argued that if everyone refused to pull their own weight society would quickly fall apart. We all know that there are many people who, because of circumstances or disabilities cannot work right now, but there are also people that can work and refuse to. They have chosen to live on welfare or the generosity of others instead.

According to Kant, the categorical imperative makes this morally and ethically wrong, because if it were a universal law, everyone that could

39 work would decide to take it easy instead, and you can imagine what that world would be like.

Lack of charity If that last one made Kant sound like a cold-hearted guy this view more than makes up for it. He also argued that it is morally and ethically wrong to refuse to help those in genuine need of help because, again, if it were universally applied nobody would help anybody and that too would be disastrous.

Recap of Chapter 1 This first chapter has been our ethics primer, an introduction to the basic terms and concepts we will be using for the rest of this course.

In the beginning of the chapter we mentioned that a cursory internet search for the topic “massage therapist arrested” resulted in over a million hits, and we made the statement that perhaps massage schools are not teaching massage therapists ethics at all, but instead are just trying to reinforce codes of conduct and standards of practice without teaching the underlying fundamentals of ethical decision making.

What we have tried to do, albeit briefly, is to introduce an ethical decision making tool, the categorical imperative, and an appropriate model for an ethical philosophy, specifically virtue ethics and deontological (duty) ethics.

In the following chapters we will be moving into the more familiar areas of massage therapy professional conduct and we will be applying these basic concepts to the field.

40 Chapter 2: Massage Therapy Professionalism

The two foundational questions of Ethics All ethics can be summed up in two simple questions:

1. What is the right thing to do?

2. Why should I do the right thing?

From these two questions all of the other concepts develop. Every word that follows in this course is designed to help you answer these two simple questions. It’s both humbling and mind boggling at the same time.

Differentiating between Morals and Ethics This might seem a little confusing to you, since we spent a lot of time in the last chapter on virtue, which of course has to do with morality.

Morals and Ethics mean exactly the same thing to most people, and that’s okay for them because they are very similar. But most people aren’t required by the rules of their professional organizations or state licensing boards to study ethics like we are, so we are going to be a little more thorough in our definitions.

Morals are used to describe a person’s personal character . They are usually formed by beliefs and convictions (or lack thereof). This is different from Ethics , which defines a person’s actions, choices or behaviors in different situations .

This can be confusing for some people because an ethical person and a moral person will usually come to the same decision on what is the right thing to do in the same situation. This is because our morals help shape our ethics. It’s our morality that tells us what is right, and it’s our ethics that tell us to do the right thing. That is why we want you to adopt an ethical philosophy like virtue ethics or deontological ethics-because if you are a moral person you will generally do well with ethical situations.

However we must acknowledge that it is possible to be a moral person with no ethics, and an ethical person with no morals- so they are in reality distinct concepts.

41 We have to make that statement, because morals are personal and subjective -what’s moral to me may not necessarily be moral to you, especially if we come from different cultures or religious traditions. But if we are both massage therapists we can both come to the same decision on what action to take in any given professional situation by following an ethical code .

We use a code of ethics to refer to those rules and ideals that we expect a massage professional with moral integrity to exhibit.

Massage therapists have a lot of power over their clients, probably more than you are aware of right now (but we will discuss that in great detail in EPS007 Understanding Power Differnetials in massage therapy). Our profession is one that gives us numerous opportunities to exploit people physically, emotionally and financially. Unfortunately our profession, which once enjoyed great esteem and respect, has suffered a loss of prestige due to those who have taken advantage of others and for this reason the ethical bar is set very high for us today.

The four key ethical principles of massage ethics This section deals with four key ethical principles that are the foundation of a good massage practice, and they are autonomy (respecting the client), nonmaleficence (not harming your client), beneficence (doing what is good for your client), and justice (obeying the laws governing your profession).

These four principles are not unique to massage therapy and you may have heard them before, especially if you are also in another medical profession. These are the basic principles of medical ethics from which the ethical codes of doctors, nurses, physical therapists, and researchers are derived. And just in case you were thinking that it shouldn’t apply to you, they are also the basic principles that shape the Code of Ethics of the American Massage Therapy Association (AMTA) and the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). The actual codes of ethics for a massage therapist and a nurse or doctor are written differently because they have different roles and scopes of practice-but the ethical principles are the same.

42 Understanding the four principles

1) Autonomy This principle is focused on the client’s independence or liberty. A competent adult has the right to make decisions about what happens to his or her body and should not be manipulated or coerced into any decisions. It also means that you recognize the need for informed consent documentation in certain circumstances. You can see this principle highlighted in the following excerpts from the NCBTMB and AMTA Standards of Practice:

NCBTMB Standard I: Professionalism h. obtain voluntary and informed consent from the client prior to initiating the session i. if applicable, conduct an accurate needs assessment, develop a plan of care with the client, and update the plan as needed

Standard V: Roles and Boundaries f. acknowledge and respect the client's freedom of choice in the therapeutic session g. respect the client’s right to refuse the therapeutic session or any part of the therapeutic and…

AMTA Standard 3 Professional Relationships with Clients 3.5 The Practitioner elicits participation and feedback from the client.

Practical Massage Application of the Autonomy Principle Have you ever had a client that you felt you could help if they were just willing to let you use a different technique?

This is a very common example of the Autonomy Principle at work in massage therapy. Sometimes you know that what the client needs is a deep tissue massage, or you know a client really well and you think they would really enjoy a hot stone massage, but they just don’t want to try it.

It can be frustrating, but you must respect their right to decide what type of bodywork they want to receive, as long as it doesn’t come into conflict with Nonmaleficence Principle, which we will talk about next.

2) Nonmaleficence The nonmaleficence principle can be summed up in the familiar phrase "first, do no harm," or the Latin, primum non nocere . If you have spent anytime watching medical shows on TV you have probably heard this tossed around-it’s inspired by the Hippocratic Oath.

Nonmaleficence is one of the principal precepts of medical ethics that all healthcare students are taught in school and is a fundamental principle throughout the world. In very simple terms it means "given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good."

It reminds the health care provider that they must consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.

This applies to massage therapists in our observance of contraindications and the limitations of our scope of practice.

NCBTMB Standard I: Professionalism k. be knowledgeable of his/her scope of practice and practice only within these limitations and…

AMTA Standard 2. Sanitation, Hygiene and Safety 2.1 Practitioner provides an environment consistent with accepted standards of sanitation, hygiene, safety and universal precautions. 2.2 Pathophysiology (Contraindications) 2.2.1 The Practitioner maintains current knowledge and skills of pathophysiology and the appropriate application of massage/bodywork.

Practical Massage Application of the Nonmaleficence Principle Imagine that you have a client that tells you that they have just been diagnosed with Deep Vein Thrombosis (DVT) and Hypertension (High blood pressure). They are going to start taking medicine for the high blood pressure, but they haven’t yet.

44 They are really stressed out and they need a massage. Yes it’s true that a nice massage might really help them relax, but you know that massage is contraindicated for DVT and shouldn’t be performed on someone with uncontrolled high blood pressure-so your primary responsibility is to tell them that you can’t do the massage-even if it would help them relax.

3) Beneficence Beneficence is defined as an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation. All professionals have the foundational moral imperative of doing right. In the context of the professional-client relationship, the professional is obligated to, always and without exception, favor the well-being and interest of the client. In health care, beneficence is one of the fundamental ethics. An integral part of work as a professional is the foundational ethic of beneficence.

An understanding of this ethic of care compels the individual health practitioner to consider his or her calling to the high standards of professionalism as a moral imperative; one that advocates for high standards and strives for the greater good.

Health care professionals have a duty of care that extends to the patient, professional colleagues, and to society as a whole. Any individual professional who neither understands nor accepts this duty is at risk for acting malevolently and violating the fiduciary principle of honoring and protecting the patient 23 .

The word “Beneficence” literally means “the quality or state of being beneficent” and in case that doesn’t help you, “beneficent” means doing good; especially performing acts of kindness and charity.

To many people this might sound like it deals exclusively with morals, which we said back on page 6 is different from ethics, but the key word here is doing good, not being good.

This principle is reflected in the standards of practice for massage therapists:

23 Beneficence and the professional's moral imperative Frank Stuart Kinsinger J Chiropr Humanit. Dec 2009; 16(1): 44–46. Published online Apr 1, 2010. doi: 10.1016/j.echu.2010.02.006

45 NCBTMB Standard I: Professionalism l. refer to other professionals when in the best interest of the client and practitioner and…

AMTA Standard 2. Sanitation, Hygiene and Safety 2.2.3 The Practitioner makes appropriate referrals to other reputable healthcare providers.

AMTA Standard 4. Professional Relationships with Other Professionals 4.2 The Practitioner's referrals to other professionals are only made in the interest of the client.

Practical Massage Application of the Beneficence Principle You can see that the two sections I selected from the Standards of Practice for the AMTA and NCBTMB both mention referrals to other healthcare professionals. The good we are doing here is not sending another professional some business, it’s sending the client to someone that can provide them with the right kind of help they need.

Imagine that you have a client that you know engages in a lot of outdoor sports activities. While working on his back, which is deeply tanned from hours spent outside with no shirt on, you notice a large and angry looking mole that you had never noticed in any of your previous sessions with that client.

When you ask him about it he tells you that the area is pretty sore, but he figured it was just a pimple or a scratch, because he couldn’t see it.

Now of course you know that many melanomas start as a new skin growth on the skin, especially when they change color, shape, or size relatively rapidly and are painful. You also know that he is constantly exposing himself to large amounts of UVB rays, which can cause direct damage to skin cells’ DNA, and is believed to be the cause of most skin cancers.

So in this example, the correct application of the beneficence principle is to inform your client of what you see (which is very different from making a

46 diagnosis) and making an appropriate referral, which in this case would be to a dermatologist to get the mole checked out.

This is an easy situational example because the potential risk to the client is great and there is no reason at all for you not to make the referral, unless you’re just lazy, so let’s try one with a little more punch.

Imagine now that you receive a call from a potential new client that tells you she has Leukemia and is currently undergoing chemotherapy. Her doctor supports the idea of massage therapy as a complimentary treatment for the mitigation of symptoms and he has medically cleared her to receive treatment, and her insurance has approved her to be seen once a week.

But you’re nervous about treating her because you know very little about Leukemia, chemotherapy and the symptoms she might be experiencing. Not to mention that you are still plagued with doubts about massage and cancer based on what you were taught years ago in massage school.

But you do know of a massage therapist in town that specializes in Oncology massage, a fellow massage therapist that has been specifically trained in the symptoms and medical treatments cancer patients are undergoing, as well as what types of massage application to provide.

In this example the application of the beneficence principle is to refer the client to the other massage therapist, the one specifically trained to deal with cancer related issues. This is a grittier example, because it definitely puts the clients interests before your own.

4) Justice The fourth key principle is justice, which is a blanket term that covers our obligation to obey the various laws and regulations that govern our industry.

This principle is expounded upon at length in the standards of practice for massage therapists:

NCBTMB Standard II: Legal and Ethical Requirements a. obey all applicable local, state, and federal laws b. refrain from any behavior that results in illegal, discriminatory, or unethical actions

47 c. accept responsibility for his/her own actions d. report to the proper authorities any alleged violations of the law by other certificants or applicants for certification e. maintain accurate and truthful records f. report to NCBTMB any criminal conviction of, or plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction (other than a minor traffic offense) by him/herself and by other certificants or applicants for certification g. report to NCBTMB any pending litigation and resulting resolution related to the certificant or applicant for certification’s professional practice and the professional practice of other certificants or applicants for certification h. report to NCBTMB any pending complaints in any state or local government or quasi-government board or agency against his/her professional conduct or competence, or that of another certificant, and the resulting resolution of such complaint i. respect existing publishing rights and copyright laws, including, but not limited to, those that apply to NCBTMB’s copyright-protected examinations and…

AMTA 7. Legal Practice 7.1 American Massage Therapy Association members practice or collaborate with all others practicing professional massage/bodywork in a manner that is in compliance with national, state or local municipal law(s) pertaining to the practice of professional massage/bodywork.

Practical Massage Application of the Justice Principle Today most states or cities require that massage therapists be licensed. Naturally in those areas it is illegal to practice massage therapy without a license, and in most cases massage therapists must meet a standard of competency or obtain an appropriately recognized education to be licensed. It is also common for the licensing authority to have an established set of principles or guidelines for massage therapy practice, or in some cases, to insist that those they license belong to certain professional organizations that do (the NCBTMB, AMTA, etc).

Some cities or states have more relaxed forms of regulation, like certification or registration. These are less formal than licensure but still provide the public with a minimum level of oversight and protection.

48 Differentiating between Laws and Ethics The law is expressed in our society through legislation and court rulings (called precedence). A law is passed that sets a conduct standard that must be met, and the courts shape the application of those laws with rulings that are then followed by future litigations. There is in effect, a gun behind every law-and a punishment for those that fail to obey. That’s a harsh way to say it, but it’s the truth.

Ethics , on the other hand, are guidelines. Generally speaking, breaches of ethics do not warrant the attention of the courts, except in those instances where a) the ethical breach coincided with a crime, like sexual battery, prostitution or negligence, or b) the ethical breach resulted in the loss of licensure, a legal requirement for practice.

The need for oversight and regulation There can be no question that massage therapy can have a significant impact on a person’s physical and emotional health, and like any service that could be harmful if not delivered properly, it must be regulated in some way.

While first it might seem that the burden of regulation is unfair for those that wish to practice bodywork, but in reality the enforcement of licensure laws do much more to help us than to hinder us.

The consumer (our massage clients), have a need to feel safe in order to benefit from massage therapy. They also have a right to expect their practitioner to have the minimum education and qualifications to perform the techniques effectively and safely.

For these reasons the governmental regulation of our profession and clearly written requirements to practice are a benefit to us. They promote and legitimize the profession while at the same time protecting the health, safety and welfare of the general public.

Protecting the massage practitioner and the public It’s easy to see how state licensure protects the public, by creating and enforcing standards of minimum competency measured through formal education, training, and examination requirements.

49 The legal regulation of massage therapy also protects the massage therapist. Having eligibility requirements needed to practice massage therapy ensures that our fellow practitioners are qualified to represent our profession to the public. This is important, because it only takes one visit to an untrained practitioner to sour a consumer on the industry for a lifetime, and that’s lost revenue for all of us.

Scope of Practice Scope of Practice is a legal term that we owe to the practice of medicine. It refers to a written vocational definition that is used by state and national licensing boards for various medical professions. The Scope of Practice defines the procedures, actions, and processes that are permitted for the licensed individual.

The Scope of Practice limits the professional to the practices that are appropriate to their specific education and experience.

By providing a legal framework for the scope of massage therapy practice, professional licensing boards help consumers know what to expect when they visit a massage therapist. It also allows them to select the appropriate style of massage therapy for their needs. We are going to be discussing issues that relate specifically to Scope of Practice later, because it’s one of the areas where massage therapists get into ethical trouble the most frequently.

The regulation of massage therapy through licensure enables a state or town to discipline a massage therapist if needed. This is important, because as we stated earlier breaches of ethics are not typically a matter for the courts unless they coincide with a crime, and if the state regulates a profession it is likely to have statutes that are in line with the ethics of the profession-giving the state the authority to enforce ethical conduct.

In addition to legal actions, licensure gives the public a formal grievance process that helps prevent unethical or unscrupulous massage therapists from practicing.

Universal standards of Massage Therapy Professionalism Massage therapists are a diverse group. There are a lot of different kinds of people using different modalities of bodywork. Many of these fields of

50 bodywork have ancient and cultural roots, which blend elements of tradition and spirituality into their practice.

If you were to ask the average person on the street to describe what they expect the doctor to look like when they go to a doctors office they will probably give you similar answers, the same can be said for nurses, personal trainers, hair dressers, yoga instructors or even nail technicians. There is diversity of gender, age and ethnicity of course, but there is a great deal of commonality in the appearance of these professionals because they (for the most part) have been trained in similar ways and are practicing in a similar fashion.

Massage therapists are different. We are wild cards. Some massage therapists wear pleated khaki pants and polo shirts; others wear sandals and tie-dye shirts.

I’ve been to massage therapy “clinics” that were so medically themed you would swear you were in a doctors office, and I received an ayurvedic hot oil massage in an a room so filled with incense smoke it was hard to see the Tibetan tapestries on the wall.

What’s my point?

When you ask the average person on the street to describe what they expect a doctor, nurse, physical therapist or personal trainer to be like when they go see them they have an answer that is based on their experience-what they encountered in the past informs the image they have of the profession.

So when you ask the average person on the street what they would expect to see when they go to a massage therapist there answer is going to be formed the same way, and unfortunately, if they have never been to a massage therapist they are going to have an image based on what they have seen on TV, and let’s face it, that is rarely good.

So it’s important that no matter what modality we use or what cultural tradition flavors our massage therapy practice we all need to have some universal standard of professionalism .

51 The following topics have been taken from the NCBTMB standards of practice, Standard I Professionalism and they make a pretty great starting point for this discussion.

Treat each client with respect, dignity and worth This doesn’t just mean being nice and courteous to your clients. If you are nice to your clients because they are your clients than you are treating them as an instrumental good and not an intrinsic good (you remember what those terms mean, right?) You need to treat your clients with dignity , and that is by definition a state, quality or manner worthy of esteem or respect. Dignity in a massage therapy practice supports and promotes the autonomy of the client and does not undermine their modesty or self- respect.

To treat someone with dignity is to treat them as a being of worth, in a way that is respectful of them as individuals. Dignified care, or the lack of it, can have a profound effect on a client’s well being, not to mention your massage business.

A model of dignified treatment The model that the Somatic Arts and Sciences Institute uses to teach our massage therapy students dignified treatment is as follows

Respect for others is not a feeling, it is an action . If you are not showing it, you are not doing it. The way you show it is:

Making polite in conversation. This includes always greeting clients, even if they are not there to see you.

Demonstrating thoughtfulness and caring by inquiring to their needs.

Keeping them informed of what is happening (or if they are waiting, why it is not happening yet).

Meeting their needs within our scope of practice.

Going out of your way to ensure their privacy and modesty. Many massage therapists become so comfortable with the human body they forget that modesty is of great importance.

52 Being ever mindful that the body being worked on is inhabited by a mind and a soul and is not a piece of meat to be tenderized, or a “problem to be fixed”.

Failing to treat a person with dignity is the same as deliberately taking away their dignity.

Dignity is the end result of being treated with respect. It is an internal condition and is deeply connected to feelings of self worth well being and purpose.

Use professional verbal, nonverbal and written communications Using professional verbal communication skills is more than just not using “street speak” when dealing with your clients, it’s also about using clear and direct language to avoiding miscommunication. As a professional body worker it’s important that we be able to use correct anatomical and biomechanical terms to explain what we are doing, but in a client-friendly manner that is not jargon. We’re not there to impress them with how many Greek and Latin words we know, but we do need to instill them with a sense of confidence in our professional competency-so you need to be familiar enough with the anatomical language to describe what you are doing, as well as being prepared to translate that into terms our clients can understand.

Communication with other healthcare professionals also requires a certain level of comfort when employing medical terminology.

Voice management is just as important as vocabulary. This doesn’t just refer to accurate pronunciation, which is essential in sounding knowledgeable, but it also relates to appropriate pitch and intonation, which helps establish rapport with the client, project a calm and relaxed atmosphere in your massage practice and can directly address anxieties your clients may have about massage therapy.

Human beings react to tonal qualities in speech in a very profound way. Before I was a massage therapist I was a behaviorist and a social worker that worked for state and country mental health agencies. One of the first things I used to tell the family members and professionals that worked with my clients was to be mindful of their intonation. The human brain takes cues from other people in how they should react-that is why a panic

53 spreads in a crowd so quickly, when you hear one person scream in terror, it scares you, and soon you are screaming in terror too.

The same thing happens when you speak slowly and calmly to someone who is anxious, their brain picks up the tonal signal and it tells them “It’s okay, there’s nothing to be worried about here.”

This is also a skill that large companies teach their customer service people-it’s called “handling”.

This aspect of voice management is especially pertinent when dealing with new clients who have never experienced a massage before and aren’t sure what to expect.

As body workers we should be more aware than most of the importance of nonverbal cues (i.e. body language) when dealing with our clients and coworkers. Experts agree that the paralinguistic elements of speech reveal true feelings and emotions much more effectively than what is being said verbally 24 .

It’s important for us massage therapists to develop non-verbal communication skills and that begins with increasing an awareness of body language, enabling us to better read and interpret their clients' physical and emotional signs (expressions of anger, melancholy, etc.), while simultaneously projecting a comforting and calming presence.

"Nothing feels so good as being understood, not evaluated or judged. When I try to share some feeling aspect of myself and my communication is met with evaluation, reassurance, distortion of my meaning, I know what it is to be alone." Carl Rogers, psychologist

Active listening is a simple skill that is almost never used by people who are not paid to do it. Professional therapists, psychologists and clergy are trained to listen in this way, and that is why they are sought out by people to unburden themselves.

24 HOCKING, J. E., KAMINSKI, E. P., BAUCHNER, J. and MILLER, G. R. (1979), DETECTING DECEPTIVE COMMUNICATION FROM VERBAL, VISUAL, AND PARALINGUISTIC CUES1. Human Communication Research, 6: 33–46. doi: 10.1111/j.1468-2958.1979.tb00289.x

54 Active listening means that you are paying attention to what the person is saying, and not thinking about what you want to say when it’s your turn to talk. Give your clients your complete attention, really hear what they are saying, and then rephrase what they say back to them.

Rephrasing does two things, first it makes sure that you truly understand what they are saying, and second, it reassures them that you are, in fact, hearing them.

Your brain works four times the rate that someone can speak 25 , so it is only natural that when we are having a conversation we are thinking ahead about what we want to say rather than actually listening.

Active listening requires expending energy. While it may seem like a passive activity, to be an effective listener requires inner discipline and focus.

Some things to keep in mind:

The act of listening should be tiring; it requires energy to do it right. If your mind is drifting try changing body positions to stay focused. Practice listening, it takes time to be really good at it.

The Four Steps of Active Listening 1. Focus on the person Establish—and keep—eye and face contact with the speaker. Reinforce what is being said is being heard through non-verbal facial expressions.

2. Use Receptive Language Follow and encourage the speaker's train of thought by using receptive language; e.g., "I see," "Hmmm," "Un huh," etc.

3. Listen for Key Words Listen for key words, in this case, words that describe feelings or physical pain. When you hear words like “stressed, angry or frustrated” or “burning, knotted, achy”-all of these are clues that might help you give a better treatment during your session.

25 Rogers, Carl, and Richard E. Farson. "Active listening." Organizational Psychology, 3rd edn. New Jersey: Prentice Hall (1979).

55 4. Rephrase When rephrasing it is important to stay as close as possible to the ideas expressed. It is also important to put the message into your own words to avoid sounding like you are mindlessly parroting back her statements.

You can use phrases like “So you are saying that your neck feels so tight you fell like you can’t move your head?” It is a simple, but very effective tool.

Employing active listening skills helps to ensure a successful interaction and the appropriate employment of massage techniques. It also demonstrates that the practitioner truly values and respects the client.

Cultural awareness is also an important part of communicating with our clients. We live in a pluralistic society, which requires a degree of sensitivity and awareness to different cultures, values and languages. This is discussed in more detail later in this course.

It can be easy for a massage therapist to forget the importance of written communication in the application of our profession, especially when working in an area where massage therapy is considered a luxury pampering as opposed to a therapeutic complimentary medical treatment.

Very few massage therapists working in a day spa bother to document anything with their clients. In some venues, such as vacation resorts, cruise ships, and retreat destinations this is justified, the client will more than likely never be seen again in that facility. But for most of us return business is something we strive for, and over time the accumulated knowledge of our clients particularities helps us to provide a more therapeutic massage and massage environment.

But it may be necessary to one day transfer that client to another therapist, or another therapist may take over for you if you have to take an extended leave of absence, and in that case having a written record of your sessions with the client could be invaluable.

I discuss the importance of SOAP note taking in relation to continuity of care later in this course, but for right now let me just emphasize that any notes you take regarding your client should be clear and coherent, and should include accurate spelling, appropriate medical terminology,

56 abbreviations and acronyms, all of which are vitally important for communicating the needs of a client in writing.

Providing a safe and comfortable environment As massage therapists we have a responsibility to provide a safe and comfortable environment for our clients. In many locations this is also a legal requirement, with state or local authorities enforcing a specific set of standards for massage establishments.

The following is a list of basic safety measures that can be implemented in a massage therapy establishment to ensure client safety.

A first-aid kit should be properly stocked and readily available at all times and all of the staff should be aware of first-aid kit locations.

In order to be compliant with many federal, state and local regulations, fire extinguishers should be on the premises available. The staff should be aware of all extinguisher locations and should be trained on their proper use.

Fire extinguishers must be checked regularly.

A written emergency plan should be posted in plain view in all massage rooms, hallways and in the entry lobby/waiting area. The plan includes standard emergency procedures for specific incidents such as power outages, fire, earthquakes, tornadoes, hurricanes and other natural disasters as well as criminal and/or acts of terror. Phone numbers of local police, fire and emergency medical assistance are visible and easily accessible.

Routine evacuation drills should be regularly scheduled for facilities with multiple employees.

A safe exit map should be posted in each room within full view of all occupants. It should indicate the direction to multiple exits using colored or highlighted arrows.

All cleaning and maintenance supplies should be stored in appropriate containers in accordance with applicable federal, state

57 and local regulations, and in compliance with appropriate manufacturer's guidelines.

All floor surfaces (e.g., wet treatment rooms and locker rooms) should be designed and constructed to accommodate the intended activities for each area, and promote safety.

Signage should be posted to alert and educate clients about possible risks in areas such as: rooms with hot stone heaters, wet areas, saunas, steam rooms, hydrotherapy whirlpools, and any other potentially hazardous area.

The Massage Establishment should have an automatic monitoring system for ensuring appropriate control of temperatures in all areas- including rooms where hydrotherapy applications or hot stones may exposed the client to high thermal stress.

The massage establishment should have an operating procedures manual, updated regularly and shared with all staff. These procedures should keep the facility current with all applicable federal, state and local regulations.

The massage establishment should have an up-to-date file of all MSDS (Material Safety Data Sheets) for all chemical products used within the spa. This includes cleaning products as well as spa treatment products. The information should be readily available to all staff.

The massage establishment must have access to clean, fresh, drinking water for all guests.

The massage establishment must be maintained in a clean and sanitary condition to prevent illness and/or disease.

If the massage establishment makes use of specialized equipment, such as hot stone heaters, humidifiers, hydrotherapy tubs, pool or Vichy showers etc they should be used only by properly trained staff, and a record of the training should be kept on site. This would include certificates of completion from workshops or memorandums of

58 internal training for facilities that have staff capable of providing said training.

The massage establishment should have a designated safety officer or risk management team (for larger businesses) in place that is specifically responsible for overseeing the issues on this list and updating both management and staff, on a consistent basis.

Standard precautions and professional hygienic practices Every massage practitioner needs to look like a competent professional when they are working; after all they are representing all of us. Every time you see a client that has never had a massage before you are creating the mental image of massage therapy that will inform their judgments of the profession from that point forward, so it’s pretty important.

The type of business setting they are in often dictates what a massage therapist wears to work. If they are working in a medical office it is very appropriate for them to wear scrubs, especially if that is what the other staff members wear.

Massage clinics, day spas and wellness centers often require employees to wear a shirt bearing the company logo, whether they are working on clients or at the front desk.

Whatever garments are worn by the massage therapists while carrying out their functions should (obviously) be clean and should not have sleeves that will touch the clients skin during a massage.

Due to the importance of distinguishing ourselves from sex industry workers that only pose as massage therapists the choice of clothing worn should be modest and not sexually suggestive or provocative.

No jewelry should be worn on hands and the nails should be short and filed to prevent scratching the client or accumulating skin cells and massage lubricant underneath them.

Hair should be clean and well groomed, and should be restrained so that it doesn’t touch the client when close work is being done.

Deodorant must be worn and perfume, if worn should be discreet.

Lesions on the hands should be appropriately covered with bandages.

Assessment and Intake Procedures There are three important steps that should be taken prior to treating any new client and those are: 1. Informed consent must be obtained. 2. Intake forms/medical questionnaire must be completed. 3. Verbal summation of intake and informed consent.

1. Obtaining informed consent before starting the session Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment 26 . It originates from the legal and ethical right the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.

An informed consent agreement for massage therapists provides an opportunity for you to convey in writing what the client should expect from a massage therapy session with you. It also states the limitations of what the client should expect. The information enables the client to choose whether or not to receive the services you provide, and acts as a safeguard in the event liability issues arise during or after the service is provided.

Elements of full informed consent The most important goal of informed consent is that the client has an opportunity to make an informed decision about whether or not they wish to receive a massage treatment.

An informed consent should include: A description of your style of massage, modality and techniques.

The benefits, limitations and contraindications of massage.

Possible outcomes that can be expected (but not guaranteed).

26 Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834-1840.

60 The process of disrobing and draping, and how their modesty is protected during the session.

A short description of your credentials and areas of expertise.

An overview of your scope of practice, detailing what you can and cannot do based on your credentials.

A statement assuring the client that you will maintain confidentiality and privacy.

A list of session duration and fees, unless they are posted elsewhere on the premises.

Any special policies for cancellations and late arrivals.

If you offer insurance reimbursement programs.

Any collaborative relations with other health professionals.

2. Intake forms/medical questionnaire must be completed. The informed consent form is often used in conjunction with the client intake form, and is only completed by the client on his or her first visit. In the client intake form, the client provides information regarding his or her health history. This is of course an important tool when it comes time to perform the client assessment.

Proper intake procedures are a vital and often overlooked element of a successful massage practice. We all have days where we are busy, and client appointments are stacked closely together, leaving us little to time to get to know a first time client.

A good intake and assessment is too important to let slip through the cracks. The use of a standardized intake form can help you keep safe from potentially dangerous clients by establishing clear boundaries before the session even starts.

A well crafted intake form will not only identify the areas of tension and/or pain the client is experiencing, but it can also serve to ease the anxieties of

61 a nervous client by spelling out clearly and concisely why is going to take place.

An intake form that uses a body map and pain scale can give both the therapist and client a starting point for a dialogue about the clients needs and what they hope to accomplish in the upcoming treatment session. While indispensable for new clients, a good intake form can and should be used with existing clients at least quarterly. This will help you stay current with their medical condition as well as their contact information.

What to include in the intake form At a minimum, your massage therapy intake form should include the following elements:

Contact Information You need to collect the name, address, phone number, and e-mail address of your client so that you can follow up with them after the session.

Don’t neglect to ask them their date of birth. This is useful for more than just age verification, a clever massage therapist will keep track of their clients birthdays and will mail or email them a coupon for their birthday to show them that you value them as a customer.

Of course if you are in a medically oriented massage practice that bills insurance companies you would also need their date of birth for that as well.

A Brief Medical History And Questionnaire This doesn’t need to be as long as those that are filled out in a doctor’s office, but as a minimum you should be asking your clients to disclose if they have any allergies (especially to nut-based products and oils), recent surgeries they may have undergone, cardiovascular conditions, especially those that involve blood clotting complications.

You will also want them to list any medical conditions for which they are currently receiving medical care, any infectious diseases they may have recently had and a catchall category of “any medical condition that you think may be impacted by massage therapy”. Remember, your clients aren’t necessarily going to know if they have a condition that contraindicates massage, but if you leave it open they are

62 more likely to volunteer information so that you can make a better decision about their care.

A Note regarding medical questionnaires Have you ever noticed that many doctors office questionnaires have a “Yes” or “No” box listed next to questions like “Have you ever been diagnosed with varicose veins?” instead of a simple check box where the patient can put a check in the box next to the condition?

A friend of mine that is a doctor once share with me that many doctors prefer medical questionnaires that ask “Yes” or “No” for each condition because many clients will skip over check boxes, mostly because they are in a hurry and they don’t want to read carefully.

If the option is to just put an X in the box if you have the condition, how do you as a practitioner know that they didn’t just miss or skip the question?

If the questionnaire asks them to please mark “yes” or “no” there should be no blank boxes-and if there are you should need to ask them about each one during the intake assessment.

Session Goals This section of the form asks your client to clearly state what they expect to get out of the massage therapy appointment. This may be simple relaxation, but if could be relief from pain, increased mobility or any number of other purported benefits of massage they have heard about.

This is important for you because it gives you a better chance of making them a satisfied customer, by zeroing in on exactly what they hoped to get out of the session, and it also helps to prevent dissatisfied customers by alerting you to unrealistic expectations ahead of time.

If your client indicates their goal for the massage is something that you do not feel is realistically attainable from your practice (like weight loss, curing diabetes, realigning their zodiac, whatever). If this is the case, you have an ethical responsibility to explain the limitations of bodywork in regards to their expectations.

63 Disclaimers and Other Policy Information The bottom of the intake form is usually reserved for a general disclaimer that informs the client that the practitioner is not a doctor and will not diagnose illness or prescribe medicine. This is also a good place for a disclaimer regarding inappropriate sexual conduct and cancellation policies, especially in regards to prepaid appointments.

3. Verbal summation of informed consent and intake Information After your client has signed the informed consent and has completed the intake form and medical questionnaire the practitioner needs to take a moment to read over it briefly and ask the client some follow up questions.

This is a crucial step and is often missed by busy practitioners. Even when therapists take the time to have their clients fill out the intake form, some of them think they are so busy they don’t even bother to look at it, much less ask the client any follow up questions.

When reviewing the intake form please remember this should be done in private. Many day spas, resorts and even massage clinics have their clients fill out their intake forms in a waiting area (which is fine) but the appropriate place to review the information with the client is in a treatment room, not in a waiting room. Any discussion or questions about the medical questionnaire or intake form are of a private nature and are inappropriate for a waiting room.

The first thing you should always ask your client when reviewing the intake documentation is “Do you have any questions?”

If they do not voice any questions or concerns you should address any medical condition that is indicated on the form.

Naturally if the client checked “yes” to any condition that could possibly contraindicate massage you should ask further questions to ascertain whether this is a medical contraindication (allowable if approved by a physician and appropriately monitored) or an absolute contraindication.

If they failed to mark either “Yes” or “No” for any medical condition you should ask them why, do not just assume they do not have the condition if they failed to mark anything.

64 Clarifying their goals and intentions If your intake form includes a body map your client may indicate a particular area that they want you to focus on. You should take an opportunity to ask them to describe what they are feeling in this area, is it pain or tightness? If it’s pain, what type of pain (burning, aching, etc) and is it stationary or does the pain radiate.

If there is pain, be sure to ask them if they have any suspicions as to the cause. It might take a little extra time to go through the medical questionnaire with your client, but they will be grateful for the extra time you took to clarify their needs.

If the client is just there to get a relaxing massage to unwind from stress, as is often the case, this process will go even quicker.

Don’t forget to verbalize the disclaimers and policies You can’t just assume that your client read and took the legal disclaimer seriously. Many clients will either skip over the legal disclaimers without reading them or will simply assume that it’s something you are required to put on the form and that it doesn’t really apply to them.

The best way to deal with it is to simply summarize the disclaimers and policies in a conversational tone. You can point at the legal disclaimers and policies section on the form and say something like “Did you see this party down here where it says that I am not a doctor and will not give you any medical advice or diagnose any conditions and that any inappropriate behavior will result in the client being asked to leave?”

Usually they will just nod or say that they did read it and that’s enough to cover your bases. Once they hear you reiterate the policies out loud they will know that you mean business and it will help you keep everything on a professional level.

Orientating the client to the Massage Room The first time you bring a client into your massage room you should always take a moment to acquaint them with the features of the room. This is an important part of making them comfortable so it shouldn’t be skipped.

You should start with the room fully lit so they can see the areas that you are pointing out to them, which should include where they can place their

65 clothes and personal items. You will also want to take a few moments to show them how they will be draped during the massage. Taking an extra minute to ensure the client that their modesty will be protected will go along way towards helping the client relax, especially if it is their first massage session ever.

Appropriate draping and instructions Before your client disrobes you should show them exactly how they should lie on the massage table and how the draping should cover them. This is an important and often overlooked detail. Not all massage therapists start their massage treatments the way you do, so need to tell them what to expect, like “We’re going to start with you face down, and I will work on your back first, then your arms and hands, then your legs, etc.”

Do not assume the client knows that they only have to undress to their comfort level. Many clients do feel some anxiety about what they are supposed to leave on and take off, but don’t want to embarrass themselves by asking what they are afraid is an obvious and silly question. The best practice is to not make the client ask at all, but instead to informing them that they have options as to what clothing they leave on.

The client should not disrobe until the practitioner is out of the room, and the therapist should ask if the client is covered before reentering.

We spend a lot of time reiterating the importance of protecting a client’s modesty, but there are times when the therapist must be protected from the client’s lack of modesty.

Dealing with immodest clients We sometimes forget that when we tell a client to “undress to their comfort level” that there are people who are more comfortable not wearing clothes at all. While it might sounds strange there are clients who ask to not be draped at all.

It may be that the client is a nudist and feels more relaxed when they are completely uncovered, or perhaps they are hoping that, by exposing themselves completely they stand a better chance of moving the massage in an inappropriate direction.

66 Regardless of their motivation, it isn’t appropriate to massage a client without some level of draping. This is not a situation where “the customer is always right”-and just because their “comfort level” is to lie on the massage table completely nude while you work on them it doesn’t mean that is what has to happen.

Yes, you are a professional body worker and the human body is nothing to be ashamed of, but you have a right to modesty as well as the client, and that means you do not have to be exposed to an undraped client, so do not let them convince you otherwise.

Massage to the breast, gluteal region and groin There are times when massage to the female breast is warranted for medical reasons, for example breaking up scar tissue associated with breast augmentation, injury, or even breast tumor removal related to breast cancer. It has also been recommended for relief from pain associated with pregnancy, congestion, edema, and lymphedema. Regardless of the reason, breast massage should only be initiated at the client’s request and the reason for it should be clearly and explicitly spelled out in the informed consent form.

The same is true for massage in the groin area (specifically meaning areas adjacent to the genital region-the genitals are not to be massaged or uncovered for any reason).

The gluteal region is an area that is more frequently a cause of discomfort for many people so massage of the glutes is more readily accepted, but it is still considered a private area and should remain draped during the massage. Many techniques can be successfully employed for the gluteal region directly through the draping (over the sheet).

A therapist performing a massage on an area such as the breasts, gluteal region, or groin area needs to inform the client that they have the right to continue, modify or discontinue the massage therapy treatment at any time during the process.

Know the limits of your Scope of Practice Scope of practice is a legal term used by professional licensing boards and other certifying organizations for various health care professions that

67 defines the procedures, actions, and processes that are permitted for an individual that operates under that particular license.

The purpose of the scope of practice is to ensure the vocation is practiced in a safe and consistent manner, according to local, state, or national laws.

The assumption in scope of practice is that the massage practitioner has, as evidenced by licensure, already obtained a sufficient education in the physiological effects, indications, contraindications, and proper application of massage techniques. In most states this licensure is obtained through standardized tests or competency evaluations.

Since each state in the United States has their own licensing board there is variation in the scope of practice between the different states.

For example, in the state of New York the massage licensing board ordinance says, “The practice of the profession of massage therapy is defined as engaging in applying a scientific system of activity to the muscular structure of the human body by means of stroking, kneading, tapping, and vibrating with the hands or vibrators for the purpose of improving muscle tone and circulation.”

Compare this to the state of Ohio, which defines massage therapy as “the treatment of disorders of the human body by the manipulation of soft tissue through the systematic external application of massage techniques, including touch, stroking, friction, vibration, percussion, kneading, stretching, compression, and joint movements within the normal physiologic range of motion; and adjunctive thereto, the external application of water, heat, cold, topical preparations, and mechanical devices.”

Lastly look at Texas, their massage licensing board describes massage therapy as “the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for the purpose of body massage and includes effleurage (stroking), petrissage (kneading), tapotement (percussion), compression, vibration, friction, nerve strokes, and Swedish gymnastics.”

Despite the differences from state to state there are some commonalities. Generally speaking, all state licensing boards define massage therapy as the manipulation of soft tissue of the body for a therapeutic purpose.

68 Ignorance is not an excuse-know your local laws What a massage therapist can do and what titles we can use to refer to ourselves varies from state to state, and in some states, like California, they vary from city to city. As with any licensed professional, the burdens of knowing the laws that govern you are your responsibility.

Diagnosing clients is practicing medicine without a license One of the easiest mistakes a massage therapist can make is to diagnose their client. We can tell our clients what we observe when working on them, but we can’t tell them what is actually wrong with them, in other words, we can’t name the condition.

Unfortunately this is a mistake that massage therapists can make very easily. After all we spend a lot of time learning about different conditions, including their signs and symptoms, and when we see something that our training has taught us might be pathological, we are professionally obligated to tell the client.

But we can’t make a diagnosis. Remember the example of the client with the suspicious mole on their back that I used when I was discussing the principle of beneficence?

You can and should tell your client that you see a mole that has changed shape, or color and that you think they should have it looked at by a doctor. You absolutely can’t say that they have skin cancer.

If you always try to describe what you see in the most ordinary, nonmedical terms and you should not have to worry about being outside the boundaries of your scope of practice.

Recognize the limits of your knowledge Avoid commenting on subjects that are outside of your area of expertise. The public comes to us with an expectation of knowledge. One of the benefits of having a professional certificate on your wall is that it conveys a sense of education and engenders trust in our opinion-so don’t give it lightly.

If your client asks you questions that are outside of your area of expertise or are beyond your current knowledge base don’t try to wing it, just be humble and tell them that you don’t know or it’s not in your field. When you

69 can honestly admit that something is not in your area of expertise it is not something to be ashamed of, on the contrary, you are demonstrating a commitment to the body of knowledge that you do possess and your clients faith in that knowledge will be strengthened.

The difference between a prescription and a suggestion I have had many clients ask me for tips on how they can reduce the strain on their body that brought them in for a massage in the first place. For example, I’ve had clients ask me how to ergonomically adjust a desk so that their neck isn’t strained looking at a monitor, or what stretches they should do before a spin class to avoid soreness in the legs. I’m sure you have had these types of questions too, I think it is a natural assumption that people have that if we know how to make muscular tension go away there is a good chance we have a few ideas on how to prevent it from occurring in the first place.

It’s logical and often true, as body workers we do have keen insights on muscular tension forms and how in some cases it can be prevented from becoming a painful issue, but how we deliver those tips is very important.

For example, if you were to tell your client that they should be doing 10 repetitions of a certain stretch before spin class you have crossed the line into prescribing therapeutic exercises, which is not only outside of our scope of practice in some states it can actually violate the law.

But you can make suggestions. Instead of authoritatively telling the client what they should do, I say something like “Well before I do a workout that uses the leg muscles I like to stretch like this…” and that way you can put your knowledge to good use without violating your scope of practice.

Avoid Contradicting other Healthcare Professionals I would like to believe that no massage therapist would ever knowingly do this, but unfortunately I have met many massage therapists who hold strong anti-pharmaceutical beliefs and truly think that medical doctors have no business prescribing medications of any kind, so I know they are out there.

It is never appropriate for a massage therapist to second guess a doctor, nurse, or physical therapist when it comes to areas that are outside of our scope of practice. Even if your client approaches you and tells you that they

70 do not agree with their doctor, it’s not your place to encourage them to disregard their physician’s recommendations, even of you agree with them.

For example, if your client were to say

“Since I started taking this prescription my doctor gave me for my blood pressure I’ve found I’m having trouble catching my breath-I think it’s making me worse, I’m just going to stop taking it. What do you think?”

How would you respond to this question? Hopefully you would encourage your client to call their physician and express their concerns to them directly, without discontinuing the medication. For all you know the doctor has prescribed them medication because they are in the beginning stage of congestive heart failure, and one of the symptoms of congestive heart failure is difficulty breathing-the condition might actually be much worse without the medication, the point is, we are not doctors and we have no business second guessing them. If our client voices a concern to you about their medication or treatments prescribed by their doctor, the only ethical and responsible reaction from you is to redirect them back to their doctor.

Make Appropriate Referrals We do not often make referrals like other medical specialists, but we can and should be prepared to suggest an appropriate medical professional if our client is complaining of symptoms that obviously cannot be treated by massage.

Take some time to prepare a list of local specialists that you can refer your clients to. Keep this reference list handy for when it is needed, which hopefully will not be very often. Keep in mind that most specialists require a referral from a general practitioner, so your client will still be getting a referral from their doctor to see a specialist, but it still doesn’t hurt to have a list of medical specialists in your community, especially if you know any of them through professional channels.

Who does what? If you are not sure what kind of doctor treats different illnesses and injuries you can refer to this list.

Allergist or Immunologist - conducts the diagnosis and treatment of allergic conditions.

71 Anesthesiologist - treats chronic pain syndromes; administers anesthesia and monitors the patient during surgery.

Cardiologist - treats heart disease

Dermatologist -treats skin diseases, including some skin cancers

Gastroenterologist - treats stomach disorders

Hematologist/Oncologist - treats diseases of the blood and blood-forming tissues (oncology including cancer and other tumors)

Internal Medicine Physician - treats diseases and disorders of internal structures of the body.

Nephrologist - treats kidney diseases.

Neurologist - treats diseases and disorders of the nervous system.

Neurosurgeon - conducts surgery of the nervous system.

Obstetrician - treats women during pregnancy and childbirth

Gynecologist - treats diseases of the female reproductive system and genital tract.

Nurse-Midwifery - manages a woman's health care, especially during pregnancy, delivery, and the postpartum period.

Occupational Medicine Physician - diagnoses and treats work-related disease or injury.

Ophthalmologist - treats eye defects, injuries, and diseases.

Oral and Maxillofacial Surgeon - surgically treats diseases, injuries, and defects of the hard and soft tissues of the face, mouth, and jaws.

Orthopaedic Surgeon - preserves and restores the function of the musculoskeletal system.

72 Otolaryngologist (Head and Neck Surgeon) - treats diseases of the ear, nose, and throat,and some diseases of the head and neck, including facial plastic surgery.

Pathologist - diagnoses and treats the study of the changes in body tissues and organs which cause or are caused by disease

Pediatrician - treats infants, toddlers, children and teenagers.

Plastic Surgeon - restores, reconstructs, corrects or improves in the shape and appearance of damaged body structures, especially the face.

Podiatrist - provides medical and surgical treatment of the foot.

Psychiatrist - treats patients with mental and emotional disorders.

Pulmonary Medicine Physician - diagnoses and treats lung disorders.

Radiation Onconlogist - diagnoses and treats disorders with the use of diagnostic imaging, including X-rays, sound waves, radioactive substances, and magnetic fields.

Diagnostic Radiologist - diagnoses and medically treats diseases and disorders of internal structures of the body.

Rheumatologist - treats rheumatic diseases, or conditions characterized by inflammation, soreness and stiffness of muscles, and pain in joints and associated structures

Urologist - diagnoses and treats the male and female urinary tract and the male reproductive system

It is also a good idea to make a list of mental health counselors, especially those that deal with domestic violence, grief issues and substance abuse

Speak Respectfully Of Your Fellow Professionals Nothing makes a person look less professional than hearing them denigrating another professional. We need to have respect for all other medical professionals, even if we do not agree with their decisions or methodology.

73 Of course they make mistakes, and some may rely on surgery or drugs more than we would like, but they make choices based on their education and experience and we have to let our clients make their own choices about their medical care.

It is always wrong to denigrate another professional, but especially so when the client has faith in that medical professional. If you speak ill of a doctor that your client trusts you are basically insulting their judgment, and what’s worse, you may potentially shake their faith in a professional that may be the best person to provide care for them.

When it comes to our professional image there are two crucial mistakes we can make, to undervalue massage therapy, or to over estimate its efficacy.

I used to tell my students that it’s okay to be a massage therapist; you don’t have to try and be a doctor or a physical therapist. Massage therapy is a noninvasive treatment that can ease pain without side effects, can help lower stress, and most experts agree that stress is a leading cause of many illnesses plaguing our society. It is loved by people the world over, and is offered in every vacation resort and destination because it is a true pleasure.

But always remember there is limits to what it can do, it’s not a universal cure-all and it’s not the pinnacle of healing knowledge. It can definitely facilitate the healing of damaged tissues, but the real miracle is what the body does on it’s own.

To stay within our scope of practice we have to be realistically grounded in what massage therapy is and isn’t. We must be mindful of our advice and suggestions, and we need to honor and respect our fellow healthcare practitioners.

Recap of Chapter 2 In this chapter we covered the four principles of medical ethics from which the standards of practice for massage therapy are derived. Those four principles are autonomy (respecting the client), nonmaleficence (not harming your client), beneficence (doing what is good for your client), and justice (obeying the laws governing your profession).

74 We also discussed the need for massage regulation, and the resulting scope of practice rules that come from licensing boards and regulatory bodies. While these different regulatory bodies all vary in details there are some universally agreed definitions for massage therapy, which includes the manual manipulation of soft tissue. We discussed some of the pitfalls common to massage therapy when it comes to scope of practice, specifically accidentally “diagnosing” our clients, practicing medicine without a license by “prescribing exercises” and contradicting the orders of doctors and others healthcare providers.

And lastly we looked at the importance of maintaining our image by keeping our relations with other healthcare providers on a professional and respectful level.

75 Chapter 3: Legal and Ethical Requirements Obey all applicable local, state, and federal laws It’s the first provision of the NCBTMB Standards of Practice, Standard II: Legal and Ethical Requirements .

Standard II of the NCBTMB Standards of Practice is all about obeying the law, which is an important part of being a licensed professional since the authority that grants you that license and your professional status is the law. To ignore and disobey the law is to undermine your own standing as a professional. Why would your status as a professional recognized and endorsed by the law, be of any value if you don’t hold to the very laws that grant you that status?

It would be nice if we lived in a world where we didn’t have to tell our licensed professionals that they should obey the law. But we do not live in that world, we live in a world where everyday we see or hear another story about:

Doctors that violated their scope of practice by prescribing controlled substances illegally.

Businessmen that share inside information that damages their own corporations stock value.

Politicians that use their offices to do favors for campaign donors, at the expense of their constituents.

Scientists that take bribes in the form of “research funding” to pronounce bogus facts that support twisted ideologies.

Police officers abuse their authority and take bribes.

I’m willing to bet that each item on the list above stands out as being blatantly wrong to you. Some of them might even make you really angry. Why?

Because each one of them is a violation of the public trust. When you break the laws of your profession you are violating the public trust too, just like the people on that list.

76 Why you should obey the laws Laws, regulations, and ethical guidelines figure very importantly in the conduct of massage therapy. Laws and regulations serve a variety of purposes. Some of these purposes serve the community as a collective-our licensing fees go to support the regulatory infrastructure, for example.

Of course, they are mostly for the more obvious purposes protecting the public and the practitioner.

History of regulation Massage therapy has been regulated in various forms in the United States for almost a century now. The earliest regulation in the United States was passed in Ohio in 1915 27 , and was slowly followed by other states.

In nearly every state the purpose for massage regulation was to curtail prostitution and to help the public discern trained therapeutic massage professionals from those offering illicit sensual massage. Enforcement has ranged from sanctions such as letters of warning, to punishments that have include loss of license, fines and even imprisonment.

Enforcement of State Laws Laws pertaining to massage therapy can be found in various statutes and codes that serve a variety of purposes such as maintaining confidentiality and ensuring adequate levels of training. In some states the laws are grouped with other manual body workers, like physical therapists, chiropractors and personal trainers, or with other spa related industries like estheticians and cosmetologists. In some areas the laws pertaining to massage establishments are lumped in with other closely regulated activities, such as gambling establishments.

In many states now in the USA, massage therapy state boards exist and have the responsibility of regulating members of the massage profession in their jurisdiction. There are numerous laws and regulations that give these boards their power and responsibility, as well as the specific procedures for the regulation of the professionals under their authority. The boards themselves must obey numerous laws and regulations pertaining to their own conduct. The board’s regulatory responsibilities include reviewing

27 The History of Massage: An Illustrated Survey from Around the World By Robert Noah Calvert

77 complaints from the public, issuing sanctions and even working with law enforcement when necessary.

Why should you obey the law? An ethics centered approach Blind adherence to the letter of the law can lead to a morally vacuous attitude where actions are considered acceptable if they are within the limits of the law. This legalistic approach is common today and it explains why so many people that are accused of doing something wrong hide behind a technical interpretation of the law rather than the spirit of the law, which they know they have violated. You can hear it in their voice when they boastfully say they were “not indicted or convicted”-as if that was the same as saying they did nothing wrong.

The problem with this attitude is the assumption that legal standards are as broad and far-reaching as ethical principles, and they are not.

Although obeying the law is definitely an important part of being a responsible citizen it is often not the fulfillment of our ethical duty. The law is the minimum standard of propriety, the absolute bottom level of acceptable behavior . It tells us what behaviors we will be punished for doing, not what we should be doing to be ethical massage therapists

When people use the law as an ethical guide they develop what I like to call the “compliance mentality”-meaning that they judge what is right or wrong based on whether it is legal or illegal. While that might keep you from being fined or imprisoned it will not make you an ethical person, because many unethical practices are perfectly legal. For example, there is nothing illegal about taking advantage of the power differential in massage therapy to get clients to book multiple appointments ahead of time, but it is highly unethical.

It’s easy to lose sight of what’s right or wrong when you adopt a “Do only what you have to do to stay out of trouble” mindset, which is the inevitable outcome of relying on the law as your ethical boundary.

So the ethical centered approach is to go beyond the law, to set your personal ethical standards much higher than what the law demands.

78 Going beyond mere compliance Going beyond compliance means not looking for ways around existing laws, but respecting the spirit of the law. Here is a practical example:

In the town where our school is located the city ordinance specifically forbids doing massage outside of a designated “massage establishment” for compensation. In other words, we were forbidden to perform outcall massage (visiting a persons home) or even to do chair massages at a public venue if we were receiving any compensation (even if it was just a gratuity).

As you might imagine this riled many of the local massage therapists, since massage therapists in the next town over could freely visit clients in their homes if they wished, or set up a chair massage station at the local country club, simple things that are accepted parts of our trade.

So many massage therapists decided that, since they felt the law was stupid they were perfectly justified in finding a sneaky way around it. What they did was add “Wellness consultant” to their business cards and websites, and then went to the clients home to do a wellness consultation- which was perfectly fine. Then, after the client paid them for the consultation they gave them a massage, for free of course, which was in keeping with the law, since they were not receiving any compensation for it.

These people were focusing on compliance and were using the law as their ethical boundary. The problem is, their strategy didn’t work. A local massage therapist (who was in obeying both the letter and the spirit of the law) reported them to the police, who then set up a “wellness consultation”- and the result was a massage therapist being fined for breaking the city ordinance.

So in this example, to go beyond mere compliance meant to adhere to the spirit of the law, which was to not engage in massage therapy outside of the designated establishments. Now what they should have done is exactly what a better informed group of massage therapists did later, they petitioned the city council to update the laws to be more in step with the times-and they did so.

Obeying the law as part of the social contract Remember back in chapter 1 when I mentioned social contract theory?

Social contract theory is the idea that person’s moral and/or political obligations are dependent upon a contract (agreement) among all the people in the society in which they live.

Well when you decided to become a massage therapist you signed onto that social contract, in other words you said “I want the right to call myself a massage therapist and charge people money for my services, and in return I will follow the rules that society has in place for massage therapists.” You knew going into it that there were rules to follow, and you agreed to them. You signed the social contract .

Like all contracts, there is a penalty for breaking it. It really doesn’t matter if you disagree with the rule, or if it’s outdated or stupid. Nobody made you become a massage therapist against your will, you volunteered for it, so when you break the contract by violating the law, you are inviting the punishment.

That being said, contracts are amendable, and so are laws. If you are chafing under a regulatory environment that is unfair to massage therapists, by all means, mobilize, organize, and get the laws changed.

That’s how the social contract works.

Refrain from illegal, discriminatory, or unethical actions This is also taken from the NCBTMB standards of practice. I have included it here because it’s a broad statement and one worthy of examination.

It doesn’t say “refrain from breaking laws pertaining to massage therapy”-it says, “refrain from illegal, discriminatory or unethical actions”. This means that they are holding their professionals to a standard of conduct that is completely aboveboard. In effect, it is saying that as a professional massage therapist you will not:

80 Cheat on your taxes.

Drive a vehicle while intoxicated.

Assault another human being.

Possess, buy or sell illegal narcotics.

Steal or commit fraud.

None of these things seem to have any relation to our interaction with our massage clients (except for the assault or stealing perhaps). So why would the NCBTMB include such a broad statement in their standards of practice?

What does it matter to my massage clients if I was arrested for a DUI? That has nothing to do with them, or my work. I keep my personal life and my professional life separate.

This statement is indicative of the idea of compartmentalization that many people have in our modern world, that you can be one person while you are at work and someone else while off work. The problem is that this is not a true statement. Yes, you do behave differently at work, and your relationship with your clients is very different from your relationship with your friends and family, but you are the same person. You cannot break laws outside of your work without it spilling over into your professional life. We are going to discuss that in more detail later when we look at roles and boundaries. Our lives are not compartmentalized, they are intricately interconnected, and nothing happens in a vacuum.

This statement also prohibits discriminatory actions. In our diverse society it is inevitable that you are going to be exposed to a multitude of clients from different ethnicities, cultures, nationalities and genders. We have an entire course dedicated to ethnic and cultural sensitivity , so I am not going to focus on that here, but I will touch on the issue of gender discrimination.

There is a cognitive dissonance in our profession regarding gender equality. We are conditioned from our first day in massage school to accept the fact that most clients have a gender preference in massage

81 therapists and to not take it personally. We are told there are many female clients that are “just not comfortable” getting a massage from a male therapist and even more male clients not comfortable getting a massage from a male therapist. Of course they are right, that is a fact of our industry.

As a male massage therapist I never had an issue with this, I have no problem with clients preferring a female massage therapist, because I know there are plenty of clients out there that prefer male therapists. Where this becomes an issue is in hiring practices , and it can be an expensive lesson to learn.

If you own a massage business and you hire massage therapists to work for you or rent space to them in your establishment you may be tempted to show preference to female therapists based on “what your clients prefer.” You might think (correctly) that the majority of your clients would prefer a female therapist over a male one, and as a result, not offer to rent a space to a male massage therapist or even to hire one.

The problem with this is that it violates the law, specifically Title VII of the Civil Rights Act of 1964 (Title VII).

This law makes it illegal to discriminate against someone on the basis of race, color, religion, national origin, or sex. The law also makes it illegal to retaliate against a person because the person complained about discrimination, filed a charge of discrimination, or participated in an employment discrimination investigation or lawsuit. The law also requires that employers reasonably accommodate applicants' and employees' sincerely held religious practices, unless doing so would impose an undue hardship on the operation of the employer's business.

The argument that “my clients prefer female massage therapists” would not be a permissible defense if the male massage therapist decided to go forward with a lawsuit. A man owning an automobile repair shop could make the same argument, that his customers would prefer to not have their car worked on by a woman, even if she had all the necessary skills, knowledge and certifications.

Title VII allows for discrimination based on protected characteristics (except race), when that characteristic is what is called a "Bona Fide Occupational

82 Qualification" (BFOQ). To be a BFOQ, being a member of that group is essential to the job.

To use this exception to the rule against discrimination, an employer must be able to prove that no member outside the desired group could perform the job. A good example would be a job for a women's bathroom attendant.

Unfortunately there are far too many successful male massage therapists to make this argument.

Dealing with your clients gender discrimination So how do you, as a massage establishment owner, deal with the reality of a clientele that has a definite gender bias? Here is a useful and practical tip I picked up running both a massage business and a student clinic in a massage school:

How you ask the client makes a huge difference. There are many clients who will ask for a massage therapist of a specific gender, and that really is okay, they may have significant insecurities, a history of past abuse or a number of other psychological issues at work, or they may just prefer the hands of a male or female.

But when you are booking a new client, either over the phone or at the front desk, if they haven’t stated that they want a male or female you can ask them.

Do not ask them if they prefer a male or female massage therapist.

That is a sexually loaded question. You are framing the massage in sexual terms, and asking them what their preference is.

Instead, ask them “Does it mattes to you if the massage therapist is male or female?

Of course some will still say they prefer one or the other, but you will find many people reply back that it doesn’t matter to them, when asked this way. Why? You have reframed the question, and taken the emphasis away from sexual preference and placed it where it really belongs, on whether or not it matters.

83 If you don’t think that such a small detail in wording can make a big difference, just ask yourself if there is a difference between:

“You can undress to your comfort level” and “strip down to your underwear”. Yes wording makes a big difference.

Accept responsibility for his/her own actions “We all want progress, but if you're on the wrong road, progress means doing an about-turn and walking back to the right road; in that case, the man who turns back soonest is the most progressive.” -C. S. Lewis

Part of being an ethical professional is taking responsibility for our own actions. When we make excuses for our mistakes or blame our clients, our coworkers, our licensing board or the economy we are not only failing to take responsibility, but we are nurturing a character trait that is very common in people who fail to succeed in business.

In taking responsibility we are giving ourselves the power to chart the course of our massage practice, and are therefore taking an active role in deciding where it goes, and where it takes us.

When you realize that everything you achieve or fail to achieve in your massage business is ultimately up to you it frees you from the burden of excuse making. The excuse is the great detour on the path of success, it’s the seductively cool and shady downhill path that is easier to walk, but takes you in the wrong direction. Sometimes you need to be going uphill in the hot sun to get where you want to be.

Mistakes are a part of life, we all make them, and when we make a mistake the quickest way to get back on track is deal with it openly and directly.

You may find your massage business in a slump and it’s easier to believe that the laws of your city or state are interfering with your ability to really succeed financially.

Maybe you could earn extra money if you added facials and waxing to your menu, even though you are not a licensed cosmetologist, you

84 have friends that are and they have shown you how to do it, why shouldn’t you earn extra money?

Or maybe your city has an ordinance that prohibits massage therapists from working after 7:00 pm-who are they to tell you when you can’t work?

Maybe your client is tired of going to his Chiropractor, and he knows you used to work with one; he’s willing to pay you to adjust his spine. You’ve seen the chiropractor do it enough times…why shouldn’t you do it?

These are just examples of common temptations massage therapists face, there are of course many more. With each one there is the convenient detour of excuse, just waiting to show you the easier way. But of course each one of these things is outside of your Scope of Practice, and the result of being caught doing any of them would, at the very least, be a fine, if not a loss of license all together. So you can see that the analogy of the detour is really appropriate, because it takes you to somewhere other than where you wanted to go in the first place. Instead of your desired destination-financial gains for your business, it actually takes you to financial ruin.

We all have free will, which means that we are ultimately responsible for all of our successes and failures in our practice.

Of course there will be external obstacles to overcome, and sometimes these obstacles will cause you to lose some business and stumble, but if you take responsibility for your actions and try to make the ethical decision you will rebound much quicker.

I have an example from my own career that is very appropriate. I was halfway through a 2-year lease for my massage office when my landlord decided to demolish the building next door (which he also owned) and to build a new office complex there. This meant that for the next 8-9 months there would be bulldozers, jackhammers, and power saws working only a few feet away from my massage room.

My clients complained about the noise and asked me to visit them in their homes (prohibited in my town) or to work late at night (also prohibited).

I was losing money like crazy, and when I talked to the landlord he was not sympathetic, after all, he had a lot of money invested in the new building and that was his priority.

So I found myself in a situation where it would have been easy to justify breaking the local laws-after all, I had bills to pay, and the landlord was creating an obstacle to my business that was out of my control.

But I didn’t want to go that route. The situation was out of my control, but my choices were still under my control. Eventually I did have to confront my landlord and demand to be released from the lease on the grounds that he was making it impossible to conduct my business and he agreed. While it was a hassle moving to a new location it turned out to be a better one in the end, and my clients appreciated that I moved because they weren’t happy with the noise.

Did I lose some money? Yes. Did I have to go through the hassle of moving and applying for a new establishment permit? Yes.

Did I maintain my integrity and high ethical standards? Yes, and it was worth every cent.

When we realize that ultimately no external obstacles can be blamed for our choices it seems like a huge responsibility. It’s easy to make an unethical choice when faced with situations that are out of your control-but you are always in control of your choices.

Report to the proper authorities any alleged violations of the law by other certificants or applicants for certification This provision of the NCBTMB Standards of Practice, Standard II: Legal and Ethical Requirements applies to all NCBTMB Certified Massage Therapists and it places on us the duty of policing our fellow NCBTMB Certified Massage Therapists.

It does not apply to massage therapists in our community that are not certified by the NCBTMB-which is one of the reasons why that organization can claim to be elevating the practice of massage therapy, they are literally holding their members to a different, higher standard than non-NCBTMB certified massage therapists.

This is, ethically speaking a deontological-based mandate, or in other words, an ethical duty, to preserve the image of the certified massage therapy professional by reporting members that violate the law.

Maintain accurate and truthful records This provision of the NCBTMB Standards of Practice, Standard II: Legal and Ethical Requirements applies not just to SOAP notes, but to all documentation related to your practice. It essentially means that you will not:

Fail to keep treatment records as required by your employer. Falsify any record relating to your practice Sign, or issue in your professional capacity, a document that you know contains a false or misleading statement

The Other Reporting Requirements The NCBTMB Standards of Practice, Standard II: Legal and Ethical Requirements also requires it’s members to Report:

Any criminal conviction of, or plea of guilty, nolo contendere, or no contest to, a crime in any jurisdiction (other than a minor traffic offense) by him/herself and by other certificants or applicants for certification

Pending litigation and resulting resolution related to the certificant or applicant for certification’s professional practice and the professional practice of other certificants or applicants for certification

Pending complaints in any state or local government or quasi- government board or agency against his/her professional conduct or competence, or that of another certificant, and the resulting resolution of such complaint

The rationale behind these reporting mandates is rooted in the idea of elevating the profession and holding it’s members to standards that will engender respect and trust in the massage consumer, law enforcement and the public in general.

Recap of Chapter 3 In this chapter we reviewed the NCBTMB Standards of Practice, Standard II: Legal and Ethical Requirements . These can be summarized in one sentence:

As a professional you shouldn’t break the law but if you do, you must be honest and face the consequences.

The Standard II requirements are strongly influenced by deontological (duty-based) ethics in that they require the practitioner to take actions that are outside of the relationship between practitioner and client, specifically to report infractions of the law committed by other certificants.

While most of the standards of practice are related to the relationship between the practitioner and the client, these standards hint at the broader relationship between the practitioner and society. In a sense the requirements of standard II are all about our social contract. The public trusts us, and law enforcement agencies permit us to work in exchange for our agreement to abide by the law and the provisions of our licensing boards and certifying agencies.

88 Chapter 4: Roles and Boundaries

Laws and Licensing Boards (a necessary evil) Have you ever spent time thinking about your states massage licensing board? I mean other than cursing them for making you pay fees and take continuing education courses. Do we really need them?

Many people say yes, we do need them. Those people usually own schools (or are continuing education providers, wink wink) and they financially benefit from the existence of licensing boards-the boards make you buy their product.

But do YOU think a licensing board is needed? Ask yourself what would happen in there was nobody regulating the practice of massage in your state. Would you still be able to practice?

The standard textbook answer is that it benefits you by minimizing the competition (only people who have met certain standards can practice) and it protects the public (again, only people that have met certain standards can work on them).

The definition of a license Although we don’t think of it very often, the word license literally means “permission”-or more specifically, permission to engage in a regulated activity.

Think about all of the things you need a license to do.

We need a license to drive an automobile, because the government has said that it is dangerous to operate a vehicle without meeting certain educational and competency standards.

We need a license to practice medicine or law, because the government has said that to do so without the proper education and training puts the public at risk.

We need a license to get married; because at some point in our collective past it was decided that allowing people to marry certain other people (i.e. cousins, sisters, sheep, multiple partners, etc) would be harmful to society, or at the very least, would make things exceedingly complicated.

But wait…that’s not all.

You also need a license to sell real estate (as a business, not your personal real estate) because apparently the government thinks that is dangerous too.

Cosmetologists need a license, because the government needs to protect us from…what? Bad haircuts? Well, they would say the spread of head lice and other hygienic threats.

Of course you need a license to sell alcoholic beverages to the public, because if you are not selling it to the right people (i.e. children) it is bad for society. This is probably why we don’t have drive-through windows in liquor stores.

But of course, the ultimate license is that of commerce. You need a business license to buy or sell anything in most municipalities. Think about that…you could open a store in your town selling nothing but play-dough 28 . It’s safe, non-toxic (you can eat it!) and fun. To the best of my knowledge, nobody, in the history of humanity, has ever been wronged or in any way harmed by play-dough.

But if you open a store selling it in your town, you had better get a business license, because apparently, the government thinks it has the right (duty? responsibility?) to regulate the buying and selling of things. Call me a cynic, but I think it just might have something to do with the collection of sales tax.

So back to the question of massage licensing.

Are you, as a massage therapist, better off if your state requires you to have a license? Is the public better off?

Well I would think that most of us would agree that it’s pretty good for doctors to need a license to practice medicine. That’s not a profession where just anybody should be hanging a sign up in front of their office because they feel they would be pretty good at telling people what’s wrong with them.

28 Not to be confused with a product with a similar name that is a registered trademark of Hasbro toys inc. and as such would not be mentioned in this course unless they were paying me to do so. They are not.

So how about massage therapy? A massage isn’t like a prescription for medication. If the person isn’t good at it, it’s not going to kill anyone (usually ).

The argument in favor of massage licensing as a means of protecting the public has more to do with deterring criminal behavior than avoiding practitioner incompetence.

The belief among the ruling bureaucracy is that requiring massage therapists to be licensed will prevent prostitutes from using massage as a cover for their activity, and will hopefully deter rapists, molesters and hidden camera hiding perverts from opening up their own massage practices.

Of course, this doesn’t work. Why? For the same reason that making guns illegal doesn’t stop criminals from using guns. To think that passing a law will somehow make criminals stop breaking laws is a delusion that is rampant in the United States.

Do people really think that requiring you to spend six months or more in school, spending thousands of dollars and taking difficult tests to get a license, will really stop a pimp from whipping up a fake NCBTMB certificate on his computer? That is of course assuming he wanted to go so far to fool anyone, usually they just say their “employees” massage therapists and open up shop.

If you don’t think that happens just google “massage therapist arrested for…” and pop some popcorn and sit back and enjoy hours of entertaining reading.

Each year in this country, and in every state, there are prostitutes arrested who are posing as massage therapists. That is why we get still calls from “Johns” looking for a “happy ending” in our legitimate massage businesses. Most states have licensing boards, but they do not seem to be able to prevent this from happening. So what good are they?

By now you are probably thinking, “ Wow, this guy has an axe to grind with the licensing boards… ” but I don’t. I really do believe that massage

91 therapists are better off with licensing boards, because it is all about a perception of public trust .

Public trust and the image of massage therapy You see we all know that there are bad people out there pretending to be licensed massage therapists. 29 We still benefit from licensing because when we tell a customer that we are licensed it instills a sense of trust. It allows them to lower their guard and trust us, which is a good thing.

Trust is a crucial element in massage therapy. If you have ever worked on a client that was not entirely comfortable with massage you know that it’s very difficult to get someone to relax when they’re anxious about the procedure. They hold their muscles rigid and their breathing is rapid and shallow. It might take half of their session just to get them to relax enough for you to knead their muscles.

It could also have to do with their perception of what massage therapy is, having based their opinions on what they have seen on television shows or in the news.

In case you haven’t notice, anytime a massage therapist is mentioned in the news it is never good. It’s always “ prostitution ring uncovered ” or “massage therapist having an affair with ______” or “ the alleged perpetrator attacked the masseuse… ”

Just once, I would like to hear “ Local massage therapist saves client by administering CPR ,” or “ Massage therapist reduces stress of police department, given key to the city by mayor .”

We are definitely a profession that needs a publicist, someone to help us recreate our image in the public mind.

Organizations like the NCBTMB and the AMTA do their best to present to the public an image of massage therapy that is noble, reputable and professional, but they can only do so much. The truth is, nobody can mold the image of what massage therapy is in the minds of the people in your community better than you.

29 And of course, there are bad people that actually are licensed massage therapists, but we are just going to ignore that for right now

92 To the people of your city, YOU are the ambassador of our profession. You represent all of us. They will base their opinion of what massage therapy is based, not just on how you do your job, but how you live your life.

What you do while you are outside of the massage room is just as important as what you do inside.

Ethics are not limited to the workplace One of the characteristics of our modern society is that we tend to segment our lives. What I mean by this is that we act differently in different environments.

Part of that is perfectly natural. We are taught as children to behave a certain way at school, and that way is usually a little different than how we behaved at home. Even at school, we acted differently in the classroom than we did on the playground.

Adapting our behaviors to the environment is one of the things that separate us from wild animals, whose behaviors are dictated by instinct alone.

We expect massage therapists to behave ethically and professionally when they are at work. That is the minimum standard. I would hope any spa owner would fire a massage therapist that doesn’t present a professional image to the public. But what about when they are not at work? That is when things get tricky.

One of the hardest ethical concepts for my new massage therapy students to grasp was the idea that we are massage therapists all the time.

The paradox of professional boundaries. Most of this course deals with the specifics of how you should guide your actions and your decision-making at work. It’s definitely not our place to tell you how to live your personal life.

But I will tell you that how you live your personal life will eventually affect your professional life. It is unavoidable, because we live in a community of people. Your massage business doesn’t operate in a vacuum.

93 The simple example that I used to give my students was the one below. We are going to call it Scenario A.

Scenario A It’s Saturday night and you are single, so you go out to the club. You’re just blowing off steam from a stressful week so you have a few drinks, just enough to help you relax. You meet someone cool, and you dance and you flirt. You might even get handed a phone number. An innocent evening of harmless fun is had.

Monday morning you are back and work and your first appointment, a new client, comes in.

It’s your dance partner from Saturday night.

Well now, this is awkward .

Maybe it’s just a coincidence. If you live in a smaller community this can easily happen. We discuss it later in the section on Managing Dual Relationships.

Of course there is always the possibility that while you were in the bathroom at the club your dance partner struck up a conversation with one of your friends and found out where you worked. That could be either very romantic or seriously creepy, depending on the person’s intent and your own views, but the point is, your personal life just seeped into your professional life. It happens.

Now if you are a professional it should be easy for you to slip into “ this is me at work” mode and to treat the person just like any other client-but the far more interesting question is, will the client still see you as a professional, or will the image of you writhing on the dance floor be overwhelmingly burned into their subconscious?

It has a lot to do with how you behaved yourself at the club.

In a perfect world we would say that a person shouldn’t judge someone at work by how they acted when they are off the clock. If the person can’t separate the “ you from the club ” with the “ you at work ”, that’s their problem!

But we don’t live in a perfect world, do we?

To illustrate that point, here is Scenario B.

He then takes the upper part of the leash and starts to beat the cringing dog with it like it’s a whip, all the while cursing angrily. He then walks way, dragging the abused dog behind him.

The next day you have an appointment with a new dentist. You are surprised to see that your new dentist is the same man you saw hitting the dog in the park.

So how comfortable are you with this guy drilling in your mouth?

Can you separate the dentist from the man walking the dog?

Maybe he has great professional ethics and would never hurt a patient unnecessarily, but that’s not the point . The point is that how you see him as a dentist has probably been colored by how you saw him outside of work. It’s true for us too.

Now invariably some of you are wondering why I have included this section on professional image and public perception of massage therapy in an ethics course.

Traditionally, ethics course are limited to dealing with conflicting ideas of what is right, wrong and professional in the workplace and make no mention of professional image outside of the work environment.

In Scenario A the ethical question is how do you conduct yourself with the person once they have shown up as your client, not how you conducted

95 yourself at the club on Saturday night. It’s important to recognize that fact, but it’s equally important to recognize that how you conduct your personal life will greatly influence what kind of ethical challenges you face in your professional life. The two can only be separated by so much; after all you are just one person.

So if your dance partner in Scenario A did track you down because they have a romantic interest in you, there is a good chance that you are going to have to draw on the ethical code to guide your behavior.

The purpose of an ethical code Massage therapists have a need for ethical principles to guide decision making when values are in conflict . In a perfect world, we would not need an ethical code. We need one because the world is not perfect.

Industry leaders recognize the impact that ethical values, behaviors and practices can have on our profession, your personal reputation and your massage businesses bottom line.

A code of ethics is a set of guidelines that defines acceptable behavior for members of an organization or group. Ideally, an organization tailors its code of ethics to its needs and values.

Usually an organizations ethics policy reinforces the moral principles and commitments of an organization by spelling out acceptable and responsible behavior in a way that is clear to all within the organization. In addition to guiding us, it broadcasts to non-massage therapists what we are all about.

A good code of ethics can serve as a guide when you face an unusual situation and you are not sure what the right thing to do is.

“It's not hard to make decisions when you know what your values are.” ― Roy Disney

On the following pages there is a copy of the Code of Ethics for the National Certification Board for Therapeutic Massage and Body Work.

The NCBTMB Code of Ethics NCBTMB certificants and applicants for certification shall act in a manner that justifies public trust and confidence, enhances the reputation of the

96 profession, and safeguards the interest of individual clients. Certificants and applicants for certification will:

I. Have a sincere commitment to provide the highest quality of care to those who seek their professional services.

II. Represent their qualifications honestly, including education and professional affiliations, and provide only those services that they are qualified to perform.

III. Accurately inform clients, other health care practitioners, and the public of the scope and limitations of their discipline.

IV. Acknowledge the limitations of and contraindications for massage and bodywork and refer clients to appropriate health professionals.

V. Provide treatment only where there is reasonable expectation that it will be advantageous to the client.

VI. Consistently maintain and improve professional knowledge and competence, striving for professional excellence through regular assessment of personal and professional strengths and weaknesses and through continued education training.

VII. Conduct their business and professional activities with honesty and integrity, and respect the inherent worth of all persons.

VIII. Refuse to unjustly discriminate against clients and/or health professionals.

IX. Safeguard the confidentiality of all client information, unless disclosure is requested by the client in writing, is medically necessary, is required by law, or necessary for the protection of the public.

X. Respect the client's right to treatment with informed and voluntary consent. The certified practitioner will obtain and record the informed consent of the client, or client's advocate, before providing treatment. This consent may be written or verbal.

97 XI. Respect the client's right to refuse, modify or terminate treatment regardless of prior consent given.

XII. Provide draping and treatment in a way that ensures the safety, comfort and privacy of the client.

XIII. Exercise the right to refuse to treat any person or part of the body for just and reasonable cause.

XIV. Refrain, under all circumstances, from initiating or engaging in any sexual conduct, sexual activities, or sexualizing behavior involving a client, even if the client attempts to sexualize the relationship unless a pre-existing relationship exists between an applicant or a practitioner and the client prior to the applicant or practitioner applying to be certified by NCBTMB.

XV. Avoid any interest, activity or influence which might be in conflict with the practitioner's obligation to act in the best interests of the client or the profession.

XVI. Respect the client's boundaries with regard to privacy, disclosure, exposure, emotional expression, beliefs and the client's reasonable expectations of professional behavior. Practitioners will respect the client's autonomy.

XVII. Refuse any gifts or benefits that are intended to influence a referral, decision or treatment, or that are purely for personal gain and not for the good of the client.

XVIII. Follow the NCBTMB Standards of Practice, this Code of Ethics, and all policies, procedures, guidelines, regulations, codes, and requirements promulgated by the National Certification Board for Therapeutic Massage & Bodywork.

98 On the following pages there is a copy of the Code of Ethics for the American Massage Therapy Association.

Code of Ethics This Code of Ethics is a summary statement of the standards of conduct that define ethical behavior for the massage therapist. Adherence to the Code is a prerequisite for admission to and continued membership in the American Massage Therapy Association (AMTA).

Principles of Ethics. The Principles of Ethics form the first part of the Code of Ethics. They are aspirational and inspirational model standards of exemplary professional conduct for all members of the association. These Principles should not be regarded as limitations or restrictions, but as goals for which members should constantly strive.

Massage therapists/practitioners shall:

Demonstrate commitment to provide the highest quality massage therapy/bodywork to those who seek their professional service.

Acknowledge the inherent worth and individuality of each person by not discriminating or behaving in any prejudicial manner with clients and/or colleagues.

Demonstrate professional excellence through regular self-assessment of strengths, limitations, and effectiveness by continued education and training.

Acknowledge the confidential nature of the professional relationship with clients and respect each client’s right to privacy within the constraints of the law.

Project a professional image and uphold the highest standards of professionalism.

Accept responsibility to do no harm to the physical, mental and emotional well-being of self, clients, and associates.

Rules of Ethics. The Rules of Ethics are mandatory and direct specific standards of minimally-acceptable professional conduct for all members of

99 the association. The Rules of Ethics are enforceable for all association members, and any members who violate this Code shall be subject to disciplinary action.

Massage therapists/practitioners shall:

Conduct all business and professional activities within their scope of practice and all applicable legal and regulatory requirements.

Refrain from engaging in any sexual conduct or sexual activities involving their clients in the course of a massage therapy session.

Be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

Refrain from using AMTA membership, including the AMTA name, logo or other intellectual property, or the member’s position, in any way that is unauthorized, improper or misleading.

Refrain from engaging in any activity which would violate confidentiality commitments and/or proprietary rights of AMTA or any other person or organization.

Effective Date May 1, 2010

The Therapeutic Role When a person visits a massage therapist with the intent of benefiting from their services they are entering a relationship. In the field of health care professionals this is known as the Therapeutic Relationship .

The therapeutic relationship is not specific or exclusive to Massage Therapy; it is a relationship that exists between all health care practitioners and their patients. Doctors, Nurses, Pharmacists and Psychologists, all play a role in a therapeutic relationship.

Central to the nature of the therapeutic relationship is the belief that what is done is by the practitioner (in our case, the massage therapist) is done with

100 the goal of helping or healing. So it is right to assume that nothing harmful should arise out of the relationship. While this may seem simplistic and even obvious, it is a profound truth and needs to be recognized and used as a lens through which to examine all of our actions within the role of our profession.

As odd as it may seem, many unhealthy relationships have been born of the intimacy that is inherent in the massage profession. This is why so many state licensing boards require ongoing ethics training, not because there are new ethics to be learned each year, but because we need constant reminders of the importance of maintaining healthy boundaries and fruitful therapeutic relationships.

The Clients Expectations A client enters into the Therapeutic Relationship with certain expectations. These expectations help form the boundaries of the relationship from the client’s perspective.

Competency-The Client expects the Massage Therapist to know what they are doing. More specifically, they expect you to have what is known as “Expert Knowledge”. They are assuming that you have attended an appropriate school and have been well trained.

Physical Safety- The Client expects to be free from physical dangers when in the massage room. Many states require Massage Establishments to be inspected by the Health Department, Fire Department or even the local Police Department before a license is issued. This is part of maintaining the aura of trust and safety in a place of business.

Emotional Safety- The Client needs to feel that their massage therapist is offering them a place to unwind and release pent up emotions, pain and stress. The “safe haven” is critical to the massage relationship. Trust and confidentiality are essential components of this safety.

It is important to remember that the benefits of Massage can only be gained when a Client is able to place themselves in one of the most vulnerable positions imaginable.

101

Reviewing Basic Ethical Concepts

Informed Consent Informed consent is a legal condition whereby a person can be said to have given consent based upon a clear appreciation and understanding of the facts, implications and future consequences of an action. In terms of massage therapy this means that they understand what treatments are going to be performed and the purpose and goals of each.

Right of Refusal Clients have the right to refuse the service for any reason at any time. If they determine that the session should be stopped right in the middle, their needs must be respected. Be aware that a session interrupted before completed may also cause a problem in the financial agreement, unless otherwise spelled out in the Intake form.

The Right of Refusal also applies to you as a massage practitioner. You can end a session at any time, for any reason.

Confidentiality A client’s information, both written and verbal should be considered sensitive and private at all times. Conversations that occur during a session should never be repeated outside of the massage room, or even included in the SOAP notes unless it is directly relevant to their physical condition.

The therapist must remember that even the smallest breach of confidentiality, such as repeating a funny story the Client shared with you with your coworkers, represents a loss of trust in the Therapeutic Relationship. If you will openly discuss one thing that occurred in your session what is to stop you from sharing the more private things?

Also keep in mind that a client may not want to be approached outside the treatment clinic. If you see a client walking down the street and stop and say hello, this may violate their right of confidentiality, as they may not want it be known that they are seeking treatment. Some people are very uncomfortable with the idea of their coworkers, friends or even family knowing that they are receiving massage therapy.

102 Boundaries A Boundary is a space within a perimeter that may be a physical, emotional or mental space. There are many different boundaries, spatial, legal, physical and emotional, etc.

There are also many different types or styles of boundaries. They can be strong, healthy boundaries, rigid and inflexible boundaries, or boundaries that are diffuse and unclear. We will examine how each relates to the Therapeutic Relationship in just a moment. Before we can do that it is important to recognize the difference between a boundary crossing and a boundary violation.

A boundary crossing is a relatively common event that is often unavoidable in our profession. We are, after all, human, and so are our clients. A boundary crossing occurs when we behave in a manner that is inconsistent with our professional relationship. For example:

You have a client named Jennifer that you have been treating regularly for a few months. She recently informed you that she is a distributor of aromatherapy products and invites you to her home to view the products.

This is a boundary crossing; you and your client are now moving beyond the boundaries of your therapeutic relationship and are entering a Dual Relationship .

Strong healthy boundaries are flexible. While we should avoid making a practice of crossing boundaries (they are boundaries for a reason) it is necessary to realize that rigid, inflexible boundaries can be unhealthy as well. As human beings interacting with other human beings our boundaries should be able to accommodate minor shifts. If this were not the case we would be very uncomfortable any time we encounter a client outside of our massage establishment.

A boundary violation is an entirely different situation. A violation occurs when a boundary crossing is harmful or exploitive. This can be harmful to the client, but it can also be harmful to the therapist, violations can occur on either side of the boundary.

103 Different boundaries

Spatial boundaries The spatial boundary is the invisible “three feet of personal space” that most Americans claim as their comfort zone 30 . This is why strangers in the movie theater will usually leave an empty seat between them, or why people boarding a bus will sit in an empty row before choosing to sit in an empty seat beside a total stranger. We like a buffer between us and people we do not know well.

When we are in the massage room this boundary is consensually crossed. In order to perform most manual massage techniques we must be in very close proximity to the person, well inside the “three feet”. It is important for the massage practitioner to realize that this boundary crossing does not and should not extend outside the massage room.

When your client is in the waiting room, or completing intake information in your massage room, you should be observing a respectable distance.

Medical doctors usually demonstrate this principle rather well. Think about the last time you visited a doctor for a medical exam. There you are sitting on the table wearing that ridiculous paper gown. The doctor comes in and greets you, and then sits down on a stool to discuss your condition, or symptoms, etc.

Even though he is about to touch you and palpate areas you usually do not make available to strangers, they are still observing the spatial boundary by sitting on a stool or standing a few feet away.

It could be easy for massage therapists to forget that just because they routinely cross the spatial boundary with a client in the massage room, this boundary does exist and needs to be recognized.

Appropriate touch Touch is at the heart of what we do, and that is why it is so important to spend time analyzing what is appropriate and inappropriate in regards to it. Our clients are paying us to touch them in a very specific, goal oriented fashion.

30 I say Americans because this is not universal! People from other countries may have entirely different spatial boundaries. This is described in more detail in EPS003 Cultural Sensitivity for Massage Therapists.

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In the traditional 31 treatment setting, only the hands, forearms and elbows should be making contact with the client. These parts of our body are permitted to cross the spatial boundary during the massage. The client should not feel other parts of our body during the massage if it can be avoided.

I once received a massage from a woman in a day spa while on vacation. The massage was great, but several times during the massage I could feel the woman’s abdomen and breasts as she leaned over the table to work on me. Because I teach massage I knew that this was because she was fairly short and the table was too high for her. It was perfectly innocent, but it was distracting and might cause problems for her in the future.

Sensuality vs Sexuality The word sensual means “a pleasure relating to any of the senses or sense organs”. There can be no argument that massage is sensual . Unfortunately many people mistake sensuality for sexuality, an understandable mistake, they are closely related.

Therapeutic Massage never includes any type of sexual touch. That being said, how does one differentiate between two closely related types of touch?

Intent and geography . If the intent of the massage is to provide sexual arousal or stimulation it is no longer therapeutic, it is sexual and a boundary violation . While it is difficult to describe in verbal or written terms, all massage therapists know that your intent can be conveyed by your touch, regardless of the actual technique you are performing.

If you have ever shaken hands with a car salesman you know what I am talking about, their mouth says “pleased to meet you” but their hands say “hello commission!”

31 I am referring to Swedish massage, certain modalities, such as Thai Massage, require much more physical contact between the practitioner and the client, which is one of the reasons why they are done fully clothed!

105 therapeutic massage. Ever. Throughout the history of Massage Therapy there have been people who have tried to reintroduce inappropriate sexual touch through various systems and modalities that claim legitimacy but are in fact only thinly veiled acts of prostitution.

A woman’s breasts should only be massaged if it is therapeutically indicated, which is actually quite rare given the lack of muscle tissue in the breast itself. When situations do arise that indicate manual massage of the breast tissue it is generally related to glandular function and should be clearly indicated on an informed consent form and SOAP notes.

Quality of touch The quality or depth of touch in the massage should be discussed before the session begins. Many intake forms ask the client to indicate the kind of pressure they want, and checking in to ask, “how’s the pressure?” should be standard practice for most therapists.

Often professional body workers will find conditions that they feel may require deeper pressure than the client may be comfortable with. It is easy for us to fall into a trap of thinking that we know what is best for them and that if they will just let us use heavier pressure we can take care of what needs to be done. The problem with this is that if the pressure is beyond their comfort level they will tense up, causing an intensification of the ‘pain- spasm-pain’ cycle instead of interrupting it, which is our desired goal.

Causing the client unnecessary physical pain is a boundary violation . If we have to convince them that they need to endure it in order to get well, then we are actually being abusive! If our desire is to truly help them and facilitate their healing the correct approach is to clearly explain why deeper pressure is indicated, instruct them on pain management techniques (i.e. breathing, visualization, etc) and to obtain an informed consent form. If they are still unwilling to deal with some physical discomfort during the massage than that is their choice, and we must respect that.

Therapeutic touch outside of the massage room An area that is not often addressed in massage school is the need for therapeutic touch outside of the massage room. On page 9 above we used the example of the medical doctors observation of spatial boundaries. Sometimes it is appropriate to touch someone outside of the massage

106 room, especially if the person is nervous or distressed and you need to convey empathy and trust.

The greeting When a client enters your business for the first time it is always a good idea to greet them with a handshake. In my massage school I teach my students to greet them with both hands, one is shaking their hand and the other hand is clasped over it. In the study of body language this is referred to as the “double handshake”. The double handshake means you are sympathetic or caring, and it implies trust. It says to the person “You are important enough for me to use both hands”.

Another variant is the shoulder-handshake. When shaking hands with a client you can demonstrate empathy and trust by placing a hand on their shoulder. These are two examples of appropriate therapeutic touch outside of the massage room. Human beings need to be touched; we are wired give and receive physical affection. Both of these methods cross the spatial boundary in a safe and socially acceptable way.

While it might seem insignificant or even trivial, small things like the handshake set the physical boundaries outside of the massage room and that is important for keeping strong boundaries inside the massage room.

I have often found that a well timed offer of a handshake is a great deterrent to other forms of physical greetings that may present themselves, which brings us to…

Hugging As strange as it might seem to you, I frequently get asked if it is Okay to hug a client. I usually answer with “ Why would you hug them ?” They figure out if it is appropriate themselves when they try to answer my question.

A hug can be intimate and inappropriate or it can be friendly and supportive, depending on the intent behind it (see “intent” above). It is a common practice in many churches for people to hug total strangers. There is certainly nothing sexual or inappropriate behind it, but the context lends to the appropriateness of the situation .

107 I will not go on record stating that a massage therapist should never hug a client. I myself had a 70-year-old widow that would give me a hug every time she left my office. In this case I could find no legitimate reason to refuse the hug, the intent was clear and non-threatening. She lived with persistent pain and I helped her deal with it, she was grateful.

I will go on record saying that massage therapists should be very, very careful in regards to this kind of touch. Some people (and a lot of massage therapists) are just huggers, they want to hug everybody. Given the sensitive and intimate nature of our work, if you make a habit of giving out hugs you will eventually get yourself into trouble.

Your ability to freely hug may be a sign of your own health and emotional wellness, but to someone who has been emotionally hurt it could be more significant than you intend. It leads easily into Transference and can cause even more emotional harm to a person you are trying to encourage.

Remember that people that have been emotionally abused often have difficulty knowing what is appropriate and what is not, and your encouraging hug may be taken for something very different than intended.

My advice to all the “huggers” of massage therapy is to hold back as much as possible and to use good judgment. Most professionals do not hug their clients, and neither should we. Remember the context of your relationship and act only in a manner that is helpful and healing.

Legal boundaries Legal boundaries are those that deal with the state and local laws pertaining to the practice of therapeutic massage. This is in effect your scope of practice-the legal definition of what you can do in your practice and what you cannot do.

Laws vary widely across the United States regarding the practice of massage therapy. In some states the laws vary by cities-each city having a unique set of ordinances that govern the practice of massage in that municipality.

Even though there is a wide variation, some things are universal to massage and these can be addressed here.

108 External Manipulation Only Every set of laws that I have seen governing massage practice in the United states defines massage as being manipulation of the outside of the body only. While this may seem like common sense to us there are many massage therapists that are practicing techniques for treatment of Temporomandibular Joint Disorder (TMJD) that requires you to work the muscles of the jaw from inside the mouth. This is a practice which is illegal in many areas, and practitioners should consult their state and local ordinances before engaging in this practice. If the ordinance states “external parts of the body” this technique is off limits for you.

Many “Old School” Doulas and Midwives are also taught to assist pregnant women in preparing for childbirth by engaging in perineal massage, which consists of massage back and forth over the bottom area of the vaginal tissues. This is also a violation of most massage ordinances. (It is also a practice that should only be performed by licensed midwives and not Doulas, and never massage therapists).

Practicing Medicine without a License This is arguably the most common ethical mistake that massage therapists make, and most of them are not even aware that they are doing it. As massage therapists we are not allowed to diagnose our clients, yet many massage therapists do it every day . We are taught Anatomy and Pathology in massage school so that we can successfully identify conditions to treat and contraindications to avoid. We are never, under any circumstances, supposed to diagnose people with conditions when they come to us for massage therapy. While many massage therapists would say “I have never diagnosed anyone” they are not realizing that they probably have. It is very easy to do-if you are massaging a person with Ischemia and you tell them that is why their muscle is so tight and why it hurts them so badly-you have just given them a medical diagnosis.

You could be a very knowledgeable massage therapist with extensive medical and anatomical training. You could be 100% correct about their condition and you may be able to treat them for it very effectively. But if you tell a client that they have a medical condition, you are making a diagnosis and you are practicing medicine without a license .

Thankfully avoiding this mistake is just as easy as making it. We are professional body workers and we do want to facilitate the healing of our

109 clients. If you are working with someone that you believe has a medical condition that they are unaware of, all you need to do is talk to them in straightforward and candid terms.

In the above example, if you are massaging an individual with Ischemia you can have a conversation with them afterwards regarding your suspicions. That conversation could sound something like this:

“I am not a Doctor and am not qualified to make a medical diagnosis , but what I am feeling in your Bicep is consistent with Ischemia, a condition in which blood flow is restricted. You may want to seek professional medical care and get a professional opinion”.

In this example I am stating my opinion, based on what I have been taught, but I am making it very clear that I am not giving a diagnosis. I am not even saying that it is Ischemia, I am stating that what I feel is consistent with it, which means it feels like it might be that. This allows you to give them the benefit of your experience and knowledge without acting outside of your scope of practice. It may seem like splitting hairs, but it is an important distinction.

Selling in your Practice Many massage therapists sell products inside of their massage practice. These vary greatly, but typical retail items are related to massage, such as vitamins and herbal supplements, scented or aromatherapy candles, body and skin care products, etc.

There are legal requirements that must be met if you are selling products in your business. You must obtain a retailers permit (aka sellers permit) and you may be required to obtain a different business license, depending on your local ordinance. The ethical issues that arise with selling products out of your massage business deal with what products you are selling.

Vitamins and Herbal supplements, magnetic therapy equipment, topical ointments of all kinds and other forms of alternative medicine are often sold by massage therapists. The ethical issues that arise here is that people often seek out massage therapists when they are dealing with pain. People who suffer from persistent (chronic) pain are likely to be predisposed to believing any claim that may offer relief. In addition to this, the massage therapist, by virtue of our credentials and education, carry an

110 aura of “Expert Knowledge” which makes people even more likely to believe us when we tell them that something will take away their pain.

If you are a devout believer in a brand of vitamins, herbal supplements or magnetic therapy, and you genuinely believe that a product will help your client, you have no ethical issue. But if you look at a client that is hurting as a potential buyer for your product, you are in dangerous territory.

Ask yourself, if they try this product, believing that it will work, and it doesn’t, how is that going to affect them emotionally? How is it going to impact their trust level with me? Is this really in their best interest, or is it in mine?

When you tell a client that a product may help their health you are speaking with Expert Knowledge as a health care professional. Your credibility is literally on the line if you are recommending a product. If the product is a fraud, than so are you.

Keep that in mind before you recommend any product you are selling.

Physical boundaries Physical boundaries are those that deal with our comfort level with our bodies. It would be an easy assumption that people who have sought out a massage therapist are comfortable with their bodies being manipulated by a total stranger.

If you have ever given a massage to someone who was just stiff as a board, and obviously uncomfortable, you know that it isn’t true. Some people are just not comfortable with a massage, but have received a gift certificate from someone they didn’t want to disappoint, or have become so tired of living with discomfort they have finally “worked up the nerve” to try it out.

Most massage therapists are people that are comfortable with their own bodies. They can easily get a massage and generally have few hang-ups when it comes to others touching them. For this reason we have to be reminded that not everybody has the same comfort level with his or her own body.

111 To avoid violating this boundary in the therapeutic relationship you must take care to avoid assumptions about people’s lack of modesty. Never tell yourself that they must be comfortable with being undraped if they are getting a massage. Explain all procedures, including draping, before starting each massage with a new client.

In addition to concerns about modesty some clients are uncomfortable with certain techniques, types of product or other methodology that is regular practice for the practitioner.

In these instances the practitioner has the option of making a referral to another appropriate body worker, or adjusting their own practice to meet the tastes of the client. You should not try to coerce a client into doing things your way if they are not comfortable. Better to refer them to someone else than to make them uncomfortable with massage by forcing your ways on them.

Emotional boundaries The most difficult boundaries to determine are emotional boundaries. Emotional boundaries come in to play when dealing with issues of Transference and Countertransference.

Transference and Countertransference In any human relationship there is a transference of feelings, thoughts and attitudes. All of our present interactions are colored and shaped by the interactions of our past. The relationship between a massage therapist and their client is no different.

Empathy vs Energy Transfer For many years massage schools have taught (and still teach) that a clients negative energy can be transferred to the massage therapist during the massage and that the massage therapists energy can travel likewise to the client.

While it is not our intent to refute this, an important distinction must be made here. This is not transference and countertransference.

Transference and countertransference are a function of the mind. The feelings we have towards our clients originate in us; they are not drawn from the client.

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Part 1: Transference (The Client) Every massage therapist has dealt with a client that has shared a past massage experience, both good and bad. Every client brings with them a perception of massage in some way shaped by these past experiences. But what about the client’s other past experiences with touch? These too are brought to the massage table to a greater or lesser degree. Some clients will direct the feelings of these past experiences toward their therapist. This is known as transference .

This is a perfectly natural function of the unconscious mind. We say that it is a function of the unconscious mind because it is not a deliberate thought or choice, it happens completely without the intent and often without the knowledge of the person.

For the most part this phenomenon is harmless. It becomes an issue of concern when the touch is associated with thoughts and feelings that could interfere with the therapeutic process.

Some massage modalities are undeniably sensual in nature. Swedish, Ayurvedic, even Lymphatic Drainage can all bring to mind past experiences of intimate, romantic touch.

Misplaced romantic feelings are not the only form of transference encountered by massage therapists. The client may associate pain from an injury with a massage therapist who is helping them recover from an accident. This is frequently reported by physical therapists who are helping patients in long term rehabilitation. As the patient works through painful exercise routines with the physical therapist he may begin to transfer feelings of resentment (of the pain/injury) to the physical therapist, who is then seen as a manifestation of that pain. Many physical therapists have been called “sadistic”, “bully” and even “torturer” through gritted teeth by a patient they are helping back to health .

This same misplaced resentment can appear in therapeutic massage. In fact it can be even more profound, as the very word massage generally implies a pleasant sensation. When the therapist is working through scar tissue, applying deep tissue massage or working with atrophied muscles the client may feel the practitioner is hurting them on purpose. After all, massage is supposed to feel good, isn’t it?

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A third form of transference can develop when a client begins to see their massage therapist as a psychological rescuer.

Many people turn to massage therapy as a means of coping with stress. It is very common for the client to share the sources of their stress with their therapist during the session. This “unburdening” is common in massage and is not inherently bad. For many people, the massage room is the only safe place they have to “blow off steam”.

This becomes negative transference when the client begins to think of their massage therapist as a person they can turn to outside of the massage session or if they begin to see the therapist as the only person they can talk to. Both of these situations lead the client and therapist into the Drama Triangle .

The Drama Triangle The Drama Triangle is a graphic representation of a social dynamic involving three people in the distinctive roles of victim, persecutor, and rescuer.

In massage therapy, the client would be the victim in the scenario. They receive massage therapy for relief from the stress caused by the persecutor (husband, wife, mother, boss, etc), which makes the massage therapist the rescuer.

114 A practical example: During the massage the client “unburdens” himself by describing a fight with his wife. The therapist listens to his side of the story during the massage, and the client feels better afterwards.

Later when he goes home and has to deal with his spouse another fight erupts. He calls his massage therapist and makes another appointment. At the next appointment he relates the details of the new fight.

The massage therapist in this example is now “coming to his rescue” by providing a nurturing presence that is always ready to passively listen to his side of the story. His wife makes him feel bad; the massage therapist rescues him by making him feel better.

While this scenario may sound familiar to many massage therapists, it is surprising how many do not realize that they are being slowly but inexorably drawn into a conflict that they do not belong in.

By passively listening to the client when they vent about their spouse they are, in effect, bolstering the clients beliefs, which may not be accurate or healthy. After venting to someone for an hour that does not disagree with them or offer different points of view they will naturally believe that they are totally correct in their assertion that it is “all the other persons fault” or that they really are “being treated unfairly”. This could lead them to exasperate the situation further-which causes them to need the rescuer even more.

Identifying Negative Transference in Clients As stated previously, transference is natural and is part of any human interaction. The practitioner need only be concerned with negative transference, which in this context means it could lead the client to develop feelings or attitudes that are harmful to the therapeutic relationship. If the massage practitioner is able to identify the warning signs of these feelings and attitudes early enough they can be redirected.

We will now examine some indicators of Negative Transference in the three scenarios listed above. After the indicators we will suggest measures for redirecting the client away from these thoughts and feelings.

115 Romantic/Erotic Transference This is perhaps the most familiar to massage therapists as it is generally addressed in the core training.

Many people associate the sensual nurturing touch in a massage as romantic or erotically stimulating. In this situation we are not talking about the grossly inappropriate client that calls looking for a “happy ending”, but rather a good massage client who, because of needs that have not been addressed, begins to feel that need met in the touch of the massage therapist.

Romantic/Erotic Transference Warning Signs The following list of possible indicators of romantic/erotic transference is gender neutral (applies to men or women) and is intended as a reference only. Some of these could be purely innocent, but if more than one occurs with the same individual there is a good chance they are developing inappropriate feelings in your therapeutic relationship.

Does your client: Come to the massage appointment “dressed up”. Bring you small, thoughtful gifts for no reason. Asks you to attend purely social functions. Makes persistent inquires into your social life. Undrape themselves ‘accidentally’ in session.

Redirecting Romantic/Erotic Transference Should you believe that your client is experiencing romantic/erotic transference it is your ethical responsibility to attempt to redirect this thought or cease treatment, referring the client to another therapist.

This should be done tactfully and professionally. In many cases, a straightforward conversation may be all that is needed to redirect the situation.

A practical example: “I appreciate you asking me to go with you to the concert this Saturday, but you are my client and it would be inappropriate for me to go with you. I try very hard to keep my professional life and my private life separate.”

116 The emphasis on separating professional and private life leaves no ambiguity. While it may sound a little rude, it clearly defines the boundaries while gently pointing out to the client that they are attempting to cross them. If done early enough, this may redirect any thoughts the client may have, and while transference may still occur, you are not facilitating it.

As a massage therapist you will be accustomed to receiving gratuities from appreciative clients. Most often this is money, but occasionally other gifts may be given. While this is not necessarily an indicator of romantic transference, it could be. If your client gives you a gift that is expensive, extraordinarily thoughtful or blatantly romantic (flowers, candy, wine, etc) you should confront the situation in a manner similar to the example above and attempt a redirection.

If your client is ‘accidentally’ undraping himself or herself, purposefully and repeatedly undressing in front of you or gently reaching out to touch you during a massage it is time for more dramatic steps. It has moved beyond thoughts and feelings and into action, and it needs to be stopped immediately.

In any of these situation the massage therapist should immediately end the session and have a very frank discussion of boundaries. Let the client know that you will no long be able to serve him or her effectively and make a referral to another massage professional.

Remember, it is unethical for you to have a romantic or sexual relationship with a client-and to do so would put your license at risk.

Pain/Resentment Transference More common with physical therapists but still a factor for massage practitioners, clients can transfer feelings of pain and resentment to their therapist when they are dealing with treatments that are uncomfortable.

Pain/Resentment Transference Warning Signs This type of transference will be apparent in the attitude and language of your client.

Does your client: Make sarcastic remarks during your sessions. Ask if the treatment is necessary.

117 Accuse you of using more pressure then necessary.

Redirecting Pain/Resentment Transference If you are feeling hostility from your client and you believe that the cause of it is Pain/Resentment Transference you can address it by educating your client on the nature of the physical condition you are treating. As this type of massage is most frequently done in rehabilitation centers or physical therapy offices this could be as easy as sitting down with the client’s file and reviewing the information with him/her. Remind them that it is actually the injury that is causing their discomfort and that you are in fact helping them recover from it. This may have to be done several times, but this type of verbal redirection can help them realign their thoughts. Remember that transference occurs on an unconscious level, and that by bringing it to the forefront of their mind you are making them aware of the issue.

Transference and the Drama Triangle If you have a client that routinely talks out his/her stress while on the table and more often then not the source of that stress is another person you are being drawn into the drama triangle. This only becomes a problem when the client begins to see the massage practitioner as a person they can turn to outside of the massage session.

As helpers and nurturers it is easy for us to “be there” for our clients when they need someone to talk to, but if they are calling you to vent outside of the massage session they are crossing an important boundary. The Drama Triangle Warning Signs This type of transference will be apparent if your client displays the following behaviors.

Does your client: Call you to talk about their stresses or relationships outside of the massage session. Talk about their stress (centered around another person) during every massage. Make massage appointments (in your opinion) just to update you on their latest arguments or fights.

Breaking Out of the Drama Triangle If you find yourself in this situation the first step is to take yourself out of the triangle, the second is to reestablish the boundaries.

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To take yourself out of the triangle you should confront the client when he/she arrives for their next massage. Let them know that you do not believe they are getting the full benefit of the massage when they talk nonstop about the source of their stress. If that does not work, you can be honest and tell them that their constant talking about their personal issues is making it difficult for you to concentrate on your work, and ask them to stop.

If they agree to not talk about their source of stress during the massage you can proceed and that should be the end of it. If they do not agree, or they agree and yet continue to talk about their stressor during the massage you should take the next step, which is to refer them to another massage practitioner.

If your client has agreed to relax during their session and not talk about their stressor you have succeed in taking yourself out of the triangle. The next step is to reestablish the boundaries of your client practitioner relationship.

If your client is calling you to talk about their stressor outside of the massage session this needs to stop immediately. You must let your client know that professional boundaries must be maintained and that any calls should be regarding massage services, not venting or emotional support. While your client may need these things, it is outside of your scope of practice to provide them and you should refer him/her to the appropriate professional (psychologist, marriage and family counselor, social worker, clergy, etc).

Part 2: Counter Transference (The Massage Practitioner)

Counter Transference in Therapeutic Massage Up to now we have been examining the potential unconscious thoughts and feelings that a client may bring into the session, but massage practitioners also have these thoughts and feelings that can be directed towards our clients. It is just as important to recognize these feelings in us and to deal with them appropriately.

Countertransference occurs when the massage therapist begins to direct unconscious thoughts and feelings toward their client.

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As stated previously, transference and countertransference is a normal human psychological phenomenon-it happens to all of us to a greater or lesser degree. It only becomes a problem when we allow it to distort or interfere with our professional therapeutic relationships. The most important factor in avoiding negative countertransference issues is self- awareness. If we are aware of our feelings and thoughts about our clients we are able to maintain proper boundaries at all times.

Assess Your Feelings As a massage therapist you are going to have feelings about your clients. You will have clients you like, and clients that you do not. That is natural and unavoidable, and it happens to all of us.

To avoid countertransference issues you should assess your feelings toward your clients. Be honest with yourself, your feelings are natural and a part of you-even if you do not like them, it’s all right to have them. Recognizing them is the key to managing them. Use the tools on the following pages to perform an assessment of two of your clients, one you like and one you do not. (If you do not have a client that you do not like you are a very lucky massage therapist!)

Client Feeling Assessment Tool Choose two clients, one you like and one you do not (or a least one you do not look forward to seeing). Think about why you like or do not like this person and list at least three reasons. (If you are doing this course online you can print out this page or copy it on a piece of paper.)

Do you do anything different for the client you like or do not like? Be honest! It is not uncommon to give extra time, discounts or similar preferential treatment to clients we like and to not do the same for clients we do not like. Is this wrong? Not necessarily, after all, there is nothing wrong with rewarding a good client by giving them extra time on the table, but you need to be aware of your feelings and to bring them to the conscious part of your mind.

120 CLIENT FEELING ASSESSMENT TOOL

Client I like: ______Client I don’t like: ______

Reasons why Reasons why

1)______1)______

2)______2)______

3)______3)______

Is my massage different with this Is my massage different with this person? What do I do differently person? What do I do differently for this person? for this person?

121 Romantic/Erotic Countertransference As stated in part 1, many people associate the sensual and nurturing touch of massage with romance and eroticism. Even though we are professional body workers we are still human and as such are naturally subject to sexual attraction.

It is important that we recognize these thoughts and feelings early and make a deliberate effort to not dwell on them.

You do not have to deny your attraction to a client, but you should be aware that your Romantic/Erotic feelings could have a subtle influence on your professional judgment.

If you find that you are struggling with Romantic/Erotic Countertransference you need to remind yourself of your Code of Ethics and your core training about boundaries. If you are so strongly attracted to a client that it is distracting you from your therapeutic relationship it is time to refer that client to another therapist.

Familial Countertransference Of course not all countertransference issues stem from Romantic/Erotic feelings. It is just as easy to feel strongly toward a client that reminds you of a beloved family member, a good friend or a former mentor. Could these feelings be leading you to compromise your judgment by offering unreasonable discounts, agreeing to therapy that might be contraindicated so as to not disappoint them, etc?

Ineffectiveness and Countertransference There are many physical conditions that are beyond the ability of the massage therapist to treat and this can cause frustration for the practitioner.

It is easy for us to transfer that feeling of frustration with a client’s condition to frustration with that client. We feel inadequate because we are unable to achieve our desired goal, and the client becomes a walking, talking reminder of that fact. If you are a person that has struggled with feelings of inadequacy in the past this can be particularly difficult for you.

A similar source of frustration is with the client that continually injures the same area, as with professional athletes.

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When we are working with someone who repeatedly causes damage to their body it is easy for us to resent that on an unconscious level.

If you find that there are some clients that you do not look forward to seeing you should examine your feelings toward them. You may discover that you have feelings about your clients you were completely unaware of.

Remember, it’s ok to have positive or negative feelings toward your clients, that is what makes you human. Behaving in a consistent manner with both, and not letting it interfere with your treatment is what makes you a professional.

Countertransference and the Code of Ethics We stated earlier that Self-Awareness is the most important factor in avoiding negative countertransference issues. If you routinely assess your feelings, especially regarding your clients, you will be more likely to avoid problems that may occur as a result of them.

But what if you are totally unaware of your feelings?

The massage therapist code of ethics, presented by the NCBTMB exists to give you clearly defined boundaries in your profession. If you are making a conscious effort to adhere to the code of ethics in your daily practice you are far less likely to be led into conflict by unconscious feelings toward your clients.

Massage therapist deal in intimate physical relationships on a daily basis. Our challenge is to develop rapport and empathy with our clients while at the same time maintaining well-defined boundaries of professionalism. The nature of our work forces us to deal with many of the fears, needs and longings of clients as well as ourselves.

Maintaining a correct ethical posture in this profession requires us to continually assess our thoughts and feelings and to develop our sense of self-awareness and to constantly be in tune with it.

To stay grounded you can repeatedly ask yourself the following questions during your work:

123 • Am I focusing on the therapeutic relationship?

• Are my personal issues intruding into this treatment?

• Are my reactions blurring ethical boundary lines?

Since massage therapists and clients are both human, transference and countertransference is inevitable. Dealing effectively and proactively with this phenomenon is what separates professional excellence from unethical behavior.

By developing self-awareness and understanding the basis of your feelings, a massage therapist can address, minimize and manage transference and countertransference that would otherwise jeopardize the therapeutic relationship.

Power Differential There are natural power differentials in most human relationships, including those between parent and child, teacher and student, employer and employee, and, of course, massage therapist and client.

In the therapeutic relationship massage therapists have the more powerful position. They are the authority figures whose actions, by virtue of their roles, directly affect the well-being of the other. The client is in the more vulnerable position. In theory and ethical practice, the power differential exists for the purpose of bringing benefit to these more vulnerable individuals; that is, the child's well-being should be enhanced by a parent's care, the employee should benefit from the employer's management, and so on.

In massage therapy the physical aspects of practice amplify the power differential. The client takes a position - usually lying or sitting - and allows the practitioner access to his or her body. The practitioner positions himself or herself within the client's personal space, often leaning over him or her. In many modalities the client is partially or fully unclothed. Although draping is used for modesty, the psychological effect of the unclothed client and the clothed practitioner increases the imbalance of power. Finally, as the practitioner's hands make physical contact and at times forceful manipulation the client's physical safety and welfare is literally in the practitioner's hands.

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It is the responsibility of the practitioner to ensure that this power differential is not used for abusive or exploitive purposes. This could be anything from engaging in sexual conduct to selling products that the client really does not need.

The Different Types of Power Two social psychologists (John French and Bertam Raven) 32 conducted a study of social power in 1959. The result of this study was a division of social power into five different categories.

Their study shows how the different forms of power come into play in almost all social interactions. It is of particular importance to massage therapy in that the relationship between massage therapist and client is one that has a substantial power differential.

Before we can begin any serious study of the phenomenon known as Power Differential we first examine and define the different types of Power. The basic definition of Power in the context of Social interactions is

The ability or official capacity to exercise control authority or influence.

When we use the term Power in this course, we are referring to our ability to influence and even control our clients. There are different types of Power that can be exercised by people, and we are going to look at them and compare them now.

Reward power This form of power is based on the perceived ability to give positive consequences or remove negative ones. The strength of the reward power increases with the magnitude of the rewards which can be given. It also depends upon the perceived probability that the person with the power to give the reward will actually follow through and gives it. For example, a wealthy miser with a reputation for stinginess has no Reward power, since nobody that knows he is wealthy perceives any chance of receiving a reward for serving him. If the same man was wealthy and had a reputation for giving lavish gifts he would then possess considerable reward power.

32 French, J. R. P., Raven, B. The bases of social power. In D. Cartwright and A. Zander. Group dynamics. New York: Harper & Row, 1959.

125 People would try to please him based on their perception that they could be rewarded for doing so.

Massage Therapists do not typically wield this type of power, but it is possible. Rewarding clients for referrals or sending a coupon for an extra 30 minutes for being a loyal customer are both perfectly ethical examples of massage therapists using reward power to influence their clients.

Coercive power This is the perceived ability to punish those who do not conform to your ideas or demands. This is definitely not commonly encountered in the practitioner-client dynamic. If you are using coercive power on your clients, you probably will not be a massage therapist very long. A possible example would be threatening to stop serving your client if they do something (or fail to do) you want.

Legitimate power This form of power is based on the perception that someone has the right to prescribe behavior due to election or appointment to a position of responsibility. This does not come in to play at all in the practitioner-client dynamic, we have added it merely because it is a recognized form of power.

Referent power This is power through association with others who possess power. If people do what you say because some other powerful person told them to listen to you, you have Referent Power. The second most common form of power in the practitioner client dynamic, Referent Power is prevalent in massage therapy when the client is referred to the massage therapist by a medical doctor or another person in their life that has significant influence over them.

This is hugely important in the field of massage therapy. As you know one of the best forms of advertising for a massage therapist is “word of mouth” advertising. This is the best advertising for us for several reasons.

Massage therapy is a very personal experience, one that many people are more than a little apprehensive about. After all, as a first time massage

126 client we are basically undressing for a total stranger and laying on a table, allowing them to manipulate our bodies.

This is a huge leap of faith for some people, and one that would not be possible at all if it were not for the recommendation of someone they trust.

In this respect the massage therapist has referent power.

If the potential client’s best friend, whom she has known for over a decade, refers you to her as “a really good massage therapist” you have inherited a small bit of the trust the client has in her friend. She knows here friend would not steer her wrong, so when she recommends you as being the right therapist for her, she is transferring some of that trust to you.

The potential client may never have worked up the courage to take that step, to go and visit a massage therapist, if it were not for her close friends recommendation. Referent Power is, in many ways, a massage therapist’s best friend.

Because of the extremely close and personal nature of our work we need this kind of power to reach those who would not normally seek out our services, which is (unfortunately) a large segment of the population.

As a massage therapist you should be aware of the effect of referent power because it directly impacts your practice. You can capitalize on this psychological phenomenon by implementing marketing tactics that optimize referent power.

A good example of this would be referral cards.

I used these with success in my massage practice. Basically it is a card that a client can give someone else to refer them to you. I would give select clients “Gift Coupons” that they could give to their friends, coworkers, etc.

These Coupons would give the new potential client a substantial discount if they came to see me for a 1-Hour massage. The Clients I would give these cards too would enter the name on the line that says “From” (they are the one giving them out as gifts).

127 I would explain to them that I would reward them for doing so, every time someone brought in one of the cards they had signed I would give them the same benefit (the same discount the new client was getting).

A simple example Gift Coupon.

The back would have the details and limitations, limit one coupon per visit, limited to Swedish Massage, cannot be redeemed for cash, not usable with any other offer, etc

Simple and very effective advertising.

When you employ this type of marketing you are exercising reward power on your current client. You are convincing them to go out and advertise for you, by promising them the reward they will get when someone brings in the coupon they give out.

More importantly, you are taking advantage of the referent power that is inherent in this form of marketing. The people passing out the cards will naturally be giving them to people they know in some way, thereby transferring the trust in that relationship to you.

A perfectly ethical and effective use of referent power in your massage practice.

Expert power This type of power is based on having distinctive knowledge, expertise, special ability or skills. This is the power most often wielded by the massage therapist. People listen to us because we are trained professionals. They disrobe and lie in a helpless, vulnerable position for us because we are not only professionals, but we are considered experts-we had to go to school to learn how to do it, that separates us from other people. It also makes them predisposed to believe us when we tell them that a treatment will help them, or a product might make them better.

128 As you might imagine this naturally opens the door to all kinds of ethical dilemmas for the massage therapist.

Have you ever wondered why Doctors do not sell medications?

Think about it for just a moment. You go to see a doctor for a medical condition. He examines you, he diagnoses you and he writes you a prescription so that you can buy the medication for the diagnosed condition somewhere else.

Wouldn’t it be more convenient if the doctor and pharmacist were in the same office?

It would definitely be more convenient for them!

Someone long ago figured out that there was a serious ethical danger in having the doctors financially benefit from selling the medication they prescribe. The reason is really obvious, nothing would stop them from prescribing things you don’t need, just to wring more money out of you.

You do not have their expert knowledge, so you would not know if they were prescribing you something you really need or just fleecing you. By keeping the profit of the pharmaceuticals away from the doctors the medical community hopes to prevent them from being tempted in this fashion 33 .

Now on that note we should look at the growing number of massage therapists that are selling nutritional supplements or magnetic “healing” jewelry out of their massage practice.

If someone is visiting a massage therapist for treatment of a physical condition it is based on the idea that the massage therapist is qualified to treat him or her in some regard, based on their expert knowledge.

Is it then unethical for us to financially benefit from selling products in our practice that allegedly treat those same conditions? Would we not be in the same ethical quandary as the doctors?

33 Let’s pretend we do not know that doctors can buy shares of the pharmaceutical companies that make the drugs they prescribe, thereby financially benefiting from their proliferation.

129 It is an interesting question, and one you will have to answer for yourself. I would say no, because we are not part of the diagnostic process. We are not diagnosing the condition, we are on the treatment end of it, and so in this example we are closer to the pharmacy than the doctors. Therefore there would be no ethical problem with providing a product that we genuinely believe will help.

And that brings us into the next part of the discussion, which is treatments or products that are questionable.

This is a very touchy 34 subject in the field of massage and body work. There are many modalities that are currently being practiced that are, shall we say, a little light on the empirical data.

That does not mean they are not effective, it is just that no serious medical or scientific studies have proven them to be effective. We could spend hours just reviewing the many studies that have been done on acupressure points alone, some showing them to be very effective, just as many showing them to be as effective as a placebo group.

But that is not the point of this course. We are dealing with the effect of the Power Differential in massage therapy and this just happens to be an area that calls in to question the ethical considerations of massage practices that have not been scientifically proven to be effective.

A good example is Cellulite Removal Massage. Before you send me angry emails because you are a die-hard believer in Cellulite massage let me simply provide you with a quote from a Dermatologist:

Massage and tissue manipulation techniques are employed to enhance the removal of accumulated fluid in the dermis area. These techniques do not remove the cellulite, but may have a temporary effect in reducing the amount of 'dimpling' appearance. Similar to endermologie, deep massage may induce alterations in dermis connective tissue (Silver, Siperko, and Seehra 2003). However, massage appears to offer only short-term minor skin changes, probably more related to the removal of excess fluid (Rawlings, 2009). 35

34 “Touchy subject” in massage. Did you see what I did there? That’s funny. 35 Cellulite: A Review of its Anatomy, Physiology and Treatment Len Kravitz, Ph.D. and Nicole J. Achenbach, B.S.

130 I have seen many, many massage ads that have offered a treatment that specifically says it “removed” cellulite, when it does not. It does reduce the dimpling appearance (which is probably what the client wants anyway) so why not write these ads in a way that is consistent with the facts?

Another questionable practice that has infiltrated massage therapy is that of Colonic irrigation. I have no problem at all stating that this is unethical, bad science and should be avoided.

If you are lucky enough to not know what this is let me enlighten you, it is the practice of giving an enema (flushing the rectum and colon with water) for the sake of removing fecal matter that is, the practitioners claim, flooding the clients system with toxins.

This dubious and in fact, dangerous, practice owes its popularity to the theory of "autointoxication", which has been around for a very long time but has been medically debunked since the beginning of the 20 th century (early 1900s).

This theory states that stagnation of feces in the colon (large intestine) produced toxins that are then reabsorbed by the body.

There are still many, many people in the naturalist and holistic health movement that believe this, even though it has been definitively been proved to not be true.

And unfortunately many of the believers in this “alternative health practice” are in massage therapy! I have encountered three massage therapists in my state alone that offer colonic irrigation in their massage practice, and it is actually illegal 36 in this state. But they still do it.

There are still persons promoting the use of herbal enema and laxative remedies using autointoxication as justification. There is currently no shortage of advertisements for laxatives and other products promoting bowel regularity.

36 California is one of the few remaining states that has no state massage laws, just local cities ordinance. Nearly all of them, every city, town and county, prohibits massage therapists from engaging in any treatment on the “interior” of the body-and that includes enemas.

131 Colonic irrigation is an invasive practice and not allowed to be performed by nonphysicians in some states. This procedure is very painful for most people and is very dangerous. The list of very real hazards include perforation of the colon, infection from improperly cleaned instruments, dehydration due to electrolyte imbalances, excessive fluid absorption and overload leading to heart failure

Deaths have been reported from both perforation and infection.

Massage Therapists should not be doing this, or encouraging others to try it.

Which takes me back to the point of this course. It is very easy for a massage therapist who believes in this practice to influence somebody else to try it, and in this particular situation the results can be quite severe.

Selling Products Another example is aromatherapy products. Let me begin with stating, for the record, I am a believer in aromatherapy. There is a sound scientific basis for the idea that chemical receptors in the nasal cavity can affect brain chemistry. The simplest example I can give you is that smelling food cooking can cause your mouth to water, even if you are not hungry.

So that being said, there can be very grandiose claims made by aromatherapy practitioners. Claims that are, at best, exaggerated and at worst downright fraudulent. So like many things it is not the practice itself that is questionable, just the execution of it that must be carefully watched.

One of the best things about aromatherapy is that it allows you to sell products that you can make yourself to your massage clients. There are also many different companies that specialize in direct sales or multilevel marketing of aromatherapy products and many massage therapists have jumped on the bandwagon.

This is not necessary a bad thing but it is a slippery slope and it makes it very easy to “play doctor”.

For example, you practice aromatherapy and you have a massage client on the table that is complaining of headaches and you just happen to have a Lavender/Peppermint/Rosemary candle in stock that the manufacturer

132 claims is great for headaches. The client has not asked for aromatherapy advice…they are there for a massage. Do you suggest the candle? It seems like an easy sale.

It is an easy sale, especially if they are on the table and you are working on them at the time, since not only do you have expert power on your side, but that power is magnified by the fact that you are standing over them, while they are lying beneath you, practically naked (more about this amplification later).

So what if the same client sees the certificate on your wall that says you have taken an aromatherapy for massage therapists course and specifically asks you for aromatherapy advice? In my opinion you would now be in the clear to discuss it with him or her, just as long as you do so either before or after the session and not while they are on the table.

Some massage therapists frown on selling any therapeutic products at all. I would disagree with them on principle, since we are in effect selling a therapeutic product (massage) to people every day. Selling therapeutic products is itself, not an unethical practice.

Exploiting your position as a massage therapist is, so you need to ever mindful of the clients position and state of mind when entering into any discussion of products.

To get back to the point, people are inclined to believe claims we make as to the effectiveness of certain treatments on the body based on our expert knowledge, which gives us expert power.

The Differential in Massage It is impossible to achieve a therapeutic relationship between client and practitioner without a differential in power.

There is a naturally occurring power differential in most relationships: between parent and child there is Coercive and Reward Power. Between a teacher her students there is Legitimate and Expert Power ; between a Day Spa owner and her staff there is Legitimate Power and Reward Power ; and of course between massage practitioners and clients there is Referent and Expert Power .

133 In the relationships of Parents, Teachers and Employers it is obvious who has the most power. They are the authority figures who the others depend on for guidance, and in some cases sustenance and protection.

In theory, and in ethical practice, the power differential exists for the purpose of bringing benefit to these more vulnerable individuals: the child’s well-being should be enhanced by the parent’s care; the employee should benefit from the employer’s management.

As stated earlier, there is an implicit acknowledgment that the practitioner has a specific skill (massage) that is sought out by the client. This is a form of Expert Power . Many people have intimate partners that are willing to try and “rub out their knots” but they do not have the necessary knowledge of muscular structure and function to do this right. They come to us because we have knowledge that others do not.

There is also the situation where the client is referred by a medical doctor or another person in their life that has trust or authority. This is Referent Power , and it means that the power of the referring person is represented in you, by virtue of the referral.

Regardless of the type, the power is amplified by the physical aspects of massage.

The client takes a very subservient position, usually lying down, with the practitioner over them. The practitioner is within the client’s personal space often leaning over the client. Often the client is partially or fully unclothed. Although draping is used to protect the modesty of the client, the psychological effect of the unclothed client and the clothed practitioner increases the imbalance of power. Finally, as the practitioner’s hands make physical contact with the client’s body, the client’s physical safety is literally in the practitioner’s hands.

The increased perception of the power differential in a hands-on session puts the client in a highly vulnerable position. The client feels less free to defend against intrusions or to question unexpected behavior by the practitioner. The client may feel uncomfortable about raising concerns, complaining about the treatment process or making requests, especially if it is their first massage and they are not sure how it is normally done.

134 The client may find it difficult to say “no” or to question the practitioner’s behavior, even if the client feels uncomfortable or exposed. In the most extreme cases the client may even refrain from communicating anything that could possibly be construed as negative for fear of reprisal or loss.

The power differential can also interfere with the goals of the therapeutic relationship even when the practitioner is doing everything right. A client may became hesitant to make a request out of a sense of vulnerability, a fear of appearing foolish and concerns over possibly upsetting the practitioner. The psychological effects of the power differential in this situation remains unperceived until a need arose requiring the client to make a request, and finds it strangely difficult, or if a therapist makes a recommendation that the client is not comfortable with (such as selling a product or recommending multiple sessions) and they find it hard to say no.

The Massage Practitioner’s Role It is clear that you, the massage practitioner has more power in the therapeutic relationship. There may come a time when you are tempted to misuse that power. It is very easy to take advantage of some clients physically, emotionally, financially or professionally.

Some Examples of misusing your power:

• A practitioner is treating a client who happens to be a dietician and asks, “Since I have you here, could you just answer this quick little question about what I could do to loose some weight fast?”

• A practitioner who is raising money for a non-profit groups asks for a donation during a session.

• During a session the client begins talking about a celebrity whom the practitioner has wanted to meet and the practitioner asks for a personal introduction.

• While working on a client you begin encouraging them to buy an alternative medicine product that you sell. This is a highly unethical practice that is done often in massage therapy. If you are suggesting the product while they are on the table it is much harder for them to say no. If you do sell alternative healing products to your clients, the correct time to

135 do this is during the consultation or after the session, not while they are on the table.

To achieve a truly ethical practice, the person in power must regularly assess themselves and consciously say “no” to something she could probably get and must instead choose to focus entirely on the needs of the client, who is the person with less power. The practitioner must mindfully enforce the integrity of the client’s boundaries in a situation where the client has voluntarily relaxed them.

The Client and boundary testing Massage therapists are required to be aware of roles and boundaries, but clients frequently are unaware of where their boundaries should be. This may manifest itself as clients that offer things that may be inappropriate. For instance a client suggests that he can get you backstage at a concert where he works or get you a serious discount on a home entertainment center.

Empowering your clients You are in a position to increase the power of your clients, in effect lessening the natural differential that exists in the therapeutic relationship. This is accomplished by encouraging your clients to take a more active role in the session.

Empowering techniques you can use:

• Ask them for feedback after each session. Let them know that you want them to tell you if there is something that needs to be done during the session, and that it is all right for them to let you know it. Be sure to ask them after the session, when they are dressed and sitting in a somewhat equal position.

• Incorporate some active and passive exercises to your normal massage routine. Encourage them to take an active part in the session. Keep in mind that many clients just want to relax during their massage, and this might not be appropriate.

• Begin a session by asking them what they specifically want done in that visit. Don’t just assume that everything is the same, just because you see this client regularly.

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Remember Even though you may be doing your best to empower your clients, the power differential always exists on some level in a therapeutic relationship.

A review of Professional Boundaries As a health care professional, the massage therapist should strive to inspire confidence in their clients, treat all clients and other practitioners professionally, and promote the clients’ welfare. Clients should expect a massage therapist to act in their best interests and to respect their modesty, privacy and dignity.

This means that a massage therapist should abstain from obtaining personal gain at the client’s expense by selling them products or services they know are not effective and they should refrain from inappropriate involvement in the client’s personal life.

The professional boundary is the invisible barrier between the power of the massage therapist and the vulnerability of the client. The power of the massage therapist comes from the professional position and the referral by people the client trusts.

Establishing boundaries allows the massage practitioner to control this power differential and allows a safe connection to meet the client’s needs.

Boundary violations can result when there is confusion or ambiguity between the needs of the massage therapist and those of the client. Such violations are characterized by excessive personal disclosure by the massage therapist, secrecy or even a reversal of roles. This can happen very easily when a massage therapist engages in conversations during a massage, and in an attempt to show empathy for the clients situation, shares personal information.

Boundary violations can cause stress for the client, which may not be recognized by the client until later, when harmful consequences have been brought about.

Boundary crossings are brief excursions across boundaries that may be inadvertent, thoughtless or even purposeful if done to meet a

137 special therapeutic need. The most basic and common is hugging a regular client after a session. This happens in massage business many times and is usually totally benign, but it is a boundary crossing and needs to be recognized as such.

Boundary crossings can and should be temporary resulting in a return to established boundaries. Even so, they should be evaluated by the massage therapist for potential client consequences and implications. Repeated boundary crossings should be avoided as they make boundary violations easier.

Professional sexual misconduct is an extreme form of boundary violation and includes any behavior that is seductive, sexually demeaning, harassing or reasonably interpreted as sexual by the client. This includes a perceived encroachment on the modesty of the client, which is why informed consent forms must be used whenever a draping procedure varies from the recognized standards.

Professional sexual misconduct is an extremely serious violation of the massage therapist’s professional responsibility to the client. It is a breach of trust not just between the client and the practitioner, but between the community and the massage therapist as well.

In short, when one massage therapist does this, it hurts all of us.

A massage room should be seen as a place of safety, and is where the majority of client interactions should occur for effectiveness and client safety.

The Unburdening Client It is not at all uncommon for a client on the massage table to want to talk about their stressors. This is a perfectly natural process of “unburdening” and is common with massage practice, especially if the client is a regular and feels the massage therapist has an idea of what they are going through.

There is nothing wrong with this at all, in fact it is a healthy way for a client to blow off steam in a safe environment.

138 It can become an issue when we become too interested in the events being related to us.

There is reflected in the generic “continuum of involvement” scale that is used by many in the medical profession, including doctors, nurses, psychologists and social workers. I find it applies to massage therapists as well.

Over-involvement with a client is on the right side of the continuum; this area includes boundary crossings, boundary violations. You might start drifting to this side by being just a little too interested in your client’s situation. You are not just listening to them talk about their stress, you are asking questions about it and digging deeper.

Under-involvement lies on the left side; this means you are not only not paying attention to the clients story, you seriously don’t care. They are just a piece of meat on the table for you to tenderize. This leads to disinterest and neglect.

There are no definite lines separating the safe zone from the ends of the continuum; instead, it is a gradual transition or blending. That is why we have to continually take stock of our feelings

This continuum provides a visual frame of reference to assist massage therapists in evaluating their own and their colleagues’ professional-client interactions. In a specific instance where a boundary violation has occurred all of the facts should be taken into consideration.

The massage therapist should be asked: What was the intent of the boundary crossing? Was it for a therapeutic purpose? Was it in the client’s best interest? Did it optimize or detract from the therapeutic relationship?

It is the massage therapist’s responsibility to monitor and maintain boundaries. As the licensed professional the burden of professional boundaries is entirely on us, we should not expect our clients to be aware

139 of boundaries or the least concerned with them. When they violate them, it is our responsibility to rein them it.

Here are some key factors in boundary maintenance:

The massage therapist should work within the safe zone of the continuum of involvement. The massage therapist should examine any boundary crossing, be aware of its potential implications and avoid repeated crossings. Variables such as Dual relationships Transference and Countertransference affect the delineation of boundaries. Actions that overstep established boundaries to meet the needs of the massage therapist are boundary violations. The massage therapist should be especially alert when the massage therapist has a personal or business relationship, as well as a professional one (i.e. your client is also your accountant, your sons teacher, etc).

Identifying Boundary Crossing There are some common behavioral indicators that can alert the massage therapist to potential boundary issues, for which there may be reasonable explanations.

If you find yourself displaying one or more of the following behavioral indicators you need to take some time out for self-examination.

Excessive Self-Disclosure – The massage therapist discusses personal problems, feelings of sexual attraction or aspects of his or her intimate life with the client. As stated earlier, this is often done in an attempt to express empathy for the client; it can quickly become a problem.

“Super Hero Syndrome”– The massage therapist believes that he or she is the only person that understands or is the only one with the necessary massage skills to help a particular client.

“Therapeutic immunity”- The massage therapist believes themselves to be immune from even developing an unhealthy relationship with a client, and therefore is not willing to discuss the issue or even entertain the idea.

140 Special time/treatment – The massage therapist spends inappropriate amounts of time with a particular client. We are not talkig about giving extra time as a reward for a loyal or referring client, when that is done it should involve a formal notice, like a thank you card with a certificate declaring the extra time has been earned.

No we are talking about a one-hour massage that ends up being a two and half hour massage.

Flirtations – The massage therapist communicates in a flirtatious manner, perhaps employing sexual innuendo, off-color jokes or offensive language. Always inappropriate and a sign of trouble.

Secretive Behavior – The massage therapist keeps secrets with the client and /or becomes guarded or defensive when coworkers or others question their interactions.

Failure to Protect Client – The massage therapist fails to recognize feelings of sexual attraction to the client, and continues to see him or her when they should refer them to another practitioner.

Power Differential is a necessary part of many relationships. If there was no power differential between a student and a teacher, the teacher would not be able to impart their wisdom. The same for children and parents. If there was not a substantial difference in power between a doctor and their patient they would not be able to treat them effectively, and the same goes for massage therapists.

If the client is not in the vulnerable position of laying on a table and letting go control of their bodies we would not be able to exercise our skills to their benefit.

Recognizing that power differentials exist is important. We need to understand that it influences our clients in way that makes them more likely to trust us and believe what we tell them, and that gives us a powerful responsibility.

Are we going to be using that power differential for therapeutic purposes only, or are we exploiting it for our own ends? You need to weigh each

141 decision you make with your client by this standard to stay on the ethical path.

Dual Relationships Many Massage Therapists, particularly those in smaller towns, often find themselves caring for clients for whom the therapeutic relationship overlaps with another relationship (e.g. , social or professional). This is called a Dual Relationship .

A dual relationship exists when an individual simultaneously or sequentially participates in two roles 37 . A dual relationship exists when, in addition to the professional relationship, there is some other relationship with the individual: friend, family member, student or business partner.

Problems with dual relationships may be explained by our expectation of role fulfillment . The roles people play in our lives have inherent expectations, meaning we expect people to behave a certain way depending on what role they play. Conflicts occur when the expectations attached to one role call for behavior, which is incompatible with that of another role.

Whenever possible massage therapists should avoid dual relationships , but in many situations this is impossible and it is for those situations that we prepare ourselves to handle them in the most ethical and conscientious way possible. Keep in mind that, because of their potentially serious consequences, some dual relationships are always prohibited , such as sexual relationships with your clients. These are never ethical must be avoided.

Because some dual relationships are unavoidable we can use some practical problem solving models to help navigate these relationships without causing harm to our clients or ourselves.

Commonly encountered Dual Relationships in Massage Therapy Anytime a person that you knew prior to meeting them in your massage consultation is a Dual Relationship. Some of these relationships are very casual in nature, others are more formal, but if you know the persons name, there is a relationship present.

37 Carroll, Schneider & Wesley (1985)

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Casual Relationships These are the most common in small towns or rural areas, where “everybody knows everybody”. Your clients’ will most likely be people you know or at the very least will be related to people you know. Maintaining proper confidentiality is always important, but in these types of environments it can be challenging.

Professional A Professional level Dual Relationship can be a coworker or another service provider that you trade services or referrals with. Common examples include the other service providers in the day spa where you work, a chiropractor you work with or see professionally, etc. This could also be your Childs teacher or doctor, another professional that you deal with in a totally different way.

Familial These are relatives. Aunts, uncles, cousins, In-laws, siblings, all those people we are connected to by blood and marriage.

Romantic The most commonly talked about Dual Relationship, the romantic relationship refers to people we are intimately involved with. In the context of this course we are assuming that the romantic relationship came before the therapeutic one-if it is the other way around there is a serious problem.

A Decision-Making Model The model presented below is designed specifically to address potential dual relationship ethical dilemmas. It is neither so broad as to leave the practitioner without guidance, nor so specific as to 'dictate behavior. It should encompasses all potential dual relationship problems that may arise, regardless of the professional context in which they occur.

143 The Decision-Making Model Low Power Mid-Range Power High Power Peers (trading with other similar Some Power differential but Clear Power differential with professionals) clear boundaries. obvious influence (ie they would do what you tell them) Brief duration or infrequent Intermediate duration regular Long duration the relationship visits contact over a brief period of has been in existence for a long time. time and is likely to continue. Clear Termination (Cruise ship, Uncertain Termination An Indefinite Termination A regular Resorts etc) irregular client that is likely to be client that has a firm schedule of seen again. appointments.

Assumptions Seven assumptions are required to use the model.

First, the model is applicable to all professional relationships in which you engage. The model assumes that your role is that of a professional, regardless of the context in which the relationship with the client takes place.

Second, the aspirational goal of striving to avoid all dual relationships is unrealistic in many circumstances. The purpose of the model is to assist massage therapists in managing these relationships more sensitively and effectively, when they cannot be avoided.

Third, due to the inherent high risk, all additional relationships with clients should be evaluated to assess potential harm.

Fourth, the model assumes that not all dual relationships are exploitive per se. It presumes that in some circumstances, dual relationships may be pursued with low risk and may be beneficial; dual relationships must, however, be avoided whenever there is a reason to believe that they may prove harmful.

Fifth, the model is intended to sensitize you to the relevant issues, and make recommendations for action.

Sixth, the model assumes that the practitioner's dilemma is the result of contemplating the addition of a second relationship to an existing one. It is not intended for situations where multiple relationships are already in existence.

144 Seventh, the dimensions below must be assessed from the perspective of the client, not from that of the practitioner.

The Model The model is taken from a psychological model used for clinicians and has been adapted here for use by massage therapists. It is based upon the use of three dimensions, which are believed to be basic and critical to the ethical decision-making process.

The first dimension is Power. It refers to the amount or degree of power which the massage therapist a may have in relation to a client. Power can vary widely. The massage therapist who listens to complaints and gives suggestions about shin splints has far less power than the massage therapist that listens to a client describe mental and emotional stressors. Some people seek out massage for relief from pain and tension, but for others it is the only refuge of peace in a turbulent life, or the only nurturing and healthy touch they have ever received. That gives the therapist a great deal of power.

The second dimension is Duration. Duration of the Relationship is an aspect of power because power increases over time. Power is lower when relationships are brief, such as in a single assessment session for referral, and increases as relationships continue, such as that of a long time client.

The third dimension is Clarity of Termination. As health care professionals massage therapists differ from doctors and physical therapists in that there does not have to be a clear end to the professional relationship. Many healthcare practitioners are seen for a specific condition, and it is understood that the relationship will end when the condition is successfully treated. Massage is preventative care and can go on indefinitely. This model assumes that the professional relationship continues, as long as the client wishes it to.

Using the Decision-Making Model When a massage therapist is contemplating an additional relationship, the model is to be used as follows. -

Step 1. Assess the current relationship according to the three dimensions. From the clients’ perspective, where does the relationship fall

145 on each? How great is the power differential, how long has the relationship lasted, and has it clearly ended? If the relationship falls to the right side on two or three of the dimensions (i.e., higher power, longer duration and no termination), the potential for harm is high, and no other relationship should be contemplated.

If the relationship falls to the left side on the three dimensions (i.e., low power, short duration, and clearly terminated), one may move down to the next level. When the relationship falls at mid-range on the three dimensions, some types of additional relationships may be permissible, and the massage therapist may move down to the next level.

Step 2. Examine the contemplated relationship along the three dimensions, as was done for the current relationship. If the contemplated relationship falls to the right side of the dimensions (i.e., it would involve great power over a long time with an uncertain termination), then it should be rejected if the existing relationship also falls to the right. If the proposed relationship falls either in the mid-range or to the left side of the dimensions, it may be permissible, and the massage therapist should move down to step three.

For example, you might be invited to go to a recreational event (thus initiating a friendship) with the spouse of a person whom you have been treating for recovery from a moderate injury.

In this case you had some power, but for only a brief and clearly-defined time period, and termination of the professional relationship was unambiguous. The new relationship, although of indeterminate duration and uncertain termination, involves little or no power differential.

Another possibility is that the first relationship may fall to the left side on the dimensions, but the contemplated relationship might fall to the right. In this case, the new relationship may be acceptable.

Step 3. Examine both relationships for role incompatibility if they fall within the mid-range or to the left side of the dimensions.

Role incompatibility increases as a function of greater differences in expectations of the two roles, greater divergence of the obligations of the two roles, and an increase in the power differential. If the two different roles

146 are highly incompatible, then the contemplated relationship should be refused.

For example, a massage therapist that owns a Day Spa and has employees should not take their employees as their massage clients. The two roles (boss and massage therapist) are highly incompatible and should not be mixed.

Step 4. Obtain consultation from a colleague. Consistent with the seventh assumption, the new relationship must be assessed from the standpoint of the consumer, and decisions should be made on the most conservative basis. Consultation with a colleague should be considered a routine matter when making such decisions. A colleague familiar with the circumstances, the client, and the decision-maker is the ideal choice. For example, a colleague might consider it inadvisable that a recently divorced, and possibly lonely female 38 massage therapist accepts an invitation for bartering of services from a single male handy man. She just wants her sink fixed and doesn’t want to pay a plumber, it seems reasonable to her at the time, but she is inviting a client to her house to do something that is traditionally done by a male romantic partner. An outside observer would see the potential for trouble that might be missed by a person inside the situation.

Step 5. Discuss the decision with the client if you choose to proceed with the additional relationship. He or she must be willing and able to understand what a Dual Relationship and that it comes with guidelines that must be recognized.

18 Steps in Ethical Decision-Making Adapted and modified by a list prepared by Kenneth S. Pope, Ph.D., ABPP Melba J. T. Vasquez, Ph.D., ABPP

1. Identify the situation that requires ethical decision-making. What is the clearest possible statement of the ethical question or issue? Sum it up in your mind in clear and simple language: don’t over complicate it.

38 Gender roles can obviously be reversed here no sexism is implied.

147 2. Anticipate who will be affected by your decision . No one lives in a vacuum. It is rare that our ethical decisions affect only a single client or a single colleague and no one else. If you have a client that frequently complains about their spouse during your sessions and you give that client advice to “leave him!” or “divorce her!” or “You shouldn’t put up with that!” you may be influencing that relationship in a very inappropriate way.

3. Figure out what need you are meeting for the client. There are times when people are lonely and isolated and massage therapists become their only social interaction. Maybe they are in a troubled marriage or are widows/widowers and are missing physical intimacy (not sex-positive healthy touch ). If this is the case, you need to be aware of the socialization element that is a factor and maintain proper boundaries. There is nothing wrong with this type of therapeutic relationship, as long as it is kept in the appropriate context, which is your responsibility.

4. Assess your relevant expertise-are you in over your head? Massage Therapists are awesome people! We can facilitate healing with our hands and our hearts, but we are not doctors and we are not psychologists. If your client has health or psychological problems that are beyond your ability to deal with, you need to be honest and let that client know.

5. Review relevant formal ethical standards. Do the ethical standards speak directly or indirectly to this situation? Are the ethical standards ambiguous when applied to this situation? Does this situation involve conflicts within the ethical standards or between the ethical standards and other (e.g., legal) requirements or values? In what ways, if at all, do the ethical standards seem helpful, irrelevant, or misdirected when applied to this situation?

6. Review relevant legal standards. Do legislation and case law speak directly or indirectly to this situation? Do the legal standards speak to this situation in a way that is clear? Are there conflicts within the legal standards or between the law and other requirements or values? Do the relevant laws seem to support-or at least allow-the most ethical response to the situation, or do they seem to work

148 against or block the most ethical response? Would it be helpful to consult an attorney?

7. Review the relevant research and theory. Is there new research or theory that helps us to conceptualize, understand, or respond to the situation?

8. Consider how your personal feelings, biases, or self-interest might affect your ethical judgment and reasoning. Does the situation make you angry, sad, or afraid? Do you find yourself eager to please someone? Do you desperately want to avoid conflict? Do you find yourself concerned that doing what you believe is most ethical will get you into trouble, will make someone mad at you, will be second- guessed by colleagues who disagree with you, or would be hard to square with the law? Will doing what seems ethically right cost you time, money, referrals, prestige, a promotion, your job, or your license?

9. Consider what effects, if any, that social, cultural, religious, or similar factors may have on the situation and on identifying ethical responses. The same act may take on sharply different meanings in different societies, cultures, or religions. What seems ethical in one context may violate fundamental values in another society, culture, or spiritual tradition. Are you overlooking any relevant contexts? Does the situation include social, cultural, religious, or similar conflicts?

10. Consider consultation. Is there anyone who would likely provide useful consultation for this specific situation? Is there someone who has faced a similar situation and handled it well-or who might tell you what does not work and what pitfalls to avoid? Is there someone whose perspective might be helpful? Is there someone whose judgment you trust?

11. Develop alternative courses of action. What possible ways of responding to this situation can you imagine? What alternative approaches can you create? The initial possibilities that occur to us may strike you as "not bad" or "good enough," but much better responses may occur to you if we keep searching.

149 12. Evaluate the alternative courses of action. What impact is each likely to have--and what impact could each have under the best possible and worst possible outcome that you can imagine--for each person who will be affected by your decision? What are the immediate and longer-term consequences and implications for each individual--including yourself? What are the risks and benefits? Almost any significant action has unintended consequences--what might they be for each possible course of action?

13. Try to adopt the perspective of each person who will be affected. Putting yourself in the shoes of those who will be affected by your decisions can change your understanding and help you discover what you believe will be the most ethical response to a difficult situation. You can ask yourself: what would each person consider the most ethical response? In this way you can try to compensate for some of the distortion that may occur from seeing things only from your own perspective

14. Decide what to do, and then review or reconsider it. Once you have decided on a course of action, you can--if time permits-- rethink it. Sometimes simply making a decision to choose one option and exclude all others makes you suddenly aware of flaws in that option that had gone unnoticed up to that point.

15. Act on and assume personal responsibility for your decision. In some cases, trying to weigh ethical options, reconcile ethical conflicts, and discover the most ethical response--the steps leading up to taking action--are the hard part. Once the decision is made, acting is relatively easier. In other cases, thinking through the situation may seem relatively easy-acting is hard. The most ethical response may seem to come at overwhelming personal risk or cost. When risks or costs overwhelm us, it is a natural temptation to blur or evade personal responsibility.

16. Evaluate the results. What happened when you acted? To what extent, if at all, did your action bring about the expected consequences? To what extent, if at all, were there unforeseen consequences? Knowing what you know now, would you have acted in the same way or chosen a different response to the situation?

150 17. Assume responsibility for the consequences of your action. If your response to the situation now seems-with the benefit of hindsight-to have been wrong or has caused negative consequences, what steps, if any, do you need to take to address the consequences of your decision and action? If it seems to have been incomplete, what else needs to be done to address the situation? Have your actions and their consequences brought about new ethical challenges?

18. Consider implications for preparation, planning, and prevention. Did this situation and the effects of your response to it suggest any useful possibilities in the areas of preparation, planning and prevention? Are there practical steps that would head off future problems or enable you and others to address them more effectively? Would changes in policies, procedures, or practices help?

Massage therapy is a field that deals exclusively with intimate relationships in a professional context. Those relationships can be therapeutic, healthful and nurturing, or they can be harmful to both the client and the therapist.

Each person brings into the relationship a unique background of experiences; feelings and attitudes that will help shape this relationship. It is possible that the client, or even the therapist, will bring with them past pain, fear or anxieties that will need to be addressed.

It is the responsibility of the therapist to maintain the integrity of the therapeutic relationship. Maintaining that integrity is absolutely impossible without knowing and understanding the different roles and boundaries involved.

Summary of Massage Therapy Roles and Boundaries Massage therapy is a field that deals exclusively with intimate relationships in a professional context. Those relationships can be therapeutic, healthful and nurturing, or they can be harmful to both the client and the therapist.

151 It is the responsibility of the therapist to maintain the integrity of the therapeutic relationship. Maintaining that integrity is absolutely impossible without knowing and understanding the different roles and boundaries involved.

A therapeutic relationship is a professional relationship between health care practitioners and their clients or patients.

Many stateboards require us to take ethics courses regularly not because there are updates with new ethics but because we need constant reminders of ethical boundaries.

Our clients should have a reasonable expectation that we are competent (well trained and knowledgeable), that they will be physically safe and that they will be free from emotional abuse and exploitation.

Informed consent is a statement that the client understands what treatments are going to be done and the purpose for it.

We must always be mindful of the right of refusal, which means that clients have the right to refuse or stop treatment at any time AND the therapists right to refuse or stop treatment at any time.

We must always be mindful of our clients right to confidentiality. A breach of confidentiality occurs when you repeat any part of a conversation that occurs between you and your client while in session, if you divulge that an individual is a client of yours to another party or if you fail to keep SOAP notes and intake forms in a locked container.

A boundary violation is a potentially harmful behavior that is inconsistent with the established boundaries of a relationship. A strong healthy boundary is firm, but adaptable. A spatial boundary is the “personal space” around a person. Common examples of boundary violations in massage therapy are causing your client pain by using more pressure than needed in a technique, draping them in an ineffective manner or insisting on performing a technique they are not comfortable with.

The function of a scope of practice is to clearly define the acceptable practices covered by a specific license. Massage therapists can stray outside of their scope of practice if they diagnose their clients, recommend

152 that their clients ask their doctor for a specific medication or tell a client to stop a prescribed medication or medical treatment. All of those things are considered practicing medicine without a license.

The difference between a sensual touch and a sexual touch is the intent of the practitioner and the area of the body that is being massaged.

Selling products out of your massage practice is not wrong, but care must be taken to avoid ethical problems. Your clients are predisposed to believe you in health care matters and your desire to make a sale may lead you to influence someone to buy something that may not help them. In some cases the products are not regulated by the food and drug administration and may not be safe for the client.

Transference occurs when a client is transfering feelings from one relationship into their therapeutic relationship. Some possible symptoms of Transference can be your client buying you expensive gifts and giving them to you as a "tip", a client calls you to ask for advice in their personal life or if your client asks questions about your personal life.

Countertransference occurs when the therapist transfers feelings from one relationship into their therapeutic relationship. Some possible symptoms of countertransference include being disappointed when a specific client does not call, getting frustrated that a client is not making progress in their health, or offering to massage a client for free just because you enjoy their company.

Many Massage Therapists, particularly those in smaller towns, often find themselves caring for clients for whom the therapeutic relationship overlaps with another relationship (e.g., social or professional). This is called a Dual Relationship. A dual relationship exists when an individual simultaneously or sequentially participates in two roles . A dual relationship exists when, in addition to the professional relationship, there is some other relationship with the individual: friend, family member, student or business partner.

153 Section 2: Ethics in Massage Marketing

Instructions Thanks for downloading this Somatic Arts and Sciences continuing education course. You’re on section 2 now, 6 hours in! Keep reading.

Taking the quiz To take the quiz you can click the link on the website below this book.

Target Audience This continuing education course has been designed to meet the educational needs of massage therapists.

Degree of Difficulty Beginner/Entry Level

Course Description This course is designed to offer an overview of the ethical concerns in massage advertising.

Educational Objectives Upon completion of this home study continuing education course, the massage practitioner should be able to: Detail examples of effective and ethical massage advertising. Identify unethical or deceptive advertisements.

154 INTRODUCTION This course is presented for educational purposes only. It was developed and marketed specifically for massage therapists that are required to obtain continuing education hours for licensing purposes. The author is not giving medical, legal or other professional advice.

This course is classified as “ Cognitive ” learning, meaning that there is no hands on portion.

The Somatic Arts and Sciences Institute strives to provide the most up to date and accurate material possible, however research and new discoveries continue daily and we assume no responsibility for errors or omissions due to the rapid advancement of science.

Warning: Ethics courses make you think This is one of my more controversial courses. I love ethics courses because, if done right, they make people a little uncomfortable. So consider yourself warned. But don’t worry; we have a course evaluation process that allows you to give me whatever kind of feedback you wish.

This course has garnered some attention from critics (probably other CE providers) because it examines the marketing practices of massage therapists and it questions the effectiveness of some “alternative healing” practices that have crept into the world of massage therapy.

We massage therapists are, if I can presume to generalize a bit, a very accepting people. We tend to be open minded and flexible, and we don’t like judging others or having our own methodology judged. In fact, we can be a wee bit too sensitive sometimes. I think it is part of our empathic nature. Our sensitivity allows us to be aware of what others are feeling and that’s good, but it can also lead to our feelings being hurt.

So before we get too deeply into this course let me explain something.

This course is about ethical advertising and how it relates to massage therapy. Ethical advertising means that you are not promising something you can’t deliver.

What’s interesting about ethics is that there is a great deal of cultural background that goes into the decision making process. Ethics are often

155 not simply black and white, like anatomy and pathology courses. Different people see things differently. But one thing we can agree on, telling the truth in advertising is the ethical thing to do.

Telling the truth seems like a pretty basic ethical standard, a good place for us to get started. The world's best example of truth in advertising may be a tiny "Help Wanted" ad that appeared in the London papers in 1900:

"Men wanted for hazardous journey. Small wages, bitter cold, long months of complete darkness, constant danger, safe return doubtful. Honor and recognition in case of success. Ernest Shackleton."

Believe it or not, that was a real ad run by Ernest Shackleton, a now famous Antarctic Explorer. What is so surprising about the ad isn’t that he told the truth; it was that hundreds of young men answered it!

Chapter 1. Why there is a need for ethical massage marketing This course covers ethical issues and concerns and their impact on every day decision-making in advertising a massage business. Ethical marketing strategies are examined and contrasted with inappropriate and deceptive advertising.

Many massage schools today spend very little time on advertising, or business principles in general. This is unfortunate, as it is desperately needed in our industry.

Many massage schools will spend a week or less of their program on business principles, including bookkeeping and marketing. Given that close to two-thirds of the massage therapists in the United States are self employed 39 this is something that they should be spending more time on.

Marketing is a key factor to success in most businesses, but in the massage therapy business it is crucial to develop ethical and effective marketing principles.

39 Acording to the US Labor Department index.

156 Our industry has suffered greatly for the mistakes of others. Prostitutes posing as massage establishments and poorly trained massage therapist practicing alternative medicines that have little effectiveness 40 have been far more visible in the media than the majority of hard working, honest and competent massage therapists that are working in our country.

In this course we will examine the two most prevalent ethical problems in massage: the illicit sex industry and the “snake oil” market.

The past returning to haunt us For many years it was a common practice for brothels in the United States to operate under the name “Massage Parlors”. The terms are still synonymous in many other countries.

Unfortunately many cities still use the term Massage Parlor when referring to massage establishments in their ordinances and they will frequently group massage business with “casinos, dance halls and adult book shops”.

This negative stereotype has kept many people who would be good massage clients away while at the same time drawing those we would prefer to not see in the industry.

So how do we market our business in a manner that attracts the right clientele and discourages those seeking illicit sexual services?

By carefully tailoring the content and placement of advertising to convey to the public the nature of our business we can work to overcome decades of negative publicity perpetrated by those that have slandered the good name of massage therapy.

Advertising Content Advertising, regardless of the medium, is expensive . Printed media, like newspapers, mailers, and magazines charge by the word or line. Radio and television charge by the second and sign makers charge by the square inch. Whatever form of advertising you are using to market your business it is going to be expensive, which is why most advertisements you see for products are short and to the point.

40 I am not saying that all Alternative Medicine is ineffective, but it seems the ones that are get the most media coverage.

157 One of the great secrets to success in business (ANY business) is to find a need, and then fill it.

We know there is a need for massage therapy. People need a way to deal with the stresses of life, they need to be relived of pain and discomfort, and sometimes they need to pamper themselves-or someone else. The need is real, and the people are out there-so how do you reach them in an ethical and effective way?

The content of your marketing material refers to the language and images you use. As I said above, advertising is expensive-so you have to make the most impact with the least amount of material. The content of an ethical ad that uses a picture that will make a statement with it-a statement that says, “This meets your need”.

The ad should not create a need in the mind of the viewer (although many high paid advertising companies do this-but remember, this course is about ethical marketing).

If the need is legitimate and ethical (stress and pain relief or pampering) the advertisements should clearly convey that. If it does not clearly convey the legitimacy of your business then you are inviting the wrong type of clientele. You do not have to advertise “inappropriately” to get the wrong clients, but if you advertise ambiguously it will have the same effect.

What need is she offering to meet in this business?

It is clear that she takes credit cards at least.

We can clearly see that she is open for busin ess 7 days a week, form 9am to 9pm.

This may be an ad for a legitimate massage therapist. She may be a highly skilled, competent and licensed massage therapist, but if the intent of this advertisement is to let you know that, she failed.

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She did manage to succeed in showing us that she is a pretty female, which given the purpose of advertising is to show a need you can fill it is pretty obvious what type of customers she is going to get.

Now compare the advertisement above with this one below.

How is this advertisement for mas sage different from the one in the picture above?

What need can be met from this business?

Both of these advertisements include a picture of a female. The one in the first picture is in a model pose, doing nothing but looking pretty. The one in the second picture is actually wearing scrubs and performing a massage.

The imagery alone suggests very different services being offered. The second image is very clear-they are advertising the massage . The first picture is advertising the woman .

The first advertisement offers no information about the massage services, other than someone that isn’t even named voted them best in their ‘category’.

The second advertisement lists the types of massage that are done. It is a simple advertisement, but it clearly conveys that it is a legitimate massage practice.

Content applies to language as well as imagery. An advertisement can look professional, but use language that intentionally or unintentionally sends the wrong message. The advertisement on the following page is

159 very professional looking and appears totally legitimate, but examine the wording.

Did you notice the usage of the words “full body massage” in this advertisement?

The term full-body massage is a legitimate term in the massage industry, indicating a massage that incorporates not only the back, but also the arms, legs, hands and feet. Unfortunately it has recently been used as a euphemism for a massage that includes the genitalia. The subtle usage of the wording “full-body massage available by request” gives the reader an indication that more than the usual massage is available, if the client asks for it.

Incorporating the term full-body massage into an advertisement may attract the attention of clientele looking for erotic services.

For those of you who are still using the term I advise you to change the wording of your advertisements. It is really unnecessary anyway, if you are advertising an hour massage it is implied that it is going to cover more than just the back. If your clients ask what is included in the 1-hour massage than you already have their attention, and your advertisement worked. The term is really unnecessary.

Dubious modalities Many dubious modalities that have surfaced over the years offering legitimate sounding treatments that are in reality thinly veiled acts of prostitution.

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Tantric Massage, Lingam Massage, Yoni Massage, Manual-release , and Full-release are all terms that are synonymous with massage-prostitution.

If you have never encountered these terms, consider yourself lucky! We do not recommend an Internet search using these terms; you will probably be very discouraged by the prevalence of bogus therapists offering these services.

Using Appropriate Content To project the right image to your potential clientele there are a few things you should consider.

Using Pictures o Is the focus on the massage or the practitioner? o Is the client properly draped? o Does it present a serene or stimulating environment? o Are my services clear or ambiguous? o If I am in the picture, am I dressed professionally?

Using Language o Am I using words or phrases that can be misconstrued? o Do I convey professionalism?

Is it OK to say I do not offer Sexual Services? Many students in my massage school ask me if it is a good idea to include a statement in their advertisements saying that they do not offer sexual services.

The answer is a big NO-unless you specifically work in a city where there is a booming illicit sex industry, such as Las Vegas or San Francisco.

The reason why is that it scares away those timid clients who are not sure massage therapy is right for them. Instead of encouraging them it is going to confirm their worst suspicions. This is especially a mistake if you include it on your web page-see choose your words carefully below.

The Internet The Internet is the most powerful tool for advertising that most massage therapists are not using! If you do not have a web page, get one.

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With each passing year the likelihood of someone going to a search engine to find a local massage therapist instead of the phonebook increases. You do not have to be a technical genius to get a simple, inexpensive internet presence, and if you take your business seriously you will invest in one as soon as possible.

Unfortunately the internet is also widely used to purvey illicit sexual services. More and more escort services and ‘illegitimate massage therapists’ are using the Internet to be found by clients.

Choose your words Carefully! One thing to keep in mind if you have a web page is that search engines like Google and Yahoo! use programs called “crawlers” to read your web pages. These programs take the words off of your web page and these are how people “find” your web page when they do a search-based on the words.

Take a look at the sample web site on the following page. This is a simple page that belongs to a totally legitimate massage therapist. Unfortunately some of the words on her page have earned her some unwanted attention.

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In this example Karen (this web page is fictitious, by the way) has gone out of her way to let people know she is a professional. Unfortunately the search engines do not read the context of the page-only the words themselves. Look at what it found:

Words appearing This web page would definitely come up on Please the search indicated on the previous page. Comfort Full Does that mean the searcher would call her? body massage Maybe a nd maybe not, but I would rather not Hotel even show up on his search. Professional Sex ual The internet is a fantastic advertising tool, Services but like any tool, you have to understand how Masseuse it works to use it effectively. Visit

Advertisement placement Highly paid advertising executives know that an advertisement, no matter how well crafted, is wasted unless it is seen (or heard) by its target

Massage photo on website compliments of imagerymajestic / FreeDigitalPhotos.net 163 audience. They put just as much attention into putting it in the right place as they do in making the advertisement itself. You should too.

Would you hand out your business cards on a street corner where prostitutes work? No-of course you wouldn’t. But massage therapists are still using services like craigslist.com to advertise their business, even though prostitutes pretending to be massage therapists and escort services are using it too.

In order to separate ourselves from these illicit sex industries we need to start with not advertising side by side with them.

You wouldn’t open a massage business next door to an adult bookstore, so why would you advertise your business with a website that offers prostitution?

Signs If you own a massage establishment you probably have some kind of sign, maybe on a storefront window or even just on a door. What does your sign say about your business? Does it have an image, and if so, does it project the image you want for your business?

Look at this simple massage sign. Red neon lights are synonymous with the sex industry.

While this may be a legitimate massage business it’s a pretty safe bet that they get more than their fair share of calls for inappropriate services.

164 Massage therapists often have to work in the evening, people work during the day and they get massages on their days off or after work, so working at night is a reality for many of us.

If you are running a massage establishment that is open at night and you want visibility there are other options to explore.

The sign to above is a clever way of using neon in a way that clearly shows the massage is non-sexual.

Notice that they opted for a cool blue rather than a hot red.

There are also custom LED lights that can be designed to show intricate patterns, or you can opt for a regular sign that has lights shining on it, instead of glowing in a pulsating, sexual way.

Neon signs are designed to STIMULATE!

165 The purpose of your sign is to let people know where your business is. It does not have to be stimulating or exciting, just visible.

Remember you do not have to look like a brothel to send the wrong type of message; any ambiguity leaves the imagination room to fill in the blanks. Massage therapy has had decades of bad publicity in this country, so if we leave our business up to the publics imagination we are destined to continue getting the wrong type of calls.

Take extra care in presenting your business to the public. Make sure they know that you are a licensed and well trained professional, and that you are offering a therapeutic service, not an exotic entertainment.

The Snake Oil Market In the days of the American Old West many Chinese immigrants came to work on the railroads. Many of them brought exotic new medicines from their homeland, one of which was a liniment Made from snakes-“Snake Oil”.

This liniment was used as a treatment for muscle inflammation and soreness in china for centuries and was a legitimate and well- respected medicine.

Unfortunately then, just like today, there were many unscrupulous people that were ready to take advantage of the sick and miserable with an alternative medicine that was ineffective. They capitalized on the new influx of exotic medicines to sell tonics (many of which were just watered down alcohol) that they claimed were “snake oil”.

The Snake oil salesman became so famous in the American West that they have earned a place in western movie legend. You’ve seen them in the old shoot-em up movies:

166 The slick salesman comes into town with a wagon full of wonder ointment, guaranteed to cure everything from coughs to baldness. They get a “volunteer” from the audience (called a Shill) who pretends to be sick and then takes a sample of the miraculous new wonder drug and then- HEALED!

Well the snake oil salesman are still at it, and unfortunately far too many massage therapists fall victim to their sales pitches.

Worse than that, many massage therapists will pass on a dubious product to a market, becoming, in effect, the Shill.

I like to think that most of them are themselves victims, truly believing that their product is effective, but many of them know (or at lease suspect) that it isn’t working at all.

I am not going to go into details of what I believe are bogus alternative medicines. I do believe in many alternative forms of medicine that are practiced today and it is not my place to tell anyone which ones are effective and which ones are not.

Alternative medicines are called alternative medicines because they are practices that have not been accepted by the mainstream medical field yet. Some are outright rejected by the mainstream, but this doesn’t mean it’s wrong. The mainstream medical community has been wrong many, many times in history. A lot of people believe that the medical community as we know it today is so blinded by greed that it can’t see any practice not tied to expensive pharmaceuticals as worthwhile. I am a believer in alternative medicines, but I am also a believer in ethical massage practices.

You have an ethical responsibility to your clients to pursue the truth about alternative medicines.

Pursuing the truth means reading articles and research written by people who may not agree with you on the effectiveness of these methods. All too often we only read material on alternative medicines that agree with what we want to believe.

In some cases we only read material written by the sellers of the product or method that we are using!

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This form of self-reinforcement only perpetuates practices that may not be effective. We are quick to criticize others for not being open-minded when it comes to accepting alternative, non-traditional healing practices, but we have to be open minded as well when it comes to scientific evidence.

I will not tell you what practices are the modern day “snake oils”-you will have to decide that yourself. But before you do…do some research.

Just an example: The Vogel Crystal Before you all start sending me hate emails let me just say that if you believe in the healing power of crystals-that’s fine. I am not doubting you or questioning your practice. But we need an example and this one is as good as any.

Some of you may be familiar with the Vogel Crystal. The Vogel Crystal is a quartz crystal that resembles the one in the picture below.

It was named after Dr. Marcel Vogel a research and development man for IBM.

Dr. Vogel designed many inventions and was awarded several patents, including several computer di sk drives still in use today.

He founded a company, Vogel Luminescence Inc. which made a variety of products. He also designed the vogel crystal which allegedly focuses "universal life force" by concentrating it to a higher level. Vogel crystals are cut to the exact angle of 51 degrees 51 minutes and 51 seconds or the exact angle of the Great Pyramid of Giza. The crystal is designed after the geometry of the Tree of Life symbol.

It became very popular with energy workers that utilyzed it in their practice, often by holding it over the Chakras or by moving it back and forth over their clients body.

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Well this sounds somwhat scientific, the man who began the practice was a scientist after all.

The problem is...

Dr. Vogels degree was honorary, he did not earn a P.h.d. in anything. While he knew a great deal about science, he openly stated that the idea for the channeling of the "universal life force" came to him in a dream .

I mean no disrespect to Dr. Vogel, he was an undeniably brilliant man, very knowledgeable in chemistry and physics. But many crystal users in the alternative medicine industry are engaging in a healing practice based on… a dream he had ? Really?

If you carefully examin Dr. Vogels achievements you will see that he acomplished many great things and his ideas about crystals and enrergy are actually good-but they have been taken over and used (out of context) by people that want to sell an easy to manufacture “healing product”.

Have you ever noticed that most places that sell books about the Healing Power of Crystals also sell…Healing Crystals?

It follows the same pattern as the Snake oil salesman in the old west. What started as a legitimate medical ointment used in China for thousands of years was taken over by people out to make a quick buck.

But they work! The Placebo Effect Yes its true, a lot of alternative medicine products do work. The Healing Crystal above may completely stop a migraine headache in its tracks if held over the forehead. Especially if the person with the headache believes it will work. This is called the placebo effect .

A placebo effect occurs when a treatment or medication with no therapeutic value (a placebo) is administered to a patient and the patient's symptoms improve. The patient believes and expects that the treatment is going to work, therefore it does. The placebo effect is also a factor to some degree

169 in clinically effective therapies, and explains why patients respond better than others to treatment despite similar symptoms and illnesses. 41

Unrealistic claims in massage marketing When you advertise your therapeutic massage services are you presenting a fair and accurate picture of what you and your massage can accomplish?

Just because you have had a great deal of success with reducing migraine suffering in a few clients it is not fair or ethical to promote your treatment as a “cure” for migraines.

The same goes for Temporomandibular Joint Disorder (TMJD), Fibromyalgia, Lupus or any other condition, which is frequently treated with massage. We know these things are helped by massage, but we should also be honest with the public regarding what results they can expect.

Is it ethical to advertise “relief from the pain associated with TMJD ”? Absolutely!

Is it ethical to advertise “relief from TMJD?” No-because that implies you are making the condition go away, and you are not.

In the past clients have asked me if massage therapy can help remove cellulite. I told them that if I really believed it could I would advertise that-I would be rich in no time at all!

There are so many things that we know massage does for the body. We do not need to push the envelope by claiming to be able to heal medical conditions that require much more extensive treatments than a weekly 1- hour massage can provide.

People that are suffering from chronic pain have impaired judgment-they want to believe they can be healed. They are also predisposed to believing us because of our education, and the power differential 42 .

Successful massage should always be client centered, and that applies to marketing principles as much as treatment. We are struggling to undo

41 Harrington , Anne. The Placebo Effect: An Interdisciplinary Exploration. Cambridge, MA: Harvard University Press, 1999. 42 For more on the power differential see EPS007: Understanding the Power Differential in Massage Therapy

170 decades worth of bad publicity that has made massage synonymous with prostitution or new age gurus.

Every massage therapist has a responsibility in this area. We all have to do our part to elevate the appearance and substance of our profession.

171 Chapter 2. Different forms of marketing This chapter deals with many of the various marketing strategies that are taught in our nation’s business schools. As I said before, marketing is not an area we learn about in massage school, but it is critically important for your success, especially if you are self-employed.

When I was teaching at a massage school full time I used to ask my students “What is your business?”

Invariably they would answer with “massage therapy” and I would yell “Wrong! Massage therapy is your profession; making money is your business . If you don’t learn how to think like a business person you will not be in business for very long.”

Of course there are many massage therapists that want nothing to do with running a business, they are content to just work for someone else and that’s great, I am assuming that you are not one of them if you are reading this course.

When you read about these different marketing strategies you might be tempted to think that they don’t apply to you or your business, especially those ideas that involve technology.

Do not allow yourself to think this way. If you own a massage business you can apply these marketing strategies. They might not all be appropriate for your particular situation, but the underlying concepts are applicable. As you read them try to imagine ways that you could use the concepts to promote your own business.

Affinity marketing Affinity marketing (also called partnership marketing) is an approach to marketing that involves multiple businesses forming a partnership to attract customers who may have an interest in what those businesses are selling or providing. The partners usually have some relation among their products such that a common target audience would be interested in product offerings among all the partners; such a relation or common target audience is termed an affinity . Affinity may also refer to the customer's feeling of affinity for one or more of the partnership's products or brands. Affinity marketing programs have three parts: cross-endorsements among

172 the partnering businesses, shared incentives for participation among the businesses and enhancement package of benefits for the customers.

An example of affinity marketing would be a credit card company partnering with a professional sports team to place the team's logo on the credit card, team members endorsing the card, and an enhancement package consisting of bonus points earned going toward discounts on team events or merchandise. The target audience would be people interested in the use of a credit card who like the team. The shared incentives would be more credit card usage and brand loyalty for the bank and more event and merchandise purchases for the sports team. The sports team may also receive a share of transaction volume on the cards.

Another example is a telecommunications service company partnering with an airline operator to offer discounts or bonuses on roaming plans for frequent flyers.

In 2014, Dunkin' Brands announced a multi-year partnership with Liverpool F.C. to promote both brands together.

In e-commerce, affinity marketing takes the form of sharing referrals among partners through banner ads, icons and hyperlinks. Web search engines may participate in affinity marketing by selling links to keyword searches. Among the goals of e-commerce affinity marketing partnerships are to increase website visibility, increase website traffic and boost sales. Web- based affinity partnerships often attempt to improve affinity marketing by personalizing advertisements according to information learned about customers.

For you as a massage therapist there are many, many opportunities for you to partner with businesses that share an affinity for bodywork. Here are just a few suggestions:

Do you know any personal trainers? Think about it, their clients are all very body conscious, and if the personal trainer is working them out good, they are going to need massage. What if you partnered with a personal trainer to sell packages that include training sessions and massage?

There is a long-standing affinity between the beauty industry and massage therapy. Looking good and feeling good go hand in hand, and many

173 women (and some men) see going to the salon as a pampering treat, which is why so many offer massage. This one is very common in our industry- now you know why!

Aggressiveness strategy Business strategies can be categorized in many ways. One popular method is to assess strategies based on their degree of aggressiveness .

Aggressiveness strategies are rated according to their marketing assertiveness, their risk propensity, financial leverage, product innovation, speed of decision making, amongst others. Typically the range of aggressiveness strategies is classified into four categories: prospector, defender, analyzer, and reactor.

Prospector strategy This is the most aggressive of the four strategies. It typically involves active programs to expand into new markets and stimulate new opportunities. New product development is vigorously pursued and offensive marketing strategies are a common way of obtaining additional market share. They respond quickly to any signs of market opportunity, and do so with little research or analysis.

A large proportion of their revenue comes from new products or new markets. They are often highly leveraged, sometimes with a substantial equity position held by venture capitalists. The risk of product failure or market rejection is high. Their market domain is constantly in flux as new opportunities arise and past product offerings atrophy.

They value being the first in an industry, thinking that their “first mover advantage” will provide them with premium pricing opportunities and high margins. Price skimming is a common way of recapturing the cost of development. They can be opportunistic in headhunting key employees, both technical and managerial. Advertising, sales promotions, and personal selling costs are a high percentage of sales.

An example of this in our industry are those spas and clinics that offer the latest “name brand” fad massage therapy technique (not naming any names-but you know what I’m talking about, the type of techniques that you can only use the trademarked name if you have attended one of their special workshops). Once they have a practitioner that is trained in this

174 new modality they splash advertisements for it across their menus and on their windows. They are gambling that their investment in the new service gives them an edge on the competition.

Defender strategy This strategy entails a decision not to aggressively pursue markets. As a result, they tend to do none of the things prospectors do. A defender strategy entails finding, and maintaining a secure and relatively stable market. Rather than being on the cutting edge of trends; a defender tries to insulate themselves from changes wherever possible.

In their attempt to secure this stable market they either keep prices low, keep advertising and other promotional costs low, offer a limited range of products, or offer better quality products or customer service. They tend to be slower in making decisions and will only commit to a change after extensive research and analysis.

Their goals tend to be efficiency oriented rather than effectiveness oriented. In massage terms, these are therapists that really cater to their clients, doing their best to win people over by going the extra mile and doing more for them than their competitors.

As you can imagine, this strategy relies heavily on return customers.

Analyzer The analyzer is in between the defender and prospector. They take less risk and make less mistakes than a prospector, but are less committed to stability than defenders. They are seldom a first mover in an industry, but are often second or third place entrants.

They tend to expand into areas close to their existing core competency. Rather than offer wholly new services, they make incremental improvements in existing services. Rather than expanding into new markets, they gradually expand existing markets. They try to maintain a balanced portfolio of products with some stable income generators and some potential winners. They watch the developments in their industry closely, but don’t act until they are sure that the time is right.

Reactor

175 A reactor has no proactive strategy, often reacting to events as they occur. They respond only when they are forced to by environmental pressures. This is the least effective of the four strategies. It is without direction or focus (and unfortunately is where most massage businesses are by default).

Alliance marketing Alliance marketing is marketing activity undertaken by more than one entity, jointly to promote and sell a concept, product or service which has benefit to all the involved parties.

An example of alliance marketing is a Destination Alliance where hotels, restaurants and attractions come together to jointly fund and market their destination. The stakeholders understand that by marketing their destination jointly and pooling their resources that the marketing impact they can achieve will be stronger and benighted all stakeholders in that location.

Other examples can be found on Zednet.co.uk who list a number of articles which give further insight into the types of alliances which are created.

Alliance Marketing is similar to Joint Venture Marketing except it does not always involve the creation of a company and brand in its own right to sell and market the product or service.

Alliance marketing is also used where a group of companies often in new technology areas come together to sell the technology concept. An alliance will always have a common theme which all stakeholders can benefit from.

The first day spa I worked at utilized this type of marketing. It was a large building in a shopping center that was shared with a few nice restaurants, a Yoga Studio and a Gourmet Coffee Shop. All of the businesses pooled their advertising dollars to run commercials on local TV stations and radio for “the plaza shopping center” which briefly mentioned all of the businesses therein. Individually none of them could pay for the commercials, but by working together they all benefited. Look at the businesses around your massage practice. Could this work for you?

Ambush marketing

176 Ambush marketing is a marketing strategy wherein the advertisers associate themselves with, and therefore capitalize on, a particular event without paying any sponsorship fee.

The word "ambush" as used in the expression ambush marketing, means "an attack from a hidden position" and is derived from the old French verb embuschier, having the meaning "to place in a wood."The term "ambush marketing" was coined by marketing strategist Jerry Welsh, while he was working as the manager of global marketing efforts for the American Express Company in the 1980s.

Types of ambush marketing:

"Predatory" ambushing: Intentional false claims to official sponsorship by a non-sponsor and/or intentional false denial by a non-sponsor concerning a market competitor's official sponsorship, in each case with the intent to confuse consumers and gain market share from the competing official sponsor. Obviously this is unethical-don’t do it.

"Coattail" ambushing: The attempt by a brand to directly associate itself with a property or event by "playing up" a connection that is legitimate but does not involve financial sponsorship. This can be ethical as long as you don’t make any false claims of sponsorpship.

Ambushing via trademark/likeness infringement: The intentional unauthorized use of protected intellectual property. Such properties can include the logos of teams or events, or making use of unauthorized references to tournaments, teams or athletes, words and symbols. Obviously this is unethical-don’t do it.

Ambushing "by degree": Marketing activities by an official sponsor above and beyond what has been agreed on in the sponsorship contract. For example, an "ambush by degree" of a sports event may involve a sponsor's handing out free promotional T-shirts without the permission of the sports league supervising the event. That sponsor may have already covered the stadium with its signs, or the sports league or participating teams may have made an earlier agreement – perhaps even an exclusive one – to let a different sponsor hand out shirts. In either case, ambush by degree clutters the available marketing space; takes advantage of the participating teams and supervising league to a greater extent than they permitted; and dilutes

177 the brand exposure of official sponsors, including the other promotional efforts of the ambushing company (hence the alternative term "self- ambushing").

"Indirect" ambush marketing Ambushing "by association": The use of imagery or terminology not protected by intellectual-property laws to create an illusion that an organization has links to a sporting event or property — This form differs from direct "coattail" ambushing in that there exists no legitimate connection between the event/property and from direct ambush by infringement in that the sponsored event/property has no property rights in the images and/or words that create the illusion. Values-based ambushing: Tailoring by a non-sponsor of its marketing practices to appeal to the same values or involve the same themes as do the event and/or its promotion, such that audiences attracted to the event or its marketing will likewise be attracted to the non-sponsor's marketing — Essentially a reversal from "push" to "pull" of the causal processes through which direct "coattail ambushers" create sponsor/event-unapproved mental association with their products, this form of ambushing differs from "ambushing by association" in that the ambushing business begins by observing the event's promotional scheme and drawing inferences as to its existing thematic content, as opposed to observing the event's audience and creating new thematic content in hopes that consumers will associate the event with the thematic content created. Obviously this is unethical- don’t do it.

Ambushing "by distraction": Setting up a promotional presence at or near an event, albeit without making specific reference to the event itself, its imagery, or its themes, in order to take advantage of the general public's attention toward the event and the audience members' awareness of their surroundings — This form of ambush amounts to "free riding" upon the positive externality that the event creates for the surrounding area by "anchoring" public and individual attention there; see also "Saturation ambushing" under "Incidental" ambush marketing.

Not only is this ethical, it can be a lot of FUN! I did this for years on Black Friday. You know, the day after Thanksgiving when crazy people line up at the crack of dawn to bum rush into a store for awesome discounts.

178 My wife and I used to make the rounds on Black Friday, going to each big store and walking up and down the lines with a book of Holiday Themed Gift Certificates and flyers for our business. We usually made enough in on the spot sales to buy all of our Christmas presents in that one day.

This worked really well for us because we lived in a fairly small city (pop 80,000) and our business was on a main street with a recognizable logo in the window, so people were comfortable buying from us, it might not work in a bigger city where they don’t know if you are legit or just a person running a con.

"Insurgent" ambushing: The use of surprise street-style promotions (blitz marketing) at an event or near enough to it that the ambushing business can identify and target audience members — The "active" version of "passive" ambushing by distraction, insurgent ambushing not only takes advantage of positive externalities but creates negative externalities by intruding upon attendees' experiences of the event and detracting from those experiences' quality (cf. the distinction in biology between commensalism and parasitism).

"Parallel property" ambushing: The creation or sponsorship of an event or property that bears qualitative similarity to the ambush target and competes with it for the public's attention — An application of "ambushing by distraction" in which the ambusher-marketed product is the event/property itself, parallel-property ambushing does not intrude upon the experience of audience members (who remain free to attend whichever event or patronize whichever property they deem more attractive), but it does divert audience dollars and attendance figures from the preexisting event/property, interfering with the efforts of that event's/property's financial backers to recover their largely fixed production costs.

"Incidental" ambush marketing Unintentional ambushing: It is possible for media coverage to make passing mention of, e.g., the manufacturer of an athlete's equipment/clothing or the provider of a service used by the event's technical staff or in-person audience. Although in most cases most members of an event's mass-media audience will not infer that the mentioned business is an official sponsor of the event, such that the mention is harmless "free publicity" for the non-sponsoring business, it is

179 possible that some broadcast-audience members will at some point draw some inference of official sponsorship.

"Saturation" ambushing: "Saturation ambushers" increase their broadcast- media advertising and marketing at the time of an event but make no reference to the event itself and avoid any associative imagery or suggestion — Essentially a form of "ambushing by distraction" attenuated by the absence of advertisers' physical proximity to the event and their resulting lack of contact with in-person audience members, saturation ambushing merely capitalizes on the increased broadcast media attention and television audiences surrounding the event.

Possible Impacts of Ambush marketing

Increasing cost of sponsorships: The increasing cost of sponsorships has also increased sponsor's emphasis on return on investment. If sponsored events do not give exclusivity, the sponsor's interest on sponsorship property will be lost and the damage will extend to the whole sponsorship market. Yet when that exclusivity is lost, the value of sponsorship is also lost. When a company engages in ambush marketing the exclusivity intended to be conferred through sponsorship to a sponsor is lost. Hence, the value of sponsorship is also lost. As it is an undeniable fact that corporate sponsorship is one of the biggest money-spinning sources of revenue for the event organizers, the loss in sponsorship value will affect the financial strength of an event organizer.

Transgression on the intellectual property rights: Even when the ambush marketers are not making any direct references to the protected intellectual property rights, they in effect transgress those intellectual property rights by attempting to capitalize on such hard earned goodwill from an event. Direct and indirect references to the event symbol or the event itself are just different means for achieving illegal transgression on the rights of event organizers. Moreover, sponsors cannot get the return they anticipated. Obviously if you are ripping off someone’s logo you deserve to be fined.

Limitation to freedom of expression: Specific regulations (and/or laws) demanded by sponsors to guarantee their exclusive rights limit the freedom of expression of visitors to events (e.g. those who have been given free goods by the ambush marketeer). It is still undecided whether the

180 commercial rights of sports organizers and sponsors trump the universal human rights issues involved.

Really big examples of ambush marketing:

The Quebec-based home improvement chain Rona ambushed an advertisement in the "Nano-chromatic" campaign for the iPod Nano by placing a banner under it showing the paint dripping from the iPods falling into paint cans, advertising its paint recycling services.

During a game at the 2006 FIFA World Cup, fans were asked to remove "Leeuwenhosen" colored in the orange of the Netherlands national football team, distributed and branded by Bavaria Brewery because the brewery was not an official sponsor of the event (Budweiser was the official beer sponsor). Officials distributed orange-colored shorts to fans affected by the requirement. Bavaria Brewery was again accused of ambush marketing at the 2010 FIFA World Cup, when 36 female fans were ejected from a game (along with the arrest of two, later released, accused of violating the "Contravention of Merchandise Marks Act", a law passed in South Africa for the World Cup making ambush marketing illegal) for wearing unbranded orange miniskirts that were provided by Bavaria; Sylvie van der Vaart, wife of Dutch player Rafael van der Vaart had modeled one of the miniskirts in an advertising campaign for the brewery. ITV media pundit Robbie Earle was fired from his role when it was claimed by FIFA that he had sold tickets meant for family and friends on to Bavaria.

Also at the 2010 FIFA World Cup, South African budget airline Kulula pulled an advertisement that FIFA claimed was creating an unauthorized association with the tournament. The advertisement had described themselves as "Unofficial National Carrier of the You-Know-What" and contained images of stadiums, vuvuzelas and national flags—symbols which FIFA claimed were considered ambush marketing when used together. Kulula poked fun at the objections in subsequent ads, one which deliberately replaced the items from the first ad with similarly shaped items (such as disco balls and golf tees) and claiming the ad was for something "not next year, not last year, but somewhere in between." In a related stunt, Kulula announced it would offer free flights to anyone named "Sepp Blatter"; the offer was redeemed for a Boston Terrier dog named Sepp Blatter.

181 In October 2011, Samsung ambushed the Australian launch of the iPhone 4S by setting up pop-up store near Sydney's Apple Store; where it sold its flagship Galaxy S II smartphone to the first 10 people in line daily at a discount price of $2 AUD.

During the opening ceremony of the 2008 Summer Olympics in Beijing, former Olympic gymnast Li Ning was the final torchbearer and ultimately lit the flame at Beijing National Stadium. However, Li Ning is also the founder of a domestic shoe company of the same name. While the Li Ning company was not an official sponsor of the games, it had still associated itself with the games through its role as an equipment supplier for several Chinese Olympic teams, and through Li Ning's status as both a Chinese sports and business icon.

For the 2012 Summer Olympics in London, the London Olympic Games and Paralympic Games Act 2006 contains provisions to attempt to restrict ambush advertising at the 2012 Summer Olympics and the London Organising Committee of the Olympic and Paralympic Games (LOCOG) announced that it would attempt to crack down on the relatively new form of online keyword ambush marketing. A study by the Global Language Monitor found that many non-affiliated brands, such as Subway, Red Bull, and Sony are among the top rated on GLM's Brand Affiliation Index (BAI). The BAI measures the perceived relationship between the Games and the particular brand. In September 2013, the Global Language Monitor released an update for Sochi 2014. P&G, Samsung and GE led the Worldwide Partners but trailed non-affiliated marketers Philips, Siemens and Adidas. When measured by the BAI,10 of the top 15 spots were occupied by the non-affiliated marketers – with the bottom five spots all held by top sponsors.

Once Sochi 2014 concluded, Red Bull had scored the highest overall BAI, while worldwide Olympic partners Procter & Gamble and Samsung followed in second and third place. P&G and Samsung both had critically acclaimed marketing campaigns that were well received by international audiences. Ambusher Subway took fourth place, besting Coke and Panasonic. Non-affiliated brands Rolex, Unilever and Siemens followed. Meanwhile, the last three spots on the table were occupied by Olympic sponsors, Visa Card, Omega and Atos. GLM noted that Burton Snowboards and Apple Computer also made an impression with the worldwide audience.,

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Prior to the Games, LOCOG demanded the removal of advertisements for the betting company Paddy Power which announced that it was the official sponsor of "the largest athletics event in London this year"; an egg-and- spoon race in the French village of London, Burgundy. LOCOG reversed its decision after Paddy Power threatened to take the organizers to court.

When announcing the planned lawsuit, a Paddy Power spokesmen quipped that "It’s a pity they didn't put the same energy in to the ticketing and security arrangements for the Games that they put into protecting their sponsorship revenue streams."

For the 2011 Rugby World Cup and the 2015 Cricket World Cup, New Zealand has enacted laws to combat ambush marketing, according to former Sports Minister

Article marketing Article marketing is a type of advertising in which businesses write short articles about themselves, their company or their field of expertise as a marketing strategy. A primary style for the articles includes a bio box and byline (collectively known as the resource box) about the business.

Traditional Article Marketing Article marketing has been used by professionals for nearly as long as mass print has been available. A business provides content to a newspaper, possibly on a timely topic such as an article on tax audits during tax season, and the newspaper may use the article and include the business's name and contact information. Newspapers and other traditional media have limited budgets for gathering content and these articles may be used in the business section of the newspaper.

Internet Article Marketing Internet article marketing is used to promote the authors expertise of their market, products or services online via article directories. Article directories with good web page ranks receive a lot of site visitors and may be considered authority sites by search engines,leading to high traffic. These directories then give PageRank to the author's website and in addition send traffic from readers. Articles and article directories attract search engines because of their rich content.

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Business Owners, Marketers and Entrepreneurs attempt to maximize the results of an article advertising campaign by submitting their articles to a number of article directories. However, most of the major search engines filter duplicate content to stop the identical content material from being returned multiple times in a search engine results page. Some marketers attempt to circumvent this filter by creating a number of variations of an article, known as article spinning. By doing this, one article can theoretically acquire site visitors from a number of article directories.

Most forms of search engine optimization and internet marketing require a domain, internet hosting plan, and promoting budget. However, article marketing makes use of article directories as a free host and receives traffic by way of organic searches due to the listing's search engine authority.

The primary goal behind article marketing is to get search engine traffic to the article so that the author can strengthen their authority and influence within their field, while also leveraging that traffic for their own site(s). The key to article marketing is that the author should be providing value with their articles, not just promoting their site, products or services.

This is another strategy I have employed several times. Most local newspapers have a page or section dedicated to businesses. They have to run stories in it to sell ad space, so they are out looking for stories about businesses all the time. Contact the reporter that handles that page and have them write your business up. Trust me, they are looking for stories all the time! I did this when I opened my first massage business with my wife, and then again when I opened my first (and second) massage school in California.

I also did it a fourth time when I sponsored a “Constitution Week Speech Contest” for the local high school students. I challenged the local high school students to record a speech about the US Constitution and upload it to youtube.com on constitution week. –I asked members of the Veterans of Foreign Wars to judge the speeches and I awarded a $100 gift certificate from our local Target store to the winner.

We held an award presentation at the VFW hall-and there were hundreds of parents there, not to mention the VFW members and their spouses who

184 thought I was completely awesome for putting together this event and challenging the young people to love our country. They all knew my business was the one sponsoring the event.

For the price of a paper certificate for each participant and a $100 gift certificate for the winner I bought an amazing amount of publicity as the sponsor. It was reported on in both the radio and the paper, and I didn’t have to pay for either.

Are you getting the idea? Article video marketing Article video marketing is a new type of internet marketing and advertising in which business create 2-5 minute short videos about specific topics using content from articles and other text sources. The videos are then uploaded to various video sharing websites like YouTube for distribution and exposure.

Converting articles into videos There are several ways to for turning articles into videos. The most traditional way is by creating a powerpoint presentation of the original article, which is basically transforming the article text into an animated slideshow. Relevant pictures are then added to the slideshow and voice is recorded over each slide to create a voice-over narration for the video. Finally, the presentation is recorded using a screen capture software like Camtasia and the slideshow is now turned into a video that can be uploaded to a video sharing site like YouTube for sharing.

Advantages Article video marketing is an extension of Article marketing but serves as an alternate medium for businesses to convey their message to a wider audience, and get more exposure. Being an audio-visual medium, articles turned into videos also reduce the time required to read the articles.

Brand language Brand language is the body of words, phrases, and terms that an organization uses to describe its purpose or in reference to its products. Brand language is used in marketing to help consumers connect specific words or ideas to specific companies or products. When developing a brand language word choice and tone are the two fundamental components. Word choice is the vocabulary that is used in the marketing or

185 advertising, while tone refers to the attitude of the advertisement. Tone is not limited to language, it can also be incorporated through visual elements as well as delivery.

Brand language is a part of verbal brand identity, includes naming of both corporation and the products they sell as well as taglines, voice, and tone. Another benefit of developing a brand language is the ability for a corporation or product to be recognizable across international borders, while other advertising codes can be misinterpreted, words can be translated to ensure brand unity.

Primary goal As a part of the advertising world brand language's primary function is to identify a company or product and also differentiate that company/product from competitors. The language is used to get the attention of the consumer and then to relay information about what is being advertised. It is also used to ensure that when people communicate about the product there are fewer misunderstandings and more clarity about purpose and the role that this commodity wants to play in the lives of the consumer.

The brand language can also be associated with competing for investors, recruiting talent, or acquiring business partners.

Brand language is also often used internally within a company. For motivational and leadership situations, branding language helps to promote the brand values and is treated as a commodity alongside the actual products and/or company.

Examples When positive words become strongly associated with particular brands, these words can become assets—to the point that competing brands may find the words difficult to use. For example, in his book Brand Sense (Kogan Page, 2005) Martin Lindstrom quotes extensive word association research carried out by Millward Brown demonstrating the strong link between the words “magic” and “kingdom” and Disney. Disney appears to have made a successful investment in “owning” these words. Lindstrom’s studies found that Disney has the highest number of words that are associated with one specific brand (among brands that were surveyed). Along with “magic” and “kingdom” Disney has been shown to have branded the words: “dreams,” “creativity,” “fantasy,” “smiles” and “generation”. The

186 study that he conducted asked people to associate those words with a brand and over 80% of people asked said that they thought of Disney. Part of the reason that Disney has been so successful is that they are able to seamlessly integrate traditional and new media markets in a way that allows them to reach large audiences with a stable continuous message.

Other campaigns that have powerful brand language recognition are Kellogg’s and Gillette. Part of the idea with branded language is to go beyond just a slogan and to imbue ordinary words with the idea or essence of a particular brand. With Kellogg’s the word that is associated with them is “crunch”. With Gillette the word that consumers see as synonymous with the brand is “masculine.” In this case the word masculine also conjures socially constructed ideologies, which helps the brand become a more stable construction in the mind of consumers.

The disadvantage of very strong brand language associations is that they may prove a hindrance if a brand wishes to position itself differently.

Delivery channels

This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (December 2012) In Brand Sense, Lindstrom says brand language starts from the bottom up and “not suddenly placed on top like a piece of decorative icing”. So, as well as being competitive, brand language should be delivered as consistently as possible through all formal delivery channels.

With the expansion of social media, there is a new market for advertising and the use of branding language. Social media allows for companies to move beyond the more traditional forms of advertising and into a new arena. However, it is important that the language of the advertising remain consistent throughout a campaign no matter what the platform. Different social media sites offer various audiences and come with particular and differing platforms. Using the right language and jargon is important so that companies seems engaged and are able to spread their message to multiple audiences.

Brand recognition can inspire an influx of followers or friends, but if the social media content is seen as lacking then it can cause audiences to

187 negatively perceive a company. When employing social media resources it is crucial that a company begin to view their “brand as a personality”. It is important for companies to know why they are using these social media sites – it might be education, a playful persona, or a desire to attract more people to an online store. Clarity of focus will allow companies to build their sites around this one particular point, which helps consumers recognize the brand and follow it. Knowing the purpose of the social media site also allows for the company to tailor the site to the specific needs of the commodity. Here tone becomes important as it allows for audiences to better understand how to engage with the site and through that, the company or product.

One of the facets that is unique to new media, and specifically social media, is the dialogue that is expected to take place between a company and the consumers. Unlike traditional marketing formats, which send information one way, social media enables immediate and direct feedback from a myriad of users. Many companies find that it challenging to “move from faceless corporation to friend”. Because of this some choose not to engage in social media or only do so marginally. Companies must be able to assess the brand attributes and translate that into a personality so that online users feel that they can form a relationship with these companies and products.

Brand language is delivered externally through formal marketing communications, such as advertising and public relations. It is present wherever written and spoken language is used to communicate a proposition. This includes recruitment, corporate communications, investor relations, sales presentations, conference speaking, retail staff and whenever an individual answers the telephone on behalf of the brand.

Areas and authorities that offer brand language

Brand agencies Brand design agencies have diversified beyond their roots in brand logo and packaging design into corporate identity and brand language. They are global businesses with the scope to ensure that brand naming and brand language works in different languages. In English-speaking countries, leaders include Landor and The Brand Union, both part of WPP Group, and Interbrand. Interbrand has dedicated verbal identity departments in both London and New York.

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Specialist brand language consultancies Since the early 2000s, a few specialist brand language consultancies (also known as tone of voice consultancies) have emerged, with the ability to roll out brand tone of voice.

One of the first was Afia", founded in 2004 by Ben Afia. Ben was one of just a handful of people talking about tone of voice at that time and established tone of voice across Boots.

Others include Wordtree, a UK-based "boutique" consultancy, and Quietroom, London-based "brand language consultants". Wordtree published the first book to outline a methodology for creating tone of voice in 2012 - Brand Language: Tone of Voice the Wordtree Way.

Digital and social media companies Brands are tracking social media in order to understand how people are talking about them. In English-speaking countries, practitioners include Visible Technologies, Vivo Data, Lexalytics and Polecat. The corollary is that they contribute to how brands are talking about themselves. Linguabrand claims to have invented brand language analytics and to provide brand vocabulary and tone of voice measurement. Their slogan is, "Companies report in numbers but compete with words."

Brand writers This new emphasis on brand language has led to the emergence of a new breed of writers - these are a hybrid of brand consultant and word expert, with a good dose of consumer psychology and change management know- how in the mix. This new breed are brand writers - the kind of people who use left and right brain, who can take corporate and brand strategy and create a style of communication that supports and accelerates those business goals. Liz Doig, author of Brand Language: Tone of Voice the Wordtree Way calls herself a brand writer.

Copywriters There are large numbers of freelance copywriters that have repositioned themselves as brand language experts. John Simmons, a copywriter, has written extensively on how brands can use words more effectively. His books include 'We, Me, Them and It (Texerre), Dark Angels (Cyan) and

189 The Invisible Grail (Cyan). Simmons was also a founding director of 26, a UK-based organisation promoting the use of better brand language.

Business model A business model describes the rationale of how an organization creates, delivers, and captures value, in economic, social, cultural or other contexts. The process of business model construction is part of business strategy.

In theory and practice, the term business model is used for a broad range of informal and formal descriptions to represent core aspects of a business, including purpose, business process, target customers, offerings, strategies, infrastructure, organizational structures, trading practices, and operational processes and policies. The literature has provided very diverse interpretations and definitions of a business model. A systematic review and analysis of manager responses to a survey defines business models as the design of organizational structures to enact a commercial opportunity. Further extensions to this design logic emphasize the use of narrative or coherence in business model descriptions as mechanisms by which entrepreneurs create extraordinarily successful growth firms.

Business models are used to describe and classify businesses, especially in an entrepreneurial setting, but they are also used by managers inside companies to explore possibilities for future development. Well-known business models can operate as "recipes" for creative managers. Business models are also referred to in some instances within the context of accounting for purposes of public reporting.

Over the years, business models have become much more sophisticated. The bait and hook business model (also referred to as the "razor and blades business model" or the "tied products business model") was introduced in the early 20th century. This involves offering a basic product at a very low cost, often at a loss (the "bait"), then charging compensatory recurring amounts for refills or associated products or services (the "hook"). Examples include: razor (bait) and blades (hook); cell phones (bait) and air time (hook); computer printers (bait) and ink cartridge refills (hook); and cameras (bait) and prints (hook). A variant of this model is Adobe, a software developer that gives away its document reader free of charge but charges several hundred dollars for its document writer.

190 In the 1950s, new business models came from McDonald's Restaurants and Toyota. In the 1960s, the innovators were Wal-Mart and Hypermarkets. The 1970s saw new business models from FedEx and Toys R Us; the 1980s from Blockbuster, Home Depot, Intel, and Dell Computer; the 1990s from Southwest Airlines, Netflix, eBay, Amazon.com, and Starbucks.

Today, the type of business models might depend on how technology is used. For example, entrepreneurs on the internet have also created entirely new models that depend entirely on existing or emergent technology. Using technology, businesses can reach a large number of customers with minimal costs.

Theoretical and empirical insights to business models

Design logic and narrative coherence Design logic views the business model as an outcome of creating new organizational structures or changing existing structures to pursue a new opportunity. Gerry George and Adam Bock (2011) conducted a comprehensive literature review and surveyed managers to understand how they perceived the components of a business model. In that analysis, these authors show that there is a design logic behind how entrepreneurs and managers perceive and explain their business model. In further extensions to the design logic, George and Bock (2012) use case studies and the IBM survey data on business models in large companies to describe how CEOs and entrepreneurs create narratives or stories in a coherent manner to move the business from one opportunity to another. They also show that when the narrative is incoherent or the components of the story are misaligned that these businesses tend to fail. They recommend ways in which the entrepreneur or CEO can create strong narratives for change.

Studying collaborative research and the accessing of external sources of technology, Hummel et al. (2010) found that in deciding on business partners, it is important to make sure that both parties’ business models are complementary. For example, they found that it was important to identify the value drivers of potential partners by analyzing their business models, and that it is beneficial to find partner firms that understand key aspects of our own firm’s business model.

191 Shift from Pipes to Platforms Sangeet Paul Choudary (2013) distinguishes between two broad families of business models in an article on Wired Magazine. Choudary, of Platform Thinking, contrasts Pipes, linear business models, with Platforms, networked business models. In the case of Pipes, firms create stuff, push them out and sell them to customers. Value is produced upstream and consumed downstream. There is a linear flow, much like water flowing through a pipe. Unlike pipes, platforms do not just create and push stuff out. They allow users to create and consume value.

In an op-ed on MarketWatch, Choudary, Van Alstyne and Parker further explain how business models are moving from Pipes to Platforms leading to disruption of entire industries.

Platform Business Models In an earlier article on Harvard Business Review, Sangeet Paul Choudary elaborates on the three elements of a successful platform business model. The Toolbox creates connection by making it easy for others to plug into the platform. This infrastructure enables interactions between participants. The Magnet creates pull that attracts participants to the platform. For transaction platforms, both producers and consumers must be present to achieve critical mass. The Matchmaker fosters the flow of value by making connections between producers and consumers. Data is at the heart of successful matchmaking, and distinguishes platforms from other business models.

Chen (2009) pointed out that the business model in the twenty-first century has to take into account the capabilities of Web 2.0, such as collective intelligence, network effects, user generated content, and the possibility of self-improving systems. He suggested that the service industry such as the airline, traffic, transportation, hotel, restaurant, Information and Communications Technology and Online gaming industries will be able to benefit in adopting business models that take into account the characteristics of Web 2.0. He also emphasized that Business Model 2.0 has to take into account not just the technology effect of Web 2.0 but also the networking effect. He gave the example of the success story of Amazon in making huge profits each year by developing a full blown open platform that supports a large and thriving community of companies that re-use Amazon’s On Demand commerce services.

192 Applications Malone et al. at MIT found that some business models, as defined by them, indeed performed better than others in a dataset consisting of the largest U.S. firms, in the period 1998 through 2002, while they did not prove whether the existence of a business model mattered.

In the context of the Software-Cluster, which is funded by the German Federal Ministry of Education and Research, a business model wizard for software companies has been developed. It supports the design and analysis of software business models. The tool's underlying concept and data were published in various scientific publications.

The concept of a business model has been incorporated into certain accounting standards. For example, the International Accounting Standards Board (IASB) utilizes an "entity's business model for managing the financial assets" as a criterion for determining whether such assets should be measured at amortized cost or at fair value in its financial instruments accounting standard, IFRS 9. In their 2013 proposal for accounting for financial instruments, the Financial Accounting Standards Board also proposed a similar use of business model for classifying financial instruments. The concept of business model has also been introduced into the accounting of deferred taxes under International Financial Reporting Standards with 2010 amendments to IAS 12 addressing deferred taxes related to investment property.

Both IASB and FASB have proposed using the concept of business model in the context of reporting a lessor's lease income and lease expense within their joint project on accounting for leases. The concept has also been proposed as an approach for determining the measurement and classification when accounting for insurance contracts. As a result of the increasing prominence the concept of business model has received in the context of financial reporting, the European Financial Reporting Advisory Group (EFRAG), which advises the European Union on endorsement of financial reporting standards, commenced a project on the "Role of the Business Model in Financial Reporting" in 2011.

Business model design Business model design refers to the activity of designing a company's business model. It is part of the business development and business strategy process and involves design methods.

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Definitions of business model

Economic consideration Stewart and Zhao (2000) defined the business model as ‘‘a statement of how a firm will make money and sustain its profit stream over time.’’

Component consideration[edit] Osterwalder et al. (2005) consider the Business Model as the blueprint of how a company does business. Slywotzky (1996) regards the business model as ‘‘the totality of how a company selects its customers, defines and differentiates it offerings, defines the tasks it will perform itself and those it will outsource, configures its resources, goes to market, creates utility for customers and captures profits.’’

Strategic outcome Mayo and Brown (1999) considered the business model as ‘‘the design of key interdependent systems that create and sustain a competitive business.’’

Definitions of business model design or development Zott and Amit (2009) consider business model design from the perspectives of design themes and design content. Design themes refer to the system’s dominant value creation drivers and design content examines in greater detail the activities to be performed, the linking and sequencing of the activities and who will perform the activities.

Design themes emphasis of business model design[edit]

Environment-Strategy-Structure-Operations (ESSO) Business Model Development Developing a Framework for Business Model Development with an emphasis on Design Themes, Lim (2010) proposed the Environment- Strategy-Structure-Operations (ESSO) Business Model Development which takes into consideration the alignment of the organization’s strategy with the organization's structure, operations, and the environmental factors in achieving competitive advantage in varying combination of cost, quality, time, flexibility, innovation and affective.

Design content emphasis of business model design

194 Business model design includes the modeling and description of a company's: Value propositions Target customer segments Distribution channels Customer relationships Value configurations Core capabilities Partner network Cost structure Revenue model

Business model design is distinct from business modeling. The former refers to defining the business logic of a company at the strategic level, whereas the latter refers to business process design at the operational level.

A business model design template can facilitate the process of designing and describing a company's business model.

Daas et al. (2012) developed a decision support system (DSS) for business model design. In their study a decision support system (DSS) is developed to help SaaS in this process, based on a design approach consisting of a design process that is guided by various design methods.

Examples of business models In the early history of business models it was very typical to define business model types such as bricks-and-mortar or e-broker. However, these types usually describe only one aspect of the business (most often revenue model). Therefore, more recent literature on business models concentrates on describing business model as a whole instead of one most visible aspects.

The following examples provide an overview for various business model types that have been in discussion since the invention of term business model:

Bricks and clicks business model Business model by which a company integrates both offline (bricks) and online (clicks) presences. One example of the bricks-and-clicks model is

195 when a chain of stores allows the user to order products online, but lets them pick up their order at a local store.

Collective business models Business system, organization or association typically composed of relatively large numbers of businesses, tradespersons or professionals in the same or related fields of endeavor, which pools resources, shares information or provides other benefits for their members. For example, a science park or high-tech campus provides shared resources (e.g. cleanrooms and other lab facilities) to the firms located on its premises, and in addition seeks to create an innovation community among these firms and their employees.

Cutting out the middleman model The removal of intermediaries in a supply chain: "cutting out the middleman". Instead of going through traditional distribution channels, which had some type of intermediate (such as a distributor, wholesaler, broker, or agent), companies may now deal with every customer directly, for example via the Internet.

Direct sales model Direct selling is marketing and selling products to consumers directly, away from a fixed retail location. Sales are typically made through party plan, one-to-one demonstrations, and other personal contact arrangements. A text book definition is: "The direct personal presentation, demonstration, and sale of products and services to consumers, usually in their homes or at their jobs." Distribution business models, various

Value-added reseller model Value Added Reseller is a model where a business makes something which is resold by other businesses but with modifications which add value to the original product or service. These modifications or additions are mostly industry specific in nature and are essential for the distribution. Businesses going for a VAR model have to develop a VAR network. It is one of the latest collaborative business models which can help in faster development cycles and is adopted by many Technology companies especially software.

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Fee in, free out Business model which works by charging the first client a fee for a service, while offering that service free of charge to subsequent clients.

Franchise Franchising is the practice of using another firm's successful business model. For the franchisor, the franchise is an alternative to building 'chain stores' to distribute goods and avoid investment and liability over a chain. The franchisor's success is the success of the franchisees. The franchisee is said to have a greater incentive than a direct employee because he or she has a direct stake in the business.

Freemium business model Business model that works by offering basic Web services, or a basic downloadable digital product, for free, while charging a premium for advanced or special features.

Call to action (marketing) Do you have a website for your massage business? If you don’t you should get one. Seriously, it doesn’t cost that much and these days people go to their smart phones first to look for a business, so you need to be on the web. One of the most important features of a website is a CTA is a banner, button, or some type of graphic or text on a website meant to prompt a user to click it and continue down a conversion funnel.

Did I lose you with jargon? The conversion funnel is a word image to describe getting people from looking at your website to buying on your website (it looks like a funnel on paper).

In massage terms, their should be a button or banner on your website that allows people to either:

a. Book an appointment online (make them prepay!) or b. Buy a gift certificate.

This is an essential part of inbound marketing as well as permission marketing in that it actively strives to convert a user into a lead and later

197 into a customer. The main goal of a CTA is a click, or a scan in the case of a qr code, and its success can be measured via a conversion rate formula that calculates the number of clicks over the times the CTA was seen. Another way to test the effectiveness of a CTA is using A/B testing where several graphics are presented to a user and the graphic with highest success rate becomes the default.

Cause marketing Cause marketing or cause-related marketing refers to a type of marketing involving the cooperative efforts of a for profit business and a non-profit organization for mutual benefit. The term is sometimes used more broadly and generally to refer to any type of marketing effort for social and other charitable causes, including in-house marketing efforts by non-profit organizations. Cause marketing differs from corporate giving (philanthropy), as the latter generally involves a specific donation that is tax deductible, while cause marketing is a marketing relationship not necessarily based on a donation.

The first known case of cause marketing in America was in March, 1974 when Carr & Associates International was formed by John T. Carr as a way of "giving back" by engaging Charitable Causes and Businesses to support each other. The organization was promoted by John T. Carr's focus on enlisting businesses to give back referral fees on what they might normally spend for marketing; and having those funds redirected toward the Charitable Cause of the buyer's choice.

In 1976, the first major cause marketing campaign was executed through a partnership between the Marriott Corporation and the March of Dimes. Marriott's objective was to generate highly cost-effective public relations and media coverage for the opening of their 200-acre (0.81 km2) family entertainment center, Marriott's Great America in Santa Clara, CA. The March of Dimes's objective was to greatly increase fundraising while motivating the collection of pledges by the program’s deadline. The promotion was conducted simultaneously in 67 cities throughout the Western United States. This cause marketing campaign and partnership raised an unprecedented $2.4 million to become the most successful promotion in the history of Chapters West of the March of Dimes, while providing hundreds of thousands of dollars in free publicity and stimulating a 2.2 million person attendance, a regional theme park record, for the opening year of the Marriott entertainment complex.

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The program was conceived and directed by Bruce Burtch. Burtch has been hailed the "Father of Cause Marketing" by the Cause Marketing Forum, the industry's primary association. Burtch is credited with coining the phrase, "Do well by doing good", a term now ubiquitous in the cause marketing field, which was his answer to the CEO of a major corporate foundation when asked what his goal in life was in 1977. Over the past three decades Burtch's work expanded far beyond cause marketing as he developed an international reputation for developing and training cross- sector partnerships - partnerships between two or more partners from the nonprofit, for-profit, education or government sectors. His research has discovered nearly 70 distinct benefits that partners can receive in a cross- sector partnership.

Another of the first examples of a cause-related marketing campaign was initiated in 1979 by Rosica, Mulhern & Associates for Famous Amos cookies. In this campaign, Wally Amos became the National Spokesperson for the Literacy Volunteers of America. According to the organization, Wally has alerted more people to the illiteracy problem than any other person in history. This strategic cause marketing tie-in helped to tell the Famous Amos Cookie story while maintaining visibility, and is responsible for many new and expanded literacy programs. This case study is now used in university classrooms nationwide as an example of successful "cause- related marketing". In 1982 Nancy Brinker, founder of Susan G. Komen for the Cure was an early pioneer of cause marketing, allowing millions to participate in the fight against breast cancer through businesses that share Komen's commitment to end the disease.

The recent interest in cause-related marketing is generally argued to stem from American Express, who apparently coined the phrase in 1983. Following various pilot schemes in 1981, American Express developed a campaign which donated funds to a number of different non-profit organizations as part of the San Francisco Arts Festival. Essentially every time someone used an American Express Card in the area, a 2-cent donation was triggered and each time new members applied for a card a larger contribution was made. The marketing goals that American Express had for this programme were apparently exceeded. Card usage was reported as having increased significantly and relationships between American Express and their merchants also improved as a result of the promotion. From the charity's point of view, despite being a short-term

199 campaign, $108,000 was raised, making a significant contribution to their work. The terms "cause-related marketing" and "cause marketing" continued to grow in usage since that time. In more recent years the term has come to describe a wider variety of marketing initiatives based on the cooperative efforts of business and charitable causes.

Background According to a report published by onPhilanthropy, cause marketing sponsorship by American businesses is rising at a dramatic rate. Citing an IEG, Inc. study, $1.11 billion was spent in 2005, an estimated $1.34 billion will be spent in 2006, and the number is expected to rise further in 2007. As an update, IEG[8] reported that $1.44 billion was spent in 2007 and $1.52 billion in 2008. Due to the recession, growth is expected to slow in 2009 with the projections being $1.57 billion total to be spent on cause marketing.

Cause-related marketing is a powerful marketing tool that business and nonprofit organizations are increasingly leveraging. According to the Cone Millennial Cause Study in 2006, 89% of Americans (aged 13 to 25) would switch from one brand to another brand of a comparable product (and price) if the latter brand was associated with "good cause". The same study also indicated that a significant percentage surveyed would prefer to work for a company that was considered socially responsible. This can be linked to the increase in workplace giving programs. Earlier studies by Cone indicate an upward trend in the number of Americans who associate their own buying habits with cause marketing as well as an expectation that those companies to be "good corporate citizens". These studies also show a substantial increase from just before to just after the September 11, 2001 attacks.

Numerous other studies have also been conducted to show that cause- related marketing has helped to increase a company's profits. For example, in the cause marketing campaign by American Express (to which the term "cause marketing" is attributed), the company saw a 17% increase in new users and a 28% increase in card usage.

Benefits The possible benefits of cause marketing for nonprofit organizations include an increased ability to promote the nonprofit organization's cause via the greater financial resources of a business, and an increased ability to

200 reach possible supporters through a company's customer base. The possible benefits of cause marketing for business include positive public relations, improved customer relations, additional marketing opportunities, and making more money.

Online cause marketing

Overview Although originally a marketing strategy that occurred offline, cause marketing has been conducted more and more through online channels in the last decade. This is due in part to the increasing percentage of households with internet connections. As with other types of marketing campaigns, companies can leverage online marketing channels along with other offline channels such as print and media. (Sometimes referred to as integrated marketing).

The advent of online cause marketing has allowed consumers, for example, those who are loyalty program members, to take a far more active role in cause marketing. This is democratized transactional giving. It means consumers, rather than companies, decide which causes to support and advocate for. An example of how this works could be a company allowing its loyalty program members to convert unredeemed rewards, such as points or miles, into cash donations to causes of the customers' own choosing, rather than have the company select the charities. An online platform is necessary to connect the customers to a large-enough selection of charities.

Online charity auctions In recent years, online auctions have been used in cause marketing strategies using a number of different online auction platforms. Companies have created programs to help sellers and corporations donate a percentage of their sales to a nonprofit organization through the use of auctions. Businesses and nonprofit organizations can also use the program for cause marketing and nonprofit fundraising programs.

Companies and charities can not only raise money through online auctions, but create awareness for a specific cause or charity. Online auction bidders can view photos, descriptions and suggested bids of items online, as opposed to items in a showroom. Most online auctions use a style of bidding called proxy bidding, in which the online system makes bids for the

201 actual participant in increments up to the maximum bidding amount set by the participant.

Alternatively, many online auctions are manual auctions, in which the participant comments or posts their bid themselves before a particular ending auction time. Sometimes, participants will call or email their bid to the online auctioneer, with the auctioneer updating the auction in real time. This type of charity auction works best for auctions with fewer items, or auctions with an expectation for fewer bids.

Close Range Marketing Close range marketing, commonly referred to as CRM, is a form of proximity marketing. Close Range Marketing allows businesses to both promote goods and services and involve their customers in interacting with the business.

Need an example? I had a student from my school rent a small room for massage in a hair and nail salon. She used to take her massage chair out into the waiting room and do FREE 10 minute teasers on the people waiting to get their hair done. Simple-but effective.

Consumer-generated advertising Consumer Generated Advertising refers to advertising on consumer generated media. This term is generally used to refer to sponsored content on blogs, wikis, forums, social networking web sites and individual Web sites. This sponsored content is also known as sponsored posts, paid posts or sponsored reviews. The content includes links that point to the home page or specific product pages of the website of the sponsor. Examples include Diet Coke and Mentos videos, and Star Wars fan films.

Sponsored posts have been defined as the promoted entries or posts which contain links that point to a webpage or specific product pages of the website of the sponsor for which the creator of the content receives compensation in the form of money, products, services or in other ways. As opposed to the graphical ads (in the form of banners or buttons), which have been around on websites for quite some time, the sponsored content may be in the form of feedbacks, reviews, opinion, videos, etc. Forrester Research uses the term sponsored conversation which refers to sponsored conversation which involves payment to bloggers and other consumers

202 who generate the advertising, to create transparent and genuine content about the brand.

Similarly, the term Communal marketing refers to a marketing practice that incorporates public involvement in the development of an advertising/marketing campaign. Such a campaign invites consumers to share their ideas or express their articulation of what the brand means to them through their own personal stories, with the use of print media, film or audio. The resulting consumer-generated content is then incorporated into the campaign. Finally, the result of this collaboration is showcased, often in a cross-media campaign, to invite the extended community of like-minded individuals to share in the results, thereby creating a communal bond between the "brand champions as advertisers" and other individuals who have a natural affinity with what the brand has to offer. The result provides the brand with a way to create a deeper connection with their core market, while also opening up new pathways to extend the relationship to new customers. Consumer-generated marketing is not the same as viral marketing or word of mouth advertising, however, the result of it achieves a high level of publicity within high relevance communities. These communities are extremely critical to the success of a brand, and normally follow the 80/20 rule, where 20% of the brand's customers account for 80% of its sales. The very act of reaching out to consumers to invite them in as co-collaborators and co-creatives, is a fundamental component of the marketing campaign. The construct naturally lends itself to other consumer- marketing activities, like "communal branding" and "communal research."

Anytime a brand reaches out to its audience to invite them in to become co- collaborators in the development of an advertising campaign, they are participating in a "communal branding" effort. Whenever marketing decisions are the result of communing with the brand's audience to help drive the development of a campaign, they are engaging in "communal research." For example, Peter Jackson, in the making of The Lord of the Rings, reached out to loyal followers of the book to help weigh in on some major directorial decisions.

The practice of consumer-generated marketing has been in use for several years with the emergence of communal forms of information sharing including weblogs, online message boards, podcasts, interactive broadband TV, and other new media that has been adopted by consumers

203 at the grass roots level to establish community forums for discussing their customer experiences.

Joel Moss Levinson won 11 consumer generated marketing contests, and earned more than $200,000 in money and prizes, by creating corporate jingles and short commercials.

Content marketing Content marketing is any marketing that involves the creation and sharing of media and publishing content in order to acquire and retain customers. This information can be presented in a variety of formats, including news, video, white papers, e-books, infographics, case studies, how-to guides, question and answer articles, photos, etc.

Content Marketing has been defined in multiple ways. The meaning of the term depends a lot on the purpose and context. One of the most used definition is “the technique of creating and distributing relevant and valuable content to attract, acquire and engage a clearly defined target audience in order to drive profitable customer action"

Content marketing creates interest in a product through educational, entertaining or informative material. Successful content marketing relies on providing "consistent, high-quality content that solves people's problems".

The following examples demonstrate early use of content to disseminate information about a brand, and build a brand's reputation:

Backin package (1902) 1891: August Oetker sold small packages of his Backin baking powder to households with recipes printed on the back. In 1911 he started publishing his very successful cookbook. It went through major updates over past 100 years and is one of the most successful cookbooks globally reaching 19 million printed copies. All recipes originated from the test kitchen of the Oetker company and the book was carefully written as a textbook to teach cooking from scratch. Oetker was very aware of the need for good marketing, practical communication and use of his doctor title to lend authority to his marketing.

204 1895: John Deere launched the magazine The Furrow, providing information to farmers on how to become more profitable. The magazine, considered the first custom publication, is still in circulation, reaching 1.5 million readers in 40 countries in 12 different languages.

1900: Michelin developed the Michelin Guide, offering drivers information on auto maintenance, accommodations, and other travel tips. 35,000 copies were distributed for free in this first edition.

1904: Jell-O salesmen went door-to-door, distributing their cookbook for free. Touting the dessert as a versatile food, the company saw its sales rise to over $1 million by 1906.

The phrase "content marketing" was used as early as 1996, when John F. Oppedahl led a roundtable for journalists at the American Society for Newspaper Editors. In 1998, Jerrell Jimerson held the title of "director of online and content marketing" at Netscape. In 1999, author Jeff Cannon wrote,“In content marketing, content is created to provide consumers with the information they seek.”

Recently, content marketing has become more prominent, especially where digital and online marketing is concerned. Seth Godin, American author and Marketeer stated in 2008 that 'content marketing was the only marketing left.'

A lot of massage therapists have blogs. This really does work people, I can’t stress it enough. A blog where you just write about massage therapy related issues can direct people to your massage business. This has a lot to do with the way search engines work. Without getting to specific, let me just say that when someone in your town jumps on a search engine and types in “Massage in [your town]” the search engine will direct them to the most relevant and topical website. Blogs get priority because they are updated frequently, which means “fresh content” to plugged in generation- so yes, writing articles on your massage blog about Fibromyalgia or the importance of stretching really does translate into more customers being directed to your business. That’s why there are so many of them out there.

Cross-media marketing Cross media marketing is a form of cross-promotion in which promotional companies commit to surpassing the traditional advertisements and decide

205 to include extra appeals to their offered products. The material can be communicated by any mass media such as e-mails, letters, web pages, or other recruiting sources. This method can be extremely successful for publishers because the marketing increases the ad’s profit from a single advertiser. Furthermore, this tactic generates a good liaison between the advertiser and the publisher, which also boosts the profits.

One of the first steps to integrate cross media tactics effectively into a specific project is to evaluate and examine a customer’s preferences. Scheduling – When should I contact the customer? Rate – What is the correct time frame to leave between the delivery of my first, second and third message to the customer? Pacing - How frequently should I check up on the customer? Incidence – If a customer is not responding, how long should I continue to pursue the offer?

The first notable occurrence of cross media marketing occurred in 1977 with the release of the film Saturday Night Fever and its respective soundtrack. The single "How Deep Is Your Love" by The Bee Gees was originally meant to be recorded by Yvonne Elliman for an unrelated album, but it was decided by RSO Records to have The Bee Gees record it and released in an effort to promote the film. The release of the film promoted not only the released single but the entire soundtrack.

More recent examples include companies promoting music artist's concerts, followed by having one of the artist's songs used in a commercial for the company.

Customized Offers For mail, companies use the information collected from their customer analysis to provide the individuals with personalized letters or upcoming offers. On the internet, customization permits users to have access to exclusive messaging. In addition, the VDP assists the marketing process by talking to each specific group of customers and giving them personal attention rather than treating them all the same way. This consumer and company process is very common in large online retailers such as Amazon.com. The more personalized an offer is to the target audience, the more prone they are to react positively.

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Some of the data that can be investigated to strengthen personalizing the offer includes: Personal information including the customer’s age, gender, and living environment (small town or city) Calculating the customer’s expiration date of a magazine subscription is very important because then the marketing company is able send the individual a notice about re-subscribing. Keeping track of a customer’s involvement and acceptance rate in the company’s offers is very essential. If a customer is providing the company with constant business than sending them an offer for in store redemption is common courtesy.

Customer advocacy Customer advocacy is a specialized form of customer service in which businesses focus on what is best for the customer. It is a change in a business culture that is supported by customer-focused customer service and marketing techniques.

A customer advocacy policy encompasses all aspects of customer contact, including products, services, sales and complaints. Some examples of a customer advocacy approach are suggesting a product even if the profit margin is less for the company, setting service call appointments based on the customer's (not the company's) preferred hours, or recommending a competitor's product because it is better at meeting the customer's needs. However, there are times when, if a customer is happy with you, they will pay more for the service as a 'per se' talent fee.

Customer advocates are facilitators between customers and the company. They are trained in cross-functional roles and empowered to provide customers with assistance in all areas of the business. The role of the customer advocate is three-fold:

To be the main contact for the customer in handling a question or problem, and to keep the customer updated with timely and frequent information about progress towards resolving the issue.

To facilitate a resolution by bringing together the appropriate department heads.

207 To implement a procedure that ensures the problem does not occur again, or recommends products or services to better meet customers' needs.

Measuring customer advocacy Customer advocacy can be integrated into a company’s strategic goals and measured through customer satisfaction, retention, and profitability.

How can this apply to your massage business? Well if you are a single owner operator it just means following up with your clients better (this is discussed in my course BMS004: Client Retention for Massage Therapists ). If you own a spa or massage clinic and have employees or subcontractors you can designate one to be your customer advocate, meaning they administer all of the satisfaction surveys and follow up calls after appointments to see how the client is feeling after the massage, etc.

Customerization Customerization is the customization of products or services through personal interaction between a company and the customer.

A company is customerized when it is able to dialogue with individual customers and respond by customizing its products, services, and messages on a one-to-one basis. Customerization requires a company to shift its marketing model from seller-centric to buyer-centric. The goal is to help customers better identify what they want, and enables companies to have the ability to adapt personalization and one-to-one marketing initiatives for the digital marketing environment. Customerization uses a “build-to-order” mass customization process to deliver a product or service that fits the needs of the customer, and is a critical aspect of the emerging new marketing paradigm.

The word customerization is a neologism, defined as the combination of operational customization and marketing customization.

An important aspect to customerization is the ability to gather information from and about the customer. There requires interaction between the customer and the company in order to receive feedback to evaluate, revise and re-respond. Customerization typically results in improved quality and/or innovation. Though customerization programs have a generic set of activities and a common philosophy, the specifics of their implementation will vary with a unit or organization. Customerization combines mass

208 customization and elicitation of individual customer demand information by involving customers, and is regarded as the next generation of mass customization.

Both mass customization and customerization are attempts to provide products and services to better meet the needs of customers, and rely on the Internet as a vehicle for implementing this concept in an economically friendly way.

Customerization combines mass customization with customized marketing and empowers consumers to design the products and services of their choice. In contrast to mass customization and personalization, customerization does not require a lot of prior information about the customer. In effect, customerization redefines the relationship between the firm and its customers. The customer designs the product and service while the firm “rents” out to the customer its manufacturing logistics and other resources.

Strategies Customerization and other major trends such as the growing influence of globalization and the Internet have large implications for marketing and business strategies, as well as operations of the firm of the 21st century.

Customerization requires an effective integration of marketing, operations, R&D, finance, and information. It also requires a reinvention of the firm’s orientation and processes, especially as they relate to R&D, operations, marketing and finance, and changes to the organizational architecture required to support this integration. The rise of the Internet does not replace standard broadcast advertising, but allows for interactive communication with customers.

Customerization is not a strategy that replaces traditional mass marketing, but offers additional competitive options in developing an overall marketing strategy. The challenge facing the firm is, therefore, how to design and manage a customerization process along with mass-produced products and services.

Flexibility Firms that exhibit higher flexibility may help enhance customerization in many ways. Flexibility can meet customers’ vastly different demands, which

209 may enable the reduction of negative impacts on demand changes and capacity fluctuation. This allows the firm the ability to use ctitical resources to produce exactly what customers are looking for, and the ability to target customer groups. Flexibility also means quick response to demand changes. In co-creation process, flexibility provides firm agility to only make the products that customers want through communication with customers. This makes flexibility a critical route to customerization. Co-creation practices are well established in business-to-business contexts and are increasingly applied in business-to-consumer markets.

Challenges of customerization Customerization may raise challenges related to obtaining information from customers, enhanced customer expectations, pricing issues related to customized offerings, and the required changes to the entire marketing and business strategy of the firm.

For customerization to work effectively, there needs to be exchange of information and knowledge between companies and customers. It requires customers to be willing to share attitudes, preferences, and purchase patterns with the company on an ongoing basis. With increasing online competition and concerns about privacy, companies need to design privacy guidelines and incentive structure carefully to facilitate the knowledge exchange between themselves and their customers.

This is a no-brainer for us massage therapists. Remember way back in massage school when you learned that you are supposed to be taking SOAP notes after massages? One of the reasons is to chart their progress, but it is also useful in customizing treatments for each client. We should be doing this.

Database marketing Okay I know you are probably thinking-“This sounds too techy for me”. Hold on, this can be VERY relevant for you. In fact it can be a game changer.

Database marketing is a form of direct marketing using databases of customers or potential customers to generate personalized communications in order to promote a product or service for marketing purposes. The method of communication can be any addressable medium, as in direct marketing.

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The distinction between direct and database marketing stems primarily from the attention paid to the analysis of data. Database marketing emphasizes the use of statistical techniques to develop models of customer behavior, which are then used to select customers for communications. As a consequence, database marketers also tend to be heavy users of data warehouses, because having a greater amount of data about customers increases the likelihood that a more accurate model can be built.

There are two main types of marketing databases, 1) Consumer databases, and 2) business databases. Consumer databases are primarily geared towards companies that sell to consumers, often abbreviated as [business-to-consumer] (B2C) or BtoC. Business marketing databases are often much more advanced in the information that they can provide. This is mainly because business databases aren't restricted by the same privacy laws as consumer databases.

The "database" is usually name, address, and transaction history details from internal sales or delivery systems, or a bought-in compiled "list" from another organization, which has captured that information from its customers. Typical sources of compiled lists are charity donation forms, application forms for any free product or contest, product warranty cards, subscription forms, and credit application forms.

The communications generated by database marketing may be described as junk mail or spam, if it is unwanted by the addressee. Direct and database marketing organizations, on the other hand, argue that a targeted letter or e-mail to a customer, who wants to be contacted about offerings that may interest the customer, benefits both the customer and the marketer.

Some countries and some organizations insist that individuals are able to prevent entry to or delete their name and address details from database marketing lists.

Background Database marketing emerged in the 1980s as a new, improved form of direct marketing. During the period traditional "list broking" was under pressure to modernise, because it was offline and tape-based, and because lists tended to hold limited data. At the same time, with new

211 technologies enabling customer responses to be recorded, direct response marketing was in the ascendancy, with the aim of opening up a two-way communication, or dialogue, with customers.

Robert D. "Bob" and Kate Kestnbaum were trailblazing pioneers of the new direct marketing, who were credited with developing new metrics including customer lifetime value, and applying financial modelling and econometrics to marketing strategies. They founded Kestnbaum & Co, a consulting firm in 1967, and this was the training ground for many of database marketing's leading thinkers, including Robert Blattberg, Rick Courtheaux and Robert Shaw. Bob Kestnbaum was inducted into the DMA Hall of Fame in October 2002.

Kestnbaum collaborated with Shaw in the 1980s on several landmark online marketing database developments - for BT (20 million customers), BA (10 million) and Barclays (13 million). Shaw incorporated new features into the Kestnbaum approach, including telephone and field sales channel automation, contact strategy optimisation, campaign management and coordination, marketing resource management, marketing accountability and marketing analytics. The designs of these systems have been widely copied subsequently and incorporated into CRM and MRM packages in the 1990s and later.

The earliest recorded definition of Database Marketing was in 1988 in the book of the same name (Shaw and Stone 1988 Database Marketing):

"Database Marketing is an interactive approach to marketing, which uses the individually addressable marketing media and channels (such as mail, telephone and the sales force): to extend help to a company's target audience; to stimulate their demand; and to stay close to them by recording and keeping an electronic database memory of the customer, prospect and all commercial contacts, to help improve all future contacts and to ensure more realistic of all marketing."

Growth and evolution of database marketing The growth of database marketing is driven by a number of environmental issues. Fletcher, Wheeler and Wright (1991) classified these issues into four main categories: (1) changing role of direct marketing; (2) changing cost structures; (3) changing technology; and (4) changing market conditions.

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Changing role of direct marketing The move to relationship marketing for competitive advantage. The decline in the effectiveness of traditional media. The overcrowding and myopia of existing sales channels.

Changing cost structures The decline in electronic processing costs. The increase in marketing costs.

Changing technology The advent of new methods of shopping and paying. The development of economical methods for differentiating customer communication.

Changing market conditions The desire to measure the impact of marketing efforts. The fragmentation of consumer and business markets. Shaw and Stone (1988) noted that companies go through evolutionary phases in the developing their database marketing systems. They identify the four phases of database development as mystery lists, buyer databases, coordinated customer communication, and integrated marketing.

Sources of data Although organizations of any size can employ database marketing, it is particularly well-suited to companies with large numbers of customers. This is because a large population provides greater opportunity to find segments of customers or prospects that can be communicated with in a customized manner. In smaller (and more homogeneous) databases, it will be difficult to justify on economic terms the investment required to differentiate messages. As a result, database marketing has flourished in sectors, such as financial services, telecommunications, and retail, all of which have the ability to generate significant amounts of transaction data for millions of customers.

Database marketing applications can be divided logically between those marketing programs that reach existing customers and those that are aimed at prospective customers.

213 Consumer data In general, database marketers seek to have as much data available about customers and prospects as possible.

For marketing to existing customers, more sophisticated marketers often build elaborate databases of customer information. These may include a variety of data, including name and address, history of shopping and purchases, demographics, and the history of past communications to and from customers. For larger companies with millions of customers, such data warehouses can often be multiple terabytes in size.

Marketing to prospects relies extensively on third-party sources of data. In most developed countries, there are a number of providers of such data. Such data is usually restricted to name, address, and telephone, along with demographics, some supplied by consumers, and others inferred by the data compiler. Companies may also acquire prospect data directly through the use of sweepstakes, contests, on-line registrations, and other lead generation activities.

Business data For many business-to-business (B2B) company marketers, the number of customers and prospects will be smaller than that of comparable business- to-consumer (B2C) companies. Also, their relationships with customers will often rely on intermediaries, such as salespeople, agents, and dealers, and the number of transactions per customer may be small. As a result, business-to-business marketers may not have as much data at their disposal as business-to-consumer marketers.

One other complication is that B2B marketers in targeting teams or "accounts" and not individuals may produce many contacts from a single organization. Determining which contact to communicate with through direct marketing may be difficult. On the other hand it is the database for business-to-business marketers which often includes data on the business activity about the respective client.

These data become critical to segment markets or define target audiences, e.g. purchases of software license renewals by telecom companies could help identify which technologist is in charge of software installations vs. software procurement, etc. Customers in Business-to-Business environments often tend to be loyal since they need after-sales-service for

214 their products and appreciate information on product upgrades and service offerings. This loyalty can be tracked by a database.

Sources of customer data often come from the sales force employed by the company and from the service engineers. Increasingly, online interactions with customers are providing B2B marketers with a lower cost source of customer information.

For prospect data, businesses can purchase data from compilers of business data, as well as gather information from their direct sales efforts, on-line sites, and specialty publications.

Analytics and modeling Companies with large databases of customer information risk being "data rich and information poor." As a result, a considerable amount of attention is paid to the analysis of data. For instance, companies often segment their customers based on the analysis of differences in behavior, needs, or attitudes of their customers. A common method of behavioral segmentation is RFM (customer value), in which customers are placed into subsegments based on the recency, frequency, and monetary value of past purchases. Van den Poel (2003)[5] gives an overview of the predictive performance of a large class of variables typically used in database-marketing modeling.

They may also develop predictive models, which forecast the propensity of customers to behave in certain ways. For instance, marketers may build a model that ranks customers on their likelihood to respond to a promotion. Commonly employed statistical techniques for such models include logistic regression and neural networks.

Laws and regulations As database marketing has grown, it has come under increased scrutiny from privacy advocates and government regulators. For instance, the European Commission has established a set of data protection rules that determine what uses can be made of customer data and how consumers can influence what data are retained. In the United States, there are a variety of state and federal laws, including the Fair Credit Reporting Act, or FCRA (which regulates the gathering and use of credit data), the Health Insurance Portability and Accountability Act (HIPAA) (which regulates the gathering and use of consumer health data), and various programs that

215 enable consumers to suppress their telephones numbers from telemarketing.

Advances in database marketing While the idea of storing customer data in electronic formats to use them for database-marketing purposes has been around for decades, the computer systems available today make it possible to gain a comprehensive history of client behavior on-screen while the business is transacting with each individual, producing thus real-time business intelligence for the company. This ability enables what is called one-to-one marketing or personalization.

Today's Customer Relationship Management (CRM) systems use the stored data not only for direct marketing purposes but to manage the complete relationship with individual customer contacts and to develop more customized product and service offerings. However, a combination of CRM, content management and business intelligence tools are making delivery of personalized information a reality.

Marketers trained in the use of these tools are able to carry out customer nurturing, which is a tactic that attempts to communicate with each individual in an organization at the right time, using the right information to meet that client's need to progress through the process of identifying a problem, learning options available to resolve it, selecting the right solution, and making the purchasing decision.

Because of the complexities of B2B marketing and the intricacies of corporate operations, the demands placed on any marketing organization to formulate the business process by which such a sophisticated series of procedures may be brought into existence are significant. It is often for this reason that large marketing organizations engage the use of an expert in marketing process strategy and information technology (IT), or a marketing IT process strategist. Although more technical in nature than often marketers require, a system integrator (SI) can also play an equivalent role to the marketing IT process strategist, particularly at the time that new technology tools need to be configured and rolled out.

Challenges and limitation of database marketing While real-time business intelligence is a reality for select companies, it remains elusive to many as it is dependent on these premises: the

216 percentage of the business that is online, and the degree of level of sophistication of the software. Technology companies like Google, Dell, and Apple are best positioned to capitalize on such intelligence. For other companies, more traditional methods still apply, either to maintain communication with an existing customer base (retention) or, as a more established growth driver, to build, acquire or rent new databases (acquisition). A major challenge for databases is the reality of obsolescence - including the lag time between when data was acquired and when the database is used. This problem can be addressed by online and offline means including traditional methods. An alternative approach is real-time proximity marketing for acquisition purposes.

So how can I use Database marketing as a massage business owner you ask? Remember at the beginning of this chapter when we discussed other businesses that share an affinity with you, meaning they have customers or clients that have similar interest to yours. The example I gave you was a personal trainer. I suggested maybe you could team up with them to sell packages of training sessions and massages.

Well if they are not interested in doing that, they might be interested in selling you access to their client database. You could offer to buy a list of their customers (names, address and emails). If you want a much bigger list, try the local gyms.

Ethical warning: They may be interested in a quid pro quo , offering you a list of their clients in return for the same from you. This is NOT ETHICAL. Yes it’s a double standard, because we are bound by rules of confidentiality that the personal trainer might not be.

By the way, many of the national massage therapy organizations (and some state boards!) do sell your information to businesses like mine that sell to massage therapists. I don’t buy them, I’m too cheap to spend money on it, but if you have received an email from a CE provider you have never heard of, that’s how they get it. If you don’t want these massage therapy organizations selling your information, let them know!

Digital marketing This is another category where you might roll your eyes and say “I’m a massage therapist, I don’t know anything about computers or interweb stuff!”

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If that’s true than take a few minutes to ask your 14-year-old niece to make a facebook page for your business and to teach you how to use it, because this stuff isn’t going away.

Digital marketing is marketing that makes use of electronic devices (computers) such as personal computers, smartphones, cellphones, tablets and game consoles to engage with stakeholders. Digital marketing applies technologies or platforms such as websites, e-mail, apps (classic and mobile) and social networks. Social Media Marketing is a component of digital marketing. Many organizations use a combination of traditional and digital marketing channels.

The term 'digital marketing' was first used in the 1990s. In the 2000s and the 2010s, digital marketing became more sophisticated as an effective way to create a relationship with the consumer that has depth and relevance.

In 2012 and 2013 statistics showed digital marketing remained a growing field.

Digital marketing is often referred to as 'online marketing' or 'internet marketing'. The term 'digital marketing' has grown in popularity over time, particularly in certain countries. In the USA 'online marketing' is still prevalent, but in the UK and worldwide, 'digital marketing' has become the most common term, especially after the year 2013.

Types of digital marketing Two different forms of digital marketing exist: In pull digital marketing, the consumer actively seeks the marketing content, often via web searches or opening an email, text message or web feed Websites, blogs and streaming media (audio and video) are examples of pull digital marketing. In each of these, users have to navigate to the website to view the content. Only current web browser technology is required to maintain static content. Search engine optimization (SEO) is one tactic used to increase activity. In 2003, Martin et al. found that consumers prefer special sales and new product information, whereas "interesting" content was not useful.

218 In push digital marketing the marketer sends a message without the recipient actively seeking the content, such as display advertising on websites and news blogs. Email, text messaging and web feeds can also be classed as push digital marketing when the recipient has not actively sought the marketing message.

Some of the latest developments include 1. Segmentation: more focus has been placed on segmentation within digital marketing, in order to target specific markets in both business to business and business to consumer sectors. 2. Influencer marketing: Important nodes are identified within related communities, known as influencers. This is becoming an important concept in digital targeting. It is possible to reach influencers via paid advertising, such as Facebook or Google Adsense campaigns, or through sophisticated sCRM (social customer relationship management) software, such as Microsoft Dynamics and Salesforce CRM. Many universities now focus, at Masters level, on engagement strategies for influencers.

To summarize, Pull digital marketing is characterized by consumers actively seeking marketing content while Push digital marketing occurs when marketers send messages without that content being actively sought by the recipients.

Multi-channel communications Push and pull message technologies can be used in conjunction. For example, an email campaign can include a banner ad or link to a content download.

Direct marketing Direct marketing is a channel-agnostic form of advertising which allows businesses and nonprofit organizations to communicate straight to the customer, with advertising techniques that can include cell phone text messaging, email, interactive consumer websites, online display ads, database marketing, fliers, catalog distribution, promotional letters, targeted television commercials, response-generating newspaper/magazine advertisements, and outdoor advertising. Amongst its practitioners, it is also referred to as Direct Response.

Direct marketing messages emphasize a focus on the customer, data, and accountability. Hence, besides the actual communication, creation of

219 actionable segments, pre- and post-campaign analytics, and measurement of results, are integral to any good Direct Marketing campaign. Characteristics that distinguish direct marketing are:

A database of names (prospects, customers, businesses, etc.), often with certain other relevant information such as contact number/address, demographic information, purchase habits/history, company history, etc., is used to develop a list of targeted entities with some existing common interests, traits or characteristics. Generating such a database is often considered part of the Direct Marketing campaign.

Marketing messages are addressed directly to this list of customer and/or prospects. Direct marketing relies on being able to address the members of a target market. Addressability comes in a variety of forms including email addresses, phone numbers, Web browser cookies, fax numbers and postal addresses.

Direct marketing seeks to drive a specific "call to action." For example, an advertisement may ask the prospect to call a free phone number, mail in a response or order, or click on a link to a website. Direct marketing emphasizes trackable, measurable responses, results and costs from prospects and/or customers—regardless of medium.

Direct marketing is practiced by businesses of all sizes—from the smallest start-up to the leaders on the Fortune 500. A well-executed direct advertising campaign can prove a positive return on investment by showing how many potential customers responded to a clear call-to-action. General advertising eschews calls-for-action in favor of messages that try to build prospects’ emotional awareness or engagement with a brand. Even well- designed general advertisements rarely can prove their impact on the organization’s bottom line. The demonstrable result of Direct Marketing is the reason for its increasing popularity.

A recent study by the Direct Marketing Association reports that in 2010, marketers—commercial and nonprofit—spent $153.3 billion on direct marketing, which accounted for 54.2% of all ad expenditures in the United States. Measured against total US sales, these advertising expenditures generated approximately $1.798 trillion in incremental sales. In 2010, direct marketing accounted for 8.3% of total US gross domestic product. In 2010, there were 1.4 million direct marketing employees in the US. Their

220 collective sales efforts directly supported 8.4 million other jobs, accounting for a total of 9.8 million US jobs.

Mail order pioneer Aaron Montgomery Ward knew that using the technique of selling products directly to the customer at appealing prices could, if executed effectively and efficiently, revolutionize the market industry and therefore be used as an innovative model for marketing products and creating customer loyalty. The term "direct marketing" was coined long after Montgomery Ward's time.

In 1872, Aaron Montgomery Ward produced the first mail-order catalog for his Montgomery Ward mail order business. By buying goods and then reselling them directly to customers, Ward was consequently removing the middlemen at the general store and, to the benefit of the customer, drastically lowering the prices. The Direct Mail Advertising Association, predecessor of the present-day Direct Marketing Association, was first established in 1917. Third class bulk mail postage rates were established in 1928.

In 1967, Lester Wunderman identified, named, and defined the term "direct marketing". Wunderman—considered to be the father of contemporary direct marketing—is behind the creation of the toll-free 1-800 number and numerous loyalty marketing programs including the Columbia Record Club, the magazine subscription card, and the American Express Customer Rewards program.

Direct marketing is attractive to many marketers because its positive results can be measured directly. For example, if a marketer sends out 1,000 solicitations by mail and 100 respond to the promotion, the marketer can say with confidence that campaign led directly to 10% direct responses. This metric is known as the 'response rate,' and it is one of many clearly quantifiable success metrics employed by direct marketers. In contrast, general advertising uses indirect measurements, such as awareness or engagement, since there is no direct response from a consumer.

Measurement of results is a fundamental element in successful direct marketing. The Internet has made it easier for marketing managers to measure the results of a campaign. This is often achieved by using a specific website landing page directly relating to the promotional material. A call to action will ask the customer to visit the landing page, and the

221 effectiveness of the campaign can be measured by taking the number of promotional messages distributed (e.g., 1,000) and dividing it by the number of responses (people visiting the unique website page). Another way to measure the results is to compare the projected sales or generated leads for a given term with the actual sales or leads after a direct advertising campaign.

While many marketers recognize the financial benefits of increasing targeted awareness, some direct marketing efforts using particular media have been criticized for generating poor quality leads, either due to poor message strategy or because of poorly compiled demographic databases. This poses a problem for marketers and consumers alike, as advertisers do not wish to waste money on communicating with consumers not interested in their products.

Success of any Direct Marketing campaign, in terms of number of times the desired response may vary between the best vs. the worst of the following parameters, depends on: List or targeting (best targeting may yield up to 6 times the response, as compared with the worst targeting) Offer (best offer may yield up to 3 times the response, as compared with the worst offer) Timing (best timing for the campaign may yield up to 2 times the response, as compared with the worst timing) Ease of response (best/multiple ways offered to respond may yield up to 1.35 times the response, as compared with not-so-friendly response mechanism/s) Creativity (most creative messaging may yield up to 1.2 times the response, as compared to the least creative messaging) Media employed. The medium/media used to deliver a message can have a significant impact on responses. It's difficult to truly personalize a DRTV or radio message. One can even attempt to send a personalized message via email or text message, but a high quality direct mail envelope and letter will typically have a better chance of generated a response in this scenario.

In sum, choosing the best of all the above parameters may yield up to 58 times more response, as compared to choosing the worst of the above parameters. Addressing these helps assuage the concerns of the marketers.

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Some of these concerns have been addressed by direct marketers by the use of individual "opt-out" lists, variable printing, and better-targeted list practices. Additionally, in order to avoid unwanted mailings, members of the marketing industry have established preference services that give customers more control over the marketing communications they receive in the mail.

The term "junk mail," referring to unsolicited commercial ads delivered via post office or directly deposited in consumers' mail boxes, can be traced back to 1954. The term "spam," meaning "unsolicited commercial e-mail," can be traced back to March 31, 1993, although in its first few months it merely referred to inadvertently posting a message so many times on UseNet that the repetitions effectively drowned out the normal flow of conversation.

To address the concerns of unwanted emails or spam, in 2003, The US Congress enacted the Controlling the Assault of Non-Solicited Pornography and Marketing (CAN-SPAM) Act to curb unwanted email messages. Can- Spam gives recipients the ability to stop unwanted emails, and set out tough penalties for violations.

Additionally, ISPs and email service providers have developed increasingly effective Email Filtering programs. These filters can interfere with the delivery of email marketing campaigns, even if the person has subscribed to receive them, as legitimate email marketing can possess the same hallmarks as spam. There are a range of email service providers that provide services for legitimate opt-in emailers to avoid being classified as spam.

Consumers have expressed concerns about the privacy and environmental implications of direct marketing. In response to consumer demand and increasing business pressure to increase the effectiveness of reaching the right customer with direct marketing, companies specialize in targeted direct advertising to great effect, reducing advertising budget waste and increasing the effectiveness of delivering a marketing message with better geo-demography information, delivering the advertising message to only the customers interested in the product, service, or event on offer. Additionally, members of the advertising industry have been working to adopt stricter codes regarding online targeted advertising.

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Any medium that can be used to deliver a communication to a customer can be employed in direct marketing, including:

Email marketing Sending marketing messages through email or email marketing is one of the most widely used direct-marketing methods. One reason for email marketing's popularity is that it is relatively inexpensive to design, test, and send an email message. It also allows marketers to deliver messages around the clock, and to accurately measure responses.

Online tools With the expansion of digital technology and tools, direct marketing is increasingly taking place through online channels. Most online advertising is delivered to a focused group of customers and has a trackable response.

Display Ads are interactive ads that appear on the Web next to content on Web pages or Web services. Formats include static banners, pop ups, videos, and floating units. Customers can click on the ad to respond directly to the message or to find more detailed information. According to research by eMarketer, expenditures on online display ads rose 24.5% between 2010 and 2011.

Search: 49% of US spending on Internet ads goes to search, in which advertisers pay for prominent placement among listings in search engines whenever a potential customer enters a relevant search term, allowing ads to be delivered to customers based upon their already-indicated search criteria. This paid placement industry generates more than $10 billion for search companies. Marketers also use search engine optimization to drive traffic to their sites. Social Media Sites, such as Facebook and Twitter, also provide opportunities for direct marketers to communicate directly with customers by creating content to which customers can respond.

Mobile Through mobile marketing, marketers engage with prospective customers and donors in an interactive manner through a mobile device or network, such as a cellphone, smartphone, or tablet. Types of mobile marketing messages include: SMS (short message service)—marketing communications are sent in the form of text messages, also known as

224 texting. MMS (multi-media message service)—marketing communications are sent in the form of media messages.

In October 2013, the Federal Telephone Consumers Protection Act made it illegal to contact an individual via cell phone without prior express written consent for all telephone calls using an automatic telephone dialing system or a prerecorded voice to deliver a telemarketing message to wireless numbers and residential lines. An existing business relationship does not provide an exception to this requirement.

Mobile Applications: Smartphone-based mobile apps contain several types of messages. Push Notifications are direct messages sent to a user either automatically or as part of a campaign. They include transactional, marketing, geo-based, and more. Rich Push Notifications are full HTML Push Notifications. Mobile apps also contain Interactive ads that appear inside the mobile application or app; Location-Based Marketing: marketing messages delivered directly to a mobile device based on the user's location; QR Codes (quick-response barcodes): This is a type of 2D barcode with an encoded link that can be accessed from a smartphone. This technology is increasingly being used for everything from special offers to product information. Mobile Banner Ads: Like standard banner ads for desktop Web pages but smaller to fit on mobile screens and run on the mobile content network

Telemarketing Another common form of direct marketing is telemarketing, in which marketers contact customers by phone. The primary benefit to businesses is increased lead generation, which helps businesses increase sales volume and customer base. The most successful telemarketing service providers focus on generating more "qualified" leads that have a higher probability of getting converted into actual sales.

In the United States, the National Do Not Call Registry was created in 2003 to offer consumers a choice whether to receive telemarketing calls at home. The FTC created the National Do Not Call Registry after a comprehensive review of the Telemarketing Sales Rule (TSR). The do-not- call provisions of the TSR cover any plan, program, or campaign to sell goods or services through interstate phone calls.

225 The 2012 modification, which went into effect on October 16, 2013, stated that prior express written consent will be required for all autodialed and/or pre-recorded calls/texts sent/made to cell phone; and for pre-recorded calls made to residential land lines for marketing purposes.

Further, a consumer who does not wish to receive further prerecorded telemarketing calls can "opt out" of receiving such calls by dialing a telephone number (required to be provided in the prerecorded message) to register his or her do-not-call request. The provisions do not cover calls from political organizations or charities.

Canada has its own National Do Not Call List (DNCL). In other countries it is voluntary, such as the New Zealand Name Removal Service.

Voicemail marketing Voicemail marketing emerged from the market prevalence of personal voice mailboxes, and business voicemail systems. Voicemail marketing presented a cost effective means by which to reach people directly, by voice. Abuse of consumer marketing applications of voicemail marketing resulted in an abundance of "voice-spam," and prompted many jurisdictions to pass laws regulating consumer voicemail marketing. More recently, businesses have utilized guided voicemail (an application where prerecorded voicemails are guided by live callers) to accomplish personalized business-to-business marketing formerly reserved for telemarketing. Because guided voicemail is used to contact only businesses, it is exempt from Do Not Call regulations in place for other forms of voicemail marketing.

Voice-mail courier is a similar form of voice-mail marketing with both business-to-business and business-to-consumer applications.

Broadcast faxing Broadcast faxing, in which faxes are sent to multiple recipients, is now less common than in the past. This is partly due to laws in the United States and elsewhere which regulate its use for consumer marketing. In 2005, President Bush signed into law S.714, the Junk Fax Prevention Act of 2005 (JFPA), which allows marketers to send commercial faxes to those with whom they have an established business relationship (EBR), but imposes some new requirements. These requirements include providing an opt-out notice on the first page of faxes and establishing a system to accept opt-

226 outs at any time of the day. Roughly 2% of direct marketers use fax, mostly for business-to-business marketing campaigns.

Couponing Couponing is used in print and digital media to elicit a response from the reader. An example is a coupon which the reader receives through the mail and takes to a store's check-out counter to receive a discount.

Digital Coupons: Manufacturers and retailers make coupons available online for electronic orders that can be downloaded and printed. Digital coupons are available on company websites, social media outlets, texts, and email alerts. There are an increasing number of mobile phone applications offering digital coupons for direct use.

Daily Deal Sites offer local and online deals each day, and are becoming increasingly popular. Customers sign up to receive notice of discounts and offers, which are sent daily by email. Purchases are often made using a special coupon code or promotional code. The largest of these sites, Groupon, has over 83 million subscribers.

Direct response marketing Direct Response Marketing is designed to generate an immediate response from consumers, where each consumer response (and purchase) can be measured, and attributed to individual advertisements. This form of marketing is differentiated from other marketing approaches, primarily because there are no intermediaries such as retailers between the buyer and seller, and therefore the buyer must contact the seller directly to purchase products or services. Direct-response marketing is delivered through a wide variety of media, including DRTV, radio, mail, print advertising, telemarketing, catalogues, and the Internet.

Direct response mail order Mail order in which customers respond by mailing a completed order form to the marketer. Mail order direct response has become more successful in recent years due to internet exposure.

Direct response television Direct marketing via television (commonly referred to as DRTV) has two basic forms: long form (usually half-hour or hour-long segments that explain a product in detail and are commonly referred to as infomercials)

227 and short form, which refers to typical 30-second or 60-second commercials that ask viewers for an immediate response (typically to call a phone number on screen or go to a website). TV-response marketing—i.e. infomercials—can be considered a form of direct marketing, since responses are in the form of calls to telephone numbers given on-air. This allows marketers to reasonably conclude that the calls are due to a particular campaign, and enables them to obtain customers' phone numbers as targets for telemarketing. One of the most famous DRTV commercials was for Ginsu Knives by Ginsu Products, Inc. of RI. Several aspects of ad, such as its use of adding items to the offer and the guarantee of satisfaction were much copied, and came to be considered part of the formula for success with short-form direct-response TV ads (DRTV).

Forms of direct response marketing on television include standard short form television commercials, infomercials and home shopping networks. Short-form direct-response commercials have time lengths ranging from 30 seconds to 2 minutes. Long form infomercials are typically 30 minutes long. An offshoot of the infomercial is the home shopping industry. In this medium, items can potentially be offered with reduced overhead.

Direct response radio In direct response radio, ads contain a call to action with a specific tracking mechanism. Often, this tracking mechanism is a "call now" prompt with a toll-free phone number or a unique Web URL. Results of the ad can be tracked in terms of calls, orders, customers, leads, sales, revenue, and profits that result from the airing of those ads.

Direct response magazines and newspapers Magazine and newspaper ads often include a direct response call-to- action, such as a toll-free number, a coupon redeemable at a brick-and- mortar store, or a QR code that can be scanned by a mobile device—these methods are all forms of direct marketing, because they elicit a direct and measurable action from the customer.

Other direct response media Other media, such as magazines, newspapers, radio, social media, search engine marketing and e-mail can be used to elicit the response. A survey of

228 large corporations found e-mail to be one of the most effective forms of direct response.

Direct mail The term advertising, or direct mail, is used to refer to communications sent to potential customers or donors via the postal service and other delivery services. Direct mail is sent to customers based on criteria such as age, income, location, profession, buying pattern, etc. Direct mail includes advertising circulars, catalogs, free-trial CDs, pre-approved credit card applications, and other unsolicited merchandising invitations delivered by mail to homes and businesses. Bulk mailings are a particularly popular method of promotion for businesses operating in the financial services, home computer, and travel and tourism industries.

In many developed countries, direct mail represents such a significant amount of the total volume of mail that special rate classes have been established. In the United States and United Kingdom, for example, there are bulk mail rates that enable marketers to send mail at rates that are substantially lower than regular first-class rates. In order to qualify for these rates, marketers must format and sort the mail in particular ways—which reduces the handling (and therefore costs) required by the postal service. In the US, marketers send over 90 billion pieces of direct mail per year.

Advertisers often refine direct mail practices into targeted mailing, in which mail is sent out following database analysis to select recipients considered most likely to respond positively. For example, a person who has demonstrated an interest in golf may receive direct mail for golf-related products or perhaps for goods and services that are appropriate for golfers. This use of database analysis is a type of database marketing. The United States Postal Service calls this form of mail "advertising mail" (admail for short).

Insert media Another form of direct marketing, insert media are marketing materials that are inserted into other communications, such as a catalog, newspaper, magazine, package, or bill. Coop or shared mail, where marketing offers from several companies are delivered via a single envelope, is also considered insert media.

Out-of-home

229 Out-of-home direct marketing refers to a wide array of media designed to reach the consumer outside the home, including billboards, transit, bus shelters, bus benches, aerials, airports, in-flight, in-store, movies, college campus/high schools, hotels, shopping malls, sport facilities, stadiums, taxis—that contain a call-to-action for the customer to respond.

Direct selling Direct selling is the sale of products by face-to-face contact with the customer, either by having salespeople approach potential customers in person, or through indirect means such as Tupperware parties.

Grassroots/community marketing The door-to-door distribution of flyers and leaflets within a local community is a business-to-consumer form of direct marketing used extensively by restaurants, fast food companies, and many other business focusing on a local catchment. Similar to direct mail marketing, this method is targeted purely by area and community, and costs a fraction of the amount of a mailshot, since it is not necessary to purchase stamps, envelopes, or address lists with the names of home occupants.

Diversification (marketing strategy) Diversification is a corporate strategy to enter into a new market or industry which the business is not currently in, whilst also creating a new product for that new market. This is most risky section of the Ansoff's matrix, as the business has no experience in the new market and does not know if the product is going to be successful.

Product diversification involves addition of new products to existing products either being manufactured or being marketed. Expansion of the existing product line with related products is one such method adopted by many businesses. Adding tooth brushes to tooth paste or tooth powders or mouthwash under the same brand or under different brands aimed at different segments is one way of diversification. These are either brand extensions or product extensions to increase the volume of sales and the number of customers.

The different types of diversification strategies The strategies of diversification can include internal development of new products or markets, acquisition of a firm, alliance with a complementary company, licensing of new technologies, and distributing or importing a

230 products line manufactured by another firm. Generally, the final strategy involves a combination of these options. This combination is determined in function of available opportunities and consistency with the objectives and the resources of the company.

There are three types of diversification: concentric, horizontal, and conglomerate.

Concentric diversification This means that there is a technological similarity between the industries, which means that the firm is able to leverage its technical know-how to gain some advantage. For example, a company that manufactures industrial adhesives might decide to diversify into adhesives to be sold via retailers. The technology would be the same but the marketing effort would need to change.

It also seems to increase its market share to launch a new product that helps the particular company to earn profit. For instance, the addition of tomato ketchup and sauce to the existing "Maggi" brand processed items of Food Specialities Ltd. is an example of technological-related concentric diversification.

The company could seek new products that have technological or marketing synergies with existing product lines appealing to a new group of customers.This also helps the company to tap that part of the market which remains untapped, and which presents an opportunity to earn profit..

Horizontal diversification The company adds new products or services that are often technologically or commercially unrelated to current products but that may appeal to current customers. This strategy tends to increase the firm's dependence on certain market segments. For example, a company that was making notebooks earlier may also enter the pen market with its new product.

Horizontal diversification is desirable if the present customers are loyal to the current products and if the new products have a good quality and are well promoted and priced. Moreover, the new products are marketed to the same economic environment as the existing products, which may lead to rigidity or instability.

231 Horizontal integration occurs when a firm enters a new business (either related or unrelated) at the same stage of production as its current operations. For example, Avon's move to market jewelry through its door- to-door sales force involved marketing new products through existing channels of distribution. An alternative form of that Avon has also undertaken is selling its products by mail order (e.g., clothing, plastic products) and through retail stores (e.g.,Tiffany's). In both cases, Avon is still at the retail stage of the production process.

Conglomerate diversification (or lateral diversification) The company markets new products or services that have no technological or commercial synergies with current products but that may appeal to new groups of customers. The conglomerate diversification has very little relationship with the firm's current business. Therefore, the main reasons for adopting such a strategy are first to improve the profitability and the flexibility of the company, and second to get a better reception in capital markets as the company gets bigger. Though this strategy is very risky, it could also, if successful, provide increased growth and profitability.

Goal of diversification According to Calori and Harvatopoulos (1988), there are two dimensions of rationale for diversification. The first one relates to the nature of the strategic objective: Diversification may be defensive or offensive.

Defensive reasons may be spreading the risk of market contraction, or being forced to diversify when current product or current market orientation seems to provide no further opportunities for growth. Offensive reasons may be conquering new positions, taking opportunities that promise greater profitability than expansion opportunities, or using retained cash that exceeds total expansion needs.

The second dimension involves the expected outcomes of diversification: Management may expect great economic value (growth, profitability) or first and foremost great coherence with their current activities (exploitation of know-how, more efficient use of available resources and capacities). In addition, companies may also explore diversification just to get a valuable comparison between this strategy and expansion.

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Risks Of the four strategies presented in the Ansoff matrix, Diversification has the highest level of risk and requires the most careful investigation. Going into an unknown market with an unfamiliar product offering means a lack of experience in the new skills and techniques required. Therefore, the company puts itself in a great uncertainty. Moreover, diversification might necessitate significant expanding of human and financial resources, which may detract focus, commitment, and sustained investments in the core industries. Therefore, a firm should choose this option only when the current product or current market orientation does not offer further opportunities for growth.

In order to measure the chances of success, different tests can be done:

The attractiveness test: the industry that has been chosen has to be either attractive or capable of being made attractive.

The cost-of-entry test: the cost of entry must not capitalize all future profits.

The better-off test: the new unit must either gain competitive advantage from its link with the corporation or vice versa.

Because of the high risks explained above, many companies attempting to diversify have led to failure. However, there are a few good examples of successful diversification: Virgin Group moved from music production to travel and mobile phones Walt Disney moved from producing animated movies to theme parks and vacation properties Canon diversified from a camera-making company into producing an entirely new range of office equipment.

Diversity marketing Diversity marketing' (or in-culture marketing) is a marketing paradigm which sees marketing (and especially marketing communications) as essentially an effort in communication with diverse publics. According to the paradigm, the main focus of marketing today should be to create effective communication methods and a communication mix appropriate to each of the diverse groups active in the market.

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Diversity marketing recognizes the influence of cultural programming and acknowledges that different consumer groups have life experiences in different cultural and social settings. Because of this different cultural programming, the tastes, values, expectations, beliefs, ways of interaction, ways of entertainment, and lifestyle preferences of these groups tend to be different from others. These differences require the creation of customised marketing strategies.

An acknowledgement of the importance of diversity marketing is that AT&T Inc. has a post for this discipline at vice president level.

Evangelism marketing Evangelism marketing is an advanced form of word-of-mouth marketing (WOMM) in which companies develop customers who believe so strongly in a particular product or service that they freely try to convince others to buy and use it. The customers become voluntary advocates, actively spreading the word on behalf of the company.

Evangelism marketing is sometimes confused with affiliate marketing. However, while affiliate programs provide incentives in the form of money or products, evangelist customers spread their recommendations and recruit new customers out of pure belief, not for the receipt of goods or money. Rather, the goal of the customer evangelist is simply to provide benefit to other individuals.

As they act independently, evangelist customers often become key influencers. The fact that evangelists are not paid or associated with any company make their beliefs perceived by others as credible and trustworthy.

Evangelism comes from the three words of 'bringing good news,' and the marketing term justly draws from the religious sense, as consumers are driven by their beliefs in a product or service, which they preach in an attempt to convert others.

234 Many people believe Guy Kawasaki, the former chief evangelist of Apple Computer, to be the father of evangelism marketing. In his books “The Art of the Start" and "How to Drive Your Competition Crazy” Kawasaki states that the driving force behind evangelism marketing is the fact that individuals simply want to make the world a better place. Evangelist customers spread their recommendations and recruit new customers out of pure belief, not for goods or money.

Kinds of evangelism marketing Evangelism marketing is applicable to any kind of product (including massage therapy).

Technology evangelism is the evangelism marketing of a tool.

Platform evangelism is the evangelism marketing of the opportunity to create complementary goods for a multi-sided platform, which also involves non-marketing functions such as regulation of the platform's commercial ecosystem to maximize network effects.

Customer communities A strong avenue for evangelists is in the form of customer communities, which bring together groups of users of a product or service to share information and discuss common issues. Some companies assist with such events, for example General Motors' Saturn division in Tennessee organizes an annual summer picnic for thousands of customers. Another example is the Harley Owners Groups (HOGS), organized by Harley Davidson, which associate bikers locally and globally through quarterly and annual meetings held all over the world.

Starbucks Corporation, the coffee company, started an online customer community in 2008 called My Starbucks Idea, designed to collect suggestions for products or services and feedback from customers. During the first year of the program, My Starbucks Idea generated 70,000 ideas through the site and approximately 50 changes based on customer suggestions were implemented.

Figure of merit A figure of merit is a quantity used to characterize the performance of a device, system or method, relative to its alternatives. In commerce, such figures are often used as a marketing tool to convince consumers to

235 choose a particular brand. For example, “Four out of five Dentists agree that such-and-such tooth paste makes teeth whiter.” The figure of merit in this example is 4/5 or four-fifths.

Freebie marketing Freebie marketing, also known as the razor and blades business model, is a business model wherein one item is sold at a low price (or given away for free) in order to increase sales of a complementary good. This is why bars put out peanuts or pretzels for free. Salty peanuts and pretzels make you thirsty, and when you’re thirsty you buy drinks. Diabolical!

It is distinct from loss leader marketing and free sample marketing, which do not depend on complementarily of products or services.

Though the concept and its proverbial example "Give 'em the razor; sell 'em the blades" are widely credited to King Camp Gillette, the inventor of the disposable safety razor and founder of Gillette Safety Razor Company, in fact Gillette did not originate this model.

Free gifts A free gift is one for which the giver is not trying to get something in return

Free lunch The phrase free lunch, in U. S. literature from about 1870 to 1920, refers to a tradition once common in saloons in many places in the United States. These establishments included a "free" lunch, varying from rudimentary to quite elaborate, with the purchase of at least one drink. These free lunches were typically worth far more than the price of a single drink. The saloon- keeper relied on the expectation that most customers would buy more than one drink, and that the practice would build patronage for other times of day.

Gillette The usual story about Gillette is that he realized that a disposable razor blade would not only be convenient, but also generate a continuous revenue stream. To foster that stream, he sold razors at an artificially low price to create the market for the blades.

236 But in fact Gillette razors were expensive when they were first introduced, and the price only went down after his patents expired: it was his competitors who invented the razors-and-blades model.

Applications Freebie marketing has been used in business models for many years. The Gillette company still uses this approach, often sending disposable safety razors in the mail to young men near their 18th birthday, packaging them as giveaways at public events that Gillette has sponsored, et cetera.

Standard Oil With a monopoly in the American domestic market, Standard Oil and its owner, John D. Rockefeller, looked to China to expand their business. Representatives of Standard Oil gave away eight million kerosene lamps for free or at greatly reduced prices to increase the demand for kerosene.

Among American businessmen, this gave rise to the catchphrase "Oil for the lamps of China."

Comcast Comcast often gives away DVRs to its subscribing customers. However, the cost of giving away each free DVR is offset by a $19.95 installation fee as well as a $13.95 monthly subscription fee to use the machine. Based on an average assumed cost of $250 per DVR box to Comcast, after 18 months the loss would balance out and begin to generate a profit.

Issues The freebie marketing model may be threatened if the price of the high margin consumables in question falls due to competition. For the freebie market to be successful the company must have an effective monopoly on the corresponding goods. (Predatory pricing to destroy a smaller competitor is not covered here.) This can make the practice illegal.

Specific general examples (I’ll follow with a great massage example, so keep reading)

Printers Computer printer manufacturers have gone through extensive efforts to make sure that their printers are incompatible with lower cost after-market

237 ink cartridges and refilled cartridges. This is because the printers are often sold at or below cost to generate sales of proprietary cartridges which will generate profits for the company over the life of the equipment. In fact, in certain cases, the cost of replacing disposable ink or toner may even approach the cost of buying new equipment with included cartridges, although included cartridges are often 'starter' cartridges that are only partially filled. Methods of vendor lock-in include designing the cartridges in a way that makes it possible to patent certain parts or aspects, or invoking the Digital Millennium Copyright Act to prohibit reverse engineering by third-party ink manufacturers. Another method entails completely disabling the printer when a non-proprietary ink cartridge is placed into the machine, instead of merely issuing an ignorable message that a non-genuine (yet still fully functional) cartridge was installed.

In Lexmark Int'l v. Static Control Components the United States Court of Appeals for the Sixth Circuit ruled that circumvention of Lexmark's ink cartridge lock does not violate the DMCA. On the other hand, in August 2005, Lexmark won a case in the United States that allows them to sue certain large customers for violating their boxwrap license.

Video games This section does not cite any references or sources. Please help improve this section by adding citations to reliable sources. Unsourced material may be challenged and removed. (March 2012) Atari had a similar problem in the 1980s with Atari 2600 games. Atari was initially the only developer and publisher of games for the 2600; it sold the 2600 itself at cost and relied on the games for profit. When several programmers left to found Activision and began publishing cheaper games of comparable quality, Atari was left without a source of profit. Lawsuits to block Activision were unsuccessful. Atari added measures to ensure games were from licensed producers only for its later-produced 5200 and 7800 consoles.

In recent times, video game consoles have often been sold at a loss while software and accessory sales are highly profitable to the console manufacturer. For this reason, console manufacturers aggressively protect their profit margin against piracy by pursuing legal action against carriers of modchips and jailbreaks. Particularly in the sixth generation era and beyond, Sony and Microsoft, with their PlayStation 2 and Xbox, had prohibitively high manufacturing costs so they were forced to sell their

238 consoles at a loss, and these losses widened especially in 2002–2003 when both sides tried to grab market share with price cuts. Nintendo had a different strategy with its GameCube, which was considerably less expensive to produce than its rivals, so it retailed at break-even or higher prices. In the following generation of consoles, both Sony and Microsoft have continued to sell their consoles, the PlayStation 3 and Xbox 360 respectively, at a loss, with the practice continuing in the most recent generation with the Playstation 4 and Xbox One.

Nuclear energy Ever since the beginning of the commercial nuclear power industry, the business model has centered around selling the reactor at cost (or at a loss) and making its profits off fuel-supply contracts by exploiting vendor lock-in.

Other goods Consumers may also find other uses for the subsidized product rather than utilize it for the company's intended purpose, which adversely affects revenue streams. This has happened to "free" personal computers with expensive proprietary Internet services and contributed to the failure of the CueCat barcode scanner.

Affiliate Marketing makes extensive use of the freebie marketing business model, as many products are promoted as having a "free" trial, that entice consumers to sample the product and pay only for shipping and handling. Advertisers of heavily-promoted products such as Acai Berry targeting dieters hope the consumer will continue paying for continuous shipments of the product at inflated prices, and this business model has been met with much success.

Websites specializing in Sampling and discounts have proven to be very popular with economy-minded consumers, who visit sites which utilize freebies as link bait. The business model of these sites is to attract visitors that will click on AdSense and complete affiliate offers.

Tying Tying is a variation of freebie marketing that is often illegal when the products are not naturally related (for example, requiring a bookstore to stock up on an unpopular title before allowing them to purchase a bestseller). Tying is also known in some markets as 'Third Line Forcing.'

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Some kinds of tying, especially by contract, have historically been regarded as anti-competitive practices. The basic idea is that consumers are harmed by being forced to buy an undesired good (the tied good) to purchase a good they actually want (the tying good), and so would prefer that the goods be sold separately. The company doing this bundling may have a significantly large market share so that it may impose the tie on consumers, despite the forces of market competition. The tie may also harm other companies in the market for the tied good, or who sell only single components.

Another common example comes from how cable and satellite TV providers contract with content producers. The production company pays to produce 25 channels and forces the cable provider to pay for 10 low- audience channels to get a popular channel. Since cable providers lose customers without the popular channel, they are forced to purchase many other channels even if they have a very small viewing audience.

Legal issues Microsoft was accused of releasing Internet Explorer at no charge to destroy Netscape's market (see United States v. Microsoft).

Freebie marketing in massage therapy Okay I know this is all you care about, thanks for being patient. One of the teachers at my massage school used to own a spa where she gave local businesses in town a stack of coupons good for 15 minutes of free massage. She told them they could give them to their customers as “thank you” notes or even to their employees.

When people called in to make the appointment she would book them for the last appointment of the day and when they came in she would tell them “You can have the 15 minutes for free, but if you would like to upgrade it to an hour it would only cost…”

She said that the most of the people went for the upgrade, if not right away they changed their mind when the 15 minutes was over, because as we know, 15 minutes isn’t nearly long enough when a massage feels good.

She admitted that there were people that just came in for the free 15 minutes and that was it, but she saw it as an investment, they got a sample

240 of how good it was, and for a lot of people it was their first massage experience, so she was locked in as their therapist if they decided that they liked it.

Guerrilla marketing Now at first glance it might seem like a strategy with the word “guerilla” in the name might be unethical, but it isn’t necessarily.

The term "guerrilla marketing" comes from guerrilla warfare, which employs atypical tactics to achieve an objective. Guerilla tactics are used when you are fighting a war against a foe that has far greater resources than you. Sometimes the guerillas are the good guys! For example, the founding fathers fought a guerilla war against the British Empire to win our independence.

If you feel like your massage business is competing with businesses with a lot more money and resources than you have than guerilla marketing might be for you.

Guerrilla marketing was originally a marketing strategy in which low-cost, unconventional means (including the use of sticker bombing, flyer posting, etc.) were used in a (generally) localized fashion to draw attention to an idea, product, or service. Today, guerrilla marketing may also include promotion through a network of individuals, groups, or organizations working to popularize a product or idea by use of such strategies as flash mobs, viral marketing campaigns, or internet marketing.

Guerrilla marketing was initially used by small and medium sized businesses, but it is increasingly being adopted by big business. The concept of guerrilla marketing rises from an unconventional system of promotion that relies on patience, energy, and imagination rather than a big advertising budget. Typically, guerrilla marketing campaigns are unexpected and unconventional, potentially interactive, with consumers targeted in unexpected places. The objective of guerrilla marketing is to create a unique, engaging, and thought-provoking concept to generate buzz.

Guerrilla marketing involves unusual approaches to advertising, such as targeted promotional-driven encounters in public places, street giveaways of products, PR stunts, flash-mob presentations, or any unconventional

241 marketing intended to get results and create a memorable brand experience. Modern approaches to guerrilla marketing often utilize mobile- digital technologies. This enables advertisers to engage consumers emotionally, and frequently enough, to hopefully cause a campaign to turn viral, thereby realizing maximum returns on a relatively low initial investment.

The guerrilla marketing promotion strategy was first identified by Jay Conrad Levinson in his book Guerrilla Marketing (1984). The book describes hundreds of "guerrilla marketing weapons" in use at the time. Guerrilla marketers need to be creative in devising unconventional methods of promotion to maintain the public's interest in a product or service. Levinson writes that when implementing guerrilla marketing tactics, smaller organizations and entrepreneurs are actually at an advantage. Ultimately, however, guerrilla marketers must "deliver the goods." In The Guerrilla Marketing Handbook, the authors write: "...in order to sell a product or a service, a company must establish a relationship with the customer. It must build trust and support the customer's needs, and it must provide a product that delivers the promised benefits..."

Online Guerilla Marketing The web is rife with examples of guerrilla marketing, to the extent that many of us don't notice its presence - until a particularly successful campaign arises. The desire for instant gratification of internet users provides an avenue for guerrilla marketing by allowing businesses to combine wait marketing with guerrilla tactics. Simple examples consist of using 'loading' pages or image alt texts to display an entertaining or informative message to users waiting to access the content they were trying to get to. As users dislike waiting with no occupation on the web, it is essential, and easy, to capture their attention this way. Other website methods include interesting web features such as engaging landing pages.

Many online marketing strategies also use social media such as Facebook and LinkedIn to begin campaigns, shareable features and event host events. Other companies run competitions or discounts based on encouraging users to share or create content related to their product. Viral videos are an incredibly popular form of guerrilla marketing in which companies film entertaining or surprising videos that internet users are likely to share and enjoy, that subtly advertise their service or product. Some companies such as Google even create interactive elements like the

242 themed Google logo games to spark interest and engagement. These dynamic guerrilla marking tactics can become news globally and give businesses considerable publicity.

Undercover Marketing Undercover marketing (also known as "stealth marketing", or, by its detractors, "roach baiting") is where consumers do not realize they are being marketed to. Buzz campaigns can reach consumers isolated from all other media, and unlike conventional media, consumers tend to trust it more often, as it is usually coming from a friend or acquaintance. Overall, the person doing the marketing must look and sound like a peer of their target audience, without any signs of an ulterior motive for endorsing the item.

Example Sony Ericsson used an undercover campaign in 2002 when they hired 60 actors in ten major cities and had them accost strangers and ask them: "Would you mind taking my picture?" The actor then handed the target a brand new picture phone while talking about how cool the new device was. "And thus an act of civility was converted into a branding event.

Strategical risk Because of the nature of guerrilla marketing, the message and objective must be clearly defined in order to avoid being misunderstood. Misinterpretation by the targeted audience of the message intended to be promoted is a risk. Word-of-mouth advertising does not always stay focused enough to present the intended message. The rumor-like spread of word-of-mouth marketing is uncontrollable once released, and can result in a misrepresentation of the message or confusion about a brand.

Another risk involves wrongly timed (or wrongly placed) events, which may actually be perceived to be against the interests of the consumer. For instance, in an ill-conceived promotion which took place on January 31, 2007, several magnetic circuit boards—each with an flashing LED cartoon figure—were attached to metal surfaces in and around Boston, Massachusetts to promote the animated series, Aqua Teen Hunger Force. The circuit boards were mistakenly taken for explosive devices. Several subway stations; bridges; and a portion of Interstate 93 were closed as police examined, removed, and (in some cases) destroyed the devices.

243 Some guerrilla marketing may incite the ire of local authorities. Then risks are assessed and may still be considered worthwhile. Such was the case in Houston, Texas, when BMW Auto's ad agency, Street Factory Media, attached a replica of a Mini-Cooper (made of Styrofoam), to the side of a downtown building in January 2013. For the small cost of a city-issued fine, the company received front-page advertising in the Houston Chronicle.

Another problem presents itself if marketers fail to properly execute an undercover campaign. They run considerable risk of backlash. An example of this can be found in Sony Entertainment's on-line debacle with Zipatoni. The company attempted to promote Zipatoni through a stealth marketing campaign, which was quickly detected by the internet community, resulting in Sony immediately experiencing a backlash from video game enthusiasts.

Horizontal integration In business, horizontal integration is a strategy where a company creates or acquires production units for outputs which are alike - either complementary or competitive. One example would be when a company acquires competitors in the same industry doing the same stage of production for the creation of a monopoly. Another example is the management of a group of products which are alike, yet at different price points, complexities, and qualities. This strategy may reduce competition and increase market share by using economies of scale. For example, a car manufacturer acquiring its competitor who does exactly the same thing.

Horizontal integration is the opposite to vertical integration, where companies integrate multiple stages of production of a small number of production units.

Benefits of horizontal integration Benefits of horizontal integration to both the firm and society may include economies of scale and economies of scope. For the firm, horizontal integration may provide a strengthened presence in the reference market. It may also allow the horizontally integrated firm to engage in monopoly pricing, which is disadvantageous to society as a whole and which may cause regulators to ban or constrain horizontal integration.

Media terms

244 Media critics, such as Robert W. McChesney, have noted that the current trend within the entertainment industry has been toward the increased concentration of media ownership into the hands of a smaller number of transmedia and transnational conglomerates. Media is seen to amass in center where wealthy individuals have the ability to purchase such ventures (e.g. Rupert Murdoch).

Horizontal integration, that is the consolidation of holdings across multiple industries, has displaced the old vertical integration of the Hollywood studios. The idea of owning many media outlets, which run almost the same content, is considered to be very productive, since it requires only minor changes of format and information to use in multiple media forms. For example, within a conglomerate, the content used in broadcasting television would be used in broadcasting radio as well, or the content used in hard copy of the newspaper would also be used in online newspaper website.

What emerged are new strategies of content development and distribution designed to increase the “synergy’ between the different divisions of the same company. Studios seek content that can move fluidly across media channels.

This can be seen in massage therapy when a massage therapist rents out rooms in a business to other therapists. Think about it, they are actually your competitors, but if they are paying you rent to do their business in your office, they are kind of working for you. We’ve been doing it for years, but now you know that it actually has a name, it’s called horizontal integration .

Influencer marketing Influencer marketing, (also Influence Marketing) is a form of marketing that has emerged from a variety of recent practices and studies, in which focus is placed on specific key individuals (or types of individual) rather than the target market as a whole. It identifies the individuals that have influence over potential buyers, and orients marketing activities around these influencers.

Influencers may be potential buyers themselves, or they may be third parties. These third parties exist either in the supply chain (retailers,

245 manufacturers, etc.) or may be so-called value-added influencers (such as journalists, academics, industry analysts, professional advisers, and so on).

The first approach to that theory comes from a communication classic, The People´s Choice (Lazerfeld and Katz), a 1940 study on political communication that was also known as Multistep flow model, that claims that the majority of people are influenced by secondhand information and opinion leaders.

What is “Influence”? Most discussion on the generic topic of social influence centers on compliance and persuasion in a social environment, as exemplified in Robert Cialdini’s book Influence: Science and Practice. In the context of Influencer Marketing, influence is less about argument and coercion to a particular point of view, and more about loose interactions between various parties in a community. Influence is often equated to advocacy, but may also be negative, and is thus related to concepts of promoters and detractors.

Influencer Marketing as a Marketing Discipline Influencer Marketing, as increasingly practiced in a commercial context, comprises four main activities: Identifying influencers, and ranking them in order of importance. Marketing to influencers, to increase awareness of the firm within the influencer community Marketing through influencers, using influencers to increase market awareness of the firm amongst target markets Marketing with influencers, turning influencers into advocates of the firm. Influencer Marketing is enhanced by a continual evaluation activity that sits alongside the four main activities.

Influencer Marketing is not synonymous with word of mouth marketing (WOM), but influence may be transmitted in this manner. Thus WOM is a core part of the mechanics of Influencer Marketing.

There are substantial differences in the definition of what an influencer is. Peck defines influencers as "a range of third parties who exercise influence over the organization and its potential customers". Similarly, Brown and Hayes define an influencer as "a third party who significantly shapes the

246 customer's purchasing decision, but may never be accountable for it.". An influencer also "acts as a trusted source of information in a particular marketplace and may play a significant role in the purchasing behaviors of a portion of consumers." Keller and Berry note that influencers are activists, are well-connected, have impact, have active minds, and are trendsetters, though this set of attributes is aligned specifically to consumer markets.

Exactly what is included in Influencer Marketing depends on the context (B2C or B2B) and the medium of influence transmission (online or offline, or both). But it is increasingly accepted that companies are keen to identify and engage with influencers. As Keller and Berry note, " Business is working harder and paying more to pursue people who are trying to watch and listen less to its messages." Targeting influencers is seen as a means of amplifying marketing messages, in order to counteract the growing tendency of prospective customers to ignore marketing.

Identifying influencers The first step in influencer marketing is to identify influencers. Influencers are specific to discrete market segments, and are used as conduits to the entire target segment. While there are lists of generic influencers (such as the Time 100) they have limited use in marketing programs targeted at specific segments. You can use social media tools to find influencers based on keywords or those that belong to specific industry verticals.

Additionally, market research techniques can be used to identify influencers, using pre-defined criteria to determine the extent and type of influence. For example, Keller and Berry propose five attributes of influencers:

Activists: influencers get involved, with their communities, political movements, charities and so on. Connected: influencers have large social networks Impact: influencers are looked up to and are trusted by others Active minds: influencers have multiple and diverse interests Trendsetters: influencers tend to be early adopters (or leavers) in markets

Most of the literature on influencers focuses on consumer markets. There is less insight into business-to-business influencers. A key distinction between consumer and business markets is that most of the focus in

247 consumer markets is on consumer influencers themselves. This is because word of mouth communication is prevalent in consumer environments. In business marketing, influencers are people that affect a sale, but are typically removed from the actual purchase decision. Consultants, analysts, journalists, academics, regulators, standards bodies are examples of business influencers.

Not all business influencers are equal. Some have more influence than others, and some mechanism of ranking is required, to distinguish between key influencers and less impactful people. A model for ranking business influencers has been developed by Influencer50, thus: Market reach – the number of people an individual has the ability to connect with. Independence – whether an influencer has a vested interest in promoting a particular point of view. Frequency of Impact – the number of opportunities an individual has to influence buying decisions. Expertise – how much of a subject matter expert is the influencer. Persuasiveness - the degree of consequence in ignoring an influencer's advice. Thoroughness of role - the extent to which influence is exerted across the decision lifecycle.

Several other companies including Ammo Marketing, Liquid Intelligence and DesignKarma Inc. in the US, Agent Wildfire in Canada, SCB Partners in Europe and Vocanic in Asia have developed their own proprietary methodologies for identifying and targeting influencers for a market (or market sector).

Fred Reichheld, a consultant at Bain & Company, has developed a methodology to determine the extent to which firms' growth is influenced by customers' propensity to make referrals to colleagues. Reichheld distills his research down to a single question: how likely is it that you would recommend company X to a friend or colleague? From answers to this question, a Net Promoter Score is determined, which correlates strongly with a firm's growth rate.

Using online social media tools to identify influencers

248 Web services can be used to crawl social media sites for users that exert influence in their respective communities. Exactly how much is the user engaging the online community? The social influencer marketing firm then asks those influencers to try client products/services and discuss them on their respective social networks. Clients can then observe, through an enhanced digital dashboard, with metrics that measure the dissemination of brand mentions across numerous web platforms.

There are at least 70 companies offering online influence measurement. Advocates of this online-only approach claim that online activity reflects (or pre-empts) the trends in offline transactions. For example, Razorfish released one of the first social influencer marketing reports, entitled Fluent. The report discusses many theories surrounding social marketing, including the importance of the push/pull dynamic and online consumer empowerment, authenticity and importance of buzz marketing.

In addition, online activity can be a core part of offline decision making, as consumers research products and review sites.

Critics of this online-only approach argue that only researching online sources misses critical influential individuals and inputs. They note that much influential exchange of information occurs in the offline world, and is not captured in online media. Indeed, the majority of consumer exchanges occurs face-to-face, not in an online environment, as evidenced by Carl. He notes that "an overwhelming majority of WOM episodes (nearly 80%) ... occur in face-to-face interpersonal settings, while online WOM accounted for only seven to ten percent of the reported (WOM) episodes."

Carl concludes that "The majority of the WOM action still seems to be happening in the offline world. These findings are especially provocative since they emerge at a time when more and more organizations are paying attention to how their brands are discussed online and recent academic research has focused on online WOM. Thus it is important for organizations to keep both online and offline conversations on their radar screen."

Keller Fay announced in 2007 that "While experts have previously estimated that 80% of marketing-relevant word of mouth takes place “offline” (i.e., face-to-face or via telephone), the new results indicate that this figure is even higher - 92%."

249 More recently, Nate Elliott at Forrester observed that "the huge majority of users influence each other face to face rather than through social online channels like blogs and social networks."

And the Fluent report, though generally orientated towards online measures admits that "it is necessary to remember the effect that offline social activity has on purchasing decisions." It also notes that survey "respondents trust offline friends most, with 73 percent indicating near or complete trust versus just 33 percent for online friends."

Influencer ecosystems and roles Sources of influencers can be varied. Marketers traditionally target influencers that are easy to identify, such as press, industry analysts and high profile executives. For most B2C purchases, however, influencers might include people known to the purchaser and the retailer staff. In higher value B2B transactions the community of influencers may be wide and varied, and include consultants, government-backed regulators, financiers and user communities.

Forrester analyst Michael Speyer notes that, for small and medium-size business, "IT sales are influenced by many parties, including peers, consultants, bloggers, and technology resellers". He advises that "Vendors need to identify and characterize the influencers in their market. This requires a comprehensive influencer identification program and the establishment of criteria for ranking influencer impact on the decision process."

As well as a variety of influencer sources, influencers can play a variety of roles at different times in a decision process. This idea has been developed in Influencer Marketing by Brown & Hayes. They map out how and when particular types of influencer affect the decision process. This then enables marketers to selectively target influencers depending on their individual profile of influence.

Influencer roles through the decision process The influence of bloggers and other social media users is a topic of much discussion. This is covered in depth in Paul Gillin’s The New Influencers. Brown & Hayes also cover the subject but are less convinced of the importance of the impact of social media, particularly in B2B settings.

250 One way you can use influencer marketing is by targeting doctors and chiropractors. Write a nice letter explaining the medical benefits of massage therapy for specific conditions, and then invite the doctor to sample your business for free (or to send someone from his/her staff), this way they can recommend you to their patients in good faith.

Loyalty marketing Loyalty marketing is an approach to marketing, in which a business focuses on growing and retaining existing customers through incentives. Branding, product marketing and loyalty marketing all form part of the customer proposition – the subjective assessment by the customer of whether to purchase a brand or not based on the integrated combination of the value they receive from each of these marketing disciplines.

The discipline of customer loyalty marketing has been around for many years, but expansions from it merely being a model for conducting business to becoming a vehicle for marketing and advertising have made it omnipresent in consumer marketing organizations since the mid- to late- 1990s. Some of the newer loyalty marketing industry insiders, such as Fred Reichheld, have claimed a strong link between customer loyalty marketing and customer referral. In recent years, a new marketing discipline called "customer advocacy marketing" has been combined with or replaced "customer loyalty marketing." To the general public, many airline miles programs, hotel frequent guest programs and credit card incentive programs are the most visible customer loyalty marketing programs.

Premiums Premiums are items that a retail customer can receive by redeeming proofs of purchase from a specific product or store. This was one of the first loyalty marketing programs.

Early premium programs Beginning in 1793, a U.S. merchant started giving out copper tokens which could be collected by the consumer and exchanged for items in the store. This practice caught on and was used by many merchants throughout the 19th century. Sweet Home laundry soap, a product of the B. A. Babbit Company, came with certificates that could be collected and redeemed for color lithographs. Beginning in 1872, the Grand Union Tea Company gave tickets to customers that could be exchanged for merchandise in the company catalog of Grand Union stores.

251

Trading stamps The first trading stamps were introduced in 1891, the Blue Stamp Trading System, where stamps affixed to booklets could be redeemed for store products. The Sperry and Hutchinson Company, started in 1896 in Jackson, Michigan, was the first third-party provider of trading stamps for various companies, including dry goods dealers, gas stations and later supermarkets. S&H Green Stamps, as the company was commonly called, opened its first redemption center in 1897. Customers could take their filled booklets of "green stamps" and redeem them for household products, kitchen items, and personal items. When the G.I.s returned from World War II the trading stamps business took off when numerous third-party companies created their own trading stamp programs to offer to supermarkets and other retailers.

Marketing through children Marketers of retail products used programs targeted at children to sell to their parents through the use of premiums. Kellogg's Corn Flakes had the first cereal premium with The Funny Jungleland Moving Pictures Book. The book was originally available as a prize that was given to the customer in the store with the purchase of two packages of the cereal. But in 1909, Kelloggs changed the book give-away to a premium mail-in offer for the cost of a dime. Over 2.5 million copies of the book were distributed in different editions over a period of 23 years.

At the beginning of the Second World War, radio was a big player in the promotion and distribution of premiums, usually toys that were closely related to the radio program. There were many radio shows that offered premiums to their listeners, but Captain Midnight was one of the best known. The early sponsor of Captain Midnight was Skelly Oil, and parents could get forms to mail-in for radio premiums at the gas stations. Later, Ovaltine became the sponsor of Captain Midnight, and it continued the premiums through advertising on the labels and foil tops of Ovaltine that could be collected to exchange for Captain Midnight premiums and offering membership to the "Secret Squadron".

Boxtops In 1929, Betty Crocker issued coupons that could be used to redeem for premiums like free flatware. In 1937 the coupons were printed on the outside of packages, and later the Betty Crocker points program produced

252 a popular reward catalog from which customers could pick rewards using their points. In 2006, it was announced that the Betty Crocker Catalog was going out of business and that all points needed to be redeemed by December 15, 2006. With it, one of the earliest loyalty programs ended a 77 year tradition.

Prizes Prizes are promotional items—small toys, games, trading cards, collectables, and other small items of nominal value—found in packages of brand-name retail products (or available from the retailer at the time of purchase) that are included in the price of the product (at no extra cost) with the intent to boost sales.

Tobacco inserts Some of the earliest prizes were cigarette cards — trade cards advertising the product (not to be confused with trading cards) that were inserted into paper packs of cigarettes as stiffeners to protect the contents. Allan and Ginter in the U.S. in 1886, and British company W.D. & H.O. Wills in 1888, were the first tobacco companies to print advertisements and, a couple years later, lithograph pictures on the cards with an encyclopedic variety of topics from nature to war to sports — subjects that appealed to men who smoked. By 1900, there were thousands of tobacco card sets manufactured by 300 different companies. Following the success of cigarette cards, trade cards were produced by manufacturers of other products and included in the product or handed to the customer by the store clerk at the time of purchase. World War II put an end to cigarette card production due to limited paper resources, and after the war cigarette cards never really made a comeback. After that collectors of prizes from retail products took to collecting tea cards in the UK and bubble gum cards in the US.

Trade cards to trading cards The first baseball cards were trade cards featuring the Brooklyn Atlantics produced in 1868 by Peck and Snyder, a sporting goods company that manufactured baseball equipment. In 1869, Peck and Snyder trade cards featured the first professional team, the Red Stockings. Most of the baseball cards around the beginning of the 20th century came in candy and tobacco products produced by such companies as Breisch-Williams

253 confectionery company of Oxford, Pennsylvania, American Caramel Company, the Imperial Tobacco Company of Canada, and Cabañas, a Cuban cigar manufacturer. In fact it is a baseball set, known as the T-106 tobacco card set, distributed by the American Tobacco Company in 1909 that is considered by collectors to be the most popular set of cigarette cards. In 1933, Goudey Gum Company of Boston issued baseball cards with players biographies on the backs and was the first to put baseball cards in bubble gum. Bowman Gum of Philadelphia issued its first baseball cards in 1948 and became the biggest issuer of baseball cards from 1948 to 1952.

Modern packaged foods The most famous use of prizes in the United States (and the word "prize" in this context) is Cracker Jack brand popcorn confection. Prizes have been inserted into every package of Cracker Jack continuously since 1912. W.K. Kellogg was the first to introduce prizes in boxes of cereal. The marketing strategy that he established has produced thousands of different cereal box prizes that have been distributed by the tens of billions. Frito-Lay is a world icon in the field of in-package prizes. Besides being the current owner of Cracker Jack, the U.S. popcorn confection brand known for the "Prize Inside", Frito-Lay also regularly includes tazos and tattoos in packages of Lay's chips worldwide. In parts of Latin America, Frito-Lay has even introduced a brand called Cheetos Sorpresa (English: Surprise), which includes a licensed prize (from movies, television, and video games) in every 29–gram bag.

Direct marketing pioneers By creating a direct marketing industry through his mail order catalogue, Aaron Montgomery Ward would unknowingly enable the creation of a powerful global network that would include everything from mailing, to mail order, to telemarketing and lastly to social medias. Together Ward and his [long time] competitor Sears changed the direction of the American marketplace by introducing the concept of individuality with the term consumption, allowing therefore the generations of today to take full control of their consumption behaviors and all of this in complete privacy. Today, the mail order catalogue industry Montgomery funded is worth approximately 100 billions of dollars, and generates over 2 trillion only in [incremental] sales and supports till this day an estimated 10.9 million jobs either directly related to marketing industry or dependent upon it.

254 Mail order pioneer Aaron Montgomery Ward knew that by using the technique of selling product directly to the consumer at appealing prices could, if executed effectively and efficiently, revolutionize the market industry and therefore be used as an innovative model for marketing products and creating customer loyalty. The term "direct marketing" was coined long after Montgomery Ward's time. In 1967 Lester Wunderman identified, named, and defined "direct marketing". Wunderman — considered to be the father of contemporary direct marketing — is behind the creation of the toll-free 1-800 number and numerous mail order based loyalty marketing programs including the Columbia Record Club, the magazine subscription card, and the American Express Customer Rewards program.

Modern consumer rewards programs

Frequent flyers On May 1, 1981 American Airlines launched the first full-scale loyalty marketing program of the modern era with the AAdvantage frequent flyer program. This revolutionary program was the first to reward "frequent fliers" with reward miles that could be accumulated and later redeemed for free travel. Many airlines and travel providers saw the incredible value in providing customers with an incentive to use a company exclusively and be rewarded for their loyalty. Within a few years, dozens of travel industry companies launched similar programs. The AAdvantage program now boasts over 50 million active members.

Card linked offers The early part of 2010 saw the rise of Card Linked Offers (CLOs) as a new loyalty marketing technique for brands, retailers and financial institutions, stemming from a rise in popularity of both mobile payment and coupons. CLOs connect offers or discounts directly to a consumer’s credit card or debit card, which can then be redeemed at the point of sale. CLOs have been implemented by American Express and Groupon and CLO technology has been developed by companies such as Cartera Commerce, Womply, Cardlytics, Birdback, Clovr Media, and Offermatic. In order to receive and use CLOs, consumers must willingly opt into a CLO program and provide their credit/debit card information. When consumers see relevant CLO-enabled advertisements and product offers while browsing online, using a mobile device, watching TV, reading a newspaper or magazine or listening to the radio they can click, text or scan a QR code to

255 link the CLO-enabled ad directly to their credit/debit card. After consumers make a purchase at the designated retail location, the savings appeared are credited directly to their bank, credit card or PayPal account. As such, CLOs eliminate point-of-sale integration, mail-in rebates and paper coupons. Offers are typically based upon consumer preferences and previous purchase history. Prior to 2010, static CLOs existed for many years in the form of bank issued loyalty offers, such as points or savings on travel purchases.

Loyalty marketing impact Many loyalty programs have changed the way consumers interact with the companies from which they purchase products or services from and how much consumers spend. Many consumers in the US and Europe have become quite accustomed to the rewards and incentives they receive by being a "card carrying" member of an airline, hotel or car rental program. In addition, research from Chris X. Moloney shows that nearly half of all credit card users in the US utilize a points-based rewards program.

In recent years, the competition for high income customers has led many of these loyalty marketing program providers to provide significant perks that deliver value well beyond reward points or miles. Both American's AAdvantage program and Starwood Hotels' Preferred Guest program have received industry awards, called "Freddie Awards" by Inside Flyer Magazine and its publisher Randy Petersen for providing perks that customers value highly. These perks have become as important to many travelers as their reward miles according to research.

In his book, Loyalty Rules!, Fred Reichheld details the value to customer referral on the growth and financial performance of dozens of leading US firms. Reichheld purports that the measurement of company advocates, or promoters, is the strongest single measurable correlation between customers and corporate performance. Similarly, Chris X. Moloney has presented new findings (Loyalty World London 2006) that showed a magnetic value to a company to promote and measure customer referrals and advocacy via research and marketing.

Loyalty marketing and the loyalty business model The loyalty business model relies on training of employees to achieve a specific paradigm: quality of product or service leads to customer satisfaction, which leads to customer loyalty, which leads to profitability.

256 Loyalty marketing is an extension of that effort, relying upon word-of-mouth and advertising to draw upon the positive experiences of those exposed to loyalty business model inspired ventures to attract new customers. Fred Reichheld makes the point in his books that one can leverage the "power of extension" to draw new customers.

The rapid expansion of frequent-flyer programs is due to the fact that loyalty marketing relies on the earned loyalty of current customers to attract new loyalty from future customers. Incentive programs that are exclusive must strike a balance between increasing benefits for new customers over any existing loyalty plan they are currently in and keeping existing customers from moving to new plans. Hallmark did this through devising a program that directly rewarded customers not only for buying merchandise and utilizing Hallmark.com, but gaining additional benefits through referring their friends.

The most recent loyalty marketing programs rely on viral marketing techniques to spread word of incentive and inducement programs through word of mouth.

A massage therapy business can easily incorporate a loyalty program by tracking customer massages and offering rewards. The simplest way is the simple card stamp method: You give your customers a card with spaces for you to stamp when they come in for a massage, with the incentive of getting a free massage after paying for a set amount.

Multi-level marketing Multi-level marketing (MLM) is a marketing strategy in which the sales force is compensated not only for sales they personally generate, but also for the sales of the other salespeople that they recruit. This recruited sales force is referred to as the participant's "downline", and can provide multiple levels of compensation. Other terms used for MLM include pyramid selling, network marketing, and referral marketing. According to the US FTC, some companies that use multi-level marketing exploit members of their networks and constitute illegal pyramid schemes.

You might not think this has anything to do with a massage business, and you are right, there is no real MLM application to selling your massage services to customers. However as we mentioned in Chapter 1, many

257 massage therapists sell products out of their practice as a way to increase revenue.

One of the most common types of product for massage therapists to sell are nutritional supplements and herbs, both of which have a long tracke record of being of questionable content AND are sold in a MLM format-so this section is very relevant to those engaging in the practice.

Most commonly, the salespeople are expected to sell products directly to consumers by means of relationship referrals and word of mouth marketing. Some people use direct selling as a synonym for MLM, although MLM is only one type of direct selling.

Companies that use MLM models for compensation have been a frequent subject of criticism and lawsuits. Criticism has focused on their similarity to illegal pyramid schemes, price fixing of products, high initial entry costs (for marketing kit and first products), emphasis on recruitment of others over actual sales, encouraging if not requiring members to purchase and use the company's products, exploitation of personal relationships as both sales and recruiting targets, complex and exaggerated compensation schemes, the company and/or leading distributors making major money off training events and materials, and cult-like techniques which some groups use to enhance their members' enthusiasm and devotion.

Direct selling, network marketing, and multi-level marketing Network marketing and multi-level marketing have been described by author Dominique Xardel as being synonymous, and as methods of direct selling. According to Xardel, direct selling and network marketing refer to the distribution system, while the term "multi-level marketing" describes the compensation plan. Other terms that are sometimes used to describe multi- level marketing include "word-of-mouth marketing", "interactive distribution", and "relationship marketing". Critics have argued that the use of different terms and "buzzwords" is an effort to distinguish multi-level marketing from illegal Ponzi schemes, chain letters, and consumer fraud scams. Some sources classify multi-level marketing as a form of direct selling rather than being direct selling. The Direct Selling Association, a lobbying group for the multi-level marketing industry, reported that in 1990 twenty-five percent of members used MLM, growing to 77.3 percent in 1999. Companies such as Avon, Electrolux, Tupperware, and Kirby all originally used single level marketing to sell their goods and later

258 introduced multi-level compensation plans. By 2009, 94.2% of members were using MLM, accounting for 99.6% of sellers, and 97.1% of sales. The DSA has approximately 200 members while it is estimated there are over 1,000 firms using multi-level marketing in the United States alone.

The origin of multi-level marketing is often disputed; but multi-level marketing style businesses existed in the 1920s, 1930s with Nutrilite or California Perfume Company renamed as “Avon Products”, 1940s with the California Vitamin Company, 1960s, and even as late as the 1970s.

Independent non-salaried participants, referred to as distributors (or associates, independent business owners, dealers, franchise owners, independent agents, etc.), are authorised to distribute the company's products or services. They are awarded their own immediate retail profit from customers plus commission from the company, not downlines, through a multi-level marketing compensation plan, which is based upon the volume of products sold through their own sales efforts as well as that of their downline organization.

Independent distributors develop their organizations by either building an active consumer network, who buy direct from the company, or by recruiting a downline of independent distributors who also build a consumer network base, thereby expanding the overall organization. Additionally, distributors can also earn a profit by retailing products they purchased from the company at wholesale price.

Several sources have commented on the income level of specific MLMs or MLMs in general:

The Times: "The Government investigation claims to have revealed that just 10% of Amway's agents in Britain make any profit, with less than one in ten selling a single item of the group's products." Eric Scheibeler, a high level "Emerald" Amway member: "UK Justice Norris found in 2008 that out of an IBO [Independent Business Owners] population of 33,000, 'only about 90 made sufficient incomes to cover the costs of actively building their business.' That's a 99.7 percent loss rate for investors."

259 Newsweek: based on Mona Vie's own 2007 income disclosure statement "fewer than 1 percent qualified for commissions and of those, only 10 percent made more than $100 a week."

Business Students Focus on Ethics: "In the USA, the average annual income from MLM for 90% MLM members is no more than US $5,000, which is far from being a sufficient means of making a living (San Lian Life Weekly 1998)"

USA Today has had several articles: "While earning potential varies by company and sales ability, DSA says the median annual income for those in direct sales is $2,400." In an October 15, 2010 article, it was stated that documents of a MLM called Fortune reveal that 30 percent of its representatives make no money and that 54 percent of the remaining 70 percent only make $93 a month. The article also states Fortune is under investigation by the Attorneys General of Texas, Kentucky, North Dakota, and North Carolina with Missouri, South Carolina, Illinois, and Florida following up complaints against the company.

A February 10, 2011 article stated "It can be very difficult, if not impossible, for most individuals to make a lot of money through the direct sale of products to consumers. And big money is what recruiters often allude to in their pitches."

"Roland Whitsell, a former business professor who spent 40 years researching and teaching the pitfalls of multilevel marketing": "You'd be hard-pressed to find anyone making over $1.50 an hour, (t)he primary product is opportunity. The strongest, most powerful motivational force today is false hope."

Legality and legitimacy MLM businesses operate in all 50 U.S. states. New businesses may use terms such as "affiliate marketing" or "home-based business franchising". Many pyramid schemes attempt to present themselves as legitimate MLM businesses. Many courts, and portions of the public assert that all MLMs are essentially pyramid schemes even if they are legal.

The U.S. Federal Trade Commission (FTC) states "Steer clear of multilevel marketing plans that pay commissions for recruiting new distributors.

260 They're actually illegal pyramid schemes. Why is pyramiding dangerous? Because plans that pay commissions for recruiting new distributors inevitably collapse when no new distributors can be recruited. And when a plan collapses, most people—except perhaps those at the very top of the pyramid—end up empty-handed."

In a 2004 Staff Advisory letter to the Direct Selling Association, the FTC states:

Much has been made of the personal, or internal, consumption issue in recent years. In fact, the amount of internal consumption in any multi-level compensation business does not determine whether or not the FTC will consider the plan a pyramid scheme. The critical question for the FTC is whether the revenues that primarily support the commissions paid to all participants are generated from purchases of goods and services that are not simply incidental to the purchase of the right to participate in a money- making venture.

The Federal Trade Commission warns "Not all multilevel marketing plans are legitimate. Some are pyramid schemes. It's best not to get involved in plans where the money you make is based primarily on the number of distributors you recruit and your sales to them, rather than on your sales to people outside the plan who intend to use the products." and states that research is your best tool, giving eight steps to follow: Find—and study—the company's track record Learn about the product Ask questions Understand any restrictions Talk to other distributors (beware of shills) Consider using a friend or adviser as a neutral sounding board or for a gut check Take your time Think about whether this plan suits your talents and goals

The Federal Trade Commission issued a decision, In re Amway Corp., in 1979 in which it indicated that multi-level marketing was not illegal per se in the United States. However, Amway was found guilty of price fixing (by effectively requiring "independent" distributors to sell at the same fixed price) and making exaggerated income claims.

261 The FTC advises that multi-level marketing organizations with greater incentives for recruitment than product sales are to be viewed skeptically. The FTC also warns that the practice of getting commissions from recruiting new members is outlawed in most states as "pyramiding". In April 2006, it proposed a Business Opportunity Rule intended to require all sellers of business opportunities—including MLMs—to provide enough information to enable prospective buyers to make an informed decision about their probability of earning money. In March 2008, the FTC removed Network Marketing (MLM) companies from the proposed Business Opportunity Rule:

The revised proposal, however, would not reach multi-level marketing companies or certain companies that may have been swept inadvertently into scope of the April 2006 proposal.

Walter J. Carl stated in a 2004 Western Journal of Communication article that "MLM organizations have been described by some as cults (Butterfield, 1985), pyramid schemes (Fitzpatrick & Reynolds, 1997), or organizations rife with misleading, deceptive, and unethical behavior (Carter, 1999), such as the questionable use of evangelical discourse to promote the business (Hopfl & Maddrell, 1996), and the exploitation of personal relationships for financial gain (Fitzpatrick & Reynolds, 1997)". In China, volunteers working to rescue people from the schemes have been physically attacked.

MLMs are also criticized for being unable to fulfill their promises for the majority of participants due to basic conflicts with Western cultural norms. There are even claims that the success rate for breaking even or even making money are far worse than other types of businesses: "The vast majority of MLMs are recruiting MLMs, in which participants must recruit aggressively to profit. Based on available data from the companies themselves, the loss rate for recruiting MLMs is approximately 99.9%; i.e., 99.9% of participants lose money after subtracting all expenses, including purchases from the company." In part, this is because encouraging recruits to further "recruit people to compete with [them]" leads to "market saturation." It has also been claimed "(b)y its very nature, MLM is completely devoid of any scientific foundations." Another criticism is that MLM has effectively outlived its usefulness as a legitimate business practice. The argument is that, in the time when America was a series of relatively small, isolated towns and rural areas not easily accessible to small companies, MLM was a useful way to let people know of and buy

262 products or services. But the advent of internet commerce, with its ability to advertise and sell directly to consumers, has rendered that model obsolete. Thus, today, nearly all modern MLMs ostensibly sell vastly overpriced goods and services (if there even is a real product or service involved at all) as a thin cloak of legitimacy, while their members are driven to recruit even more people into the MLM, effectively turning these programs into pyramid schemes.

Because of the encouraging of recruits to further recruit their competitors, some people have even gone so far as to say at best modern MLMs are nothing more than legalized pyramid schemes with one stating "Multi-level marketing companies have become an accepted and legally sanctioned form of pyramid scheme in the United States" while another states "Multi- Level Marketing, a form of Pyramid Scheme, is not necessarily fraudulent."

In October 2010 it was reported that multilevel marketing companies were being investigated by a number of state attorneys general amid allegations that salespeople were primarily paid for recruiting and that more recent recruits cannot earn anything near what early entrants do.

Industry critic Robert L. FitzPatrick has called multi-level marketing "the Main Street bubble" that will eventually burst.

Nano-campaigning Nano-campaigning refers to an approach within Marketing communications, Public relations and Lobbying which uses personalized and product-specific or issue-specific tactics as the starting point for more extensive strategic campaigns. It is based on the principles of social psychology and is enabled by the application of social media technologies.

The term was first coined by US marketer and blogger, Anne Holland, on her MarketingSherpa blog, in an article of 6 October 2008. For Holland, the nano-campaign was the practical effect of the nano-niche marketing concept.

On 19 February 2009, UK campaigns consultant and writer, Dan Fox, in an article on PubAffairs, the Public Affairs Networking blog, expanded the definition to cover the broader range of communications disciplines and services.

263 He defined nano-campaigning as the tactical promotion of ideas and messages, tailored to individuals or select groups, with the strategic aim of encouraging a campaign to grow and build momentum beyond a small, focussed audience, enabled by the multiplying effects of communication technologies and social media.

In March 2009, the term was used on another marketing blog, dm horizons to describe the rejection of television by the team campaigning to promote the Indian-manufactured budget car, the Nano, in favour of, inter alia, chatrooms, news tickers, pop-ups, Facebook, Orkut, blogs, and word-of- mouth. dm horizons described this as "a nano-campaign for the Nano".

Nano-campaigning is another term for “Targeted Marketing”-and we offer a course specific to this type of marketing in our Business of Massage Series.

Online advertising Online advertising, also called online marketing or Internet advertising, is a form of marketing and advertising which uses the Internet to deliver promotional marketing messages to consumers. It includes email marketing, search engine marketing (SEM), social media marketing, many types of display advertising (including web banner advertising), and mobile advertising. Like other advertising media, online advertising frequently involves both a publisher, who integrates advertisements into its online content, and an advertiser, who provides the advertisements to be displayed on the publisher's content. Other potential participants include advertising agencies who help generate and place the ad copy, an ad server who technologically delivers the ad and tracks statistics, and advertising affiliates who do independent promotional work for the advertiser.

Online advertising is a large business and is growing rapidly. In 2011, Internet advertising revenues in the United States surpassed those of cable television and nearly exceeded those of broadcast television. In 2012, Internet advertising revenues in the United States totaled $36.57 billion, a 15.2% increase over the $31.74 billion in revenues in 2011. U.S. internet ad revenue hit a historic high of $20.1 billion for the first half of 2013, up 18% over the same period in 2012. Online advertising is widely used across virtually all industry sectors.

264 Many common online advertising practices are controversial and increasingly subject to regulation. Online ad revenues may not adequately replace other publishers' revenue streams. Declining ad revenue has led some publishers to hide their content behind paywalls.

In early days of the Internet, online advertising wasn't allowed. For example, two of the predecessor networks to the Internet, ARPANET and NSFNet, had "acceptable use policies" that banned network "use for commercial activities by for-profit institutions". The NSFNet began phasing out its commercial use ban in 1991.

Email. The first widely publicized example of online advertising was conducted via electronic mail. On 3 May 1978, a marketer from DEC (Digital Equipment Corporation), Gary Thuerk, sent an email to most of the ARPANET's American west coast users, advertising an open house for a new model of a DEC computer. Despite the prevailing acceptable use policies, electronic mail marketing rapidly expanded and eventually became known as “spam.”

The first known large-scale non-commercial spam message was sent on 18 January 1994 by an Andrews University system administrator, by cross- posting a religious message to all USENET newsgroups. Four months later, Laurence Canter and Martha Siegel, partners in a law firm, broadly promoted their legal services in a USENET posting titled "Green Card Lottery – Final One?” Canter and Siegel's Green Card USENET spam raised the profile of online advertising, stimulating widespread interest in advertising via both Usenet and traditional email. More recently, spam has evolved into a more industrial operation, where spammers use armies of virus-infected computers (botnets) to send spam remotely.

Display Ads. Online banner advertising began in the early 1990s as page owners sought additional revenue streams to support their content. Commercial online service Prodigy displayed banners at the bottom of the screen to promote Sears products. The first clickable web ad was sold by Global Network Navigator in 1993 to a Silicon Valley law firm. In 1994, web banner advertising became mainstream when HotWired, the online component of Wired Magazine, sold banner ads to AT&T and other companies. The first AT&T ad on HotWired had a 44% click-through rate, and instead of directing clickers to AT&T's website, the ad linked to an online tour of seven of the world's most acclaimed art museums.

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Search Ads. GoTo.com (renamed Overture in 2001, and acquired by Yahoo! in 2003) created the first search advertising keyword auction in 1998. Google launched its "AdWords" search advertising program in 2000 and introduced quality-based ranking allocation in 2002, which sorts search advertisements by a combination of bid price and searchers' likeliness to click on the ads.

Recent Trends. More recently, companies have sought to merge their advertising messages into editorial content or valuable services. Examples include Red Bull's Red Bull Media House streaming Felix Baumgartner's jump from space online, Coca-Cola's online magazines, and Nike's free applications for performance tracking. Advertisers are also embracing social media and mobile advertising; mobile ad spending has grown 90% each year from 2010 to 2013.

Delivery Methods

Display advertising Display advertising conveys its advertising message visually using text, logos, animations, videos, photographs, or other graphics. Display advertisers frequently target users with particular traits to increase the ads' effect. Online advertisers (typically through their ad servers) often use cookies, which are unique identifiers of specific computers, to decide which ads to serve to a particular consumer. Cookies can track whether a user left a page without buying anything, so the advertiser can later retarget the user with ads from the site the user visited.

As advertisers collect data across multiple external websites about a user's online activity, they can create a detailed picture of the user's interests to deliver even more targeted advertising. This aggregation of data is called behavioral targeting. Advertisers can also target their audience by using contextual and semantic advertising to deliver display ads related to the content of the web page where the ads appear. Retargeting, behavioral targeting, and contextual advertising all are designed to increase an advertiser's return on investment, or ROI, over untargeted ads.

Advertisers may also deliver ads based on a user's suspected geography through geotargeting. A user's IP address communicates some geographic information (at minimum, the user's country or general region). The

266 geographic information from an IP can be supplemented and refined with other proxies or information to narrow the range of possible locations. For example, with mobile devices, advertisers can sometimes use a phone's GPS receiver or the location of nearby mobile towers. Cookies and other persistent data on a user's machine may provide help narrowing a user's location further.

Web banner advertising Web banners or banner ads typically are graphical ads displayed within a web page. Many banner ads are delivered by a central ad server.

Banner ads can use rich media to incorporate video, audio, animations, buttons, forms, or other interactive elements using Java applets, HTML5, Adobe Flash, and other programs.

Frame ad (traditional banner) Frame ads were the first form of web banners. The colloquial usage of "banner ads" often refers to traditional frame ads. Website publishers incorporate frame ads by setting aside a particular space on the web page. The Interactive Advertising Bureau's Ad Unit Guidelines proposes standardized pixel dimensions for ad units.

Pop-ups/pop-unders A pop-up ad is displayed in a new web browser window that opens above a website visitor's initial browser window.[29] A pop-under ad opens a new browser window under a website visitor's initial browser window.

Floating ad A floating ad, or overlay ad, is a type of rich media advertisement that appears superimposed over the requested website's content. Floating ads may disappear or become less obtrusive after a preset time period.

Expanding ad An expanding ad is a rich media frame ad that changes dimensions upon a predefined condition, such as a preset amount of time a visitor spends on a webpage, the user's click on the ad, or the user's mouse movement over the ad. Expanding ads allow advertisers to fit more information into a restricted ad space.

267 Trick banners A trick banner is a banner ad where the ad copy imitates some screen element users commonly encounter, such as an operating system message or popular application message, to induce ad clicks. Trick banners typically do not mention the advertiser in the initial ad, and thus they are a form of bait-and-switch. Trick banners commonly attract a higher-than-average click-through rate, but tricked users may resent the advertiser for deceiving them.

Interstitial ads An interstitial ad displays before a user can access requested content, sometimes while the user is waiting for the content to load. Interstitial ads are a form of interruption marketing.

Text ads A text ad displays text-based hyperlinks. Text-based ads may display separately from a web page's primary content, or they can be embedded by hyperlinking individual words or phrases to advertiser's websites. Text ads may also be delivered through email marketing or text message marketing. Text-based ads often render faster than graphical ads and can be harder for ad-blocking software to block.

Search Engine Marketing (SEM) Search Engine Marketing, or SEM, is designed to increase a website's visibility in search engine results pages (SERPs). Search engines provide sponsored results and organic (non-sponsored) results based on a web searcher's query. Search engines often employ visual cues to differentiate sponsored results from organic results. Search engine marketing includes all of an advertiser's actions to make a website's listing more prominent for topical keywords.

Search Engine Optimization (SEO) Search Engine Optimization, or SEO, attempts to improve a website's organic search rankings in SERPs by increasing the website content's relevance to search terms. Search engines regularly update their algorithms to penalize poor quality sites that try to game their rankings, making optimization a moving target for advertisers. Many vendors offer SEO services.

268 Sponsored search Sponsored search (also called sponsored links, search ads, or paid search) allows advertisers to be included in the sponsored results of a search for selected keywords. Search ads are often sold via real-time auctions, where advertisers bid on keywords. In addition to setting a maximum price per keyword, bids may include time, language, geographical, and other constraints. Search engines originally sold listings in order of highest bids. Modern search engines rank sponsored listings based on a combination of bid price, expected click-through rate, keyword relevancy and site quality.

Social media marketing Social media marketing is commercial promotion conducted through social media websites. Many companies promote their products by posting frequent updates and providing special offers through their social media profiles.

Mobile Advertising Mobile advertising is ad copy delivered through wireless mobile devices such as smartphones, feature phones, or tablet computers. Mobile advertising may take the form of static or rich media display ads, SMS (Short Message Service) or MMS (Multimedia Messaging Service) ads, mobile search ads, advertising within mobile websites, or ads within mobile applications or games (such as interstitial ads, “advergaming,” or application sponsorship). Industry groups such as the Mobile Marketing Association have attempted to standardize mobile ad unit specifications, similar to the IAB's efforts for general online advertising.

Mobile advertising is growing rapidly for several reasons. There are more mobile devices in the field, connectivity speeds have improved (which, among other things, allows for richer media ads to be served quickly), screen resolutions have advanced, mobile publishers are becoming more sophisticated about incorporating ads, and consumers are using mobile devices more extensively. The Interactive Advertising Bureau predicts continued growth in mobile advertising with the adoption of location-based targeting and other technological features not available or relevant on personal computers.In July 2014 Facebook reported advertising revenue for the June 2014 quarter of $2.68 billion, an increase of 67 per cent over the second quarter of 2013. Of that, mobile advertising revenue accounted for around 62 per cent, an increase of 41 per cent on the previous year.

269 Email Advertising Email advertising is ad copy comprising an entire email or a portion of an email message. Email marketing may be unsolicited, in which case the sender may give the recipient an option to opt-out of future emails, or it may be sent with the recipient's prior consent (opt-in).

Chat advertising As opposed to static messaging, chat advertising refers to real time messages dropped to users on certain sites. This is done by the usage of live chat software or tracking applications installed within certain websites with the operating personnel behind the site often dropping adverts on the traffic surfing around the sites. In reality this is a subset of the email advertising but different because of its time window.

Online classified advertising Online classified advertising is advertising posted online in a categorical listing of specific products or services. Examples include online job boards, online real estate listings, automotive listings, online yellow pages, and online auction-based listings. Craigslist and eBay are two prominent providers of online classified listings.

Adware Adware is software that, once installed, automatically displays advertisements on a user's computer. The ads may appear in the software itself, integrated into web pages visited by the user, or in pop-ups/pop- unders. Adware installed without the user's permission is a type of malware.

Affiliate Marketing Affiliate marketing (sometimes called lead generation) occurs when advertisers organize third parties to generate potential customers for them. Third-party affiliates receive payment based on sales generated through their promotion.

Compensation Methods Advertisers and publishers use a wide range of payment calculation methods. In 2012, advertisers calculated 32% of online advertising transactions on a cost-per-impression basis, 66% on customer performance (e.g. cost per click or cost per acquisition), and 2% on hybrids of impression and performance methods.

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CPM (Cost Per Mille) Cost per mille, often abbreviated to CPM, means that advertisers pay for every thousand displays of their message to potential customers (mille is the Latin word for thousand). In the online context, ad displays are usually called "impressions." Definitions of an "impression" vary among publishers, and some impressions may not be charged because they don't represent a new exposure to an actual customer. Advertisers can use technologies such as web bugs to verify if an impression is actually delivered.

Publishers use a variety of techniques to increase page views, such as dividing content across multiple pages, repurposing someone else's content, using sensational titles, or publishing tabloid or sexual content.

CPM advertising is susceptible to "impression fraud,” and advertisers who want visitors to their sites may not find per-impression payments a good proxy for the results they desire.

CPC (cost per click) CPC (Cost Per Click) or PPC (Pay per click) means advertisers pay each time a user clicks on the ad. CPC advertising works well when advertisers want visitors to their sites, but it's a less accurate measurement for advertisers looking to build brand awareness. CPC's market share has grown each year since its introduction, eclipsing CPM to dominate two- thirds of all online advertising compensation methods.

Like impressions, not all recorded clicks are valuable to advertisers. GoldSpot Media reported that up to 50% of clicks on static mobile banner ads are accidental and resulted in redirected visitors leaving the new site immediately.

CPE (cost per engagement) Cost per engagement aims to track not just that an ad unit loaded on the page (i.e., an impression was served), but also that the viewer actually saw and/or interacted with the ad.

CPV (cost per view) Cost per view video advertising. Both Google and TubeMogul endorsed this standardized CPV metric to the IAB's (Interactive Advertising Bureau)

271 Digital Video Committee, and it's garnering a notable amount of industry support.

Other performance-based compensation CPA (Cost Per Action or Cost Per Acquisition) or PPP (Pay Per Performance) advertising means the advertiser pays for the number of users who perform a desired activity, such as completing a purchase or filling out a registration form. Performance-based compensation can also incorporate revenue sharing, where publishers earn a percentage of the advertiser's profits made as a result of the ad. Performance-based compensation shifts the risk of failed advertising onto publishers.

Fixed cost Fixed cost compensation means advertisers pay a fixed cost for delivery of ads online, usually over a specified time period, irrespective of the ad's visibility or users' response to it.

Benefits of Online Advertising

Cost The low costs of electronic communication reduce the cost of displaying online advertisements compared to offline ads. Online advertising, and in particular social media, provides a low-cost means for advertisers to engage with large established communities. Advertising online offers better returns than in other media.

Measurability Online advertisers can collect data on their ads' effectiveness, such as the size of the potential audience or actual audience response, how a visitor reached their advertisement, whether the advertisement resulted in a sale, and whether an ad actually loaded within a visitor's view. This helps online advertisers improve their ad campaigns over time.

Formatting Advertisers have a wide variety of ways of presenting their promotional messages, including the ability to convey images, video, audio, and links. Unlike many offline ads, online ads also can be interactive. For example, some ads let users input queries or let users follow the advertiser on social media. Online ads can even incorporate games.

272 Targeting Publishers can offer advertisers the ability to reach customizable and narrow market segments for targeted advertising. Online advertising may use geo-targeting to display relevant advertisements to the user's geography. Advertisers can customize each individual ad to a particular user based on the user's previous preferences. Advertisers can also track whether a visitor has already seen a particular ad in order to reduce unwanted repetitious exposures and provide adequate time gaps between exposures.

Coverage Online advertising can reach nearly every global market, and online advertising influences offline sales.

Speed Once ad design is complete, online ads can be deployed immediately. The delivery of online ads does not need to be linked to the publisher's publication schedule. Furthermore, online advertisers can modify or replace ad copy more rapidly than their offline counterparts.

Concerns

Banner blindness Eye-tracking studies have shown that Internet users often ignore web page zones likely to contain display ads (sometimes called "banner blindness"), and this problem is worse online than in offline media. On the other hand, studies suggest that even those ads "ignored" by the users may influence the user subconsciously.

Fraud on the Advertiser There are numerous ways that advertisers can be overcharged for their advertising. For example, click fraud occurs when a publisher or third parties click (manually or through automated means) on a CPC ad with no legitimate buying intent. For example, click fraud can occur when a competitor clicks on ads to deplete its rival's advertising budget, or when publishers attempt to manufacture revenue.

Click fraud is especially associated with pornography sites. In 2011, certain scamming porn websites launched dozens of hidden pages on each

273 visitor's computer, forcing the visitor's computer to click on hundreds of paid links without the visitor's knowledge.

As with offline publications, online impression fraud can occur when publishers overstate the number of ad impressions they have delivered to their advertisers. To combat impression fraud, several publishing and advertising industry associations are developing ways to count online impressions credibly.

Heterogeneous clients Because users have different operating systems, web browsers and computer hardware (including mobile devices and different screen sizes), online ads may appear to users differently from how the advertiser intended, or the ads may not display properly at all. A 2012 comScore study revealed that, on average, 31% of ads were not "in-view" when rendered, meaning they never had an opportunity to be seen. Rich media ads create even greater compatibility problems, as some developers may use competing (and exclusive) software to render the ads (see e.g. Comparison of HTML 5 and Flash).

Furthermore, advertisers may encounter legal problems if legally required information doesn't actually display to users, even if that failure is due to technological heterogeneity. In the United States, the FTC has released a set of guidelines indicating that it's the advertisers' responsibility to ensure the ads display any required disclosures or disclaimers, irrespective of the users' technology.

Ad-blocking Ad-blocking, or ad filtering, means the ads do not appear to the user because the user uses technology to screen out ads. Many browsers block unsolicited pop-up ads by default. Other software programs or browser add-ons may also block the loading of ads, or block elements on a page with behaviors characteristic of ads (e.g. HTML autoplay of both audio and video). Approximately 9% of all online page views come from browsers with ad-blocking software installed, and some publishers have 40%+ of their visitors using ad-blockers.

Anti-targeting technologies Some web browsers offer privacy modes where users can hide information about themselves from publishers and advertisers. Among other

274 consequences, advertisers can't use cookies to serve targeted ads to private browsers. Most major browsers have incorporated Do Not Track options into their browser headers, but the regulations currently are only enforced by the honor system.

Privacy Concerns The collection of user information by publishers and advertisers has raised consumer concerns about their privacy. Sixty percent of Internet users would use Do Not Track technology to block all collection of information if given an opportunity. Over half of all Google and Facebook users are concerned about their privacy when using Google and Facebook, according to Gallup.

Many consumers have reservations about by online behavioral targeting. By tracking users' online activities, advertisers are able to understand consumers quite well. Advertisers often use technology, such as web bugs and respawning cookies, to maximizing their abilities to track consumers. According to a 2011 survey conducted by Harris Interactive, over half of Internet users had a negative impression of online behavioral advertising, and forty percent feared that their personally-identifiable information had been shared with advertisers without their consent. Consumers can be especially troubled by advertisers targeting them based on sensitive information, such as financial or health status.

Trustworthiness of advertisers Scammers can take advantage of consumers' difficulties verifying an online persona's identity, leading to artifices like phishing (where scam emails look identical to those from a well-known brand owner) and confidence schemes like the Nigerian "419" scam. The Internet Crime Complaint Center received 289,874 complaints in 2012, totaling over half a billion dollars in losses, most of which originated with scam ads.

Consumers also face malware risks when interacting with online advertising. Cisco's 2013 Annual Security Report revealed that clicking on ads was 182 times more likely to install a virus on a user's computer than surfing the Internet for porn.

Spam The Internet's low cost of disseminating advertising contributes to spam, especially by large-scale spammers. Numerous efforts have been

275 undertaken to combat spam, ranging from blacklists to regulatorily-required labeling to content filters, but most of those efforts have adverse collateral effects, such as mistaken filtering.

Regulation In general, consumer protection laws apply equally to online and offline activities. However, there are questions over which jurisdiction's laws apply and which regulatory agencies have enforcement authority over transborder activity.

As with offline advertising, industry participants have undertaken numerous efforts to self-regulate and develop industry standards or codes of conduct. Several United States advertising industry organizations jointly published Self-Regulatory Principles for Online Behavioral Advertising based on standards proposed by the FTC in 2009. European ad associations published a similar document in 2011. Primary tenets of both documents include consumer control of data transfer to third parties, data security, and consent for collection of certain health and financial data. Neither framework, however, penalizes violators of the codes of conduct.

Privacy and Data Collection Privacy regulation can require users' consent before an advertiser can track the user or communicate with the user. However, affirmative consent ("opt in") can be difficult and expensive to obtain. Industry participants often prefer other regulatory schemes.

Different jurisdictions have taken different approaches to privacy issues with advertising. The United States has specific restrictions on online tracking of children in the Children's Online Privacy Protection Act (COPPA),and the FTC has recently expanded its interpretation of COPPA to include requiring ad networks to obtain parental consent before knowingly tracking kids. Otherwise, the U.S. Federal Trade Commission frequently supports industry self-regulation, although increasingly it has been undertaking enforcement actions related to online privacy and security. The FTC has also been pushing for industry consensus about possible Do Not Track legislation.

In contrast, the European Union's "Privacy and Electronic Communications Directive" restricts websites' ability to use consumer data much more comprehensively. The EU limitations restrict targeting by online advertisers;

276 researchers have estimated online advertising effectiveness decreases on average by around 65% in Europe relative to the rest of the world.

Delivery methods Many laws specifically regulate the ways online ads are delivered. For example, online advertising delivered via email is more regulated than the same ad content delivered via banner ads. Among other restrictions, the U.S. CAN-SPAM Act of 2003 requires that any commercial email provide an opt-out mechanism. Similarly, mobile advertising is governed by the Telephone Consumer Protection Act of 1991 (TCPA), which (among other restrictions) requires user opt-in before sending advertising via text messaging.

Permission marketing Permission marketing is a term popularized by Seth Godin (but found earlier) used in marketing in general and e-marketing specifically. The undesirable opposite of permission marketing is interruption marketing. Marketers obtain permission before advancing to the next step in the purchasing process. For example, they ask permission to send email newsletters to prospective customers. It is mostly used by online marketers, notably email marketers and search marketers, as well as certain direct marketers who send a catalog in response to a request.

This form of marketing requires that the prospective customer has either given explicit permission for the marketer to send their promotional message (like an email or catalog request) or implicit permission (like querying a search engine). This can be either via an online email opt-in form or by using search engines, which implies a request for information which can include that of a commercial nature. To illustrate, consider someone who searches for "buy shoes." Online shoe stores have searchers' permission to make an offer that solves their shoe problem.

Marketers feel that this is a more efficient use of their resources because the offers are sent to people only if actually interested in the product. This is one technique used by marketers that have a personal marketing orientation. Marketers feel that marketing should be done on a one-to-one basis rather than using broad aggregated concepts like market segment or target market.

277 In the United Kingdom, an opt-in has been required for email marketing, under The Privacy and Electronic Communications (EC Directive) Regulations 2003 since 11 December 2003.

Product bundling In marketing, product bundling is offering several products for sale as one combined product. It is a common feature in many imperfectly competitive product markets. Firms in telecommunications, financial services, health care, and information industries frequently offer products in bundles. This is again common in the software business (for example: bundle a word processor, a spreadsheet, and a database into a single office suite), in the cable television industry (for example, basic cable in the United States generally offers many channels at one price), and in the fast food industry in which multiple items are combined into a complete meal. A bundle of products may be called a package deal or a compilation or an anthology.

It has been identified settings in which bundling can be used by firms to discriminate among consumers or to extend market power into a related product market. Bundling in appropriate proportions is privately profitable, reduces a rival’s profits and overall welfare, and may drive rivals from the market.

Rationale Bundling is most successful when: There are economies of scale in production. There are economies of scope in distribution. Marginal costs of bundling are low. Production set-up costs are high. Customer acquisition costs are high. Consumers appreciate the resulting simplification of the purchase decision and benefit from the joint performance of the combined product.

Consumers have heterogeneous demands and such demands for different parts of the bundle product are inversely correlated. For example, assume consumer A values word processor at $100 and spreadsheet processor at $60, while consumer B values word processor at $60 and spreadsheet at $100. Seller can generate maximum revenue of only $240 by setting $60 price for each product—both consumers will buy both products. Revenue cannot be increased without bundling because as seller increases the price

278 above $60 for one of the goods, one of the consumers will refuse to buy it. With bundling, seller can generate revenue of $320 by bundling the products together and selling the bundle at $160. Product bundling is most suitable for high volume and high margin (i.e., low marginal cost) products. Research by Yannis Bakos and Erik Brynjolfsson found that bundling was particularly effective for digital "information goods" with close to zero marginal cost, and could enable a bundler with an inferior collection of products to drive even superior quality goods out of the market place.

Venkatesh and Mahajan reviewed the research on bundle design and pricing in 2009.

Varieties of bundling Pure bundling occurs when a consumer can only purchase the entire bundle or nothing, mixed bundling occurs when consumers are offered a choice between the purchasing the entire bundle or one of the separate parts of the bundle.

Pure bundling can be further divided into two cases: in joint bundling, the two products are offered together for one bundled price, and, in leader bundling, a leader product is offered for discount if purchased with a non- leader product. Mixed-leader bundling is a variant of leader bundling with the added possibility of buying the leader product on its own.

Bundling in political economy is a type of product bundling in which the product is a candidate in an election who markets his bundle of attributes and positions to the voters.

Bundling, market power, and competitiveness In oligopolistic and monopolistic industries, product bundling can be seen as an unfair use of market power because it limits the choices available to the consumer. In these cases it is typically called product tying. Some forms of product bundling have been subject to litigation regarding abuses of market share.

United States v. Microsoft United States v. Microsoft was a set of civil actions filed against Microsoft Corporation pursuant to the Sherman Antitrust Act of 1890 Sections 1 and 2 on May 18, 1998 by the United States Department of Justice (DOJ) and

279 20 states. Joel I. Klein was the lead prosecutor. The plaintiffs alleged that Microsoft abused monopoly power on Intel-based personal computers in its handling of operating system sales and web browser sales. The issue central to the case was whether Microsoft was allowed to bundle its flagship Internet Explorer (IE) web browser software with its Microsoft Windows operating system. Bundling them together is alleged to have been responsible for Microsoft's victory in the browser wars as every Windows user had a copy of Internet Explorer.

Relationship marketing Relationship marketing refers to an arrangement where both the buyer and seller have an interest in providing a more satisfying exchange. This approach tries to disambiguiously transcend the simple post purchase- exchange process with a customer to make more truthful and richer contact by providing a more holistic, personalised purchase, and uses the experience to create stronger ties.

From a social anthropological perspective we can interpret relationship- marketing theories and practices as commodity exchange that instrumentalise features of gift exchange. It seems that marketers— consciously or intuitively—are recognizing the power contained in 'pre- modern' forms of exchange and have begun to use it. This particular perspective on marketing opens up fertile ground for future research, where marketing theory and practice can greatly benefit from in-depth research of the principles governing gift exchange.

According to Liam Alvey, relationship marketing can be applied when there are competitive product alternatives for customers to choose from; and when there is an ongoing and periodic desire for the product or service.

Modern consumer marketing originated in the 1960s and 1970s as companies found it more profitable to sell relatively low-value products to masses of customers. Over the decades, attempts have been made to broaden the scope of marketing, relationship marketing being one of these attempts. Arguably, customer value has been greatly enriched by these contributions.

The practice of relationship marketing has been facilitated by several generations of customer relationship management software that allow tracking and analyzing of each customer's preferences, activities, tastes,

280 likes, dislikes, and complaints. For example, an automobile manufacturer maintaining a database of when and how repeat customers buy their products, the options they choose, the way they finance the purchase etc., is in a powerful position to develop one-to-one marketing offers and product benefits.

In web applications, the consumer shopping profile can be built as the person shops on the website. This information is then used to compute what can be his or her likely preferences in other categories. These predicted offerings can then be shown to the customer through cross-sell, email recommendation and other channels.

Relationship marketing has also migrated back into direct mail, allowing marketers to take advantage of the technological capabilities of digital, toner-based printing presses to produce unique, personalized pieces for each recipient through a technique called "variable data printing". Marketers can personalize documents by any information contained in their databases, including name, address, demographics, purchase history, and dozens (or even hundreds) of other variables. The result is a printed piece that (ideally) reflects the individual needs and preferences of each recipient, increasing the relevance of the piece and increasing the response rate.

Relationship marketing has also been strongly influenced by reengineering. According to (process) reengineering theory, organizations should be structured according to complete tasks and processes rather than functions. That is, cross-functional teams should be responsible for a whole process, from beginning to end, rather than having the work go from one functional department to another. Traditional marketing is said to use the functional (or 'silo') department approach. The legacy of this can still be seen in the traditional four P's of the marketing mix. Pricing, product management, promotion, and placement. According to Gordon (1999), the marketing mix approach is too limited to provide a usable framework for assessing and developing customer relationships in many industries and should be replaced by the relationship marketing alternative model where the focus is on customers, relationships and interaction over time, rather than markets and products.

In contrast, relationship marketing is cross-functional marketing. It is organized around processes that involve all aspects of the organization. In

281 fact, some commentators prefer to call relationship marketing "relationship management" in recognition of the fact that it involves much more than that which is normally included in marketing.

Martin Christopher, Adrian Payne, and David Ballantyne at the Cranfield School of Management claim that relationship marketing has the potential to forge a new synthesis between quality management, customer service management, and marketing.

Relationship marketing relies upon the communication and acquisition of consumer requirements solely from existing customers in a mutually beneficial exchange usually involving permission for contact by the customer through an "opt-in" system. With particular relevance to customer satisfaction the relative price and quality of goods and services produced or sold through a company alongside customer service generally determine the amount of sales relative to that of competing companies. Although groups targeted through relationship marketing may be large, accuracy of communication and overall relevancy to the customer remains higher than that of direct marketing, but has less potential for generating new leads than direct marketing and is limited to Viral marketing for the acquisition of further customers.

A key principle of relationship marketing is the retention of customers through varying means and practices to ensure repeated trade from preexisting customers by satisfying requirements above those of competing companies through a mutually beneficial relationship

This technique is now used as a means of counterbalancing new customers and opportunities with current and existing customers as a means of maximizing profit and counteracting the "leaky bucket theory of business" in which new customers gained in older direct marketing oriented businesses were at the expense of or coincided with the loss of older customers. This process of "churning" is less economically viable than retaining all or the majority of customers using both direct and relationship management as lead generation via new customers requires more investment.

Many companies in competing markets will redirect or allocate large amounts of resources or attention towards customer retention as in markets with increasing competition it may cost 5 times more to attract new

282 customers than it would to retain current customers, as direct or "offensive" marketing requires much more extensive resources to cause defection from competitors. However, it is suggested that because of the extensive classic marketing theories center on means of attracting customers and creating transactions rather than maintaining them, the majority usage of direct marketing used in the past is now gradually being used more alongside relationship marketing as its importance becomes more recognizable.

It is claimed by Reichheld and Sasser that a 5% improvement in customer retention can cause an increase in profitability of between 25 and 85 percent (in terms of net present value) depending on the industry. However Carrol, P. and Reichheld, F. dispute these calculations, claiming they result from faulty cross-sectional analysis. Research by John Fleming and Jim Asplund indicates that engaged customers generate 1.7 times more revenue than normal customers, while having engaged employees and engaged customers returns a revenue gain of 3.4 times the norm.

According to Buchanan and Gilles, the increased profitability associated with customer retention efforts occurs because of several factors that occur once a relationship has been established with a customer.

The cost of acquisition occurs only at the beginning of a relationship, so the longer the relationship, the lower the amortized cost. Account maintenance costs decline as a percentage of total costs (or as a percentage of revenue).

Long-term customers tend to be less inclined to switch, and also tend to be less price sensitive. This can result in stable unit sales volume and increases in dollar-sales volume.

Long-term customers may initiate free word of mouth promotions and referrals.

Long-term customers are more likely to purchase ancillary products and high margin supplemental products.

Customers that stay with you tend to be satisfied with the relationship and are less likely to switch to competitors, making it difficult for competitors to enter the market or gain market share.

283 Regular customers tend to be less expensive to service because they are familiar with the process, require less "education", and are consistent in their order placement.

Increased customer retention and loyalty makes the employees' jobs easier and more satisfying. In turn, happy employees feed back into better customer satisfaction in a virtuous circle.

Relationship marketers speak of the "relationship ladder of customer loyalty". It groups types of customers according to their level of loyalty. The ladder's first rung consists of "prospects", that is, people that have not purchased yet but are likely to in the future. This is followed by the successive rungs of "customer", "client", "supporter", "advocate", and "partner". The relationship marketer's objective is to "help" customers get as high up the ladder as possible. This usually involves providing more personalized service and providing service quality that exceeds expectations at each step.

Customer retention efforts involve considerations such as the following:

Customer valuation – Gordon (1999) describes how to value customers and categorize them according to their financial and strategic value so that companies can decide where to invest for deeper relationships and which relationships need to be served differently or even terminated.

Customer retention measurement – Dawkins and Reichheld (1990) calculated a company's "customer retention rate". This is simply the percentage of customers at the beginning of the year that are still customers by the end of the year. In accordance with this statistic, an increase in retention rate from 80% to 90% is associated with a doubling of the average life of a customer relationship from 5 to 10 years. This ratio can be used to make comparisons between products, between market segments, and over time.

Determine reasons for defection – Look for the root causes, not mere symptoms. This involves probing for details when talking to former customers. Other techniques include the analysis of customers' complaints and competitive benchmarking (see competitor analysis). Develop and implement a corrective plan – This could involve actions to improve employee practices, using benchmarking to determine best

284 corrective practices, visible endorsement of top management, adjustments to the company's reward and recognition systems, and the use of "recovery teams" to eliminate the causes of defections. A technique to calculate the value to a firm of a sustained customer relationship has been developed. This calculation is typically called customer lifecycle value.

Retention strategies may also include building barriers to customer switching. This can be done by product bundling (combining several products or services into one "package" and offering them at a single price), cross selling (selling related products to current customers), cross promotions (giving discounts or other promotional incentives to purchasers of related products), loyalty programs (giving incentives for frequent purchases), increasing switching costs (adding termination costs, such as mortgage termination fees), and integrating computer systems of multiple organizations (primarily in industrial marketing).

Many relationship marketers use a team-based approach. The rationale is that the more points of contact between the organization and customer, the stronger will be the bond, and the more secure the relationship.

Relationship marketing and traditional (or transactional) marketing are not mutually exclusive and there is no need for a conflict between them. A relationship oriented marketer still has choices at the level of practice, according to the situation variables. Most firms blend the two approaches to match their portfolio of products and services. Virtually all products have a service component to them and this service component has been getting larger in recent decades.

Relationship marketing also stresses what it calls internal marketing, or using a marketing orientation within the organization itself. It is claimed that many of the relationship marketing attributes like collaboration, loyalty and trust determine what "internal customers" say and do. According to this theory, every employee, team, or department in the company is simultaneously a supplier and a customer of services and products. An employee obtains a service at a point in the value chain and then provides a service to another employee further along the value chain. If internal marketing is effective, every employee will both provide and receive exceptional service from and to other employees. It also helps employees understand the significance of their roles and how their roles relate to

285 others'. If implemented well, it can also encourage every employee to see the process in terms of the customer's perception of value added, and the organization's strategic mission. Further it is claimed that an effective internal marketing program is a prerequisite for effective external marketing efforts. (George, W. 1990)

The six markets model Christopher, Payne and Ballantyne (1991) from Cranfield University goes further. They identify six markets which they claim are central to relationship marketing. They are: internal markets, supplier markets, recruitment markets, referral markets, influence markets, and customer markets.

Referral marketing is developing and implementing a marketing plan to stimulate referrals. Although it may take months before you see the effect of referral marketing, this is often the most effective part of an overall marketing plan and the best use of resources.

Marketing to suppliers is aimed at ensuring a long-term conflict-free relationship in which all parties understand each other's needs and exceed each other's expectations. Such a strategy can reduce costs and improve quality.

Influence markets involve a wide range of sub-markets including: government regulators, standards bodies, lobbyists, stockholders, bankers, venture capitalists, financial analysts, stockbrokers, consumer associations, environmental associations, and labor associations. These activities are typically carried out by the public relations department, but relationship marketers feel that marketing to all six markets is the responsibility of everyone in the organization. Each market may require its own explicit strategies and a separate marketing mix for each.

Live-in Marketing Live-in Marketing (LIM) is a variant of marketing and advertising in which the target consumer is allowed to sample or use a brands product in a relaxed atmosphere over a longer period of time. Much like product placement in film and television LIM was developed as a means to reach select target demographics in a non-invasive and much less garish manner than traditional advertising.

286 While LIM represents an entirely untapped avenue of marketing for both big and small brands alike it is not an all that novel an idea. With the rising popularity of experiential and event marketing in North America and Europe, as well as the relatively high ROI in terms of advertising dollars spent on experiential marketing compared to traditional big media advertising, industry analysts see LIM as a natural progression.

LIM functions around the premise that marketing or advertising agencies go out on behalf of the brand in question and find its target demographic. From that point forward avenues such as sponsorship or direct product placement and sampling are explored. Unlike traditional event marketing, LIM suggests that end-users will sample the product or service in a comfortable and relaxed atmosphere. The idea behind this technique is that the end-user will have as positive as possible an interaction with the given brand thereby leading to word-of-mouth communication and potential future purchase. If the success of traditional event and experiential marketing is shared with LIM then it could indicate quite a lucrative and fairly low-cost means of product promotion. However, due to the fact that this means of advertising is still in its infancy more research is required to determine the true success of such campaigns. Because LIM is a fairly new concept many agencies are only now beginning to incorporate it into their advertising and marketing portfolios. The first such company to explicitly offer LIM services was Hostival Connect in late 2010. It is expected that more and more agencies will begin to sell LIM type campaigns.

Seeding trial A seeding trial or marketing trial is a form of marketing, conducted in the name of research, designed to target product sampling towards selected consumers. In the marketing research field, seeding is the process of allocating marketing to specific customers, or groups of customers, in order to stimulate the internal dynamics of the market, and enhance the diffusion process. In medicine, seeding trials are clinical trials or research studies in which the primary objective is to introduce the concept of a particular medical intervention—such as a pharmaceutical drug or medical device—to physicians, rather than to test a scientific hypothesis. In software development, beta-testing may also be referred to as conducting seeding trials.

To create loyalty and advocacy towards a brand, seeding trials take advantage of opinion leadership to enhance sales, capitalizing on the

287 Hawthorne Effect. In a seeding trial, the brand provides potential opinion leaders with the product for free, aiming to gain valuable pre-market feedback and also to build support among the testers, creating influential word-of-mouth advocates for the product. By involving the opinion leaders as testers, effectively inviting them to be an extension of the marketing department, companies can create "a powerful sense of ownership among the clients, customers or consumers that count" by offering engaging the testers in a research dialogue.

In the marketing field, seeding is considered the process of allocating marketing to specific customers, or groups of customers, in order to stimulate the internal dynamics of the market, enhance the diffusion process and encourage faster adoption of the product throughout the entire population. In a marketing seeding program, a company offers some sort of promotion (free product, discounts, service trials, etc.) to a niche group of people with the intention that this would stimulate WOM. An early example of a seeding trial was during the development of Post-it notes, produced by 3M. In 1977, secretaries to senior management staff throughout the United States were sent packs of Post-its and invited to suggest possible uses for them. They soon found them to be extremely useful and became "brand champions" for the product, an early example of viral marketing. Companies that have used seeding trials include Procter & Gamble, Microsoft, Hasbro, Google, Unilever, Pepsi, Coke, Ford, DreamWorks SKG, EMI, Sony, and Siemens.

Two of the main managerial decisions revolving around seeding focus on seeding of advertising in a multinational market and the process of seeding the product itself. Determining how many and which consumers within a particular social network should be seeded to maximize adoption is a challenging task for a firm.

Self-referential marketing Self-referential marketing (SRM) is the concept of an organization placing one original product within another, thereby increasing the exposure and revenue potential of each product as well as the organization itself.

SRM was developed and coined by entertainment and design firm Earth Lion Entertainment LLC in 2014.

288 Conceptually and in practice, self-referential marketing differs from conventional product placement or embedded marketing in that both the product(s) or service(s) being advertised and the medium in which it is placed are owned and operated by the same entity.

Example scenario of self-referential marketing

Company XYZ owns and sells two products: Product A and Product B. Product A is in the form of a medium (e.g., film, online platform, etc.) and Product B is a good or service (e.g., consumer good product) placed within Product A.

Because Product B is placed within Product A, as one product’s exposure increases so does that of the other product, so that any increased exposure is mutually reinforcing. As shown in the diagram below, as the collective exposure of both products increases so does the degree of self reference for Company XYZ. This process ultimately benefits Company XYZ by increasing its overall marketing effectiveness and revenue-generating potential.

Share of voice Share of Voice in Online Advertising is an ad revenue model that focuses on weight or percentage among other advertisers. For example, if there are four advertisers on a website, each advertiser gets 25 percent of the advertising weight. This method ensures one ad will not be seen any more than the other three ads. And, since there are typically a limited number of advertisers using a Share of Voice model, ad exposure is optimized.

In other words, Share of Voice is used to "represent the relative portion of ad inventory available to a single advertiser within a defined market over a specified time period."

Share of Voice is capitalized on the concept of exclusivity. By limiting the number of ad spaces on websites, email newsletters and other digital media platforms, ads are more likely to be seen by their target audiences, thus limiting the amount of “ad noise” on the site. When you limit a website, for example, to 10 advertisers in each ad position, on average each advertiser will be seen at least once every 10 rotations.

289 Share of Voice is designed to create a mutually beneficial relationship between the advertiser and the web publisher. The advertiser is willing to pay a premium for exclusivity and less competition for their target audience's viewership. The publisher no longer has to rely on volume and can attract advertisers that want to specifically reach the publisher's audience.

Because the Share of Voice method values quality of ads over quantity of ads, publishers are perceived to have higher levels of credibility and interaction. When high quality content is presented, high quality advertisers tend to follow.

Social pull marketing The business terms push and pull originated in the logistic and supply chain management, but are also widely used in marketing.

Social Pull Marketing is the adaptation of the traditional Push–pull strategy marketing concepts to Social Media Websites. It utilizes the traditional Pull concept for a new way of Social Media Marketing. To get a basic understanding of what Social Pull Marketing is, just think of people friending you rather than you friending people.

You or your company must create a need for someone to friend you or your company. That need could be, information, electronic coupons, and other electronic items that people want, however, only your friends can get.

Facebook example: If you own a small athletic shoe manufacturing company. Your Facebook friends will receive a flow of information pertaining to the activities that your demographics would want, marathon information, healthy eating, how to walk for exercise, how to run or jog properly. Your Facebook friends would also receive special discounts via electronic coupons. By following this Social Pull Marketing strategy, your Facebook friends are pre-qualified buyers.

Real World Experiment example: Social Pull Marketing can be applied to all of the Social Media websites. "I would rather have 400 people that friended me, than have 4,000 people that I friended. The reason is, I would have 400 people that chose to be my

290 friend, they are pre-qualified buyers. The 4,000 people I friended accepted my friend request only because I asked them and most likely will not pay attention to what I have to say on my Social Media website".

For this experiment, multiple RSS feeds for one demographic (Popular Music) were used to generate one united RSS feed. The united RSS feed was sent through Twitter. For this experiment, no one actually tweeted one time, however, the test Twitter account now has over 400 followers in a few short months. This is proof that Social Pull Marketing works. The people following the test Twitter account all chose to follow it, thereby automatically building a list of Twitter followers that are interested in popular music.

291 Summary of Ethics in Massage Marketing Thank you for taking this Somatic Arts and Sciences Course. We are grateful to be a part of your continuing education experience.

Ethical advertising should always show people what needs can be met by your services.

There a need for training in ethical massage marketing because Many massage therapists are self-employed and handle their own marketing, and they can make more money by marketing better. The massage therapy industry has also been hurt with bad publicity in the past and good ethical standards in marketing can help repair some of that damage.

Content in our advertisements is very important, specifically in the two areas of language and images. When we use language that could be misinterpreted it can give people the wrong idea, even if our business is perfectly legitimate. For example, using the term “full-body massage” has been used as a euphemism for prostitution. It is an ambiguous statement-meaning it is unclear, If it’s a “full body” wouldn’t that include the breasts and genitals? We know those areas are not massaged, but does the general public? It can sound intimidating to someone not sure about getting a massage.

In reference to this course we mentioned some dubious modalities, which are legitimate sounding treatments that are in reality thinly veiled acts of prostitution.

Tantric Massage, Lingam Massage, Yoni Massage, Manual-release , and Full-release are all terms that are synonymous with massage-prostitution.

Speaking of internet searches, we also advised against placing terms like “does not offer sexual services” in your advertisements due to the fact that it can scare away timid clients and it just reminds people about massage therapies past. It also causes the web page to come up when someone

292 searches for ‘Sexual services’ and ‘massage together’ thereby actually getting the attention of the very clients you want to avoid. Search engines will pick up each word on the page and ambiguity can lead to embarrassing misunderstandings.

When thinking about placement of your advertisement you should keep in mind what other types of businesses are advertised near you and the target audience of the advertising.

We suggest that you avoid using neon signs if possible since they have long been used by the sex industry. An LED light in soft colors, or an ordinary sign on a well-lit window or with a light shining on it at night can be just as visible as a neon sign, but does not have the negative connotation that neon signs have.

The term “snake oil” refers to a fake medicine used to deceive the public. There are many people that are desperate to find a quick and easy fix for their health problems. This leads them to try alternative medicines like massage and other forms of traditional remedies. While many forms of alternative medicine are perfectly legitimate, there are some that are questionable, and others that are outright frauds. Massage therapists have an ethical obligation to research them well before incorporating them into a practice.

Be careful about the types of claims you make in your advertisements. Some safe claims to make are that massage therapy can provide relief from pain and discomfort and a decrease in stress and stress related symptoms. It can improved circulation and decrease in muscular tension.

These are easily within the mainstream medical communities expectation of massage therapy.

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The kind of claims you should avoid making are that massage can decrease any and all pain, can heal medical conditions that it cannot or that it can heal anything and everything. It sounds kind of obvious, but there are massage therapists out there claiming to be directing healing energy into curing all kinds of things.

Always be mindful of the placebo effect and it’s role in alternative medicines. This occurs when a client believes a particular treatment will work, so it seems to work. This can make it tempting for us to sell “nutritional” or “health” products in our massage practice that are very lucrative, but not necessarily effective. It unethical to sell a product that you know is not effective, even if the client believes it works.

The healing is originating from the client, so you should not be benefiting from it and you are participating in a deception, even if the client is willing to go along with it. This is bad because it damages your credibility in the eyes of other potential clients.

Many massage clients predisposed to believe in alternative medicines because they live with chronic pain, which influences their judgment.

The two factors that have led to the negative image many people in the United States have of massage therapy are the Illicit sex industry and modern day “snake oil” methodology.

While most legitimate massage therapists are good at distancing themselves from the Illicit sex industry some have fallen into the “snake oil” industry, becoming shills because they themselves believe the products work, even though there is no scientific evidence to support the claims. It is your ethical responsibility to fully investigate any product you sell in your massage practice because it is your professional image that is being lent to the product.

294 Section 3: Cultural Sensitivity for Massage Therapists

Instructions Thanks for downloading this Somatic Arts and Sciences continuing education course. You are on section 3, which means you are 9 hours in! Keep going!

Taking the Quiz To take the quiz you can click the link on the website below the book.

Target Audience This continuing education course has been designed to meet the educational needs of massage therapists.

Degree of Difficulty Beginner/Entry Level

Course Description The goal of this course is to educate the massage therapist on the important role that cultural conditioning plays in the acceptance of massage therapy as a health discipline. The views on massage therapy held by different ethnic cultures in the United States will be presented here for the massage practitioner to study and use as a marketing tool and as a means of providing more sensitive treatment.

Educational Objectives Upon completion of this home study continuing education course, the massage practitioner should be able to:

Describe how culture can influence a client’s acceptance of massage therapy. Relate strategies for conducting culturally sensitive advertising.

295 Introduction This course is presented for educational purposes only. It was developed and marketed specifically for massage therapists that are required to obtain continuing education hours for licensing purposes. The author is not giving medical, legal or other professional advice. This course is classified as “Cognitive ” learning, meaning that there is no hands on portion.

The effect of our culture on our ethical decision-making The story below is one that I can’t take credit for; it’s been used in college ethics courses for years. It’s a great tool for demonstrating how different people from different backgrounds can see the same situation in different ways.

The Girl, the Old Man, and the Sailor... On a beautiful and Sunny day five people boarded a boat for an afternoon cruise: A girl, her Fiancé her Fiancé’s Best Friend, an Old Man, and a Sailor. A sudden storm blew in sinking the boat. The five passengers were forced into two smaller boats to survive. In one boat was the Girl, the Old Man, and the Sailor. In the other boat was the girl's Fiancé and his best friend.

The boats were separated in the swirl of the storm. The boat with the Girl, the Old Man and the Sailor ended up on one island and the boat with the Fiancé and his Best Friend on another island. The Girl was distraught being away from her Fiancé and kept searching the horizon looking for him. They knew there was another island nearby but the boat would need to be fixed to get to it. She went to the Sailor and asked him to fix the boat so she could be re- united with her Fiancé. The Sailor agreed to fix the boat but only on the condition the Girl sleep with him that night.

The Girl did not know what to do so she went to the Old Man for advice. The Old Man listened to her and then said, "I cannot tell you what you should do. Follow what your heart tells you." Confused and desperate she agreed to the Sailor's condition.

After the Sailor fixed the boat they sailed and reached the other Island. The Girl was very happy to see her Fiancé and rushed into his arms. He was very happy to see her and she then told him about sleeping with the Sailor to get there. The Fiancé became very angry and brushed her aside saying, "I never want to see you again." Crying profusely the Girl began walking down the beach.

The Fiancé’s Best Friend followed her, and after about a quarter of a mile, came to her and said, "I know you two have had a quarrel. I will try to work it out, but in the meantime I will take care of you." 296

PLEASE RANK THE FIVE PEOPLE IN ORDER THAT YOU LIKE THEM OR VALUE THEM THE MOST (1 IS HIGHEST AND 5 LOWEST)

The Girl ______

The Fiancé ______

The Old Man ______

The Sailor ______

The Best Friend ______

There are many issues and questions that can make a difference in how people rank the characters.

For example, some like the Old Man the best, while others are very angry with him because he offered the Girl no assistance.

Some people think the Fiancés best friend is taking the opportunity to move in on the Girl, but what if the Fiancé best friend is a woman?

Some find the Girl to be immoral and at fault, while others are touched at her sacrifice and very upset with her Fiancé for not understanding.

The case illustrates how culture and upbringing can result in different views of the same scene.

Now I know you are taking this course alone, so there is no one for you to compare the results with, but when I used to use this at my massage school there was always an amazing variety of answers among the students.

Even the students that were good friends had different answers, to which they were generally surprised.

297 Chapter 1: Culture and your massage practice Our nations population is diverse. Those who seek our services speak a variety of languages and come from many different ethnic and cultural backgrounds, as well as economic levels. This greatly effects their views of massage therapy, healthcare and their own bodies.

A word of caution There are few topics so sensitive to people in our country as culture and race. The first step in becoming a culturally sensitive person is to address our own hypersensitivity to certain issues.

Because this is an ethics course we are going to be looking at values and culture. Let me just say at the onset, this is not a course on my values , or about what values are good. My goal is not to teach you values (your own culture and identity are responsible for that), rather I am going to simply define what the terms mean. So when I define cultural relativism and ethnocentricity, I am not saying one is better than the other, I am simply teaching you what the words mean.

The one value of mine that I would willingly inject into this course (and your heart and mind, if I could) is optimism about the subject matter.

When we watch or read the news we might be tempted to believe that the USA is a country that has a serious issue with cultural diversity, after all, there are racial or cultural clashes and conflicts occuring in our country all the time. I believe that isn’t true, because if we weren’t a country with great diversity and tolerance there would be no clashes. The strife we see is like the fever of an infection-and you know from your study of pathology that the fever is your bodies way of fighting the infection. We have cultural clashes because we strive to make things better, all the time. That is the one value of my own I will freely admit to slipping in this course. I believe that our country was founded on the idea that a group of diverse cultures can come together to make a new one, greater than the sum of its parts 43 .

That is my value, you don’t have to share it, but I hope you do.

43 Extra credit to you if you recognized that I just admitted to my own Ethnocentrism, “E Pluribus Unum” is a value that is unique to my culture, and believing that it is good and should be shared by all is Ethnocentrism. See? Ethics is fun!

298 What exactly is Cultural Sensitivity? Cultural sensitivity is an integration of knowledge, attitude, and skills that enhances crosscultural communication and appropriate/effective communication and interactions with others.

Cultural sensitivity can be divided into two equally important attributes:

Knowledge Knowledge of the effects of culture on a persons beliefs and behaviors. A baseline knowledge of how a cultural group views massage therapy can greatly empower you in regards to successful client care and marketing.

Awareness Awareness of one's own cultural attitudes and biases, and what impact they have on others.

Cultural sensitivity also includes an individual's ability to act tactfully when communicating with individuals and groups of a different culture. This includes recognizing and respecting differences in our clients in terms of their values, expectations, and past experiences. It involves examining our own cultural beliefs and biases, as well as the culture of massage therapy in the United States, and exploring how these influences might affect your therapeutic relationship.

"Culture involves everything you do, from what you eat, how you introduce people, to the rules of hygiene and physical proximity" 44

Although our society often defines culture as a person's ethnicity or race, culture is defined by a much broader range of attributes including beliefs, customs, ethnicity, race, religious affiliation, age, gender, ability, experience, geographical location, profession, economic position and more.

According to Gardenswartz and Rowe, "Health care, views of pain and suffering, life and death, individual responsibility, and predestination are influenced by culture" 45 . Cultural norms have a powerful influence on perceptions and values regarding wellness, pain, suffering, medical

44 Loden, M., & Rosener. J (1991). Workforce America/Homewood, IL: Business One Irwin. 45 Gardenswartz, L., & Rowe, A. (1993). Recognizing the power of diversity. Physician Executive, 19(6), 64-67.

299 treatment and of course, death. We all have the same basic needs, what is different is the way in which these needs are expressed and satisfied.

Culturally competent massage therapists will work to increase their knowledge of how other cultures perceive massage therapy and body work in general.

As massage therapists, our goal must be to meet the needs of our clients. In order to meet that need we must be able to present an approachable presence. A person with a substantially different cultural view of massage therapy is far more likely to seek out your services if they feel you have a decent understanding of their values and norms.

That is what this course is all about, understanding that people from different cultures view the body, gender, touch and nudity differently and that has an impact on their perception of massage therapy.

Removing the Barriers to our own sensitivity Becoming culturally sensitive can be difficult for even the most empathetic massage therapist. The United States is a wonderful land that celebrates diversity, consequently, the values, and practices of many massage therapists may differ dramatically from those of their clients.

The lack of cultural sensitivity training in massage schools may limit the access to information about the cultural or ethnic groups they may serve.

It is important to remember that there can be as many differences among people in the same cultural group as there are differences between cultural groups.

Another thing to keep in mind is the assimilation factor. Second-generation immigrants to the U.S. who are acculturated to the country’s norms may share the attitudes and beliefs of other Americans, while their parents or even older siblings may hold fast to their own traditions.

Culturally sensitive massage therapists learn about different cultures and the values that drive them. They develop nonjudgmental acceptance of cultural differences in clients and coworkers and view diversity as a strength that empowers them to achieve goals.

300 The development of cultural sensitivity depends upon on enhancing our own self-awareness, gaining new knowledge about culturally diverse groups, strengthening intercultural communication and identifying and managing cultural conflicts.

Everyone carries biases from life experiences. Being aware of them allows us to see differences and other perspectives more clearly. For example, a massage therapist who is very comfortable with his or her own body and human anatomy in general may be biased against people who are uncomfortable with undressing for a session.

Does this massage therapist mistakenly believe themselves to be “more enlightened” than the person that is uncomfortable being massage with just a linen covering them? Would they view them as unsophisticated or ignorant if their religious beliefs frowned on massage therapy?

What is Culture? Culture is a concept based on a term first used in classical antiquity by the Roman orator Cicero: "cultura animi" (cultivation of the soul). This non- agricultural use of the term "culture" re-appeared in modern Europe in the 17th century referring to the betterment or refinement of individuals, especially through education. During the 18th and 19th century it came to refer more frequently to the common reference points of whole peoples, and discussion of the term was often connected to national aspirations or ideals. Some scientists such as Edward Tylor used the term "culture" to refer to a universal human capacity.

In the 20th century, "culture" emerged as a central concept in anthropology, encompassing the range of human phenomena that cannot be directly attributed to genetic inheritance. Specifically, the term "culture" in American anthropology had two meanings:

The evolved human capacity to classify and represent experiences with symbols, and to act imaginatively and creatively; and

The distinct ways that people, who live differently, classified and represented their experiences, and acted creatively.

301 Hoebel describes culture as an integrated system of learned behavior patterns which are characteristic of the members of a society and which are not a result of biological inheritance.

Distinctions are currently made between the physical artifacts created by a society, its so-called material culture, and everything else,[4] the intangibles such as language, customs, etc. that are the main referent of the term "culture".

The modern term "culture" is based on a term used by the Ancient Roman orator Cicero in his Tusculanae Disputationes, where he wrote of a cultivation of the soul or "cultura animi", using an agricultural metaphor for the development of a philosophical soul, understood teleologically as the highest possible ideal for human development. Samuel Pufendorf took over this metaphor in a modern context, meaning something similar, but no longer assuming that philosophy was man's natural perfection. His use, and that of many writers after him "refers to all the ways in which human beings overcome their original barbarism, and through artifice, become fully human".

As described by Velkley: The term "culture," which originally meant the cultivation of the soul or mind, acquires most of its later modern meanings in the writings of the 18th-century German thinkers, who were on various levels developing Rousseau's criticism of ″modern liberalism and Enlightenment ″. Thus a contrast between "culture" and "civilization" is usually implied in these authors, even when not expressed as such. Two primary meanings of culture emerge from this period: culture as the folk-spirit having a unique identity and culture as cultivation of waywardness or free individuality. The first meaning is predominant in our current use of the term "culture," although the second still plays a large role in what we think culture should achieve, namely the full "expression" of the unique or "authentic" self.

Cultural invention has come to mean any innovation that is new and found to be useful to a group of people and expressed in their behavior but which does not exist as a physical object. Humanity is in a global "accelerating culture change period", driven by the expansion of international commerce, the mass media, and above all, the human population explosion, among other factors.

302 Cultures are internally affected by both forces encouraging change and forces resisting change. These forces are related to both social structures and natural events, and are involved in the perpetuation of cultural ideas and practices within current structures, which themselves are subject to change.

Social conflict and the development of technologies can produce changes within a society by altering social dynamics and promoting new cultural models, and spurring or enabling generative action. These social shifts may accompany ideological shifts and other types of cultural change. For example, the U.S. feminist movement involved new practices that produced a shift in gender relations, altering both gender and economic structures. Environmental conditions may also enter as factors. For example, after tropical forests returned at the end of the last ice age, plants suitable for domestication were available, leading to the invention of agriculture, which in turn brought about many cultural innovations and shifts in social dynamics.

Cultures are externally affected via contact between societies, which may also produce—or inhibit—social shifts and changes in cultural practices. War or competition over resources may impact technological development or social dynamics. Additionally, cultural ideas may transfer from one society to another, through diffusion or acculturation. In diffusion, the form of something (though not necessarily its meaning) moves from one culture to another. For example, hamburgers, fast food in the United States, seemed exotic when introduced into China. "Stimulus diffusion" (the sharing of ideas) refers to an element of one culture leading to an invention or propagation in another. "Direct Borrowing" on the other hand tends to refer to technological or tangible diffusion from one culture to another. Diffusion of innovations theory presents a research-based model of why and when individuals and cultures adopt new ideas, practices, and products.

Acculturation has different meanings, but in this context refers to replacement of the traits of one culture with those of another, such as what happened to certain Native American tribes and to many indigenous peoples across the globe during the process of colonization. Related processes on an individual level include assimilation (adoption of a different culture by an individual) and transculturation.

303 German Romanticism The German philosopher Immanuel Kant (1724–1804) has formulated an individualist definition of "enlightenment" similar to the concept of bildung: "Enlightenment is man's emergence from his self-incurred immaturity." He argued that this immaturity comes not from a lack of understanding, but from a lack of courage to think independently. Against this intellectual cowardice, Kant urged: Sapere aude, "Dare to be wise!" In reaction to Kant, German scholars such as Johann Gottfried Herder (1744–1803) argued that human creativity, which necessarily takes unpredictable and highly diverse forms, is as important as human rationality. Moreover, Herder proposed a collective form of bildung: "For Herder, Bildung was the totality of experiences that provide a coherent identity, and sense of common destiny, to a people."

Adolf Bastian developed a universal model of culture. In 1795, the great linguist and philosopher Wilhelm von Humboldt (1767– 1835) called for an anthropology that would synthesize Kant's and Herder's interests. During the Romantic era, scholars in Germany, especially those concerned with nationalist movements—such as the nationalist struggle to create a "Germany" out of diverse principalities, and the nationalist struggles by ethnic minorities against the Austro-Hungarian Empire— developed a more inclusive notion of culture as "worldview"(Weltanschauung). According to this school of thought, each ethnic group has a distinct worldview that is incommensurable with the worldviews of other groups. Although more inclusive than earlier views, this approach to culture still allowed for distinctions between "civilized" and "primitive" or "tribal" cultures.

In 1860, Adolf Bastian (1826–1905) argued for "the psychic unity of mankind". He proposed that a scientific comparison of all human societies would reveal that distinct worldviews consisted of the same basic elements. According to Bastian, all human societies share a set of "elementary ideas" (Elementargedanken); different cultures, or different "folk ideas" (Völkergedanken), are local modifications of the elementary ideas. This view paved the way for the modern understanding of culture. Franz Boas (1858–1942) was trained in this tradition, and he brought it with him when he left Germany for the United States.

English Romanticism

304 In the 19th century, humanists such as English poet and essayist Matthew Arnold (1822–1888) used the word "culture" to refer to an ideal of individual human refinement, of "the best that has been thought and said in the world." This concept of culture is comparable to the German concept of bildung: "...culture being a pursuit of our total perfection by means of getting to know, on all the matters which most concern us, the best which has been thought and said in the world."

In practice, culture referred to an élite ideal and was associated with such activities as art, classical music, and haute cuisine. As these forms were associated with urban life, "culture" was identified with "civilization" (from lat. civitas, city). Another facet of the Romantic movement was an interest in folklore, which led to identifying a "culture" among non-elites. This distinction is often characterized as that between high culture, namely that of the ruling social group, and low culture. In other words, the idea of "culture" that developed in Europe during the 18th and early 19th centuries reflected inequalities within European societies.

Matthew Arnold contrasted "culture" with anarchy; other Europeans, following philosophers Thomas Hobbes and Jean-Jacques Rousseau, contrasted "culture" with "the state of nature". According to Hobbes and Rousseau, the Native Americans who were being conquered by Europeans from the 16th centuries on were living in a state of nature; this opposition was expressed through the contrast between "civilized" and "uncivilized." According to this way of thinking, one could classify some countries and nations as more civilized than others and some people as more cultured than others. This contrast led to Herbert Spencer's theory of Social Darwinism and Lewis Henry Morgan's theory of cultural evolution. Just as some critics have argued that the distinction between high and low cultures is really an expression of the conflict between European elites and non- elites, some critics have argued that the distinction between civilized and uncivilized people is really an expression of the conflict between European colonial powers and their colonial subjects.

Other 19th-century critics, following Rousseau have accepted this differentiation between higher and lower culture, but have seen the refinement and sophistication of high culture as corrupting and unnatural developments that obscure and distort people's essential nature. These critics considered folk music (as produced by "the folk", i.e., rural, illiterate, peasants) to honestly express a natural way of life, while classical music

305 seemed superficial and decadent. Equally, this view often portrayed indigenous peoples as "noble savages" living authentic and unblemished lives, uncomplicated and uncorrupted by the highly stratified capitalist systems of the West.

In 1870 the anthropologist Edward Tylor (1832–1917) applied these ideas of higher versus lower culture to propose a theory of the evolution of religion. According to this theory, religion evolves from more polytheistic to more monotheistic forms. In the process, he redefined culture as a diverse set of activities characteristic of all human societies. This view paved the way for the modern understanding of culture.

Well so much for the history of culture. Before we can jump into how culture relates to your massage practice we have to spend just a little time on the basic concepts and terms used in our understanding of culture and how it relates to our ethics. Please indulge me just a little more as we read chapter 2, a primer of basic terms.

306 Chapter 2: A values, culture and ethics primer Acculturation means the process of adopting the cultural traits or social patterns of a group other than one’s own. In regard to immigrant groups, acculturation is the process of incorporating values, beliefs and behaviors from the dominant culture into the immigrants’ cultural worldview.

Assimilation means the process of taking on the cultural traits and characteristics of another distinct group; absorption of a new or different culture into the main cultural body; to make like; to cause to resemble.

Bicultural means the ability to understand and function effectively in two cultural environments. An individual who is bicultural is not necessarily culturally competent.

Bilingual means the ability to effectively speak two languages.

Cultural Relativism Cultural Relativism can be defined as a concept whereby cultural norms and values derive their meaning within a specific social context. The idiom “When in Rome, do as the Romans do,” is a simple means of summarizing the concept, however it implies action, whereas the history of the term relates to observation. The principle was established by anthropologist Franz Boas in the early 20th century, and was popularized by his students. From an academic point of view, this is, and should be, the sole intention of

46 Pojman, L. P. : A Defense of Ethical Objectivism

307 cultural relativism, as it is a fundamental tool for social scientists, by which they can learn about and understand another culture, and subsequently share such knowledge and observation.

For example, Western cultural norms include monogamy, care for the elderly, and sanctity of life. In contrast, Eskimo are to the contrary, with polygamy, elder abandonment to the elements (certain death), and an infanticide. As a cultural observation, these are certainly differences, and relative to each. However, when the question of which practice is right comes into play, it changes the application of the theory.

Despite its anthropological origins, cultural relativism has gained prominence as an ethical theory, however not without significant criticism. The core issue lies in applying a theory of observation and understanding to one of right and wrong, with the relative culture serving as the measure of appropriateness. As it is not the intended purpose, this ethical interpretation is inherently flawed, resulting in a confused doctrine with semantic ambiguities.

Applied in this manner, cultural relativism states that there is no singular truth on which to base ethical or moral behavior as our interpretations of truths are influenced by our own culture. Modifying our idiom, you could say that Whatever the Romans do in Rome is ethical and acceptable because that’s what they do there (and we have no right to judge them on it). Viewed in this manner, it shares the position with moral relativism that there is no absolute or universal set of values or principles that can be used to judge human behavior – what is acceptable is judged by the culture in which the actions take place, and cannot be viewed out of that context.

Cultural relativism is a normative ethical position, rather than a prescriptive one. That is to say, rather than prescribing what ought to be done in a specific situation, it merely describes how people behave in that situation, as dictated by the accepted norms.

With moral behavior being relative to (conforming with) a learned set of cultural norms rather than being relative to the actions of the individual, Cultural relativism differs from moral relativism. In this sense it considers moral behavior to be historically and contextually situated. However one criticism dismisses this notion, as cultures evolve and change, as do the subsequent norms. For example, slavery was once acceptable in western

308 cultures, but that is no longer the case. Therefore, cultural relativism can be questioned based on its foundation of a changeable set of norms.

As the basis for cultural relativism is the observation that different cultures have different sets of norms and values that govern behaviour in their culture. This is in contrast to universalism that holds the position that moral values are the same for everyone. Cultural relativists consider this to be an ethnocentric view as the universal set of values proposed by Universalists are based on their set of values. Cultural relativism is also considered to be more tolerant than universalism as, if there is no basis for making moral judgments between cultures, then cultures have to be tolerant of each other.

Conventionalism is the theory that fundamental principles of right and wrong are based on agreements in society , rather than on an external reality. In other words, if society thinks it’s morally fine to do something, than it is morally fine to do. So all moral principles are justified by virtue of their cultural acceptance. Here is one example:

In the year 1922 many public beaches had laws that mandated a woman’s bathing suit couldn’t be further than 6 inches from the knee.

The bathing suit code is one example

of conventionalism-at the time a

woman showing too much skin was

considered wrong, today we laugh

when we see this.

Culture changes, and while we might like to think that it always changes the better, the scary truth is that it doesn’t. This brings me to my second example of conventionalism: The Eugenics movement.

Eugenics was a social movement in the United States that believed we should be using science to improve the genetic features of human

309 populations through selective breeding and forced sterilization of undesirable people. It was practiced in the United States many years before similar programs in Nazi Germany even started and the U.S. programs actually inspired the Nazis. Over 20,000 “inferior” people were forcibly sterilized in California alone 47 .

It’s tempting to look at the madness of the Eugenics movement and say “the people of the past sure were ignorant”-but remember, this movement was, at the time, espoused by scientists and universities across the country 48 and the people that were fighting it then were called “ignorant” and “old fashioned”.

Culturally-specific intervention means interventions or treatments that are common to or are especially effective with a specific population or services provided by practitioners who are characteristically found within a particular population.

Expectations of high service quality remain. An example would be a Chinese individual seeing out an acupuncturist to receive moxibustion.

Culturally-specific provider means one who is characteristically found or proven especially effective within a particular cultural and linguistic population.

Culture means (a) the integrated pattern of socially transmitted human behavior that includes thoughts, communication, actions, customs, beliefs, values, and institutions, and all other products of human work or thought, characteristic of a particular community or population. (b) Cultural defines the preferred ways for meeting needs.[139] (c) Culture is created by people as a dynamic adaptive mechanism, continuously changing to allow a more effective adaptation to new circumstances. (d) Culture is a set of guidelines, both explicit and implicit, which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to behave in relation to other people, to supernatural forces and gods, and to the natural environment." (e) Culture also involves the historical circumstances leading to a group’s economic,

47 California had the most, sterilizing people against their will for decades after WWII. Curious about your state? http://www.uvm.edu/~lkaelber/eugenics 48 Blom, Philipp (2008). The Vertigo Years: Change and Culture in the West, 1900-1914. Toronto: McClelland & Stewart, Ltd. p. 334. ISBN 978-0-7710-1630-1.

310 social, and political status in the social structure. (f) Culture involves the circumstances and experiences associated with developing certain beliefs, norms, and values. Culture provides the “big story.” This story, repeated from generation to generation, provides both individuals and the group with their reason for being. If the story is not passed on by families to children, the children will make up compensatory–and typically less satisfying– stories out of deep-felt, if unconscious, necessity.

Cultural is the most broad and overarching fabric of the social environment. It may include racial, ethnic, religious, or social communities or populations. Race is separate from culture (and the very notion of it will be challenged later in this course-fun stuff ahead!). Culture is more about behavior than biology. Emphasizing culture when discussing how we develop cultural competency—and removing race from that discussion—helps to focus on the behaviors, attitudes, and practices needed in order to effectively serve diverse cultural communities.

Culture-bound behaviors or culture-bound syndrome means culture- specific behaviors, conditions, and diseases that affect a person’s health and well-being. For example, in some cultures, a person can become ill and suffer “soul loss” because another person has cursed them. In some cultures, women breast-feed babies until they are two or three years old while in others, women learn that bottle feeding is more appropriate. In some cultures, a person who sees a vision can be a gifted healer while, in others, she may be labeled schizophrenic. In some cultures, young women are circumcised when they reach puberty; in others, baby boys are circumcised.

Diverse populations means distinct groups including, but not limited to, racial and ethnic minorities, persons of color, American Indians, disabilities culture, economic class cultures, and immigrants.

Dynamics of Difference means the interpersonal interactions that occur in a cross-cultural encounter. When one culture interacts with the population of another, both may misjudge the other’s actions based on learned expectations. Each party brings to the relationship unique histories with the other group and the influence of the current political relationship between the two groups. Both will bring culturally-prescribed patterns of communication, etiquette, and problem solving. Both may bring stereotypes or underlying feeling about serving—or being served by—someone who is

311 “different.” Such tension is part of the cross-cultural encounter. Both professionals and clients should be vigilant against misinterpretation and misjudgment.

Ethnic means designating basic groups or divisions of human beings as distinguished by customs, a common language, a common history, a common religion, or other such characteristics.

Ethnocentrism This is the prejudicial view that interprets all of reality through the eyes of one’s own cultural beliefs and values. This isn’t something that is unique to us Americans, all cultures in the world do this-it’s human nature. This is important for us massage therapists because people from different cultures view massage therapy, the human body and nudity in very different ways. In fact it’s so important you are going to be reading a lot more about it later in this course.

Ethnographic interview means a meeting with a person of another culture in order to begin understanding his or her worldview, beliefs and life situation. It is a way to examine the patterned interactions and significant symbols of specific cultural groups to identify cultural rules that direct behaviors and the meaning people ascribe to such behaviors. Ethnographic interviewing helps a person understand another culture while avoiding stereotyping. An ethnographic interviewer is in control of the structure of the event, while the interviewee is in control of the cultural content of the event. The interviewer is the learner and the interviewee is the teacher.

Interpreter means an individual trained and/or certified in facilitating oral, written, or manual communication between two or more people of different languages. For the purpose of these Guidelines, a qualified interpreter possesses in-depth knowledge, not only of the language, but also of cultural values, beliefs, and verbal and non-verbal expressions.

Limited English proficiency (LEP) or persons with LEP, means individuals who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with the massage therapist.

Norms are a group-held belief about how members should behave in a given context. Sociologists describe norms as informal understandings that

312 govern individuals' behavior in society, while psychologists have adopted a more general definition, recognizing smaller group units, like a team or an office, may also endorse norms separate or in addition to cultural or societal expectations. The psychological definition emphasizes social norms' behavioral component, stating norms have two dimensions: how much behavior is exhibited and how much the group approves of that behavior.

Norms running counter to the behaviors of the overarching society or culture may be transmitted and maintained within small subgroups of society. For example, Crandall (1988) noted that certain groups (e.g., cheerleading squads, dance troupes, sports teams, sororities) have a rate of bulimia, a publicly recognized life-threatening disease, that is much higher than society as a whole. Social norms have a way of maintaining order and organizing groups.

Although not considered to be formal laws within society, norms still work to promote a great deal of social control. Social norms can be enforced formally (e.g., through sanctions) or informally (e.g., through body language and non-verbal communication cues.) Because individuals often derive physical or psychological resources from group membership, groups are said to control discretionary stimuli; groups can withhold or give out more resources in response to members' adherence to group norms, effectively controlling member behavior through rewards and operant conditioning. Social psychology research has found the more an individual values group- controlled resources or the more an individual sees group membership as central to his definition of self, the more likely he is to conform. Social norms also allow you to assess what behaviors the group deems important to its existence or survival, since they represent a codification of belief; groups generally do not punish members or create norms over actions which they care little about. Norms in every culture create conformity that allows for people to become socialized to the culture in which they live.

As social beings, individuals learn when and where it is appropriate to say certain things, to use certain words, to discuss certain topics or wear certain clothes, and when it is not. Thus, knowledge about cultural norms is important for impressions, which is an individual's regulation of their nonverbal behavior. One also comes to know through experience what types of people he/she can and cannot discuss certain topics with or wear certain types of dress around. Typically, this knowledge is derived through

313 experience (i.e. social norms are learned through social interaction). Wearing a suit to a job interview in order to give a great first impression represents a common example of a social norm in the white collar work force.

Groups may adopt norms through a variety of ways. Norms can arise formally, where groups explicitly outline and implement behavioral expectations. Laws or club rules serve as an example of this. A large number of these norms we follow 'naturally' such as driving on the right side of the road in the US and on the left side in the UK, or not speeding in order to avoid a ticket. Many formal norms serve to provide safety to the general public.

However, social norms are much more likely to develop informally, emerging gradually as a result of repeated use of discretionary stimuli to control behavior. Not necessarily laws set in writing, informal norms represent generally accepted and widely sanctioned routines that people follow in everyday life. These informal norms, if broken, may not invite formal legal punishments or sanctions, but instead encourage reprimands, warnings, or othering; incest, for example, is generally thought of as wrong in society, but many jurisdictions do not legally prohibit it.

Finally, individuals may also import norms from a previous organization to their new group, which can get adopted over time. Without a clear indication of how to act, people typically rely on their past history to determine the best course forward; what was successful before may serve them well again. In a group, individuals may all import different histories or scripts about appropriate behaviors; common experience over time will lead the group to define as a whole its take on the right action, usually with the integration of several members' schemas. Under the importation paradigm, norm formation occurs subtly and swiftly whereas with formal or informal development of norms may take longer.

Groups internalize norms by accepting them as reasonable and proper standards for behavior within the group. Once firmly established, a norm becomes a part of the group's operational structure and hence more difficult to change. While possible for newcomers to a group to change its norms, it is much more likely that the new individual will adopt the group's norms, values, and perspectives, rather than the other way around.

314 Deviance is defined as "nonconformity to a set of norms that are accepted by a significant number of people in a community or society." More simply put, if group members do not follow a norm, they become labeled as a deviant. In the sociological literature, this can often lead to them being considered outcasts of society. What is considered “normal” is relative to the location of the culture in which the social interaction is taking place. In psychology, an individual who routinely disobeys group norms runs the risk of turning into the "institutionalized deviant." Similar to the sociological definition, institutionalized deviants may be judged by other group members for their failure to adhere to norms. At first, group members may increase pressure on a non-conformist, attempting to engage the individual in conversation or explicate why she should follow their behavioral expectations. Especially with new members who perhaps do not know any better, groups may use discretionary stimuli to bring an individual's behavior back into line. Over time, however, if a member continues to disobey, the group will give up on him as a lost cause; while the group may not necessarily revoke his membership, they may give him only superficial consideration. If a worker is late to a meeting, for example, violating the office norm of punctuality, a boss or other co-worker may wait for the individual to arrive and pull him aside later to ask what happened. If the behavior continues, eventually the group may begin meetings without him since the individual "is always late." The group generalizes the individual's disobedience and promptly dismisses it, thereby reducing the member's influence and footing in future group disagreements.

Group tolerance for deviation varies across membership; not all group members receive the same treatment for norm violations. Individuals may build up a "reserve" of good behavior through conformity, which they can borrow against later. These idiosyncrasy credits provide a theoretical currency for understanding variations in group behavioral expectations. A teacher, for example, may more easily forgive a straight-A student for misbehaving—who has past "good credit" saved up—than a repeatedly disruptive student. While past performance can help build idiosyncrasy credits, some group members have a higher balance to start with. Individuals can import idiosyncrasy credits from another group; childhood movie stars, for example, who enroll in college, may experience more leeway in adopting school norms than other incoming freshmen. Finally, leaders or individuals in other high-status positions may begin with more credits and be appear to be "above the rules" at times. Even their idiosyncrasy credits are not bottomless, however; while held to a more

315 lenient standard than the average member, leaders may still face group rejection if their disobedience becomes too extreme.

Cialdini, Reno, and Kallgren developed the Focus Theory of Normative Conduct to describe how individuals implicitly juggle multiple behavioral expectations at once; expanding on conflicting prior beliefs about whether cultural, situational or personal norms motivate action, the researchers suggested the focus of an individual’s attention will dictate what behavioral expectation they follow. They define a 'Descriptive Norm' as people's perceptions of what is commonly done in specific situations; it signifies what most people do, without assigning judgment. The absence of trash on the ground in a parking lot, for example, transmits the descriptive norm that most people there do not litter. An Injunctive norm, on the other hand, transmits group approval about a particular behavior; it dictates how an individual should behave. Watching another person pick up trash off the ground and throw it out, a group member may pick up on the injunctive norm that he ought to not litter. Descriptive norms depict what happens while injunctive norms describe what should happen.

Unwritten rules that are understood and followed by society, prescriptive norms indicate what we should do. Expressing gratitude or writing a Thank You card when someone gives you a gift represents a prescriptive norm in American culture. Proscriptive norms, in contrast, comprise the other end of the same spectrum; they are similarly society's unwritten rules about what one should not do. These norms can vary between cultures; while an acceptable greeting in some European countries, kissing a stranger on the cheek constitutes a proscriptive norm in the United States.

Subjective norm is determined by beliefs about the extent to which important others want them to perform a behavior. Social influences are conceptualized in terms of the pressure that people perceive from important others to perform, or not to perform, a behavior.

Over the last few decades, several theorists have attempted to explain social norms from a more theoretical point of view. By quantifying behavioral expectations graphically or attempting to plot the logic behind adherence, theorists hoped to be able to predict whether or not individuals would conform. The Return Potential Model and Game Theory provide a slightly more economic conceptualization of norms, suggesting individuals can calculate the cost or benefit behind possible behavioral outcomes.

316 Under these theoretical frameworks, choosing to obey or violate norms becomes a more deliberate, quantifiable decision.

Intensity. The intensity of the norm tells how much the group cares about the norm, or how much group affect is at stake to be won or lost. It is represented in the Return Potential Model by the total amount of area subsumed by the curve, regardless of whether the area is positive or negative. A norm with low intensity would not vary far from the x-axis; the amount of approval or disapproval for given behaviors would be closer to zero. A high-intensity norm, however, would have more extreme approval ratings. In Figure 1, the intensity of the norm appears high, as few behaviors invoke a rating of indifference.

Another general formal framework that can be used to represent the essential elements of the social situation surrounding a norm is the repeated game of game theory.

A norm gives a person a rule of thumb for how they should behave. However, a rational person only acts according to the rule if it is optimal for them. The situation can be described as follows. A norm gives an expectation of how other people act in a given situation (macro). A person acts optimally given the expectation (micro). For a norm to be stable, people's actions must reconstitute the expectation without change (micro- macro feedback loop). A set of such correct stable expectations is known as a Nash equilibrium. Thus, a stable norm must constitute a Nash equilibrium.

From a game-theoretical point of view, there are two explanations for the vast variety of norms that exist throughout the world. One is the difference in games. Different parts of the world may give different environmental contexts and different people may have different values, which may result in a difference in games. The other is equilibrium selection not explicable by the game itself. Equilibrium selection is closely related to coordination. For a simple example, driving is common throughout the world, but in some countries people drive on the right and in other countries people drive on the left (see coordination game). A framework called comparative institutional analysis is proposed to deal with the game theoretical structural understanding of the variety of social norms.

317 Preferred language means the self-identified language, which the client prefers to use in a service or clinical encounter. The preferred language need not be the client’s native or primary language if the client indicates sufficient proficiency in English and prefers to use English.

Value (personal and cultural) A personal value is absolute or relative and ethical value, the assumption of which can be the basis for ethical action. A value system is a set of consistent values and measures. A principle value is a foundation upon which other values and measures of integrity are based.

Some values are physiologically determined and are normally considered objective, such as a desire to avoid physical pain or to seek pleasure. Other values are considered subjective, vary across individuals and cultures, and are in many ways aligned with belief and belief systems. Types of values include ethical/moral values, doctrinal/ideological (religious, political) values, social values, and aesthetic values. It is debated whether some values that are not clearly physiologically determined, such as altruism, are intrinsic, and whether some, such as acquisitiveness, should be classified as vices or virtues. Values have been studied in various disciplines: anthropology, behavioral economics, business ethics, corporate governance, moral philosophy, political sciences, social psychology, sociology and theology to name a few.

Values can be defined as broad preference concerning appropriate courses of action or outcomes. As such, values reflect a person's sense of right and wrong or what "ought" to be. "Equal rights for all", "Excellence deserves admiration", and "People should be treated with respect and dignity" are representative of values. Values tend to influence attitudes and behavior.

Personal values According to Morris Massey, values form during three significant periods: Imprint period - from birth to 7 years Modeling period - from 8 to 13 years Socialization period - from 13 to 21 years

Personal values provide an internal reference for what is good, beneficial, important, useful, beautiful, desirable, constructive, etc. Values generate behavior and help solve common human problems for survival by comparative rankings of value, the results of which provide answers to

318 questions of why people do what they do and in what order they choose to do them.

Over time the public expression of personal values that groups of people find important in their day-to-day lives, lay the foundations of law, custom and tradition. Recent research has thereby stressed the implicit nature of value communication.

Personal values exist in relation to cultural values, either in agreement with or divergence from prevailing norms. A culture is a social system that shares a set of common values, in which such values permit social expectations and collective understandings of the good, beautiful, constructive, etc. Without normative personal values, there would be no cultural reference against which to measure the virtue of individual values and so culture identity would disintegrate.

Wyatt Woodsmall points out that "'Criteria' are used to refer to 'the standards on which an evaluation is based'." Values relate then to what one wants and in what order one wants them; criteria can only refer to the evidences for achieving values and act as a comparative standard that one applies in order to evaluate whether goals have been met / values satisfied.

Cultural values The Inglehart-Welzel Cultural Map of the World, constructed by sociopolitical scientists Ronald Inglehart and Christian Welzel based on the World Values Survey.

Individual cultures emphasize values which their members broadly share. One can often identify the values of a society by noting which people receive honor or respect. In the United States of America, for example, professional athletes at the top levels in some sports receive more honor (measured in terms of monetary payment) than university professors. Surveys show that voters in the United States would not willingly elect an atheist as president, suggesting belief in a God as a generally shared value there.

Values clarification differs from cognitive moral education:

319 Value clarification consists of "helping people clarify what their lives are for and what is worth working for. It encourages students to define their own values and to understand others' values."

Cognitive moral education builds on the belief that students should learn to value things like democracy and justice as their moral reasoning develops.

Educationist Chaveen Dissanayake says that personal and cultural values can vary according to the living standards of a person.

Values relate to the norms of a culture, but they are more global and abstract than norms. Norms provide rules for behavior in specific situations, while values identify what should be judged as good or evil. While norms are standards, patterns, rules and guides of expected behavior, values are abstract concepts of what is important and worthwhile. Flying the national flag on a holiday is a norm, but it reflects the value of patriotism. Wearing dark clothing and appearing solemn are normative behaviors to manifest respect at a funeral. Different cultures reflect values differently and to different levels of emphasis. "Over the last three decades, traditional-age college students have shown an increased interest in personal well-being and a decreased interest in the welfare of others." Values seemed to have changed, affecting the beliefs, and attitudes of the students.

Members take part in a culture even if each member's personal values do not entirely agree with some of the normative values sanctioned in that culture. This reflects an individual's ability to synthesize and extract aspects valuable to them from the multiple subcultures they belong to.

If a group member expresses a value that seriously conflicts with the group's norms, the group's authority may carry out various ways of encouraging conformity or stigmatizing the non-conforming behavior of that member. For example, imprisonment can result from conflict with social norms that the state has established as law.

Furthermore, institutions in the global economy can genuinely respect values which are of three kinds based on a "triangle of coherence". In the first instance, a value may come to expression within the World Trade Organization (WTO), as well as (in the second instance) within the United Nations - particularly in the Educational, Scientific and Cultural Organization (UNESCO) - providing a framework for global legitimacy

320 through accountability. In the third instance, the expertise of member-driven international organizations and civil society depends on the incorporation of flexibility in the rules, to preserve the expression of identity in a globalized world.

Nonetheless, in a war-like economic competition, differing views may contradict each other, particularly in the field of culture. Thus audiences in Europe may regard a movie as an artistic creation and grant it benefits from special treatment, while audiences in the United States may see it as mere entertainment, whatever its artistic merits. EU policies based on the notion of "cultural exception" can become juxtaposed with the policy of "cultural specificity" on the liberal Anglo-Saxon side. Indeed, international law traditionally treats films as property and the content of television programs as a service.

Consequently cultural interventionist policies get opposed to Anglo-Saxon liberal position, causing failures in international negotiations.

321 Chapter 3: Demographics of the USA The U.S. Census Bureau estimates the country's population now to be 318,742,000, including an approximate 11.2 million illegal immigrants. The U.S. population almost quadrupled during the 20th century, from about 76 million in 1900. The third most populous nation in the world, after China and India, the United States is the only major industrialized nation in which large population increases are projected.

The United States has a very diverse population—31 ancestry groups have more than one million members. German Americans are the largest ethnic group (more than 50 million) - followed by Irish Americans (circa 35 million), Mexican Americans (circa 31 million) and English Americans (circa 27 million).

White Americans are the largest racial group; Black Americans are the nation's largest racial minority and third largest ancestry group. Asian Americans are the country's second largest racial minority; the three largest Asian American ethnic groups are Chinese Americans, Filipino Americans, and Indian Americans.

With a birth rate of 13 per 1,000, 35% below the world average, its population growth rate is positive at 0.9%, significantly higher than those of many developed nations. In fiscal year 2012, over one million immigrants (most of whom entered through family reunification) were granted legal residence. Mexico has been the leading source of new residents since the 1965 Immigration Act. China, India, and the Philippines have been in the top four sending countries every year.

In 2010, the U.S. population included an estimated 5.2 million people with some American Indian or Alaska Native ancestry (2.9 million exclusively of such ancestry) and 1.2 million with some native Hawaiian or Pacific island ancestry (0.5 million exclusively). The census counted more than 19 million people of "Some Other Race" who were "unable to identify with any" of its five official race categories in 2010.

The population growth of Hispanic and Latino Americans (the terms are officially interchangeable) is a major demographic trend. The 50.5 million Americans of Hispanic descent are identified as sharing a distinct "ethnicity" by the Census Bureau; 64% of Hispanic Americans are of Mexican descent. Between 2000 and 2010, the country's Hispanic

322 population increased 43% while the non-Hispanic population rose just 4.9%. Much of this growth is from immigration; in 2007, 12.6% of the U.S. population was foreign-born, with 54% of that figure born in Latin America.

Fertility is also a factor; in 2010 the average Hispanic (of any race) woman gave birth to 2.35 children in her lifetime, compared to 1.97 for non- Hispanic black women and 1.79 for non-Hispanic white women (both below the replacement rate of 2.1). Minorities (as defined by the Census Bureau as all those beside non-Hispanic, non-multiracial whites) constituted 36.3% of the population in 2010, and over 50% of children under age one, and are projected to constitute the majority by 2042. This contradicts the report by the National Vital Statistics Reports, based on the U.S. census data, which concludes that 54% (2,162,406 out of 3,999,386 in 2010) of births were non-Hispanic white.

About 82% of Americans live in urban areas (including suburbs); about half of those reside in cities with populations over 50,000. In 2008, 273 incorporated places had populations over 100,000, nine cities had more than one million residents, and four global cities had over two million (New York City, Los Angeles, Chicago, and Houston). There are 52 metropolitan areas with populations greater than one million. Of the 50 fastest-growing metro areas, 47 are in the West or South. The metro areas of Dallas, Houston, Atlanta, and Phoenix all grew by more than a million people between 2000 and 2008.

Many languages are used, or historically have been used in the United States. The most commonly used language is English. There are also many languages indigenous to North America or to U.S. states or holdings in the Pacific region. Languages brought to the country by colonists or immigrants from Europe, Asia, or other parts of the world make up a large portion of the languages currently used; several languages, including creoles and sign languages, have also developed in the United States. Approximately 337 languages are spoken or signed by the population, of which 176 are indigenous to the area. Fifty-two languages formerly spoken in the country's territory are now extinct.

The most common language in the United States is known as American English. English is the de facto national language of the United States, with 80% of the population claiming it as a mother tongue, and some 95% claiming to speak it "well" or "very well". However, no official language

323 exists at the federal level. There have been several proposals to make English the national language in amendments to immigration reform bills, but none of these bills has become law with the amendment intact. The situation is quite varied at the state and territorial levels, with some states mirroring the federal policy of adopting no official language in a de jure capacity, others adopting English alone, others officially adopting English as well as local languages, and still others adopting a policy of de facto bilingualism.

Since the 1965 Immigration Act, Spanish is the second most common language in the country, and is spoken by approximately 35 million people. The United States holds the world's fifth largest Spanish-speaking population, outnumbered only by Mexico, Spain, Colombia, and Argentina. Throughout the Southwestern United States, long-established Spanish- speaking communities coexist with large numbers of more recent Hispanophone immigrants. Although many new Latin American immigrants are less than fluent in English, nearly all second-generation Hispanic Americans speak English fluently, while only about half still speak Spanish.

According to the 2000 US census, people of German ancestry make up the largest single ethnic group in the United States, and the German language ranks fifth. Italian, Polish, and French are still widely spoken among populations descending from immigrants from those countries in the early 20th century, but the use of these languages is dwindling as the older generations die. Russian is also spoken by immigrant populations.

Tagalog and Vietnamese have over one million speakers each in the United States, almost entirely within recent immigrant populations. Both languages, along with the varieties of the Chinese language, Japanese, and Korean, are now used in elections in Alaska, California, Hawaii, Illinois, New York, Texas, and Washington.

Native American languages are spoken in smaller pockets of the country, but these populations are decreasing, and the languages are almost never widely used outside of reservations. Hawaiian, although having few native speakers, is an official language along with English at the state level in Hawaii. The state government of Louisiana offers services and documents in French, as does New Mexico in Spanish. Besides English, Spanish, French, German, Navajo and other Native American languages, all other

324 languages are usually learned from immigrant ancestors that came after the time of independence or learned through some form of education.

Some of the first European languages to be spoken in the U.S. are English, Dutch, German, French, and Spanish.

From the mid-19th century on, the nation had large numbers of immigrants who spoke little or no English, and throughout the country state laws, constitutions, and legislative proceedings appeared in the languages of politically important immigrant groups. There have been bilingual schools and local newspapers in such languages as German, Ukrainian, Hungarian, Irish, Italian, Norwegian, Greek, Polish, Swedish, Romanian, Czech, Japanese, Yiddish, Hebrew, Lithuanian, Welsh, Cantonese, Bulgarian, Dutch, Portuguese and others, despite opposing English-only laws that, for example, illegalized church services, telephone conversations, and even conversations in the street or on railway platforms in any language other than English, until the first of these laws was ruled unconstitutional in 1923 (Meyer v. Nebraska).

Currently, Asian languages account for the majority of languages spoken in immigrant communities: Korean, the varieties of Chinese, and various Indian or South Asian languages like Punjabi, Hindi/Urdu, Kannada, Gujarati, Marathi, Bengali, Tamil, Telugu and Malayalam, as well as Arabic, Vietnamese, Tagalog, Persian, and others.

Typically, immigrant languages tend to be lost through assimilation within two or three generations, though there are some groups such as the Cajuns (French), Pennsylvania Dutch (German) in a state where large numbers of people were heard to speak it before the 1950s, and the original settlers of the Southwest (Spanish) who have maintained their languages for centuries.

English language distribution in the United States. English was inherited from British colonization, and it is spoken by the majority of the population. It serves as the de facto official language, the language in which government business is carried out. According to the U.S. Census Bureau 80% spoke only English at Home and all but 57,097,826 of U.S. residents speak English "well" or "very well".

325 American English is different from British English in terms of spelling (a classic example being the dropped "u" in words such as color/colour), grammar, vocabulary, pronunciation, and slang usage. The differences are not usually a barrier to effective communication between an American English and a British English speaker, but there are certainly enough differences to cause occasional misunderstandings, usually surrounding slang or region dialect differences.

Some states, like California, have amended their constitutions to make English the only official language, but in practice, this only means that official government documents must at least be in English, and does not mean that they should be exclusively available only in English. For example, the standard California Class C driver's license examination is available in 32 different languages.

Spanish language distribution in the United States. Spanish was also inherited from colonization and is sanctioned as official in the territory of Puerto Rico. Spanish is also taught in various regions as a second language, especially in areas with large Hispanic populations such as the Southwestern United States along the border with Mexico, as well as Florida, parts of California, the District of Columbia, Illinois, New Jersey, and New York. In Hispanic communities across the country, bilingual signs in both Spanish and English may be quite common. Furthermore, numerous neighborhoods exist (such as Washington Heights in New York City or Little Havana in Miami) in which entire city blocks will have only Spanish language signs and Spanish-speaking people.

In addition to Spanish-speaking Hispanic populations, younger generations of non-Hispanics in the United States seem to be learning Spanish in larger numbers due to the growing Hispanic population and increasing popularity of Latin American movies and music performed in the Spanish language. A 2009 American Community Survey conducted by the United States Census Bureau, showed that Spanish is the primary language spoken at home by over 35 million people aged 5 or older, making the United States the world's fifth-largest Spanish-speaking community, outnumbered only by Mexico, Spain, Colombia, and Argentina.

Spanglish is a code-switching variant of Spanish and English and is spoken in areas with large bilingual populations of Spanish and English speakers,

326 such as along the Mexico – United States border (California, Arizona, New Mexico, and Texas), Florida, and New York City.

French language in the United States French language distribution in the United States. Counties and parishes marked in yellow are those where 6% to 12% of the population speak French at home; brown, 12% to 18%; red, over 18%. Cajun French and French-based creole languages are not included even though the Creole dialects are spoken throughout the U.S. and taught in many U.S. schools.

French, the fourth most-common language (when Chinese dialects are combined), is spoken mainly by the Louisiana Creole, native French, Cajun, Haitian, and French-Canadian populations. It is widely spoken in Maine, New Hampshire, Vermont, and in Louisiana, with notable Francophone enclaves in St. Clair County, Michigan, many rural areas of the Upper Peninsula of Michigan and the northern San Francisco Bay area.

Three varieties of French developed within what is now the United States in colonial times: Louisiana French, Missouri French, and New England French (essentially a variant of Canadian French). French is the second de facto language in the states of Louisiana (where the French dialect of Cajun predominates) and Maine. The largest French-speaking communities in the United States reside in Northeast Maine; Hollywood and Miami, Florida; New York City; certain areas of rural Louisiana; and small minorities in Vermont and New Hampshire. Many of the New England communities are connected to the dialect found across the border in Quebec or New Brunswick. More than 13 million Americans possess primary French heritage, but only 2 million speak French or French Creole at home.

German language in the United States German was a widely spoken language in some of the colonies, especially Pennsylvania, where a number of German-speaking religious minorities settled to escape persecution in Europe. Another wave of settlement occurred when Germans fleeing the failure of 19th Century German revolutions emigrated to the United States. A large number of these German immigrants settled in the urban areas, with neighborhoods in many cities being German-speaking and numerous local German language newspapers and periodicals established. German farmers also took up farming around the country, including the Texas Hill Country, at this time.

327 The language was widely spoken until the United States entered World War I.

In the early twentieth century, German was the most widely studied foreign language in the United States, and prior to World War I, more than 6% of American school-children received their primary education exclusively in German, though some of these Germans came from areas outside of Germany proper. Currently, more than 49 million Americans claim German ancestry, the largest self-described ethnic group in the U.S., but less than 4% of them speak a language other than English at home, according to the 2005 American Community Survey. The Amish speak a dialect of German known as Pennsylvania German. One reason for this decline of German language was the perception during both World Wars that speaking the language of the enemy was unpatriotic; foreign language instruction was banned in places during the First World War. Unlike earlier waves, they were more concentrated in cities, and integrated quickly.

There is a myth (known as the Muhlenberg Vote) that German was to be the official language of the U.S., but this is inaccurate and based on a failed early attempt to have government documents translated into German. The myth also extends to German being the second official language of Pennsylvania; however, Pennsylvania has no official language. Although more than 49 million Americans claim they have German ancestors, only 1.24 million Americans speak German at home. Many of these people are either Amish and Mennonites or Germans having newly immigrated (e.g. for professional reasons).

Chinese language in the United States Over 2.6 million Americans speak some variety of Chinese, making it the third most-spoken language in the country. Until the late 20th century, Yue dialects including Taishanese and Cantonese were the most common among immigrants or the descendants of immigrants, especially in California. Since the opening of the People's Republic of China, Standard Chinese (Mandarin), the official language in the PRC and Taiwan, has become increasingly prevalent. Many young Americans not of Chinese or Taiwanese descent have become interested in learning Mandarin.

In New York City at least, although Mandarin is spoken as a native language among only 10% of Chinese speakers, it is used as a secondary

328 dialect among the greatest number of them and is on its way to replace Cantonese as their lingua franca.

Tagalog language distribution in the United States. Tagalog speakers were already present in the United States as early as the late sixteenth century as sailors contracted by the Spanish colonial government. In the eighteenth century, they established settlements in Louisiana, such as Saint Malo. After the American annexation of the Philippines, the number of Tagalog speakers steadily increased, as Filipinos began to migrate to the U.S. as students or contract laborers. Their numbers, however, decreased upon Philippine independence, as many Filipinos were repatriated.

Today, Tagalog, together with its standardized form Filipino, is spoken by over a million and a half Filipino Americans, and is promoted by Filipino American civic organizations and Philippine consulates. As Filipinos are the second largest Asian ethnic group in the United States, Tagalog is the second most spoken Asian language in the country. Taglish, a form of code-switching between Tagalog and English, is also spoken by a number of Filipino Americans.

Tagalog is also taught at some universities where a significant number of Filipinos exist. As it is the national and most spoken language of the Philippines, most Filipinos in the United States are proficient in Tagalog in addition to their local regional language.

Spread of the Vietnamese language in the United States According to the 2010 Census, there are over 1.5 million Americans who identify themselves as Vietnamese in origin, ranking fourth among the Asian American groups and forming the largest Overseas Vietnamese population.

Orange County, California is home to the largest concentration of ethnic Vietnamese outside Vietnam, especially in its Little Saigon area. Other significant Vietnamese communities are found in the metropolitan areas of San Jose, Houston, Seattle, Northern Virginia, and New Orleans. Similarly to other overseas Vietnamese communities in Western countries (except France), the Vietnamese population in the United States was established following the Fall of Saigon in 1975 and communist takeover of South Vietnam following the Vietnam War.

329

Italian language in the United States Current distribution of the Italian language in the United States. The Italian language and its various dialects has been widely spoken in the United States for more than one hundred years, primarily due to large-scale immigration from the late 19th century to the mid 20th century.

In addition to Standard Italian learned by most people today, there has been a strong representation of the dialects and languages of Southern Italy amongst the immigrant population (Sicilian and Neapolitan in particular). As of 2009, though 15,638,348 American citizens report themselves as Italian Americans, only 753,992 of these report speaking the Italian language at home (0.3264% of the population).

Arabic in the United States Arabic is spoken by immigrants from the Middle East as well as many Muslim Americans. The highest concentrations of native Arabic speakers reside in heavily urban areas like Chicago, New York City, and Los Angeles. Detroit and the surrounding areas of Michigan boast a significant Arabic-speaking population including many Arab Christians of Lebanese, Syrian, and Palestinian descent.

Arabic is used for religious purposes by Muslim Americans and by some Arab Christians (notably Catholics of the Melkite and Maronite Churches as well as Rum Orthodox, i.e. Antiochian Orthodox Christians). A significant number of educated Arab professionals who immigrate often already know English quite well, as it is widely used in the Middle East. Lebanese immigrants also have a broader understanding of French as do many Arabic-speaking immigrants from North Africa.

Cherokee language Cherokee is the Iroquoian language spoken by the Cherokee people, and the official language of the Cherokee Nation. Significant numbers of Cherokee speakers of all ages still populate the Qualla Boundary in Cherokee, North Carolina and several counties within the Cherokee Nation of Oklahoma, significantly Cherokee, Sequoyah, Mayes, Adair, and Delaware. Increasing numbers of Cherokee youth are renewing interest in the traditions, history, and language of their ancestors. Cherokee-speaking communities stand at the forefront of language preservation, and at local schools all lessons are taught in Cherokee and thus it serves as the

330 medium of instruction from pre-school on up. Also, church services and traditional ceremonial "stomp" dances are held in the language in Oklahoma and on the Qualla Boundary in North Carolina.

Dutch language There has been a Dutch presence in America since 1602, when the government of the Republic of the Seven United Netherlands chartered the Dutch East India Company (Vereenigde Oostindische Compagnie, or VOC) with the mission of exploring for a passage to the Indies and claiming any uncharted territories for the Dutch republic. In 1664, English troops under the command of the Duke of York (later James II of England) attacked the New Netherland colony. Being greatly outnumbered, director general Peter Stuyvesant surrendered New Amsterdam, with Fort Orange following soon. New Amsterdam was renamed New York, Fort Orange was renamed Fort Albany. Dutch city names can still be found in New York's neighbourhoods. Harlem is Haarlem, Staten Island is Staten Eiland and Brooklyn refers to Breukelen.

Dutch was still spoken in many parts of New York at the time of the Revolution. For example, Alexander Hamilton's wife Eliza Hamilton attended a Dutch-language church during their marriage.

African-American abolitionist and women's rights activist Sojourner Truth (born 'Isabella Baumfree') was a native speaker of Dutch.

Martin Van Buren, the first President born in the United States following its independence, spoke Dutch as his native language, making him the only President whose first language was not English.

In a 1990 demographic consensus, 3% of surveyed citizens claimed descent from Dutch settlers. Modern estimates place the Dutch American population at 5 million, lagging just a bit behind Scottish Americans and Swedish Americans.

Notable Dutch Americans include the Roosevelts (Theodore Roosevelt, Franklin Delano Roosevelt, and Eleanor Roosevelt), Marlon Brando, Thomas Alva Edison, Martin Van Buren and the Vanderbilts. The Roosevelts are direct descendants of Dutch settlers of the New Netherland colony in the 17th century.

331 Around 136,000 people in the United States still speak the Dutch language at home today. They are concentrated mainly in California (23,500), Florida (10,900), Pennsylvania (9,900), Ohio (9,600), New York (8,700) and Michigan (6,600) (i.e. the city of Holland).

A vernacular dialect of Dutch, known as Jersey Dutch was spoken by a significant number of people in the New Jersey area between the start of the 17th century to the mid-20th century. With the beginning of the 20th century, usage of the language became restricted to internal family circles, with an ever-growing number of people abandoning the language in favor of English. It suffered gradual decline throughout the 20th century, and it ultimately dissipated from casual usage.

Finnish language The first Finnish settlers in America were amongst the settlers who came from Sweden and Finland to New Sweden colony. Most colonists were Finnish. However, the Finnish language was not preserved as well among subsequent generations as Swedish.

Shortly after the Civil War, many Finnish citizens immigrated to the United States, mainly in rural areas of the Midwest (and more specifically in Michigan's Upper Peninsula). Hancock, Michigan, as of 2005, still incorporates bi-lingual street signs written in both English and Finnish. Americans of Finnish origin yield at 800,000 individuals, though only 26,000 speak the language at home. There is a distinctive dialect of English to be found in the Upper Peninsula, known as Yooper. Yuper often has a Finnish cadence and uses Finnish sentence structure with modified English, German, Swedish, Norwegian, and Finnish vocabulary. Notable Finnish Americans include Gus Hall, U.S. Communist Party leader, Renny Harlin, film director, and the Canadian-born actress Pamela Anderson. Another Finnish community in the United States is found in Lake Worth, Florida, north of Miami.

Russian language The Russian language is frequently spoken in areas of Alaska, Los Angeles, Seattle, Spokane, Miami, San Francisco, New York City, Philadelphia, Woodburn, Oregon, and Chicago. The Russian-American Company used to own Alaska Territory until selling it after the Crimean War. Russian had always been limited, especially after the assassination of the Romanov dynasty of tsars. Starting in the 1970s and continuing until

332 the mid-1990s, many people from the Soviet Union and later its constituent republics such as Russia, Ukraine, Belarus, and Uzbekistan have immigrated to the United States, increasing the language's usage in America.

The largest Russian-speaking neighborhoods in the United States are found in Queens, Brooklyn, and Staten Island in New York City (specifically the Brighton Beach area of Brooklyn), parts of Los Angeles, particularly West Los Angeles and West Hollywood, parts of Philadelphia, particularly the Far Northeast and, parts of Miami like Sunny Isles Beach.

Slavic Voice of America media group serves Russian-speaking Americans out of Dallas, TX.

Hebrew Modern Hebrew is used by some immigrants from Israel and Eastern Europe. Liturgical Hebrew is used as a religious or liturgical language by many of the United States' approximately 7 million Jews.

Ilocano Like the Tagalogs, the Ilocanos are an Austronesian stock which came from the Philippines. They were the first Filipinos to migrate en masse to the United States. They first entered the State of Hawai'i and worked there in the vast plantations.

As they did in the Philippine provinces of Northern Luzon and Mindanao, they quickly gained importance in the areas where they settled. Thus, the state of Hawai'i became no less different from the Philippines in terms of percentage of Ilocano speakers.

Like Tagalog, Ilocano is also being taught in universities where most of the Filipinos reside.

Indian Languages There are many Indians in the USA, and they speak various Indian languages. Major Indian languages spoken in the USA include: Gujarati, Hindi (over 500,000 people) Punjabi, Marathi, Telugu and Tamil.

333 Irish Up to 37 million Americans have Irish ancestry, many of whose ancestors would have spoken Irish. According to the 2007 American Community Survey, 22,279 people speak Irish at home. As of 2008 it was the 76th most spoken language in the USA.

Khmer (Cambodian) Between 1981 and 1985 about 150,000 Cambodians resettled in the United States. Before 1975 very few Cambodians came to the United States. Those who did were children of upper-class families sent abroad to attend school. After the fall of Phnom Penh to the communist Khmer Rouge in 1975, some Cambodians managed to escape. In 2007 the American Community Survey reported that there were approximately 200,000 Cambodians living in the United States, making up about 2% percent of the Asian population.

Polish The Polish language is very common in the Chicago metropolitan area. Chicago's largest white ethnic groups are those of Polish descent. The Polish people and the Polish language in Chicago have been very prevalent in the early years of the city, as well as the progression and economical and social development of Chicago. Poles in Chicagoland make up one of the largest ethnically Polish population (650,000 people) in the world comparable to the city of Wrocław, the fourth largest city in Poland. That makes it one of the most important centres of Polonia and the Polish language in the United States, a fact that the city celebrates every Labor Day weekend at the Taste of Polonia Festival in Jefferson Park.

Portuguese The first Portuguese speakers in America were Jews who had fled the Inquisition; they founded the first Jewish communities, two of which stiil exist: Congregation Shearith Israel in New York and Congregation Mikveh Israel in Philadelphia. However, by the end of the 18th century the use of Portuguese had been replaced by English. In the late 19th century, many Portuguese, mainly Azoreans and Madeirans, immigrated to the United States, establishing in cities like Providence, Rhode Island, New Bedford, Massachusetts, and Santa Cruz, California. Many of them also moved to Hawaii during its independence.

334 In the mid-late 20th century there was another surge of Portuguese immigration in America, mainly in the Northeast (New Jersey, New York, Connecticut, Massachusetts). Many Portuguese Americans may include descendants of Portuguese settlers born in Africa (like Angola, Cape Verde, and Mozambique) and Asia (mostly Macau). There were around 1 million Portuguese Americans in the United States by the year 2000. Portuguese (European Portuguese) has been spoken in the United States by small communities of immigrants, mainly in the metropolitan New York City area, like Newark, New Jersey. The Portuguese language is also spoken widely by Brazilian immigrants, established mainly in Miami, New York City and Boston. (Brazilian Portuguese)

Scottish Gaelic In the 17th and 18th centuries, tens of thousands of Scots from Scotland, and Scots-Irish from the north of Ireland arrived in the American colonies. Today, an estimated 20 million Americans are of Scottish ancestry. The province of Nova Scotia, Canada was the main concentration of Scottish Gaelic speakers in North America (Nova Scotia is Latin for New Scotland). According to the 2007 American Community Survey, 1,445 people speak Scottish Gaelic at home.

Swedish There has been a Swedish presence in America since the New Sweden colony came into existence in March 1638.

Widespread diaspora of Swedish immigration did not occur until the latter half of the 19th century, bringing in a total of a million Swedes. No other country had a higher percentage of its people leave for the United States except Ireland and Norway. At the beginning of the 20th century, Minnesota had the highest ethnic Swedish population in the world after the city of Stockholm.

3.7% of US residents claim descent from Scandinavian ancestors, amounting to roughly 11–12 million people. According to SIL's Ethnologue, over half a million ethnic Swedes still speak the language, though according to the 2007 American Community Survey only 56,715 speak it at home. Cultural assimilation has contributed to the gradual and steady decline of the language in the US. After the independence of the US from the Kingdom of Great Britain, the government encouraged colonists to adopt the English language as a common medium of communication, and

335 in some cases, imposed it upon them. Subsequent generations of Swedish Americans received education in English and spoke it as their first language. Lutheran churches scattered across the Midwest started abandoning Swedish in favor of English as their language of worship. Swedish newspapers and publications alike slowly faded away.

There are sizable Swedish communities in Minnesota, Ohio, Maryland, Philadelphia and Delaware, along with small isolated pockets in Pennsylvania, San Francisco, Fort Lauderdale, and New York. Chicago once contained a large Swedish enclave called Andersonville on the city's north side.

John Morton, the person who cast the decisive vote leading to Pennsylvania's support for the United States Declaration of Independence, was of Finnish descent. Finland was part of the Kingdom of Sweden in the 18th century.

Welsh Up to two million Americans are thought to have Welsh ancestry. However, there is very little Welsh being used commonly in the USA. According to the 2007 American Comminty Survey, 2,285 people speak Welsh at home; primarily spoken in California (415), Florida (225), New York (204), Ohio (135), and New Jersey (130). Some place names, such as Bryn Mawr in Chicago and Bryn Mawr, Pennsylvania (English: Big Hill) are Welsh. Several towns in Pennsylvania, mostly in the Welsh Tract, have Welsh namesakes, including Uwchlan, Bala Cynwyd, Gwynedd, and Tredyffrin.

Yiddish Yiddish has a much longer history in the United States than Hebrew. It has been present since at least the late 19th century and continues to have roughly 148,000 speakers as of the 2009 American Community Survey. Though they came from varying geographic backgrounds and nuanced approaches to worship, immigrant Jews of Eastern Europe and Russia were often united under a common understanding of the Yiddish language once they settled in America, and at one point dozens of publications were available in most East Coast cities. Though it has declined by quite a bit since the end of WWII, it has by no means disappeared. Many Israeli immigrants and expatriates have at least some understanding of the language in addition to Hebrew, and many of the descendants of the great migration of Ashkenazi Jews of the past century pepper their mostly

336 English vocabulary with some loan words. Furthermore, it is definitely a lingua franca alive and well among Orthodox Jewry, particularly in Los Angeles, Miami and New York.

Rethinking Race The AAPA (American Association of Physical Anthropology) Statement on Biological Aspects of Race (1994) describes the popular concept of race as "being derived from 19th and early 20th century scientific formulations."

In the history of the United States and Europe it was common to divide the people of the world into three groups:

Caucasian or the so-called “white” race, for example, native residents of Britain, France, Germany etc. Natives of Uganda, Somalia, and Nigeria in Africa are considered members of the “black” or part of the black race. Koreans, Chinese, American Indians are all members of the “yellow” race.

The visible characteristics of these “races” were the basis for the categorization. Traits like skin color, hair form, bone structure and body shape.

Although it may be disturbing to see that through most of human history we have categorized people by outward traits it should be encouraging to learn that science has proved these outward traits to be incredibly insignificant.

"The concept of race is a social and cultural construction . . . . Race simply cannot be tested or proven scientifically,'' this is a quote from the policy statement issued by the American Anthropological Association .

"It is clear that human populations are not unambiguous, clearly demarcated, biologically distinct groups. The concept of `race' has no validity . . . in the human species.''

So we know that race is a socially defined concept that is used to categorize people according to their physical characteristics, like hair, skin and eyes, and as such, is a truly meaningless categorization.

As one scientist recently put it:

337 "I have no question, given what we know about human genetics, that the tall person and the short person are significantly more different than the black man and the white man of a similar height". 49

Interestingly enough each human cell has 100,000 genes, and out of those 100,000 genes only 6 are related to skin color. That is a pretty small number.

In the scientists statement above regarding the difference between a short man and a tall man she continued to point out that of the 100,000 genes in the human cell 64 of them have to do with height.

That is also a pretty small number, but it is ten times larger than the difference in skin color.

To make it even more interesting, consider that the six genes that determine skin color are present in all humans. That means that even if you have extremely pale freckled skin you have the potential to produce skin as black as an African native.

It is because we are all descended from Africa. About 40,000 years ago humans from Africa traveled north to Europe, and their skin adjusted to the environment there where they needed less protection from the sun. Over generations their skin grew lighter. They did not loose the genes for dark skin, they are still there, they are just not active. They can be partially activated by just one trip to the beach!

Some of those early pioneers went on to the snow swept plains of Siberia, where over time their eyelids grew narrow to protect them from the glare of the bright snow. As they settled in the regions of Asia and the Americas (crossing a land bridge in Alaska) they kept the distinctive eye folds.

So truly there is no scientific basis to race. Sadly, the only purpose race has is to perpetuate racism.

Racism is behind such horribly misguided ideas as biological superiority and deficits among races. This includes beliefs that intelligence, learning

49 Dr. Sylvia Spengler, a geneticist at U.C. Berkeley. http://www.sfgate.com/cgibin/article.cgi?f=/kron/archive/1998/02/23/race_part1.dtl&ao=all#ixzz1jymGUtPY

338 ability, and physical endurance are somehow linked with genetic characteristics.

These are things we know are scientifically not true, which makes me wonder why we are still asking people for their race on census forms?

339 Chapter 4: Cultural views of massage therapy, touch and nudity It is an obvious statement to say that different cultures will have different practices when it comes to body work. We have all attended massage school and have probably been at least introduced to European (Swedish) and Japanese (Shiatsu) massage. You may have also been exposed to other eastern forms, such as Ayurvedic, or Tui na. According to the American Massage Therapy Association there are over 250 recognized forms of massage being practiced in the Untied States.

All of these forms of massage are very different and partly reflect the culture of the people it originated from.

Cultural factors that influence massage

o How does the culture view body work in general?

o Is it acceptable to be massaged by the opposite sex?

o What are the cultures views on nudity?

Be aware of stereotyping While information about specific cultures can help in understanding a client, this can sometimes lead to stereotyping a person. No one should assume that a client from a specific racial or cultural background will necessarily have the same traditions or beliefs often associated with that race or culture. There are many factors that go into a person’s cultural identity including socioeconomic status, education, age, religion, gender and urban or rural living area.

Cultural views of Massage and bodywork It is impossible to create an exhaustive list of the cutural attitudes regarding massage in our diverse country, there are just too many different subgroupings to define in one study. We can look at a few large groupings in order to get a general picture of the vast differences in attitudes regarding massage therapy.

340 Massage in Europe Massage Therapy is highly regarded in Europe and is viewed as an accepted medical complimentary practice. European attitiudes toward the body and nudity lead to immodest draping. An American tourist visiting a spa in Europe can expect to be draped with only a small towel covering the genitals, and mixed male and female saunas are very common.

Massage and Americans of European ancestry When one studies a demographic map, such as the one above, they quickly discover that the Caucasian majority in the United States traces its origin to several European nations. It is interesting to note that while the Caucasian majority in the United States is largely of European descent the attitudes toward massage differ, particularly in the area of modesty.

This is due to the fact that the United States was not founded by ordinary European citizens, but by religious separatists .

In case you have forgotten your early American history, the American colonists were largely puritans, people who separated from the Church of England because they believed the religious heirarchy had too much power and that the common members of the church should have more influcence.

So the United States, while having a European ancestory, was greatly influenced by church ideas, including modesty and gender relations.

Add to this puritan origin a long history of brothels posing as massage establishments and you can begin to understand why many Americans have a more reserved attitude toward massage therapy.

For more information on massage therapy’s history of bad publicity see EPS002 Ethics in Massage Marketing.

As the majority cultural and ethnic group in the United States this is the norm we are taught in massage school-to cover the breasts of women and to uncover the gluteus muscles only as needed, and the genitals never.

341 While this is conservative by European standards, how does this compare to other groups in the United States?

Getting to know your Mexican clients With Hispanic Americans of Mexican origin being the largest recent immigrant population they are a good culture to look at as a sample in this course.

L’Art Du Massage" located in downtown Puerto Vallarta

Traditionally in Mexican families, the man is a very authoritative figure and is the head of the household

The woman is subservient to him in many ways. While this may seem shocking and highly insulting to many women in North America it is a cultural aspect of machismo ; a philosophical lifestyle that is often misunderstood.

When Americans hear the word Machismo they think of bravado, toughness, womanizing and chauvinism, and unfortunately a lot of those

342 qualities are present in the idea of Machismo. But that is only one part of the picture.

Machismo also demands that men work hard to be providers who protect and maintain the integrity of the family and make important family decisions. In short, the economic, social and physical welfare of the family is entirely the burden of the male head of the household.

They are granted a lot of liberties, but with it come all of the responsibilities. If something goes wrong in the Mexican family, the men are blamed.

The counterpart of Machismo is Marianismo , which most Americans have never even heard of. This literally means, “to be like Mary” as in the Virgin Mary , and is believed to be the true expression of femininity. It places value on being dedicated, loving and supportive wives and mothers.

The needs of the family are always to come first for the Mexican woman. She is charged with teaching children their culture and religion and for being ready to help others in her community.

This is a culture that has a collective since of community, they are more likely to get to know, help out and depend on their neighbors than the typical North American family.

In the Mexican family a great deal of a person’s individual identity is shaped by the family. Mexicans use the term familismo to describe the family identity and the strong ties that extend beyond the immediate family to an extensive family network of grandparents, aunts, cousins and even close friends of the family.

The strong importance of family tends to color the decision making of individual family members. Important choices are often made in a way that will be pleasing to the family even if it is not the first choice of the individual. As one would expect the individual does not usually make big decisions without consulting the family. Financial support of the family by the individual and vice versa is important and expected.

In Mexican culture there is still an idea of status that has not existed in the United States for quite some time. In the United States it is just a given that that everyone has equal rights and the opportunity to change his or her

343 position in society if they are motivated to do so. The culture of Mexico is, in many ways, still based on the feudal system of Spain.

When the culture of Mexico was formed under Spanish rule there were wealthy and powerful landowners called Patrons who owned all of the land of Mexico. They were responsible for caring for the “little people” that worked the land, the peasants. In Mexico they are called Peons (pronounced Pea-owns).

Under this system, like in feudal Europe, there was no upward social mobility. If you were born a Peon you would die a Peon.

This rigid hierarchy is mirrored in the family structure. They are organized based on age and sex, with older men holding the greatest power.

As one would expect with this kind of socio-family structure the idea of respect is of vital importance. This idea is called respecto , and it literally shapes all of the social interactions.

If you are meeting the family of a client who is Mexican you should be aware that great respect is expected for those in positions of authority (usually the oldest male), so you should go out of your way to address them.

Massage therapy is well regarded in Mexico, as is a host of other homeopathic medicines. In fact many of the “alternative medicines” of the United States are more commonly practiced in Mexico. Herbal remedies, reflexology, spinal and skeletal adjustments and energy work are all prevelant in Mexican medicine.

Even with the acceptance of massage therapy in the culture, there are still some cultural factors that need to be recognized when advertising your services to this population.

In many traditional Mexican families (especially first and second generation immigrants) modesty and virtue in females is empahised 50 . This means that many females of this cultural group will be uncomfortable receiveing certain massage treatments from male practitioners. It is also not

50 An Examination of Traditional Gender Roles Among Men and Women in Mexico and the United States Kim Schmitz and Sarah Diefenthaler

344 uncommon for them to be escorted to and from appointments by male members of the family. While it may seem oppressive to us, it is in actuality a form of familial affection, the older brothers, fathers, boyfriends, etc are very protective and are there to make sure their loved ones are treated appropriately.

Similar cultural patterns are observable in cultural groups from India and Arabic countries. In many muslim cultures a female receiving a massage from a male would be unthinkable.

When unsure about a persons comfort level with draping and massage it is always a good idea to ask.

Most massage schools and textbooks state that our clients should “undress to their comfort level”. If you are speaking to a person from a cultural group that is substantially different than yours you may acutally cause confusion if you use such ambiguous language.

The lack of knowledge goes both ways, if you do not know the cultural expectations of the client it is very possible that they do not know what to expect in the massage.

Culturally sensitive massage therapists will take the time to explain the differences between the different modalities, including draping procedures. If you feel that your client may be uncomfortable with the gender of the massage therapist, draping procedures and types of massage it is alright to ask them in a tactful manner.

Getting to know your Muslims Clients First and foremost, massage therapists should realize that not all people who are members of a faith group practice all aspects of that faith. There are geographical, cultural and ethnic factors involved in this identity that are not present in other faiths.

For example, people who identify themselves as Christians, Hindus or Buddhists made a choice at some point in their lives to practice this faith or lifestyle. Islam and Judaism, by contrast, is something you are born into.

If your father was a Muslim, you are a Muslim unless you specifically convert to another faith. The same is true for Judaism. So not every

345 massage client that you have will be a practicing Muslim, and those that are may not practice every aspect of it. And just like any other faith group there are significant differences based on geography. Arab, Asian, African and African-American Muslims all have similar beliefs and different practices.

I have selected Muslims to look at for this course because it is a growing population in the United States, it is one that is not well understood by the populace and it is one that has had a long history of respect for Massage Therapy.

This course is not a course on comparative religions, so we will not be going into great detail, but we will cover just a few of the basics.

The word Islam is a derivative of the word Salam , which means “peace”. It is the second-largest religion in the world and is arguably the fastest growing faith too. We generally think of it in the Middle East, but there are large Muslim communities in the United States and Europe and many in Africa.

According to a survey conducted by the Pew Research center in 2007 two thirds of the Muslims in the United States are recent Immigrants (which means that one third of all Muslims in the United States were born here from Muslim parents or are recent converts). The survey reported the ethnicity of Muslims in the U.S. as 37% white, 24% black, 20% Asian, 15% “other/mixed race” and 4% Latino.

The majority of Muslims that have immigrated to the United States have done so after 1990.

Members of the Islamic faith are known as Muslims or Moslems. The core belief of the faith is that there is one God (Allah) and the religions founder was the Prophet Muhammad. The holy book of Islam is the Quran , sometimes written as Koran.

Muslims look to the Quran and additional writings called Hadith and Sunna for a guide to how they should live. Many Muslims use prayer beads and prayer rugs. Like Judaism, they view pictures, statues or other representations of God as idol worship so it is forbidden. They extend this status to the Prophet Muhammad as well, which is why there was such

346 controversy when a Danish cartoonist featured a picture of the Prophet in a Newspaper.

There are different sub-sects of Islam within the faith. Sunnis represent about 90% and Shiites 10% to 15% of traditional Muslims.

There are also several smaller sects, including Ahmadiyya, Dawoodi Bohra, Ismaili, Sufi and Wahhabi.

Sunni Muslims are known for their practice of praying five times a day. The Shiites pray three times a day. Both groups face Mecca When they pray.

Of particular importance to massage therapists, traditional Muslims have a concept of modesty that is vastly different from that of mainstream U.S. culture.

The word "hijab" is an Arabic word that literally means curtain or cover and according to Muslims it refers to modesty, privacy, and morality. There is some debate among Muslims as to the extent of this modesty, and many define it as dressing in a manner that includes covering everything except the face and hands in public.

In some Islamic countries such as Iran and Saudi Arabia this is law, in others it is an issue for the woman to decide for herself.

Regardless of how much skin is covered, most agree that traditionally acceptable clothing shouldn’t reveal the shape of a woman’s body.

Direct eye contact with the opposite sex and any discussion of discussing bodily functions with the opposite sex are considered inappropriate in many Islamic families.

Massage Therapy is permitted but only for therapeutic purposes, massage as a means of pampering is seen as decadent.

Under no circumstances are members of the opposite sex to be massaged. An example of how serious this issue is can be seen on an Islamic American Website http://www.islamweb.net

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In this posting on a forum, a Muslim woman asks, “Can a woman work as a massage therapist?”

The answer she received is below:

“Praise be to Allah, the Lord of the Worlds; and may His blessings and peace be upon our Prophet Muhammad and upon all his Family and Companions. It is permissible for a woman to work in the field of massage for women provided the massage should be limited to other than Awrah (parts that must be covered) except if there is any dire necessity such as for medical treatment or the like. Know that the Awrah of a woman in front of women is what is between nave l and knee just as the Awrah of men in front of men. So, she may uncover her chest, legs and the like to other women except what is between navel and knee. Looking at what is between navel and knee and touching it is strictly forbidden except at the time of dire necessity. Allah knows best.” 1

So basically what this is saying is that it is permitted for a Muslim woman to massage another woman only and the area that must remain covered is the area between navel and knee (which is in keeping with standard massage practices with the possible exception of the upper leg in the front).

Important concerns for Black or African American Clients African Americans have a long history in the United States and nationally, the U.S. Census estimates that African Americans comprise more than 13 percent of the total U.S. population. Census information shows a large percentage of African Americans live in ten main states, including: New York, California, Texas, Florida, Georgia, Illinois, North Carolina, Maryland, Michigan, and Virginia.

While there is no specific cultural concerns for massage therapists when dealing with African American culture, research has shown that when comparing the health disparities of African Americans to other minority groups, there are important differences to recognize. Overall, these disparities contribute to a significantly lower life expectancy for African

348 Americans in the United States, when compared to other racial groups. This has largely been attributed to a tendency to under use available health care services. This of course applies to massage therapy as well.

Physically massage therapists need to be aware that Lupus is three times more common in African American women than in white women.

349 Chapter 5: Cross-cultural communication Language barriers in Massage Therapy Every once in a while I have an experience from my massage career that has particular relevance to a subject I am writing about.

This is one of those times.

In my first year as a massage therapist I had a young woman make an appointment with a very heavy accent. I thought it was Spanish 51 but it was Portuguese. I do not speak either, so that is not really relative to the story, but the point is I had a very difficult time understanding her and I am pretty sure she felt the same way.

I tried explaining the intake form to her as best I could and she let me know that she was also a massage therapist in her home country of Brazil, so she understood what the form was and she signed it after assuring me that she had no medical conditions I needed to be aware of.

At least, I think that is what she said. I am still not sure.

She then looked around my small office and pointed at the door to the restroom (the door was clearly marked “Restroom”) and she said:

“I go in there?”

I naturally believed that she needed to use the bathroom before the session started and was asking permission, so I told her of course.

What I did not know was that she was looking for a room to change in. A moment later she yelled “Ok I… ready” and came out carrying her clothes in a nicely folded pile.

All I could do was mutely point at the privacy screen I was planning on going behind while she changed as she sauntered by and hopped on the table with the confident grin of a lady that spends a lot of time on Brazilian beaches wearing not much more than she was when she came out of my bathroom. Which was nothing at all.

51 I live in California and the town I live in is 55% Hispanic, according to the 2010 Census data. I am also married to a Mexican American woman, which makes my family 50% Hispanic.

350 As a male massage therapist I have always worked very hard to protect the modesty of my clients, so I was quite traumatized by the misunderstanding, even though she thought nothing of it.

It is relevant to this course because it perfectly illustrates the issues that language barriers can cause in bodywork. Misunderstandings can cause a lot of embarrassment, and effective communication is needed when it comes to delivering effective therapy.

It is, of course, impossible for you to know every language that you might encounter in your practice, so what can you do?

Well it may encourage you to know that, according to experts 52 , the biggest obstacle in these situations is not the accent of the visitor but our own manner of speaking that causes the most problems!

Here are some things you can do to minimize misunderstandings when dealing with language barriers.

Do not jump to conclusions-ask for clarification “That is the bathroom, do you need to use it before we start?”

Parroting for understanding Repeat things back to make sure you understand what is being said. “So you say your neck feels really tight?”

Avoid idioms An idiom is a word or a term that is generally understood to be a figure of speech. A common massage idiom is to say “I need you to get the knots out of my back” .

To a person new to English, that sentence is totally insane.

It might seem universal to us to think of our muscles having “knots” but of course they really do not, and when you learn English as a second language you naturally take words literally. Knowing what a word means and being aware of an idiom are two entirely different things.

52 10 Strategies for Overcoming Language Barriers By Kate Berardo an intercultural trainer and consultant who specializes in programs on cross-cultural awareness, international relocation, and multicultural teambuilding.

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Do not use Industry Jargon In my opinion this should be a standing rule even if you are dealing with a client that speaks the same language as you. If they are not massage therapists or physical therapists, don’t tell them you are going to apply petrissage to their latissimus dorsi. Who are you trying to impress?

Clarify the terms In the United States we are used to thinking of massage sessions in very clearly defined units of time. An hour, a half hour, ninety minutes, etc. Make sure your client understands this is how you charge and find out how long of a session they need. Our culture runs on tight schedules, others might not.

Explain everything that is in writing verbally If you find yourself needing an informed consent, release of information or other such form being signed, make sure you go over the entire thing with them verbally. Do not assume they understand what they are signing.

Be patient! Dealing with language barriers is often difficult, but I can assure you that it is much more so for the person that does not speak the common language.

I lived in Germany for three years when I was younger and I can tell you it is a humbling experience to live in a place where you do not speak the language. Just going in a grocery store and trying to ask where something is was very intimidating, and it makes such a difference when the person is patient with you. You naturally feel very grateful to them when they try to help you, I would hope you would want to create that feeling in your clients.

Culturally sensitive interactions Each culture has its own unique rules and customs in regards to communications and being aware of some of these differences can help you avoid embarrassing misunderstandings. Each culture has its own appropriate greetings and what is a friendly gesture in one culture can be considered rude in another!

There are significant cultural variances in trivial seeming things such as shaking hands, making eye contact, observing personal space, giving gratuities, making small talk, and eating.

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Common culturally sensitive interactions

The Hand shake In Western cultures like those found in Europe and North America we place a lot of emphasis on the handshake, but at the same time we often do it without really thinking about it. Well here are a few things to think about:

In some countries (the Philippines, Poland and the Czech Republic) it is customary for a man to wait until a woman offers her hand for a shake.

In some religious groups (Hindus and Muslims) men do not usually shake hands with women at all.

In many Asian countries (China and Japan) the men will use a softer and longer handshake, they do not equate a firm handshake with assertiveness or confidence like western cultures do.

When you shake hands with someone you should always make eye contact and smile. Eye contact is handled differently in different cultures (see below) but smiling is universal.

In every culture that shakes hands it is considered impolite to remain seated while shaking hands with someone that is standing, the proper thing to do is to stand up when meeting someone (yes, even if you are a lady!).

Bowing The bow (a slight bending over at the waist) is the typical greeting in the Japanese culture. While we do not see it in the United States very often if you have a Japanese Client that greets you with a bow you should take note of the depth of the bow because that tells you the “status” of your “relationship”.

Generally speaking in the Japanese culture people will bow to the same depth of a person that is perceived as being of equal status, but if the status is one of subordination (an employee to a boss, a student to a teacher, etc) the person of lower status will bow first and will bow deeper. When you bow you should lower your eyes and keep your palms flat against your thighs.

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In the Japanese culture they view an inappropriately shallow bow in the same way we in the Unites States view the “dead fish” handshake and bowing too low is like getting the handshake from the “bone crusher”.

Since many of the Massage modalities we offer have a basis in Asian bodywork it is a good idea to have some familiarity with Chinese and Japanese customs. If you are advertising the service, you might just have a few clients visiting from China or Japan, and you will want to make them feel as comfortable as possible.

Eye contact Eyes contact is an important aspect of nonverbal communication and it has cultural implications. In the United States we have a saying:

“Look me in the eye and say that”.

Making eye contact with people is not only considered polite, it is generally regarded as a way of being open, honest and respectful. This is not the case everywhere. In many Asian cultures refusing to meet the eyes is a show of respect!

In some Latin American countries (Mexico, El Salvador, Cuba) intense, continued eye contact is considered a sign of aggression.

In European countries where the population centers are dense it is common for people to not make eye contact at all when speaking to you (don’t be offended, it is a way of maintaining privacy) and this contrasts with Europeans from more rural communities where they might make eye contact in such an intense manner it makes Americans uncomfortable.

Facial gestures Americans are very smiley people, and we should be, our country is awesome! We smile much more readily and much more often than other cultures.

When I was living overseas I once asked a friend of mine why Germans all look unhappy all of the time. She just laughed at me and said “only Americans walk around with smiles on our faces to show they are happy”. I thought that was weird, but it is actually true.

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In many European countries people do not smile as readily as Americans, but it doesn’t mean they are unhappy.

If you meet an American for the first time and they do not give you even a little hint of a smile we automatically think they do not like us or they are having a bad day. A smile goes with a greeting in the United States, but in Germany you could meet someone and shake hands and exchange pleasantries and see no change to their face at all. It is just a cultural difference and we should be aware of it and not be offended.

As if that wasn’t tricky enough in some countries people use a smile to convey the opposite of what we think it means! In Asia for example people may conceal anger by smiling.

Hand gestures Some cultures make extensive use of hand gestures when speaking, they are very animated, and others do not. It is important to keep in mind that, just as some cultures don’t use hand gestures not all hand gestures mean the same thing in every country! Here are some common gestures that mean different things to people from different countries:

The “Thumbs up”. This is actually a vulgar hand gesture in the Arab world, much like displaying the middle finger in the United States.

The “V sign” made with the first and second fingers. This originally meant “victory” and was a common way to show support for the war effort in WWII, made popular by Winston Churchill. It somehow became distorted in the American counter culture of the 60s (along with everything else) to mean “peace”.

In some cultures this hand gesture is seen as very rude, especially in New Zealand, Canada and England where if the palm is inward it is referred to as “the longbowman salute”: which is really just another way of giving the finger.

The “OK” made by making a circle with the thumb and index finger is offensive in Germany, Spain, Mexico and Brazil. In France it means “0” or “Worthless” and in Japan it actually means “money”.

355 Resting your hands on your hips is seen as a challenging stance in Mexico and Argentina.

Pointing at another person . This is impolite everywhere, but it is especially so to people from Saudi Arabia, Belgium and Portugal and it is truly insulting to someone from the Philippines.

Winking at a person is inappropriate in many countries and to a person from Australia and Taiwan it can be very insulting.

The “Moutza” is opening your palm to your target and stretching out your fingers. It seems quite harmless to most Westerners. Most of us would think you’re waving. In Greece the gesture is known as a moutza, and is one of their most traditional manual insults. With fingers slightly apart, you thrust your hand into your target’s face, usually coupling the gesture with a brash “na!”, meaning, “here you go!”.

The gesture is also insulting in Pakistan and many parts of Africa. The Japanese use a very similar sign to insult their old enemies, the Koreans. Roughly translating as ‘animal’, the signal is similar to the moutza in every way except they tuck the thumb into the palm

If you are having trouble visualizing it just do a google image search for “Moutza” and you will see it really looks like a harmless wave.

Snapping your fingers . This is an obscene gesture in Belgium.

The beckoning finger, palm up with index finger extended and crooked, rotating inward is a way we say “come over here” in America but in the Philippines it is a way of calling someone a dog.

Personal Space Personal space issues can cause discomfort when you are dealing with clients from another culture. We can unknowingly offend others by moving closer or farther away when conversing.

Cultures that highly value independence and freedom over collectivism (U.S., Canada and Northern and Western Europe), are more likely to value privacy and space. People from these cultures tend to feel uncomfortable

356 when forced to sit or stand close to people they do not know for any length of time.

By the same token, cultures that highly value the concepts of collectivism and group welfare over the individual (many Asian, Latino and Mediterranean cultures, and most Arab cultures) may prefer to stand close to one another when holding a conversation. So close that to an American, it would seem weird.

People in the United States usually stand about 3 feet apart when speaking, or rather the distance it takes for me to fully extend my arm to you for a handshake. If you get closer than that, I am going to back up a little.

In Japan the comfort distance is more than three feet (which makes sense of you have every ridden on one of their busses, they need all the space they can get.)

The British maintain a wider comfort zone than Americans.

In Italy, Mexico and Argentina the distance is much closer. In some countries in South America, like Chile, they naturally speak very close to people. If you try to back up they will just keep moving forward.

Time is relative in cultures Don’t you hate it when massage clients run late? It is always a good idea to tell new clients to come ten minutes early for their first appointment, to complete the intake form and the assessment. If your client is from another culture, you might be in for a surprise when it comes to timing.

Arriving late for appointments creates a negative reaction in the predominant U.S. culture, but other cultures are not so rigidly bound by time tables. In Mexico and many South American countries, public transportation systems rarely run on time and the streets are very crowded, so it is just ingrained in the culture to give 10-15 minutes of grace periods for appointments. This more laid back approach to schedules is not a reflection on their values, it is just a way of adapting to the reality of their infrastructure.

357 You can avoid any problems by just articulating the importance of arriving a few minutes early.

Gratuities This is a confusing topic for Americans when it comes to Massage Therapy. There are lots of articles written about when it is appropriate to accept tips as a massage therapist so I will not repeat them here but I will let you know that some cultures do not tip period. Not in restaurants, Taxis, Bellhops, etc

It is not part of their culture so they just do not do it. It doesn’t mean they are cheap or that they did not appreciate the service, it is just something they do not do.

Asian countries, in particular China, Korea, Japan etc are not cultures where tipping is done, although western influences have made it start to appear in areas where Americans and Europeans congregate.

Tipping is common in India, and European countries, but only when the service is unusually good or surpasses expectations.

The United States is really the only country where people will actual feel “jipped” if they do not get a gratuity. It is not because we are greedy, it’s because we are very liberal tippers! We just do it so much it becomes expected.

Culturally sensitive advertising When you are advertising your business you generally want to appeal to the broadest market base possible, which means tailoring your advertising material to appear to the ethnic/cultural majority in your area.

If you want to build a thriving and prosperous practice you may want to expand your advertising campaign to specific cultural minorities in your area that you feel you can serve effectively.

In order to tailor your advertising to specific cultural groups you need to understand the cultural perspective of massage therapy and bodywork. Some research may be required on your part.

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If you are advertising to a population that is uncomfortable with removing clothes for a massage you should choose pictures showing fully clothed massage techniques, like Shiatsu or chair massage.

If you speak the language of a local ethnic minority, or you have a member of your staff that does, you should always include a tagline in your advertising that announces this. It is also a good idea to run an advertisement entirely in the language of the ethnic group-which will make them feel even more comfortable. Do not underestimate the importance of advertising to people in their own language. It goes without saying that you should avoid running an advertisement in a language that you do not speak, as this would cause you confusion and frustration as people call and come in without bringing their own interpreters.

Cultural snapshots The United States of America is a business and migratory destination for people from all over the world, so it’s not impossible for you to have clients that are here on business from cultures you are totally unfamiliar with. For this reason we have assembled a short selection of 44 different countries with some unique cultural flavors that you might find enlightening.

How to use this information Firstly, all the information presented on these cultural snapshots is very generalized. Remember that people are unique individuals and do not conform to all of the stereotypes of a culture. It’s true for us in the USA and it’s true for people from Austria to Venuzuela. This material is just here to give you an idea of what a culture is like, not to predict the behavior of any individual. If you know someone from these countries that does not fit the profile here (or if you are from one of these countries and do not fit the profile) do not feel offended or insulted-the idea here is to give massage therapists in this country and idea of what to expect when meeting someone from the country/culture described, not to enforce stereotypes.

Where this information comes from This information is not my opinion; it is drawn from the " Put Your Best Foot Forward " series of cultural ettiquete books by Mary Murray Bosrock. These books are used by the U.S. State Department when preparing diplomats for assignments oversees. We have included only a general description of

359 each country, and a few details relevant to interpersonal communication, such as body language, proximity and verbal nuances.

Important assumptions First of all we know that you are a massage therapist, and if a person from another country is in your business he or she is probably okay with being touched in a professional capacity. We feel that is a safe assumption. They may not be comfortable being touched by someone of the same gender, or opposite gender.

So when you read in the material that people from a certain country/culture “do not like being touched” that does not mean they do not want a massage, it is a reference to not liking touch in interpersonal communication. When in doubt, ask if it’s okay.

On the same note, you will see that many of the cultures from Asia do not like having their head touched (it is sacred and contains the soul). Again, this refers is to touch outside the massage room, HOWEVER it would still be a good idea to ask before touching the head even in a massage, do not assume that they are okay with having their head touched during a massage if they are from one of the countries/cultures that holds this belief about the head.

360 Cultural Snapshot: Your massage client from Argentina

Where they are from Argentina, officially the Argentine Republic is a federal republic located in southeastern South America. Covering most of the Southern Cone, it is bordered by Bolivia and Paraguay to the north; Brazil to the northeast; Uruguay and the South Atlantic Ocean to the east; Chile to the west and the Drake Passage to the south.

With a mainland area of 2,780,400 km2 (1,073,500 sq mi), Argentina is the eighth-largest country in the world, the second largest in Latin America, and the largest Spanish-speaking one. Argentina claims sovereignty over part of Antarctica, the Falkland Islands, South Georgia and the South Sandwich Islands.

The People Argentines are very proud of their country and culture. They are well educated and sophisticated and like to be viewed as cosmopolitan and progressive. The culture is strongly European, with a full 97% of the population having ancestry that originally came from Europe, the remaining 3% being a mix of Mestizo, Amerindian and Asian. They are Predominantly Catholic (93%), families are highly valued and hold conservative values.

Meeting and Greeting A handshake and nod show respect when greeting someone.

An embrace and one kiss on the cheek is common between friends and acquaintances.

Body Language Argentines are touchers and stand close to each other when speaking. Do not back away.

The “O.K.” and “thumbs up” gestures are considered vulgar.

Hitting the palm of the left hand with the right fist means “I don’t believe what you are saying” or “That’s stupid.” Good things to know Don’t be offended by Argentine humor, which may mildly attack your clothing or weight.

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Always greet officials before asking them questions.

Don’t compare Argentina with the United States or with Brazil, which is considered a rival.

Avoid talking about Great Britain or the Falkland Islands (Las Malvinas). These are sensitive subjects to many Argentines.

Be careful when discussing the Perón years. People either love or hate the Peróns.

Although Argentines may be very vocal about politics and religion, avoid adding your opinions to these discussions (actually a pretty good rule for all your clients).

Especially for female therapists While machismo persists in Argentina, it is being challenged and women are gaining visibility and influence in politics and business. Argentine businesswomen are similar in status to North American businesswomen.

Piropos - flirtatious comments - are common. Men may call out "Hey, gorgeous!" as a way of greeting you. Becoming offended or acting defensive will damage your credibility. Maintain appropriate physical boundaries, but don’t be offended by such behavior.

362 Cultural Snapshot: Your massage client from Australia

Where they are from Australia officially the Commonwealth of Australia, is a country comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands. It is the world's sixth-largest country by total area. Neighbouring countries include Indonesia, East Timor and Papua New Guinea to the north; the Solomon Islands and Vanuatu to the northeast; and New Zealand to the south-east.

For at least 40,000 years before the first British settlement in the late 18th century,Australia was inhabited by indigenous Australians, who spoke languages grouped into roughly 250 language groups. After the European discovery of the continent by Dutch explorers in 1606, Australia's eastern half was claimed by Great Britain in 1770 and initially settled through penal transportation to the colony of New South Wales from 26 January 1788. The population grew steadily in subsequent decades; the continent was explored and an additional five self-governing Crown Colonies were established.

The People Home to nearly five million immigrants from 160 countries, Australia is rich in cultural diversity. Australians, or "Aussies," enjoy an easy-going lifestyle and are generally friendly and relaxed. Modesty and equality are valued .

A survey by the Bertelsmann Foundation found that "Australia is one of the least religious nations in the western world, coming in 17th out of 21 [countries] surveyed" and that "Nearly three out of four Australians say they are either not at all religious or that religion does not play a central role in their lives." While weekly attendance at church services in 2001 was about 1.5 million (about 7.8% of the population), a survey of 1,718 Australians by the Christian Research Association at the end of 2009 suggested that the number of people attending religious services per month in Australia dropped from 23% in 1993 to 16% in 2009, and while 60% of 15 to 29-year- old respondents in 1993 identified with Christian denominations, 33% did in 2009.

Meeting and Greeting Shake hands with everyone present upon meeting and before leaving. Allow women to offer their hands first.

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Women generally do not shake hands with other women.

Use titles, Mr., Mrs., and Miss when first introduced.

Australians generally move to a first-name basis quickly. Still, wait to use first names until invited to do so.

Academic or job-related titles are downplayed.

Body Language When yawning, cover your mouth and excuse yourself.

Winking at women is considered rude.

The "V" sign (made with index and middle fingers, palm facing inward) is a very vulgar gesture. The "thumbs up" gesture is also considered obscene .

Helpful Hints Stick with standard English, not Aussie terms.

Aussies dislike class distinctions and have a history of "cutting down the tall poppy." This grew out of the Australian prisoners' hatred of their British overseers. Many Australian politicians have declined the designation of knighthood for fear of alienating their constituents.

Australians sit in the front seat of a taxi/limousine. A single passenger sitting in the back seat is viewed as "putting on airs."

Australians respect people with strong opinions, even if they don't agree. Avoid discussions about the treatment of the aboriginal people.

Don’t comment on anyone's accent . Accents often distinguish social class.

If you are teased, you are expected to reply in kind, with good humor. Such self-confidence will increase an Australian's respect for you.

They do not admire a subservient attitude.

Do not sniff or blow your nose in public.

364 Cultural Snapshot: Your massage client from Austria

Where they are from Austria, officially the Republic of Austria, is a federal republic and a landlocked country of roughly 8.5 million people in Central Europe. It is bordered by the Czech Republic and Germany to the north, Hungary and Slovakia to the east, Slovenia and Italy to the south, and Switzerland and Liechtenstein to the west. The territory of Austria covers 83,855 square kilometres (32,377 sq mi) and has a temperate and alpine climate. Austria's terrain is highly mountainous, lying within the Alps; only 32% of the country is below 500 metres (1,640 ft), and its highest point is 3,798 metres (12,461 ft). The majority of the population speak local Bavarian dialects of German as their native language, and German in its standard form is the country's official language. Other local official languages are Hungarian, Burgenland Croatian, and Slovene.

The People Austrians are proud of their contributions to world civilization. They see themselves as modern, liberal and cultured. Austrians have a great love for the outdoors (i.e., walking, skiing, climbing, etc.). Although predominantly Catholic (89%), traditional family values have been weakened by modern life and government legislation. The rate of women working outside the home is one of the highest in the industrialized world.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting; shake hands with women before men.

Women should offer their hand first. Shake hands again when leaving.

Viennese men may kiss the hand of a woman. Accept this tradition graciously. A foreign man should not kiss the hand of an Austrian woman, since it is not expected and may come as a shock.

Names and Titles Titles are very important. Use last names and appropriate titles until specifically invited by your Austrian host or colleagues to use their first names.

365 Herr/Frau + professional title + surname are used when initially addressing someone. Example: Herr Doctor Bauer. Frau + professional title + surname are also used when addressing the wife of a professional. Example: Frau Doctor Bauer. All women over 18 are Frau, even if they are not married.

After you initially meet someone, you can drop his/her surname and address the person using Herr/Frau + professional title alone. Example: Herr Doctor or Frau Doctor.

Body Language Austrians are reserved and formal . Kissing, hugging, touching and physical closeness in public are not common.

Eye contact is very important to Austrians.

Helpful Hints Austrians are not Germans. Austria and Germany have very different customs. Never refer to an Austrian as a German.

Austrians may find personal compliments embarrassing.

Do not put hands in your pockets while speaking to anyone.

Especially for Women Men enter public businesses before women; this is a show of respect, like holding a door open is in our culture, do not misinterpret it for rudeness.

Offer your hand first upon meeting or greeting a man.

366 Cultural Snapshot: Your massage client from Belgium

Where they are from Belgium, officially the Kingdom of Belgium, is a federal monarchy in Western Europe. It is a founding member of the European Union and hosts the EU's headquarters as well as those of several other major international organisations such as NATO. Belgium covers an area of 30,528 square kilometres (11,787 sq mi) and has a population of about 11 million people.

Straddling the cultural boundary between Germanic and Latin Europe, Belgium is home to two main linguistic groups: the Dutch-speaking, mostly Flemish community, which constitutes about 59% of the population, and the French-speaking, mostly Walloon population and Brussels inhabitants, which comprises 41% of all Belgians. Additionally, there is a small group of German-speakers who are officially recognized.

The People Belgium is comprised of two primary cultural groups. The Dutch-speaking Flemings live in Flanders, in the north, and make up 55% of the population. The French-speaking Walloons live in Wallonia, in the south, and make up 33% of the population. Hard work and an appreciation for culture are important values to Belgians, who think of themselves as Europeans first, Walloons or Flemings second, and Belgians third. Strong family systems are vital to Belgian society. Extended families live in separate homes, but often settle in or near the town where they were raised.

Meeting and Greeting Shake hands with everyone present -- men, women, and children.

Shake hands again when leaving.

Repeat your name when being introduced.

Language Dutch, French and German are all widely spoken in Belgium. Speak English if in doubt.

Body Language It is considered impolite to snap your fingers.

367 Do not put your hands in your pockets, yawn, scratch or use toothpicks in public.

Feet should never be put on chairs or tables.

Back slapping is considered offensive.

The "okay" sign means zero.

Helpful Hints Avoid discussing personal matters or linguistic divisions with Belgians.

In Belgium it is expected that a man will rise when a woman enters the room. They also stand on public transportation until women are seated.

Do not flaunt wealth or be noisy or loud in public.

Do not ask personal questions about private lives.

Try to sneeze and blow your nose in private.

368 Cultural Snapshot: Your massage client from Bolivia

Where they are from Bolivia, officially known as the Plurinational State of Bolivia. It is a landlocked country located in western-central South America. It is bordered by Brazil to the north and east, Paraguay and Argentina to the south, Chile to the southwest, and Peru to the west.

Prior to Spanish colonization, the Andean region of Bolivia was a part of the Inca Empire, while the northern and eastern lowlands were inhabited by independent tribes. Spanish conquistadors arriving from Cuzco and Asunción took control of the region in the 16th century. During most of the Spanish colonial period, Bolivia was known as Upper Peru and administered by the Royal Court of Charcas. After the first call for independence in 1809, 16 years of war followed before the establishment of the Republic, named for Simón Bolívar, on 6 August 1825. Bolivia has since endured periods of political and economic instability, including the loss of various peripheral territories to its neighbors, such as Acre, parts of the Gran Chaco and its coast.

Modern Bolivia is a democratic republic that is divided into nine departments. Its geography varies from the peaks of the Andes in the West, to the Eastern Lowlands, situated within the Amazon Basin. It is a developing country, with a medium ranking in the Human Development Index and a poverty level of 53 percent. Its main economic activities include agriculture, forestry, fishing, mining, and manufacturing goods such as textiles, clothing, refined metals, and refined petroleum. Bolivia is very wealthy in minerals, especially tin.

The Bolivian population, estimated at 10 million, is multiethnic, including Amerindians, Mestizos, Europeans, Asians and Africans. The main language spoken is Spanish, although the Guarani, Aymara and Quechua languages are also common, and all four, as well as 34 other indigenous languages, are official. Bolivia's diversity has contributed greatly to its rich art, cuisine, literature, and music.

369 The People Bolivians are very proud of being one of the few countries that have successfully promoted multicultural integration. Vice President Víctor Hugo Cárdenas, elected in 1993, was the first indigenous person elected to this high office in South America. Bolivians are kind, gentle people, who are concerned for each other's welfare. Friendship is a very important value. The family is the central unit in the social system. Education is valued, but still not achievable for all people. Although it is legally compulsory for ages six to 14, fewer than half of all children finish primary education.

The ethnic composition of Bolivia is diverse. The largest of the approximately three dozen native groups are the Quechuas (2.5 million), Aymaras (2 million), then Chiquitano (180,000), and Guaraní (125,000). So the full Amerindian population is at 55%; the remaining 30% are mestizo (mixed Amerindian and white), and around 15% are white.

According to the 2001 census conducted by the National Institute of Statistics of Bolivia, 78 percent of the population is Roman Catholic, followed by 19 percent Protestant and 3 percent non-religious (either agnostic or atheist). Protestantism and traditional indigenous beliefs are expanding.

Meeting and Greeting The customary greeting is a handshake. Shake hands when meeting and departing.

Close male friends may embrace. Female friends embrace and touch cheeks.

Body Language Bolivians stand very close when conversing .

You will be viewed as untrustworthy if you do not maintain direct eye contact .

Correct posture while sitting and standing will be noticed. A slumping posture is rude. The “so-so” gesture (rocking your palm-down open hand from side to side) means “no” in Bolivia.

370 Helpful Hints Know something about Bolivian sports. It will be appreciated.

Don't talk about poverty, religion, drugs or the United States' drug policy. The United States' military activity in Bolivia is a sore spot with many citizens .

Do not give political opinions on Bolivia.

Never praise Chile, Brazil or Paraguay. Bolivia has lost wars with and land to all its neighbors.

Make an effort to use Spanish in conversation. It will be appreciated.

Bolivians appreciate people who are warm and friendly.

Especially for Women Machismo is very strong in Bolivia, and women are considered subordinate . This puts severe restrictions on women's social and work behavior.

When doing business with Bolivian men, emphasize your credentials and experience.

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Cultural Snapshot: Your massage client from Brazil

Where they are from Brazil, officially the Federative Republic of Brazil, is the largest country in both South America and the Latin American region. It is the world's fifth largest country, both by geographical area and by population. It is the largest Portuguese-speaking country in the world, and the only one in the Americas.

Bounded by the Atlantic Ocean on the east, Brazil has a coastline of 7,491 km (4,655 mi). It is bordered on the north by Venezuela, Guyana, Suriname and the French overseas region of French Guiana; on the northwest by Colombia; on the west by Bolivia and Peru; on the southwest by Argentina and Paraguay and on the south by Uruguay. Numerous archipelagos form part of Brazilian territory, such as Fernando de Noronha, Rocas Atoll, Saint Peter and Paul Rocks, and Trindade and Martim Vaz. It borders all other South American countries except Ecuador and Chile and occupies 47 percent of the continent of South America.

Brazil was inhabited by numerous tribal nations prior to the landing of explorer Pedro Álvares Cabral in 1500, who claimed the area for Portugal. Brazil remained a Portuguese colony until 1808, when the capital of the empire was transferred from Lisbon to Rio de Janeiro after French forces led by Emperor Napoleon Bonaparte invaded Portugal. In 1815, it was elevated to the rank of kingdom upon the formation of the United Kingdom of Portugal, Brazil and the Algarves. Its independence was achieved in 1822 with the creation of the Empire of Brazil, a unitary state governed under a constitutional monarchy and a parliamentary system. The country became a presidential republic in 1889, when a military coup d'état proclaimed the Republic, although the bicameral legislature, now called Congress, dates back to the ratification of the first constitution in 1824. An authoritarian military junta had led the nation from 1964 until 1985. Brazil's current Constitution, formulated in 1988, defines it as a federal republic. The Federation is composed of the union of the Federal District, the 26 states, and the 5,564 municipalities.

The People Brazilians are friendly and free-spirited, with an incredible zest for life. They are very risk-oriented and very creative. Predominantly Roman Catholic

372 (73%), families are large and often include extended family members. Family, educational and socioeconomic backgrounds are important to Brazilians.

Meeting and Greeting Take time to greet and say good-bye to each person present.

Women kiss twice -- once on each cheek -- if they are married. Single women add a third kiss.

Body Language Physical contact is part of simple communication. Touching arms, elbows and backs is very common and acceptable. Brazilians also stand extremely close to one another. Do not back away.

The "O.K." sign is considered very rude and vulgar; the "thumbs up" gesture is used for approval .

Wiping your hands together means "it doesn’t matter."

Clicking the tongue and shaking the head indicates disagreement or disapproval.

Helpful Hints Inherited wealth and a good family background are very desirable in Brazil, much more so than in the USA where we value entrepreneurs and “self- made” wealth.

Brazilians are extremely casual about time. Being ten to fifteen minutes late is normal, and twenty to thirty minutes late is not unusual .

Soccer (football), family, Brazil’s beautiful beaches and the country’s rapid growth are all appropriate conversation topics.

Politics, poverty, religion, Argentina (considered a rival) and the deforestation of Brazil are not . Personal topics such as age, salary and marital or job status are also unacceptable.

Brazilians are expressive and passionate conversationalists. Be prepared to be interrupted.

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Don’t refer to Brazilians as Latins.

Especially for Women As women increasingly join the workforce, machismo has become less common. Younger, better-educated women have values that correspond closely to those of North American women. Women are well-accepted and are prominent in education, medicine and journalism and as small business owners.

Brazilian women are very aggressive, in both their business and personal lives.

Especially for Men Brazilian women can be very aggressive romantically and forward to the point of harassment.

374 Cultural Snapshot: Your massage client from Canada

Where they are from Canada is a country in North America consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic to the Pacific and northward into the Arctic Ocean. At 9.98 million square kilometres in total, Canada is the world's second-largest country by total area and the fourth-largest country by land area. Its common border with the United States is the world's longest land border shared by the same two countries.

The land that is now Canada has been inhabited for millennia by various Aboriginal peoples. Beginning in the late 15th century, British and French colonies were established on the region's Atlantic coast. As a consequence of various conflicts, the United Kingdom gained and lost North American territories until left, in the late 18th century, with what mostly comprises Canada today. Pursuant to the British North America Act, on July 1, 1867 three colonies joined to form the autonomous federal dominion of Canada. This began an accretion of provinces and territories to the new self- governing dominion. In 1931, Britain granted Canada full independence in most matters with the Statute of Westminster 1931. The Canada Act 1982 severed the vestiges of legal dependence on the British parliament.

Canada is a federal parliamentary democracy and a constitutional monarchy, with Queen Elizabeth II as its head of state. Canada is a member of the Commonwealth of Nations. The country is officially bilingual at the federal level. It is one of the world's most ethnically diverse and multicultural nations, the product of large-scale immigration from many countries, with a population of approximately 35 million as of December 2012. Its advanced economy is one of the largest in the world, relying chiefly upon its abundant natural resources and well-developed trade networks. Canada's long and complex relationship with the United States has had a significant impact on its economy and culture.

Canada is a developed country and one of the wealthiest in the world, with the eighth highest per capita income globally. It ranks among the highest in international measurements of education, government transparency, civil liberties, quality of life, and economic freedom. Canada also ranks among the world's most educated countries, and was ranked first worldwide in the number of adults having tertiary education with 51% of adults having

375 attained at least an undergraduate college or university degree according to OECD's 2012 survey.

The People The vast majority of Canadians claim European ancestry. Four in nine Canadians claim some British ancestry and a little less than one in three have some French ancestry. Eighty percent of the residents in Quebec have French ancestry. Eighty percent of native French speakers live in Quebec (the others are mostly in New Brunswick, and parts of Ontario and Manitoba). Other European groups include Italians, Germans and Ukrainians (especially in the prairie states).

Broadly speaking, Canada has been divided into two distinct societies, one French-speaking (see "Quebec" below) and one English-speaking. Because they don't form as cohesive a group as French-speaking Canadians, only very general observations can be made about English- speaking Canadians; they are generally thought of (and consider themselves) more reserved, less aggressive and less excitable than their neighbors to the south.

Most Canadians identify themselves very strongly with their province. Canadians continue to wrestle with the question, "What does it mean to be Canadian?" and take pains to differentiate themselves from citizens of the United States.

Regional Differences Atlantic Canada (includes the Maritimes -- Nova Scotia, New Brunswick, and Prince Edward Island -- and Newfoundland): Primarily of British descent, the residents of the less prosperous Atlantic provinces of eastern Canada are generally more reserved, stolid, provincial and old-fashioned. Newfoundland is unique, with a dialect and culture that draws comparisons with the Irish and the people of western England.

Ontario: Residents of Canada's most populous province -- the country's economic, political and cultural colossus -- are generally thought of as more business-like and conservative than other Canadians.

Western Canada (includes Alberta, Saskatchewan and Manitoba): Residents of Canada's western provinces are generally more open,

376 relaxed, friendly and direct than other Canadians (comparisons are often made with inhabitants of the western United States).

British Columbia: Canada's unconventional westernmost province is seen by Canadians as the land of the future, and has more in common with Seattle than Toronto. Like many other western Canadians, many residents of British Columbia feel somewhat estranged from "easterners" (a general code word for those from Ontario and Quebec).

Quebec (and other areas of Francophone Canada): French Canadians, and especially the Québécois (or citizens of Quebec, pronounced "keh- beck-wah") have a very strong sense of cultural identity and are very nationalistic. The European influence is strongly felt in Quebec, whose people consider themselves the "defenders of French civilization in North America." Because of their animated good nature, Québécois are sometimes called the "Latins of the North."

The North: Residents of the sparsely populated north are seen as rugged embodiments of the Canadian pioneer spirit.

Meeting and Greeting In general, Canadians are more reserved and polite than Americans, and take matters of etiquette a little more seriously.

Shake hands and introduce yourself when meeting Canadians for the first time. Always shake hands firmly when meeting or departing. Eye contact is important.

When a woman enters or leaves a room, it is polite for men to rise. Men normally offer their hands to women.

Kissing on the cheeks in the French manner is quite common in Quebec. When close friends and family meet in Quebec, they use first names and kiss both cheeks. An older French Canadian man may kiss the hand of a woman. Accept this gesture graciously.

Canadians are somewhat more formal than Americans with regard to names and titles. Use last names and appropriate titles until invited by your Canadian client to use their first names. First names are normally used only

377 by close friends and family. Western Canadians may use first names more frequently than other Canadians.

In Quebec, coworkers of similar status generally use first names in private, but always last names in public.

Academic titles and degrees are important to French Canadians. You should know and use them properly.

Language English and French are both official languages of business in Canada. However, virtually all international business is conducted in English.

Most French Canadians speak and understand English, but prefer to use French. Check ahead of time to find out if an interpreter will be necessary.

Body Language Generally speaking, Canadians are more reserved than Americans.

Canadians generally don't touch very much when conversing.

Maintaining a certain amount of personal space is important.

French Canadians are generally more animated and expressive than other Canadians.

Some gestures have different meanings in Quebec. For example, "thumbs down" is considered offensive in Quebec, as is slapping an open palm over a closed fist. Like the rest of their countrymen and women, French- Canadians use the "thumbs up" sign to mean "okay. "The "okay" sign made with the index finger and thumb means "zero" in Quebec.

It's considered bad form by many in Quebec to talk with your hands in your pockets.

Sneeze or blow your nose as quietly as possible using a handkerchief or tissue. If possible, leave the room. Do not yawn or scratch in public.

Although the relationship between Canada and the United States is generally quite good, some Canadians perceive Americans as arrogant.

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Helpful Hints Do your homework about Canada. Most Americans are appallingly ignorant of Canadian history, culture and geography.

Recognize that important regional differences exist in Canada and prepare to adapt.

When in Quebec, learn a little French; Québécois greatly appreciate it when you take the effort to talk to them in their native language.

Do not compare Canada with the United States.

Do not use the term "Native Americans" to refer to indigenous peoples. Many Canadians find the term offensive. Canadians refer to members of these groups as "people of the First Nations."

Do not take sides in debates about contentious national issues (especially when they concern such issues the status of Quebec, the place of the French and English languages in Canadian society, etc.).

379 Cultural Snapshot: Your massage client from Chile

Where they are from Chile, officially the Republic of Chile, is a South American country occupying a long, narrow strip of land between the Andes mountains to the east and the Pacific Ocean to the west. It borders Peru to the north, Bolivia to the northeast, Argentina to the east, and the Drake Passage in the far south. Chilean territory includes the Pacific islands of Juan Fernández, Salas y Gómez, Desventuradas, and Easter Island in Oceania. Chile also claims about 1,250,000 square kilometres (480,000 sq mi) of Antarctica, although all claims are suspended under the Antarctic Treaty.

Chile's northern desert contains great mineral wealth, principally copper. The relatively small central area dominates in terms of population and agricultural resources, and is the cultural and political center from which Chile expanded in the late 19th century when it incorporated its northern and southern regions. Southern Chile is rich in forests and grazing lands, and features a string of volcanoes and lakes. The southern coast is a labyrinth of fjords, inlets, canals, twisting peninsulas, and islands.

Spain conquered and colonised Chile in the mid-16th century replacing Inca rule in northern and central Chile but failed to conquer the independent Mapuche that inhabited south-central Chile. After declaring its independence from Spain in 1818, Chile emerged in the 1830s as a relatively stable authoritarian republic. In the 19th century, Chile saw significant economic and territorial growth ending Mapuche resistance in the 1880s and gaining its current northern territory in the War of the Pacific (1879–83) after defeating Peru and Bolivia. In the late 1960s and early 1970s, the country experienced severe left-right political polarization and turmoil. This development culminated with the 1973 Chilean coup d'état that overthrew Salvador Allende's left-wing government and instituted a 16- year-long right-wing military dictatorship that left more than 3,000 people dead or missing. The regime headed by Augusto Pinochet ended in 1990 after it lost a referendum in 1988 and was succeeded by a centre-left coalition which ruled through four presidencies until 2010.

Chile is today one of South America's most stable and prosperous nations. It leads Latin American nations in rankings of human development, competitiveness, income per capita, globalization, state of peace, economic freedom, and low perception of corruption. It also ranks high regionally in

380 sustainability of the state, and democratic development. Chile is a founding member of the United Nations, the Union of South American Nations and the Community of Latin American and Caribbean States.

The People Chileans are very nationalistic and are proud of their country, as well as of their literacy -- the 95% rate puts them among the best educated in the world. Predominantly Roman Catholic (89%), family is the primary structure of society. The father is still considered the head of the family, but the mother is an important decision-maker. People are judged by their educational and family backgrounds, not by race.

Meeting and Greeting Chileans are very warm and expect visitors to reciprocate. They may be formal at first, but move to friendship very quickly.

A handshake, a warm hug and one kiss on the right cheek are common greetings among friends.

Always greet the head of the household or most senior person first.

Body Language Chileans stand closer than North Americans do. Do not back away.

Never click your fingers to or at anyone.

Never beckon with your index finger.

A chin flick means "I couldn’t care less." Educated people do not use this gesture.

Hitting the palm of your left hand with your right fist is considered a vulgar gesture.

Helpful Hints Do not make comparisons between the United States and Chile.

Show interest in and talk about family, especially children.

Do not talk about politics or human rights.

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Especially for Women Traditionally, men have dominated private and public life in Chile. However, attitudes are changing at home and in the workplace. Women now make up 30% of the labor. In addition, many women hold important political and business positions as ministers and top executives.

Typical North American professional women are often viewed as cold, pushy and non-feminine.

It is common for men to stare at women. It is harmless and meant to flatter .

382 Cultural Snapshot: Your massage client from China

Where they are from China, officially the People's Republic of China (PRC), is a sovereign state located in East Asia. It is the world's most populous country, with a population of over 1.35 billion . The PRC is a single-party state governed by the Communist Party, with its seat of government in the capital city of Beijing. It exercises jurisdiction over 22 provinces, five autonomous regions, four direct-controlled municipalities (Beijing, Tianjin, Shanghai, and Chongqing), and two mostly self-governing special administrative regions (Hong Kong and Macau). The PRC also claims the territories governed by Taiwan, a separate political entity officially known as the Republic of China (ROC), as its 23rd province, a claim which is controversial due to the complex political status of Taiwan.

Covering approximately 9.6 million square kilometers, China is the world's second-largest country by land area, and either the third or fourth-largest by total area, depending on the method of measurement.[i] China's landscape is vast and diverse, ranging from forest steppes and the Gobi and Taklamakan deserts in the arid north to subtropical forests in the wetter south. The Himalaya, Karakoram, Pamir and Tian Shan mountain ranges separate China from South and Central Asia. The Yangtze and Yellow Rivers, the third- and sixth-longest in the world, run from the Tibetan Plateau to the densely populated eastern seaboard. China's coastline along the Pacific Ocean is 14,500 kilometres (9,000 mi) long, and is bounded by the Bohai, Yellow, East and South China Seas.

The history of China goes back to the ancient civilization – one of the world's earliest – that flourished in the fertile basin of the Yellow River in the North China Plain. For millennia, China's political system was based on hereditary monarchies, known as dynasties, beginning with the semi- mythological Xia of the Yellow River basin (c. 2000 BCE). Since 221 BCE, when the Qin Dynasty first conquered several states to form a Chinese empire, the country has expanded, fractured and been reformed numerous times. The Republic of China (ROC) overthrew the last dynasty in 1911, and ruled the Chinese mainland until 1949. After the defeat of the Empire of Japan in World War II, the Communist Party defeated the nationalist Kuomintang in mainland China and established the People's Republic of China in Beijing on 1 October 1949, while the Kuomintang relocated the ROC government to its present capital of Taipei.

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China had the largest and most complex economy in the world for most of the past two thousand years, during which it as seen cycles of prosperity and decline. Since the introduction of economic reforms in 1978, China has become one of the world's fastest-growing major economies. As of 2013, it is the world's second-largest economy by both nominal total GDP and purchasing power parity (PPP), and is also the world's largest exporter and importer of goods. China is a recognized nuclear weapons state and has the world's largest standing army, with the second-largest defence budget. The PRC has been a United Nations member since 1971, when it replaced the ROC as a permanent member of the U.N. Security Council. China is also a member of numerous formal and informal multilateral organizations, including the WTO, APEC, BRICS, the Shanghai Cooperation Organization, the BCIM and the G-20. China is a regional power within Asia and has been characterized as a potential superpower by a number of commentators.

The People Deeply rooted in Chinese society is the need to belong and conform to a unit, whether the family, a political party or an organization. The family is the focus of life for most Chinese. Age and rank are highly respected. However, to the dismay of older people, today's young people are rapidly modernizing, wearing blue jeans and sunglasses, drinking Coke and driving motorbikes.

A 2007 survey by the Horizon Research Consultancy Group found that individuals who self-identify as Buddhists made up 11–16% of China's adult population, while Christians comprised around 3–4%, and Muslims comprised approximately 1%. “Freedom” of religion is guaranteed by China's constitution, although religious organizations that lack official approval can be subject to state persecution.

Meeting and Greeting Shake hands upon meeting. Chinese may nod or bow instead of shaking hands, although shaking hands has become increasingly common.

When introduced to a Chinese group, they may greet you with applause. Applaud back.

384 Senior persons begin greetings. Greet the oldest, most senior person before others. During group introductions, line up according to seniority with the senior person at the head of the line. Names and Titles Use family names and appropriate titles until specifically invited by your Chinese host or colleagues to use their given names.

Address the Chinese by Mr., Mrs., Miss plus family name. Note: married women always retain their maiden name.

Chinese are often addressed by their government or professional titles. Names may have two parts; for example: Wang Chien. Traditional Chinese family names are placed first with the given name (which has one or two syllables) coming last (family name: Wang; given: Chien).

Body Language The Chinese dislike being touched by strangers. Do not touch, hug, lock arms, back slap or make any body contact.

Clicking fingers or whistling is considered very rude.

Never put your feet on a desk or a chair. Never gesture or pass an object with your feet.

Blowing one's nose in a handkerchief and returning it to one's pocket is considered vulgar by the Chinese.

To beckon a Chinese person, face the palm of your hand downward and move your fingers in a scratching motion. Never use your index finger to beckon anyone.

Chinese point with an open hand. Never point with your index finger.

Helpful Hints Chinese find "no" difficult to say. They may say "maybe" or "we'll see" in order to save face.

Always refer to China as "China" or "People's Republic of China," never as "Red China," "Communist China" or "Mainland China."

385 Always refer to Taiwan as "Taiwan" or "Province of Taiwan," never "China," "Republic of China" (the name adapted by the Nationalist forces after they fled to Taiwan) or "Free China."

Do not in any way suggest that Taiwan is not part of China.

Show respect for older people. Offer a seat or right of way through the door to a colleague or older person as a polite gesture.

Refrain from being loud, boisterous or showy.

Do not be insulted if the Chinese ask personal questions such as "How much money do you make?" "How many children do you have?" or "Are you married?" Just change the subject if you do not want to answer.

Asking about divorce would cause a Chinese person to lose face.

Forcing the Chinese to say "no" will quickly end a relationship.

Most Chinese women don't wear wedding rings. Don't assume marital status.

Especially for Women China is a male-dominated society. However, there are many women in business in China and some occupy high-ranking positions and important managerial jobs. They continue to work toward sexual equality.

386 Cultural Snapshot: Your massage client from Colombia

Where they are from Colombia, officially the Republic of Colombia, is a country situated in the northwest of South America, bordered to the northwest by Panama; to the east by Venezuela and Brazil; to the south by Ecuador and Peru; and it shares maritime limits with Costa Rica, Nicaragua, Honduras, Jamaica, Dominican Republic and Haiti. It is a unitary, constitutional republic comprising thirty-two departments.

The territory of what is now Colombia was originally inhabited by indigenous peoples including the Muisca, Quimbaya, and Tairona. The Spanish arrived in 1499 and initiated a period of conquest and colonization ultimately creating the Viceroyalty of New Granada, with its capital at Bogotá. Independence from Spain was won in 1819, but by 1830 "Gran Colombia" had collapsed with the secession of Venezuela and Ecuador. What is now Colombia and Panama emerged as the Republic of New Granada. The new nation experimented with federalism as the Granadine Confederation (1858), and then the United States of Colombia (1863), before the Republic of Colombia was finally declared in 1886. Panama seceded in 1903.

Since the 1960s, the country has suffered from an asymmetric low-intensity armed conflict. The conflict escalated in the 1990s, but since 2000 the conflict has decreased considerably.

Colombia is ethnically diverse, the descendants of the original native inhabitants, Spanish colonists, Africans originally brought to the country as slaves, and 20th-century immigrants from Europe and the Middle East have produced a diverse cultural heritage. This has also been influenced by Colombia's varied geography, and the imposing landscape of the country has resulted in the development of very strong regional identities. The majority of the urban centres are located in the highlands of the Andes mountains, but Colombian territory also encompasses Amazon rainforest, tropical grassland and both Caribbean and Pacific coastlines.

Ecologically, Colombia is one of the world's 17 megadiverse countries, and is considered the most megadiverse per square kilometer. Colombia is a middle power with the third largest economy in Latin America, is part of the CIVETS group of six leading emerging markets and is an accessing

387 member to the OECD. Its principal industries include oil, mining, chemicals, health related products, food processing, agricultural products, textile and fabrics, garments, forest products, machinery, electronics, military products, metal products, home and office material, construction equipment and materials, banking, financial services, software, IT services and the automotive industry.

The People Colombia has one of the most successful economies in South America, despite adverse conditions and a very unequal distribution of wealth. A small number of Colombians hold most of the country's wealth and political power, but the middle and working classes are growing in Colombia's cities. Colombians are hardworking and peace loving. Politeness, proper behavior, good manners and courtesy are valued. Colombians are very proud of their democracy and independence. They do not like or want outside interference and want to address internal challenges on their own.

Meeting and Greeting Shake hands with everyone when entering or leaving a room.

Body Language Smiling is very important.

Never put your feet on furniture.

Yawning is impolite and viewed as a sign of hunger or sleepiness.

Always cover your mouth when yawning.

It is considered demeaning to beckon someone with your index finger. Instead, beckon with your palm down, waving your fingers or your whole hand.

Helpful Hints Time and punctuality are not stressed. Colombians will typically arrive up to thirty minutes late for social engagements.

Don't offer your opinions about politics or religion.

388 Be prudent when you talk about drugs. Colombia is working with the United States' government in the war against drugs, but U.S. foreign policy is not viewed positively by many Colombians.

Do not be offended if you are called a “gringo.” Colombians use this term to refer to people from the United States, and it is not meant to be insulting.

Colombians consider Panama to have been stolen from them by norteamericanos eager to build the Panama Canal. Try to stay away from this touchy subject.

Especially for Women A woman in the workforce is treated as any man, notwithstanding special courtesy and manners.

Men may flirt or make comments; simply ignore them. Women should be careful not to do anything that might be considered flirtatious, which may be misinterpreted.

389 Cultural Snapshot: Your massage client from Denmark

Where they are from Denmark is a Nordic country in Northern Europe, located southwest of Sweden and south of Norway, and bordered to the south by Germany. The Kingdom of Denmark comprises Denmark and two autonomous constituent countries in the North Atlantic Ocean, the Faroe Islands and Greenland. At 43,094 square kilometres (16,639 sq mi), with a population of around 5.64 million inhabitants, Denmark consists of a peninsula, Jutland, and the Danish archipelago of 443 named islands, of which around 70 are inhabited. The islands are characterised by flat, arable land and sandy coasts, low elevation and a temperate climate. A Scandinavian nation, Denmark shares strong cultural and historic ties with its overseas neighbours Sweden and Norway. The national language, Danish, is very closely related and mutually intelligible with Swedish and Norwegian.

The unified kingdom of Denmark emerged in the 10th century as a proficient seafaring nation in the struggle for control of the Baltic Sea. Danish rule over the personal Kalmar Union, established in 1397, ended with Swedish secession in 1523. The following year, Denmark entered into a union with Norway until its dissolution in 1814. Denmark inherited an expansive colonial empire from this union, of which the Faroe Islands and Greenland are remnants. Beginning in the 17th century, there were several cessions of territory; these culminated in the 1830s with a surge of nationalist movements, which were defeated in the 1864 Second Schleswig War. Denmark remained neutral during World War I. In April 1940, a German invasion saw brief, military skirmishes while the Danish resistance movement was active from 1943 until the German surrender in May 1945. An industrialized exporter of agricultural produce in the second half of the 19th century, Denmark introduced social and labour-market reforms in the early 20th century, making the basis for the present welfare state model with a highly developed mixed economy.

The Constitution of Denmark was signed on 5 June 1849, ending the absolute monarchy which had begun in 1660. It establishes a constitutional monarchy—the current monarch is Queen Margrethe II—organised as a parliamentary democracy.

Danes enjoy a high standard of living and the country ranks highly in numerous comparisons of national performance, including education,

390 health care, protection of civil liberties, government transparency, democratic governance, prosperity and human development. Denmark is frequently ranked as the happiest country in the world in cross-national studies of happiness. The country ranks as having the world's highest social mobility, a high level of income equality, has one of the world's highest per capita incomes, and has one of the world's highest personal income tax rates. A large majority of Danes are members of the National Church, although the Constitution guarantees freedom of religion.

The People Danes are respected for their accomplishments in science, art, literature and architecture. They value tolerance and diversity. The individual is also highly regarded in Danish culture. Danes are very proud of their excellent educational system. Although the Danes value close and stable family lives, they have one of the highest divorce rates in Europe. Most women work outside the home.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands with women first, and shake hands again when leaving.

Body Language Danes do not like to be touched.

Helpful Hints Danes may have an ironical way of expressing themselves. They may say, "It's wonderful weather," when it is pouring rain, or "It is a trifle chilly," when it is stifling hot.

Danes say "thank you" for everything--anytime, anywhere.

Danes do not use the expression, "How are you?" as loosely as Americans. Do not ask this question unless you have developed a personal relationship with someone and truly wish to know.

Use proper etiquette with Danes. Relaxed, polite manners are appreciated. Refrain from abundantly complimenting or commenting on anyone's clothing. Never call a Dane a Swede or Norwegian.

391 Cultural Snapshot: Your massage client from Ecuador

Where they are from Ecuador, officially the Republic of Ecuador, which literally translates as "Republic of the Equator") is a representative democratic republic in northwestern South America, bordered by Colombia on the north, Peru on the east and south, and the Pacific Ocean to the west. Ecuador also includes the Galápagos Islands in the Pacific, about 1,000 kilometres (620 mi) west of the mainland, which borders Costa Rica's Cocos Island.

Ecuador's official language is Spanish, which is spoken by 94% of the population; thirteen indigenous languages are also recognized, including Quichua and Shuar. Ecuador has a land area of 283,520 km2 and a population of approximately 15.2 million. Its capital city is Quito, which was declared a UNESCO World Heritage Site in the 1970s for having the best preserved and least altered historic center in Latin America. The country's largest city is Guayaquil. The historic center of Cuenca, the third-largest city in the country in size and economically, was also declared a World Heritage Site in 1999 as an outstanding example of a planned, inland Spanish-style colonial city in the Americas.

In addition to its rich history, Ecuador is known for hosting a variety of species, many of them endemic, such as those of the Galápagos Islands. It is one of seventeen megadiverse countries in the world, with the most species diversity per unit area. The new constitution of 2008 is the first in the world to recognize legally enforceable Rights of Nature, or ecosystem rights.

According to the Ecuadorian National Institute of Statistics and Census, 91.95% of the country's population have a religion, 7.94% are atheists and 0.11% are agnostics. Among the people that have a religion, 80.44% are Roman Catholic Latin Rite, 11.30% are Protestants, 1.29% are Jehovah's Witnesses and 6.97% other (mainly Jewish, Buddhists and Latter-day Saints).

The People Ecuadorians are hospitable and warmly welcoming of visitors. They revere older people and honor experience and authority. Superiors, parents and teachers are greatly respected. Ecuador is one of the most racially divided countries of South America. Whites (Blancos) are better off economically

392 and educationally than the rest of the population. Mestizos are usually middle class. Native Ecuadorians (Indios) are considered lower class, and many live in poverty, are illiterate and often don't speak Spanish. Blacks have overcome many stereotypes.

Meeting and Greeting People shake hands when meeting for the first time.

Men may embrace each other if they are good friends.

Ecuadorians kiss once when they meet friends.

Body Language There is a good deal of touching among friends and family.

Yawning in public is rude.

Fidgeting with hands and feet is distracting and considered impolite.

Holding out a hand, as though to shake hands, and twisting it back and forth means “no.”

It is impolite to point at someone. Ecuadorians may point by puckering or pursing their lips.

393 Cultural Snapshot: Your massage client from Finland

Where they are from Finland, officially the Republic of Finland,is a Nordic country situated in the Fennoscandian region of Northern Europe. It is bordered by Sweden to the west, Norway to the north, Russia to the east and Estonia to the south over the Gulf of Finland.

As of 2013, Finland's population, of which 90% are Finns who speak Finnish, was around 5.5 million, with the majority concentrated in its southern regions. In terms of area, it is the eighth largest country in Europe and the most sparsely populated country in the European Union. Finland is a parliamentary republic with a central government based in the capital of Helsinki, local governments in 336 municipalities and an autonomous region, the Åland Islands. About one million residents live in the Greater Helsinki area (consisting of Helsinki, Espoo, Vantaa and Kauniainen), which also produces a third of the country's GDP. Other large cities include Tampere, Turku, Oulu, Jyväskylä, Lahti, and Kuopio.

From the late 12th century until 1809, Finland was part of Sweden, a legacy reflected in the prevalence of the Swedish language and its official status. It then became an autonomous Grand Duchy within the Russian Empire until the Russian Revolution, which prompted the Finnish Declaration of Independence. This was followed by a civil war where the pro-Bolshevik "Reds" were defeated by the pro-conservative "Whites" with support from the German Empire. After a brief attempt to establish a monarchy, Finland became a republic. Finland's experience of World War II involved three separate conflicts: the Winter War (1939–1940) and Continuation War (1941–1944) against the Soviet Union and the Lapland War (1944–1945) against Nazi Germany. Following the end of the war, Finland joined the United Nations in 1955 and established an official policy of neutrality. Nevertheless, it remained fairly active on the world stage, joining the Organisation for Economic Co-operation and Development (OECD) in 1969, the European Union in 1995, and the eurozone at its inception in 1999.

The People Loyalty, reliability, self-sufficiency and independence are highly valued. Finns are proud of their heritage and current society (they are leaders in peace conferences and international peace initiatives). They enjoy nature

394 and proudly protect their environment, which is one of the cleanest in the world. Finns value their privacy and appreciate others respecting it.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

Body Language Keep some physical distance from Finns. Respect their shyness and desire for privacy .

Maintain eye contact when speaking to someone.

Never talk to anyone with your hands in your pocket.

Using a sauna is very traditional in Finland, and they tend to sauna naked.

Helpful Hints Do not show emotions in public.

Never ask personal questions, such as those related to someone's religion, job or political party.

395 Cultural Snapshot: Your massage client from France

Where they are from France, officially the French Republic, is a unitary sovereign state comprising territory in Western Europe and several overseas regions and territories. Metropolitan France extends from the Mediterranean Sea to the English Channel and the North Sea, and from the Rhine to the Atlantic Ocean; due to its shape, it is often referred to in French as l’Hexagone ("The Hexagon"). France is one of only three countries (with Morocco and Spain) to have both Atlantic and Mediterranean coastlines.

By area, France is the 42nd largest country in the world but the largest country in Western Europe and the European Union (EU), and the third- largest in Europe as a whole. With a population approaching 67 million, it is the 20th most populated country and the second-most populated country in the EU. France is a semi-presidential republic with its capital in Paris, the nation's largest city and the main cultural and commercial center. The current Constitution of France, adopted by referendum on 4 October 1958, establishes the country as secular and democratic, with its sovereignty derived from the people. The nation's ideals are expressed in the Declaration of the Rights of Man and of the Citizen, one of the world's earliest documents on human rights, which was formulated during the seminal French Revolution of the late 18th century.

France has been a major power in Europe since the Late Middle Ages, reaching the height of global prominence during the 19th and early 20th centuries, when it possessed the second-largest colonial empire in the world. Throughout its long history, France has produced many influential artists, thinkers, and scientists, and remains a prominent global center of culture. It hosts the world's fourth-largest number of cultural UNESCO World Heritage Sites and receives around 83 million foreign tourists annually – the most of any country in the world.

France remains a great power with significant cultural, economic, military, and political influence in Europe and around the world. It has the world's fifth-largest military budget,[9] third-largest stockpile of nuclear weapons, and second-largest diplomatic corps. Due to its overseas regions and territories throughout the world, France has the second-largest exclusive economic zone in the world. France is a developed country and has the world's fifth-largest economy by nominal GDP and seventh-largest by

396 purchasing power parity. In terms of total household wealth, France is the wealthiest nation in Europe and fourth in the world.

French citizens enjoy a high standard of living, and the country performs well in international rankings of education, health care, life expectancy, civil liberties, and human development. France is a founding member of the United Nations, where it serves as one of the five permanent members of the UN Security Council. It is a member of numerous international institutions, including the Group of 7, North Atlantic Treaty Organization (NATO), Organisation for Economic Co-operation and Development (OECD), the World Trade Organization (WTO), and La Francophonie. France is a founding and leading member state of the EU.

Catholicism has been the predominant religion in France for more than a millennium, though it is not as actively practised today as it was. Among the 47,000 religious buildings in France, 94% are Roman Catholic. Whilst in 1965, 81% of the French declared themselves to be Catholics, in 2009 this proportion was 64%. Moreover, whilst 27% of the French went to Mass once a week or more in 1952, only 5% did so in 2006. The same survey found that Protestants accounted for 3% of the population, an increase from previous surveys, and 5% adhered to other religions, with the remaining 28% stating they had no religion.Evangelical Christianity may be the fastest growing religion in France.

The People The French adhere to a strong and homogeneous set of values. They cherish their culture, history, language and cuisine, which is considered an art. The French have been and are today world leaders in fashion, food, wine, art and architecture. They embrace novelty, new ideas and manners with enthusiasm as long as they are elegant.

Meeting and Greeting Shake hands with everyone present when arriving and leaving. A handshake may be quick with a light grip.

Men may initiate handshakes with women.

When family and close friends greet one another, they often kiss both cheeks.

397 Names and Titles Use last names and appropriate titles until specifically invited by your French host or colleagues to use their first names. First names are used only for close friends and family.

Colleagues on the same level generally use first names in private but always last names in public.

Address people as Monsieur, Madame or Mademoiselle without adding the surname.

Madame is used for all adult women, married or single, over 18 years of age (except for waitresses, which are addressed as Mademoiselle.)

Academic titles and degrees are very important. You are expected to know them and use them properly.

Body Language Do not sit with legs spread apart. Sit up straight with legs crossed at knee or knees together. Feet should never placed on tables or chairs. Toothpicks, nail clippers, and combs are not used in public.

Keep your hands out of your pockets.

Do not yawn or scratch in public. Sneeze or blow your nose as quietly as possible using a handkerchief or tissue. If possible, leave the room.

Do not slap your open palm over a closed fist (this is considered a vulgar gesture).

The "okay" sign, made with index finger and thumb, means "zero." The French use the "thumbs up" sign to say "okay."

Helpful Hints Lower your voice a little and behave graciously and you will enjoy a warm response from the French.

The French value their privacy. Don’t ask personal questions related to occupation, salary, age, family or children unless you have a well- established friendship.

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Try to demonstrate some knowledge of history, politics and French culture. Compliments may be appreciated, but usually are received by denial instead of "thank you."

The French do not tell or like to hear jokes. They prefer intelligent and satirical wit. Funny stories of real life situations are appreciated.

399 Cultural Snapshot: Your massage client from Germany

Where they are from Germany, officially the Federal Republic of is a federal parliamentary republic in western-central Europe consisting of 16 constituent states, which retain limited sovereignty. Its capital city and largest city is Berlin. Germany covers an area of 357,021 square kilometres (137,847 sq mi) and has a largely temperate seasonal climate. With 80.6 million inhabitants, it is the most populous member state in the European Union. Germany is a major economic and political power of the European continent and a historic leader in many cultural, theoretical and technical fields. After the USA, Germany is the second most popular migration destination in the world.

Various Germanic tribes have occupied what is now northern Germany and southern Scandinavia since classical antiquity. A region named Germania was documented by the Romans before AD 100. During the Migration Period that coincided with the decline of the Roman Empire, the Germanic tribes expanded southward and established kingdoms throughout much of Europe. Beginning in the 10th century, German territories formed a central part of the Holy Roman Empire. During the 16th century, northern German regions became the centre of the Protestant Reformation. Occupied during the Napoleonic Wars, the rise of Pan-Germanism inside the German Confederation resulted in the unification of most of the German states in 1871 into the German Empire, which was dominated by Prussia.

After the German Revolution of 1918–1919 and the subsequent military surrender in World War I, the Empire was replaced by the parliamentary Weimar Republic in 1918 and lost some of its territory in the Treaty of Versailles. Despite its lead in many scientific and cultural fields at this time, Germany experienced significant economic and political instability which intensified during the Great Depression. The establishment of the Third Reich or Nazi Regime in 1933 eventually led to World War II and the Holocaust. After 1945, Germany was divided by Allied occupation, and evolved into two states, East Germany and West Germany. In 1990, the country was reunified.

Germany has the world's fourth-largest economy by nominal GDP and the fifth-largest by purchasing power parity. As a global leader in several industrial and technological sectors, it is both the world's third-largest

400 exporter and third-largest importer of goods. It is a developed country with a very high standard of living, featuring comprehensive social security that includes the world's oldest universal health care system. Known for its rich cultural and political history, Germany has been the home of many influential philosophers, artists, musicians, cineasts, entrepreneurs, scientists and inventors. Germany was a founding member of the European Community in 1957, which became the EU in 1993. It is part of the Schengen Area, and has been a member of the eurozone since 1999. Germany is a great power, and a member of the United Nations, NATO, the G8, the G20, the OECD and the Council of Europe.

The People Germans value order, privacy and punctuality. They are thrifty, hard working and industrious. Germans respect perfectionism in all areas of business and private life. In Germany, there is a sense of community and social conscience and strong desire for belonging. To admit inadequacy -- even in jest -- is incomprehensible.

Meeting and Greeting Shake hands with everyone present when arriving and leaving.

When introducing yourself, never use your title. Introduce yourself by your last name only.

Never shake hands with one hand in your pocket.

Names and Titles Use last names and appropriate titles until specifically invited by your German client to use their first names.

Titles are very important. Never use titles incorrectly and never fail to use them. If unsure, err in favor of a higher title.

A Doktor can be either a medical doctor or a holder of a Ph.D. Two titles should not be used at the same time, except when addressing a letter to someone. If a person does hold several titles, the higher one is used in speaking to him/her.

401 Body Language Germans may appear reserved and unfriendly until you get to know them better.

Never put your hands in your pockets when talking with someone. "Thumbs up" gesture means "one" or is a sign of appreciation or agreement.

Making hands into two fists, thumbs tucked inside the other fingers and making pounding motion lightly on a surface expresses "good luck."

Never use the "okay" sign (index finger and thumb jointed together to make a circle). This is considered a rude gesture.

Don't point your index finger to your own head. This is an insult.

Corporate Culture

Helpful Hints Germans are more formal and punctual than most of the world. They have prescribed roles and seldom step out of line.

A man or younger person should always walk to the left side of a lady.

Traditional good manners call for the man to walk in front of a woman when walking into a public place. This is a symbol of protection and of the man leading the woman. A man should open the door for a woman and allow her to walk into the building, at which time the woman will stop and wait for the man. The man should then proceed to lead the woman to her designation.

Compliment carefully and sparingly -- it may embarrass rather than please.

Don’t lose your temper publicly. This is viewed as uncouth and sign of weakness.

Stand when an elder or higher ranked person enters the room.

Don’t shout or be loud, put your feet on furniture or chew gum in public.

402 Cultural Snapshot: Your massage client from Greece

Where they are from Greece, officially the Hellenic Republic and known since ancient times as Hellas, is a country in Southern Europe. According to the 2011 census, Greece's population is around 11 million. Athens is the nation's capital and largest city.

Greece is strategically located at the crossroads of Europe, Asia and Africa. It also shares land borders with Albania to the northwest, the Republic of Macedonia and Bulgaria to the north and Turkey to the northeast. The country consists of nine geographic regions: Macedonia, Central Greece, the Peloponnese, Thessaly, Epirus, the Aegean Islands (including the Dodecanese and Cyclades), Thrace, Crete, and the Ionian Islands. The Aegean Sea lies to the east of the mainland, the Ionian Sea to the west, and the Mediterranean Sea to the south. Greece has the longest coastline on the Mediterranean Basin and the 11th longest coastline in the world at 13,676 km (8,498 mi) in length, featuring a vast number of islands (approximately 1,400, of which 227 are inhabited). Eighty percent of Greece consists of mountains, of which Mount Olympus is the highest, at 2,917 m (9,570 ft).

Modern Greece traces its roots to the civilization of Ancient Greece, which began with the Aegean Civilizations of the Bronze Age. Considered the cradle of all Western civilization, Greece is the birthplace of democracy, Western philosophy, the Olympic Games, Western literature and historiography, political science, major scientific and mathematical principles and Western drama including both tragedy and comedy. The cultural and technological achievements of Greece greatly influenced the world, with many aspects of Greek civilization being imparted to the East through Alexander the Great's campaigns, and to the West through its incorporation into the Roman Empire.

Of course let’s not forget, much of our Western Massage techniques (the “Swedish massage”) originated in the Gymnasiums of Ancient Greece too!

The People Families are very important in Greece. Elders are highly respected, and children care for their elderly parents. Children are disciplined firmly, but parents (even those who are poor) spend a great deal of their income on

403 feeding, clothing and educating their children. Men consider it a personal honor and responsibility to care for their family.

The Greek Constitution recognizes the Orthodox Christian faith as the "prevailing" faith of the country, while guaranteeing freedom of religious belief for all. The Greek government does not keep statistics on religious groups and censuses do not ask for religious affiliation. According to the U.S. State Department, an estimated 97% of Greek citizens identify themselves as Orthodox Christians, belonging to the Greek Orthodox Church.

In a Eurostat – Eurobarometer 2010 poll, 79% of Greek citizens responded that they "believe there is a God". According to other sources, 15.8% of Greeks describe themselves as "very religious", which is the highest among all European countries. The survey also found that just 3.5% never attend a church, compared to 4.9% in Poland and 59.1% in the Czech Republic.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

Good friends are most likely to embrace and kiss.

Body Language Greeks are very demonstrative and affectionate.

Nodding your head "yes" is not polite ; say "yes" instead.

"Yes" is signified by a slight downward nod of the head; “no" is a slight upward nod of the head.

The “O.K.” sign is a rude gesture; "thumbs up" means O.K.

Helpful Hints The Greeks "pass" time, not "use" it.

Expect Greeks to ask personal questions , such as "Are you married?" or "Do you have children?" This is not considered rude, but an attempt to get to know you personally.

404 Cultural Snapshot: Your massage client from India

Where they are from India, officially the Republic of India, is a country in South Asia. It is the seventh-largest country by area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world. Bounded by the Indian Ocean on the south, the Arabian Sea on the southwest, and the Bay of Bengal on the south-east, it shares land borders with Pakistan to the west; China, Nepal, and Bhutan to the north-east; and Burma and Bangladesh to the east. In the Indian Ocean, India is in the vicinity of Sri Lanka and the Maldives; in addition, India's Andaman and Nicobar Islands share a maritime border with Thailand and Indonesia.

Home to the ancient Indus Valley Civilisation and a region of historic trade routes and vast empires, the Indian subcontinent was identified with its commercial and cultural wealth for much of its long history. Four world religions—Hinduism, Buddhism, Jainism, and Sikhism—originated here, whereas Judaism, Zoroastrianism, Christianity, and Islam arrived in the 1st millennium CE and also helped shape the region's diverse culture. Gradually annexed by and brought under the administration of the British East India Company from the early 18th century and administered directly by the United Kingdom from the mid-19th century, India became an independent nation in 1947 after a struggle for independence that was marked by non-violent resistance led by Mahatma Gandhi.

The Indian economy is the world's tenth-largest by nominal GDP and third- largest by purchasing power parity (PPP). Following market-based economic reforms in 1991, India became one of the fastest-growing major economies; it is considered a newly industrialized country. However, it continues to face the challenges of poverty, corruption, malnutrition, inadequate public healthcare, and terrorism. A nuclear weapons state and a regional power, it has the third-largest standing army in the world and ranks ninth in military expenditure among nations. India is a federal constitutional republic governed under a parliamentary system consisting of 29 states and 7 union territories. India is a pluralistic, multilingual, and a multi-ethnic society. It is also home to a diversity of wildlife in a variety of protected habitats.

405 The People India is one of the most diverse countries in the world. It is a sophisticated, modern, industrial leader that is home to many primitive tribes and millions of poor people. Religion and language separate people. The caste system limits social mobility (600,000 people belong to the lowest caste). Because of disparities in distribution of wealth, a wide gap separates the few wealthy from the many poor.

Meeting and Greeting Westerners may shake hands, however, greeting with 'namaste' (na-mas- TAY) (placing both hands together with a slight bow) is appreciated and shows respect for Indian customs.

Men shake hands with men when meeting or leaving. Men do not touch women when meeting or greeting . Western women may offer their hand to a westernized Indian man, but not normally to others. Traditional Indian women may shake hands with women but not usually with men .

Body Language Public displays of affection are not proper.

Indians generally allow an arm's length space between themselves and others. Don't stand close to Indians. Indians value personal space.

Indian men may engage in friendly back patting merely as a sign of friendship.

When an Indian smiles and jerks his/her head backward -- a gesture that looks somewhat like a Western "no" -- or moves his head in a figure 8, this means "yes."

The Western side-to-side hand wave for "hello" is frequently interpreted by Indians as "no" or "go away."

Use your right hand only to touch someone, pass money or pick up merchandise. The left hand is considered unclean. Do not touch anyone's head. The head is considered sensitive.

Feet are considered unclean. Feet are sacred for holy men and women. Pointing footwear at people is considered an insult.

406

Indians are very sensitive to being beckoned rudely. Hand and arm waved up and down (Western "good-bye") means "come here." To beckon, extend your arm, palm down and make a scratching motion with fingers kept together.

Never point with a single finger or two fingers (used only with inferiors). Point with your chin, whole hand or thumb. The chin is not used to point at superiors.

Helpful Hints When an Indian answers, "I will try," he or she generally means "no."

This is considered a polite "no."

Apologize immediately if your feet or shoes touch another person.

Do not show anger.

Especially for Women India is a male-dominated society. Western women may be accepted, but must establish their position and title immediately to warrant acceptance.

Women might not be included in social events or conversation.

407 Cultural Snapshot: Your massage client from Indonesia

Where they are from Indonesia, officially the Republic of Indonesia, is a sovereign state in Southeast Asia and Oceania. Indonesia is an archipelago comprising 13,466 islands. It encompasses 33 provinces and 1 Special Administrative Region (for being governed by a pre-colonial monarchy) with an estimated population of over 252 million people, making it the world's fourth most populous country. Indonesia's republic form of government comprises an elected legislature and president. The nation's capital city is Jakarta. The country shares land borders with Papua New Guinea, East Timor, and Malaysia. Other neighboring countries include Singapore, the Philippines, Australia, Palau, and the Indian territory of the Andaman and Nicobar Islands. Indonesia is a founding member of ASEAN and a member of the G-20 major economies. The Indonesian economy is the world's 16th largest by nominal GDP.

The Indonesian archipelago has been an important trade region since at least the 7th century, when Srivijaya and then later Majapahit traded with China and India. Local rulers gradually absorbed foreign cultural, religious and political models from the early centuries CE, and Hindu and Buddhist kingdoms flourished. Indonesian history has been influenced by foreign powers drawn to its natural resources. Muslim traders brought the now- dominant Islam, while European powers brought Christianity and fought one another to monopolize trade in the Spice Islands of Maluku during the Age of Discovery. Following three and a half centuries of Dutch colonialism, Indonesia secured its independence after World War II. Indonesia's history has since been turbulent, with challenges posed by natural disasters, corruption, separatism, a democratization process, and periods of rapid economic change.

Indonesia consists of hundreds of distinct native ethnic and linguistic groups. The largest – and politically dominant – ethnic group are the Javanese. A shared identity has developed, defined by a national language, ethnic diversity, religious pluralism within a majority Muslim population, and a history of colonialism and rebellion against it. Indonesia's national motto, "Bhinneka Tunggal Ika" ("Unity in Diversity" literally, "many, yet one"), articulates the diversity that shapes the country. Despite its large population and densely populated regions, Indonesia has vast areas of

408 wilderness that support the world's second highest level of biodiversity. The country has abundant natural resources, yet poverty remains widespread.

The People Along with unity and conformity to society's rules, honor and respect for the individual is the basis of Indonesian culture. Indonesians value loyalty to family and friends above all else. Life is simple for most people; most enjoy few modern conveniences, such as running water. Indonesia as a whole is viewed by its people as an extended family with the president, schoolmasters and leaders of business enterprises referred to as "fathers" by the public.

Meeting and Greeting Shake hands and give a slight nod when meeting for the first time. After the first meeting, a handshake is not necessary; a slight bow or nod of the head is sufficient. Shake an Indonesian woman's hand only if she initiates the greeting.

Greet people with "Selamat" (sell-a-mat), which means peace. Say it slowly and sincerely.

Body Language Good relationships involve a great deal of physical contact and touching .

Indonesians are used to an overcrowded society; they tend to ignore inadvertent invasions of space. Allowing for personal space is a sign of respect.

A man does not touch a woman in public except to shake hands, and they do not display affection in public.

The head is where the spirit resides and is considered sacred. Do not touch a person’s head .

Keep both feet on the floor when sitting. Do not cross your legs, especially not with an ankle over the knee. Sitting with good posture (rigid) and both feet on the floor is a sign of respect. Don’t allow the bottom of your feet to face or point at another person.

409 Looking someone straight in the eyes is considered staring . Avoid prolonged eye contact, which may be viewed as a challenge and may cause anger.

Point with your thumb, not your index finger. Never beckon with one finger.

The left hand is considered unclean. Do not touch food, pass or receive anything, touch anyone or point with your left hand.

Approval is sometimes shown with a pat on the shoulder, but American- style backslapping is considered offensive.

Helpful Hints Taking photographs is a way of honoring someone. Indonesians may ask to take your picture.

Civil servants are respected. Be very respectful to government workers. Never treat them as though they are your servants.

Don't assume tomorrow means tomorrow. Tomorrow may mean sometime in the future. Set specific dates and times for arrangements.

Do not chew gum or yawn in public.

Especially for Women Indonesia is a Muslim society and very male-oriented. It helps if you dress modestly.

A woman is expected to initiate a handshake.

410 Cultural Snapshot: Your massage client from Ireland

Where they are from Ireland is an island in the North Atlantic to the west of Great Britain, from which it is separated by the North Channel, the Irish Sea and St Georges Channel, and after which it is the largest island of the British Isles archipelago. It is the third-largest island in Europe and the twentieth-largest island on Earth.

Politically, Ireland is divided between the Republic of Ireland, which covers five-sixths of the island, and Northern Ireland, a part of the United Kingdom, which covers the remaining area and is located in the north-east of the island. The population of Ireland is about 6.4 million. Just under 4.6 million live in the Republic of Ireland and just over 1.8 million live in Northern Ireland.

The island's geography comprises relatively low-lying mountains surrounding a central plain, with several navigable rivers extending inland. The island has lush vegetation, a product of its mild but changeable oceanic climate, which avoids extremes in temperature. Thick woodlands covered the island until the Middle Ages. As of 2013, the amount of land that is wooded in Ireland is about 11% of the total, compared with a European average of 35%. There are twenty-six extant mammal species native to Ireland.

Prehistoric Ireland saw the arrival of humans after 8000 BC. Gaelic Ireland had emerged by the 1st century and lasted until the early 17th century. The island was converted to Christianity from the 5th century onward. Following the Norman invasion in the 12th century, England claimed sovereignty over Ireland. However, English rule did not extend over the whole island until the 16th–17th century Tudor conquest. This led to colonisation of Ireland by settlers from Britain. In the 1690s, a system of Protestant English rule was designed to materially disadvantage the Catholic majority and Protestant dissenters, and was extended during the 18th century. In 1801, Ireland became a part of the United Kingdom. A war of independence in the early 20th century was followed by the partition of the island, creating the Irish Free State, which became increasingly sovereign over the following decades, and Northern Ireland which remained a part of the United Kingdom. Northern Ireland saw much civil unrest from the late 1960s until

411 the 1990s. This subsided following a political agreement in 1998. In 1973, both parts of Ireland joined the European Economic Community.

Irish culture has had a significant influence on other cultures, especially in the fields of literature and, to a lesser degree, science and education. Alongside mainstream Western culture, a strong indigenous culture exists, as expressed for example through Gaelic games, Irish music, and the Irish language. The culture of the island has also many features shared with Great Britain, including the English language, and sports such as association football, rugby, horse racing and golf.

The People The Irish are interested in people and place great value on the individual. They are naturally courteous, quick-witted and will go out of their way to welcome visitors to their country. Don't rush the Irish. Although they work very hard, the Irish are dedicated to a less stressful lifestyle that allows time for friends and family, a visit to the pub, a cup of tea, or just a bit of a chat on the corner. Families are closely-knit and very important to the Irish.

Meeting and Greeting Shake hands with everyone present -- men, women and children -- at a business or social gathering. Shake hands again when leaving.

A firm handshake with eye contact is expected .

Body Language The Irish are not very physically demonstrative and are not comfortable with public displays of affection .

The Irish are uncomfortable with loud, aggressive, and arrogant behavior.

A "Reverse V for victory" gesture is considered obscene.

Helpful Hints The Irish respect reserved behavior. Initial meetings should be low key.

Always be sincere. The Irish dislike pretentious behavior.

Remember the Irish want to do things their way. You will not succeed if you insist on doing it "your way."

412 Cultural Snapshot: Your massage client from Italy

Where they are from Italy, officially the Italian Republic, is a unitary parliamentary republic in Southern Europe. To the north, Italy borders France, Switzerland, Austria, and Slovenia, and is approximately delimited by the Alpine watershed, enclosing the Po Valley and the Venetian Plain. To the south, it consists of the entirety of the Italian Peninsula and the two biggest Mediterranean islands of Sicily and Sardinia.

Italian territory also includes the islands of Pantelleria, 60 km (37 mi) east of the Tunisian coast and 100 km (62 mi) southwest of Sicily, and Lampedusa, at about 113 km (70 mi) from Tunisia and at 176 km (109 mi) from Sicily, in addition to many other smaller islands. The sovereign states of San Marino and the Vatican City are enclaves within Italy, while Campione d'Italia is an Italian exclave in Switzerland. Italy covers an area of 301,338 km2 (116,347 sq mi) and has a largely temperate climate. With 61 million inhabitants, it is the 5th most populous country in Europe. Among the world's most developed countries, Italy has the 4th-largest economy in the European Union, 3rd in the Eurozone and 9th in the world by GDP (IMF, 2012).

Italy's capital and largest city, Rome, has for centuries been the leading political and religious center of Western civilization, serving as the capital of both the Roman Empire and Christianity. During the Dark Ages, Italy endured cultural and social decline in the face of repeated invasions by Germanic tribes, Muslims and Normans, with Greek-Roman heritage being preserved largely by Christian monks. Beginning around the 11th century, various Italian cities, communes and maritime republics rose to great prosperity through shipping, commerce and banking (indeed, modern capitalism has its roots in Medieval Italy); concurrently, Italian culture flourished, especially during the Renaissance, which produced many notable scholars, artists, and polymaths such as Leonardo da Vinci, Galileo, Michelangelo and Machiavelli. Meanwhile, Italian explorers such as Polo, Columbus, Vespucci, and Verrazzano discovered new routes to the Far East and the New World, helping to usher in the European Age of Discovery. Nevertheless, Italy would remain fragmented into many warring states for the rest of the Middle Ages, subsequently falling prey to larger European powers such as the Holy Roman Empire, France, Spain, and

413 later Austria. Italy would thus enter a long period of decline that lasted until the beginning of the 18th century.

After many unsuccessful attempts, the second and the third wars of Italian independence resulted in the unification of most of present-day Italy between 1859 and 1866. From the late 19th century to the early 20th century, the new Kingdom of Italy rapidly industrialised and acquired a colonial empire becoming a Great Power. However, Southern and rural Italy remained largely excluded from industrialisation, fuelling a large and influential diaspora. Despite victory in World War I as one of the Big Four with permanent membership in the security council of the League of Nations, Italy entered a period of economic crisis and social turmoil, which favoured the establishment of a Fascist dictatorship in 1922. The subsequent participation in World War II, at the side of Nazi Germany and Japan forming the Axis Alliance, ended in military defeat, economic destruction and civil war. In the years that followed, Italy abolished the monarchy, reinstated democracy, and enjoyed a prolonged economic boom, thus becoming one of the most developed nations in the world, with the fifth largest economy by nominal GDP by the early 1990s. Italy was a founding member of NATO in 1949 and one of the Inner Six of the European Community in 1957, which became the EU in 1993. It is part of the Schengen Area, and has been a member of the Eurozone since 1999.

The People Cultural achievement is Italy's greatest source of pride. Inventiveness, imagination, intelligence and education are prized. Personal relations are scrupulously maintained with loyalty highly valued, especially in families. The family is the most important affiliation in Italy.

Meeting and Greeting When being introduced during a business or social meeting, shake hands with everyone present -- men, women and children. Shake hands again when leaving.

Ladies should extend their hand first to men.

Friends may greet each other with a kiss on both cheeks.

414 Names and Titles Use last names and appropriate titles until specifically invited by your Italian host or colleagues to use their first names.

Females almost always use their maiden name, especially in business and on legal documents. They generally use their married names or a combination of their married names and maiden names outside of business.

Body Language Maintain eye contact while talking. Otherwise Italians might think you are hiding something.

Italians are known for using the most body language of all European nations .

Helpful Hints Italians are open, curious and tolerant of others’ uniqueness and manners. They will tolerate lateness, inefficiency and sincere mistakes, but dislike arrogance and rudeness.

Italians enjoy a lot of good humor and can be self-deprecating.

Stand when an older person enters the room.

Cover your mouth if you must yawn, but try not to yawn.

Men should always remove their hats when entering a building.

Don’t remove your shoes in public.

Refrain from asking personal questions.

Especially for Women Only 38% of Italian women under 65 are in the labor market -- one of the lowest percentages in Western Europe.

The Italians are generally not inhibited when interacting with the opposite sex. Flirtation is part of the spirit of life in Italy .

415 Cultural Snapshot: Your massage client from Japan

Where they are from Japan is an island nation in East Asia. Located in the Pacific Ocean, it lies to the east of the Sea of Japan, China, North Korea, South Korea and Russia, stretching from the Sea of Okhotsk in the north to the East China Sea and Taiwan in the south. The characters that make up Japan's name mean "sun-origin", which is why Japan is often referred to as the "Land of the Rising Sun".

Japan is a stratovolcanic archipelago of 6,852 islands. The four largest islands are Honshu, Hokkaido, Kyushu, and Shikoku, which together comprise about ninety-seven percent of Japan's land area. Due to its location in the Pacific Ring of Fire, Japan is substantially prone to earthquakes and tsunami, having the highest natural disaster risk in the developed world. Japan has the world's tenth-largest population, with over 126 million people. Honsh ū's Greater Tokyo Area, which includes the de facto capital of Tokyo and several surrounding prefectures, is the largest metropolitan area in the world, with over 30 million residents.

Archaeological research indicates that people lived in Japan as early as the Upper Paleolithic period. The first written mention of Japan is in Chinese history texts from the 1st century AD. Influence from other nations followed by long periods of isolation has characterized Japan's history. From the 12th century until 1868, Japan was ruled by successive feudal military shoguns in the name of the Emperor. Japan entered into a long period of isolation in the early 17th century, which was only ended in 1853 when a United States fleet pressured Japan to open to the West. Nearly two decades of internal conflict and insurrection followed before the Meiji Emperor was restored as head of state in 1868 and the Empire of Japan was proclaimed, with the Emperor as a divine symbol of the nation. In the late 19th and early 20th centuries, victories in the First Sino-Japanese War, the Russo-Japanese War and World War I allowed Japan to expand its empire during a period of increasing militarism. The Second Sino-Japanese War of 1937 expanded into part of World War II in 1941, which came to an end in 1945 following the atomic bombings of Hiroshima and Nagasaki. Since adopting its revised constitution in 1947, Japan has maintained a unitary constitutional monarchy with an emperor and an elected legislature called the Diet.

416 Japan is a member of the UN, the G7, the G8, the G20. A major economic great power, Japan is a developed country and has the world's third-largest economy by nominal GDP and the world's fourth-largest economy by purchasing power parity. It is also the world's fourth-largest exporter and fourth-largest importer. Although Japan has officially renounced its right to declare war, it maintains a modern military with the world's eighth largest military budget, used for self-defense and peacekeeping roles. Japan ranks high in metrics of prosperity such as the Human Development Index, with Japanese women enjoying the highest life expectancy of any country in the world and the infant mortality rate being the third lowest globally.

The People Japan is a highly structured and traditional society . Great importance is placed on loyalty, politeness , personal responsibility and on everyone working together for the good of the larger group. Education, ambition, hard work, patience and determination are held in the highest regard. The crime rate is one of the lowest in the world.

Meeting and Greeting A handshake is appropriate upon meeting. The Japanese handshake is limp and with little or no eye contact .

Some Japanese bow and shake hands. The bow is a highly regarded greeting to show respect and is appreciated by the Japanese.

A slight bow to show courtesy is acceptable .

Body Language Nodding is very important. When listening to Japanese speak, especially in English, you should nod to show you are listening and understanding the speaker .

Silence is a natural and expected form of non-verbal communication. Do not feel a need to chatter .

Do not stand close to a Japanese person . Prolonged eye contact (staring) is considered rude.

Don’t show affection, such as hugging or shoulder slapping, in public.

417 Never beckon with your forefinger. The Japanese extend their right arm out in front, bending the wrist down, waving fingers. Do not beckon older people.

Sit erect with both feet on the floor. Never sit with ankle over knee.

Waving a hand back and forth with palm forward in front of face means "no" or "I don't know." This is a polite response to a compliment.

Never point at someone with four fingers spread out and thumb folded in.

Helpful Hints Avoid using the number "four" if possible. It has connotations of death to the Japanese.

The Japanese may ask personal questions. This is not intended to be rude, but rather a polite way to show interest. You may give vague or general answers if you feel a question is too personal.

The Japanese do not express opinions and desires openly. What they say and what they mean may be very different.

Do not expect a Japanese person to say "no." "Maybe" generally means "no."

In Japan Shiatsu massage is the most common modality, and it is performed over the clothes. Your Japanese client may not know what to expect if you are going to be performing a Swedish (classical western) massage. Take the time to explain the draping thoroughly .

418 Cultural Snapshot: Your massage client from Luxembourg

Where they are from Luxembourg, officially the Grand Duchy of Luxembourg is a landlocked country in Western Europe. It is bordered by Belgium to the west and north, Germany to the east, and France to the south. It comprises two principal regions: the Oesling in the north as part of the Ardennes massif, and the Gutland ("good country") in the south. Luxembourg had a population of 524,853 in October 2012 and has an area of 2,586 square kilometres (998 sq mi), making it one of the smallest sovereign nations in Europe.

As a representative democracy with a constitutional monarch, it is headed by a grand duke and is the world's only remaining grand duchy. Luxembourg is a developed country, with an advanced economy and the world's second highest GDP (PPP) per capita (after Qatar), according to the World Bank. Its central location has historically made it of great strategic importance to numerous powers, dating back to its founding as a Roman fortress, its hosting of a vital Frankish castle during the Early Middle Ages, and its role as a bastion for the Spanish Road between 16th and 17th centuries.

Luxembourg is a member of the European Union, NATO, OECD, the United Nations, and Benelux, reflecting its political consensus in favour of economic, political, and military integration. The city of Luxembourg, which is the capital and largest city, is the seat of several institutions and agencies of the EU. On 18 October 2012, Luxembourg was elected to a temporary seat on the United Nations Security Council for the first time in its history. The country will serve on the Security Council from 1 January 2013 until 31 December 2014. Reflecting its geographic position, Luxembourg's culture is a fusion of Romanic and Germanic Europe, integrating customs of each. Accordingly, Luxembourg is a trilingual country:

Luxembourgish, French and German are official languages . Although a secular state, Luxembourg is predominantly Roman Catholic.

419 The People Luxembourgers cherish their independence and separate identity in Europe. Modesty, friendship and strong national pride are valued. They enjoy a slower pace of life than most of northern Europe. Family is very important. Parents influence every aspect of their children's lives; however, this is weakening as more young people leave the country to study/work abroad.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

Good friends kiss cheeks, one on each side.

Body Language Luxembourgers are friendly but reserved.

Do not put your hands in your pockets.

Helpful Hints Recognize Luxembourg's uniqueness and its nationality. Do not lump the Luxembourgers together with the French or Belgians, and especially not with the Germans.

420 Cultural Snapshot: Your massage client from Malaysia

Where they are from Malaysia is a federal constitutional monarchy located in Southeast Asia. It consists of thirteen states and three federal territories and has a total landmass of 329,847 square kilometres (127,350 sq mi) separated by the South China Sea into two similarly sized regions, Peninsular Malaysia and East Malaysia (Malaysian Borneo). Peninsular Malaysia shares a land and maritime border with Thailand and maritime borders with Singapore, Vietnam, and Indonesia. East Malaysia shares land and maritime borders with Brunei and Indonesia and a maritime border with the Philippines. The capital city is Kuala Lumpur, while Putrajaya is the seat of the federal government. In 2010 the population was 28.33 million, with 22.6 million living in Peninsular Malaysia. The southernmost point of continental Eurasia, Tanjung Piai, is in Malaysia, located in the tropics. It is one of 17 megadiverse countries on earth, with large numbers of endemic species.

Malaysia has its origins in the Malay Kingdoms present in the area which, from the 18th century, became subject to the British Empire. The first British territories were known as the Straits Settlements, whose establishment was followed by the Malay kingdoms becoming British protectorates. The territories on Peninsular Malaysia were first unified as the Malayan Union in 1946. Malaya was restructured as the Federation of Malaya in 1948, and achieved independence on 31 August 1957. Malaya united with North Borneo, Sarawak, and Singapore on 16 September 1963, with si being added to give the new country the name Malaysia. Less than two years later in 1965, Singapore was expelled from the federation.

The country is multi-ethnic and multi-cultural, which plays a large role in politics. The constitution declares Islam the state religion while protecting freedom of religion. The government system is closely modelled on the Westminster parliamentary system and the legal system is based on common law. The head of state is the king, known as the Yang di-Pertuan Agong. He is an elected monarch chosen from the hereditary rulers of the nine Malay states every five years. The head of government is the Prime Minister.

Since independence, Malaysia has had one of the best economic records in Asia, with GDP growing at an average 6.5% per annum for almost 50 years. The economy has traditionally been fueled by its natural resources,

421 but is expanding in the sectors of science, tourism, commerce and medical tourism. Today, Malaysia has a newly industrialised market economy, ranked third largest in Southeast Asia and 29th largest in the world. It is a founding member of the Association of Southeast Asian Nations, the East Asia Summit and the Organisation of Islamic Cooperation, and a member of Asia-Pacific Economic Cooperation, the Commonwealth of Nations, and the Non-Aligned Movement.

The People Malays are proud of their country, their ancestral background and their economic success. Ethnic tensions exist between Malays (60%) and Chinese (31%) over preferential quotas . Chinese feel these policies make them second-class citizens; Malays support these policies, which they feel are their only way to overcome traditional dominance. The Chinese dominate the business community and live in urban areas, while ethnic Malays generally inhabit rural areas.

Meeting and Greeting Shake hands with men at business meetings and social events. Shake hands again when leaving.

Nod or give a slight bow when greeting a woman or an older person.

Introduce higher ranking people or older people first. Introduce women before men .

Western women should greet Malay men with a nod of their head and a smile.

Body Language Never touch anyone on the top of the head (home of the soul), especially a child .

Avoid touching anyone of the opposite sex unless in a professional context (in the massage room).

Use your right hand to eat, pass things and touch people. Do not pass objects with your left hand. Do not move objects with your feet or point at another person with your foot.

422 Giving a slight bow when leaving, entering or passing by people means, "excuse me."

A smile or laugh could mean surprise, anger, shock, embarrassment or happiness.

It is impolite to beckon adults.

Single fingers are not used for gesturing.

Hitting your fist into a cupped hand is obscene.

Hands in pockets signify anger.

Helpful Hints Malays judge people by who they are rather than what they do.

Family background, social position and status are all important.

Compliment sincerely, but expect Malays to deny out of modesty.

Show respect for the elderly and never smoke around them.

Understand that Malays believe that successes, failures, opportunities and misfortunes result from fate or the will of God.

Don't be surprised if Malays ask personal questions about your income, religion, etc . You may ask the same questions. There is no obligation to answer these questions.

Keep in mind that Islam is the state religion of their country and it is unlikely that they will be comfortable getting a massage from a person of the opposite gender-of course this is a generalization and is not true for every individual.

423 Cultural Snapshot: Your massage client from Mexico

Where they are from Mexico, officially the United Mexican States (Spanish: Estados Unidos Mexicanos )is a federal republic in North America. It is bordered on the north by the United States; on the south and west by the Pacific Ocean; on the southeast by Guatemala, Belize, and the Caribbean Sea; and on the east by the Gulf of Mexico. Covering almost two million square kilometres (over 760,000 sq mi), Mexico is the fifth largest country in the Americas by total area and the 13th largest independent nation in the world. With an estimated population of over 113 million, it is the eleventh most populous and the most populous Spanish-speaking country in the world and the second most populous country in Latin America. Mexico is a federation comprising thirty-one states and a Federal District, the capital city.

In pre-Columbian Mexico many cultures matured into advanced civilizations such as the Olmec, the Toltec, the Teotihuacan, the Zapotec, the Maya and the Aztec before first contact with Europeans. In 1521, the Spanish Empire conquered and colonized the territory from its base in Mexico-Tenochtitlan, which was administered as the Viceroyalty of New Spain. This territory would eventually become Mexico following recognition of the colony's independence in 1821. The post-independence period was characterized by economic instability, the Mexican-American War that led to the territorial cession to the United States, the Pastry War, the Franco-Mexican War, a civil war, two empires and a domestic dictatorship. The latter led to the Mexican Revolution in 1910, which culminated with the promulgation of the 1917 Constitution and the emergence of the country's current political system. In March 1938, through the Mexican oil expropriation private U.S. and Anglo-Dutch oil companies were nationalized to create the state- owned Pemex oil company.

Mexico has one of the world's largest economies, it is the tenth largest oil producer in the world, the largest silver producer in the world and is considered both a regional power and middle power. In addition, Mexico was the first Latin American member of the Organisation for Economic Co- operation and Development OECD (since 1994), and considered an upper- middle income country by the World Bank. Mexico is considered a newly industrialized country and an emerging power. It has the fifteenth largest nominal GDP and the tenth largest GDP by purchasing power parity. The economy is strongly linked to those of its North American Free Trade

424 Agreement (NAFTA) partners, especially the United States. Mexico ranks sixth in the world and first in the Americas by number of UNESCO World Heritage Sites with 32, and in 2010 was the tenth most visited country in the world with 22.5 million international arrivals per year. According to Goldman Sachs, by 2050 Mexico is expected to become the world's fifth largest economy. PricewaterhouseCoopers (PwC) estimated in January 2013 that by 2050 Mexico could be the world's seventh largest economy. Mexico has membership in prominent institutions such as the UN, the WTO, the G20 and the Uniting for Consensus.

The People Mexico is a very class-conscious society where social stratifications are well-defined. Upper class Mexicans will not dirty their hands with tasks they find beneath them. A sense of fatalism is quite strong among many Mexicans, who feel that their path through life is largely preordained. Macho attitudes are inculcated in Mexican males almost from birth, and machismo plays a pervasive role in shaping Mexican culture.

Meeting and Greeting Shake hands or give a slight bow when introduced.

Bow when greeting a Mexican woman. Shake hands only if she extends her hand first.

Body Language Mexicans generally stand close together when conversing. Don't show signs of discomfort, which would be considered rude by your Mexican counterpart.

Mexicans often "hold" a gesture (a handshake, a squeeze of the arm, a hug) longer than Americans and Canadians do.

Don't stand with your hands on your hips; this signifies anger. It is considered rude to stand around with your hands in your pockets.

Helpful Hints Any attempt to speak Spanish is appreciated by your Mexican counterparts and is seen as a gesture of goodwill. Demonstrating knowledge and appreciation of Mexican culture wins friends.

425 Mexicans are very proud of their independence and have a very strong sense of national identity and pride. Never compare the way things are done in Mexico with the way they are done in the United States.

Deadlines are often little more than (very) general target dates.

Note differences in class and status in Mexico, for such differences are important.

Little things count. Not saying good-bye, for example, may well offend and adversely affect your relationship to a much greater extent than it would in the United States.

426 Cultural Snapshot: Your massage client from the Netherlands

Where they are from The Netherlands is the main constituent country of the Kingdom of the Netherlands. It is a small, densely populated country, lying mainly in Western Europe, but also including three islands in the Caribbean . The European part of the Netherlands borders Germany to the east, Belgium to the south, and the North Sea to the northwest, sharing maritime borders with Belgium, the United Kingdom and Germany. The three largest and most important cities in the Netherlands are Amsterdam, The Hague and Rotterdam. Amsterdam is the country's capital. The Hague holds the Dutch seat of government. The port of Rotterdam is the largest port of Europe – as large as the next three largest combined.

The Netherlands' name literally means "Low Country", inspired by its low and flat geography, with only about 50% of its land exceeding one metre above sea level. Most of the areas below sea level are man-made. Since the late 16th century, large areas (polders) have been reclaimed from the sea and from lakes, amounting to nearly 17% of the country's current land mass.

With a population density of 406 people per km² – 497 if water is excluded – the Netherlands is a very densely populated country for its size. Only Bangladesh, South Korea and Taiwan have both a larger population and a higher population density. Nevertheless, the Netherlands is the world's second largest exporter of food and agriculture products, after the United States.

The Netherlands was one of the first countries in the world to have an elected parliament , and since 1848 it has been governed as a parliamentary democracy and a constitutional monarchy, organised as a unitary state. The Netherlands has a long history of social tolerance and is generally regarded as a liberal country, having legalised abortion, prostitution and euthanasia, while maintaining a progressive drugs policy.

The Netherlands is a founding member of the EU, G-10, NATO, OECD, WTO and a part of the trilateral Benelux economic union. The country is host to the Organisation for the Prohibition of Chemical Weapons and five international courts: the Permanent Court of Arbitration, the International Court of Justice, the International Criminal Tribunal for the Former

427 Yugoslavia, the International Criminal Court and the Special Tribunal for Lebanon. The first four are situated in The Hague, as is the EU's criminal intelligence agency Europol and judicial co-operation agency Eurojust. This has led to the city being dubbed "the world's legal capital".

The People The Dutch society is egalitarian and modern. The people are modest, tolerant, independent, self-reliant, and entrepreneurial. They value education, hard work, ambition and ability. The Dutch have an aversion to the nonessential. Ostentatious behavior is to be avoided. Accumulating money is fine, but spending money is considered something of a vice. A high style is considered wasteful and suspect. The Dutch are very proud of their cultural heritage, rich history in art and music and involvement in international affairs.

Meeting and Greeting Shake hands with everyone present -- men, women, and children -- at business and social meetings. Shake hands again when leaving. Introduce yourself if no one is present to introduce you. The Dutch consider it rude not to identify yourself.

The Dutch will shake hands and say their last name, not "Hello." They also answer the telephone with their last name.

It is considered impolite to shout a greeting. Wave if greeting someone from a distance.

Body Language The Dutch are reserved and don't touch in public or display anger or extreme exuberance.

The Dutch value privacy and seldom speak to strangers. It is more likely that they will wait for you to make the first move. Don't be afraid to do so.

The Dutch expect eye contact while speaking with someone . Moving your index finger around your ear means you have a telephone call, not "you're crazy." The crazy sign is to tap the center of your forehead with your index finger. This gesture is very rude .

428 Helpful Hints The Dutch avoid superlatives. Compliments are offered sparingly, and to say that something is "not bad" is to praise it. A person who never offers criticism is seen as either being simple-minded or failing to tell the truth.

You need not worry too much about saying something the will hurt feelings. The Dutch will argue, but seldom take offense.

Dutch humor is subtle rather than slapstick.

The Dutch speak directly and use a lot of eye contact. To people in the USA this may appear abrupt, but it is just their manner of communicating.

Do not call the Netherlands "Holland." Holland is a region within the Netherlands .

Keep your hands out of your pockets while talking to someone or shaking hands.

429 Cultural Snapshot: Your massage client from the Norway

Where they are from Norway, officially the Kingdom of Norway, is a Scandinavian unitary constitutional monarchy whose territory comprises the western portion of the Scandinavian Peninsula, Jan Mayen, the Arctic archipelago of Svalbard, and the sub-Antarctic Bouvet Island. Peter I Island is a dependent territory and thus not considered part of the Kingdom. Norway also lays claim to a section of Antarctica known as Queen Maud Land. Norway has a total area of 385,252 square kilometres (148,747 sq mi) and a population of 5,109,059 people (2014). The country shares a long eastern border with Sweden (1,619 km or 1,006 mi long). Norway is bordered by Finland and Russia to the north-east, and the Skagerrak Strait to the south, with Denmark on the other side. Norway has an extensive coastline, facing the North Atlantic Ocean and the Barents Sea.

King Harald V of the House of Schleswig-Holstein-Sonderburg-Glücksburg is the current monarch of Norway. Erna Solberg became Prime Minister in 2013, replacing Jens Stoltenberg. A constitutional monarchy since 1814, state power is divided between the Parliament, the King and his Council, and the Supreme Court. Between 1661 and 1814, Norway was an absolute monarchy, and before 1661, the King shared power with the Norwegian nobility. Traditionally established in 872 and originating in one of the petty kingdoms, Norway is one of the oldest still existing kingdoms in Europe and world-wide. The Kingdom has existed continuously for over 1,100 years, and the list of Norwegian monarchs includes over sixty kings and earls.

Norway has both administrative and political subdivisions on two levels, known as counties (fylke) and municipalities (kommune). The Sámi people have a certain amount of self-determination and influence over traditional territories through the Sámi Parliament and the Finnmark Act. Norway maintains close ties with the European Union and its member countries (despite rejecting full EU membership in two referenda), as well as with the United States. Norway is a founding member of the United Nations, NATO, the Council of Europe, and the Nordic Council; a member of the European Economic Area, the WTO and the OECD; and is also a part of the Schengen Area.

The country maintains a combination of market economy and a Nordic welfare model with universal health care and a comprehensive social

430 security system. Norway has extensive reserves of petroleum, natural gas, minerals, lumber, seafood, fresh water, and hydropower. The petroleum industry accounts for around a quarter of the country's gross domestic product. The country has the fourth-highest per capita income in the world on the World Bank and IMF lists, as well as ninth-highest on a more comprehensive CIA list. On a per-capita basis, it is the world's largest producer of oil and natural gas outside the Middle East, From 2001 to 2006, and then again from 2009 to 2014, Norway had the highest Human Development Index ranking in the world. Norway has also topped the Legatum Prosperity Index for the last five years.[19] The OECD ranks Norway fourth in the 2013 equalised Better Life Index and third in intergenerational earnings elasticity. From 2010 to 2012, Norway was classified as the most democratic country by the Democracy Index.

Two centuries of Viking raids to southern and western areas of Europe tapered off following the adoption of Christianity especially since AD 994. Norway expanded its control overseas to parts of Britain, Ireland, the Faroe Islands, Iceland, and Greenland, and Norwegian power peaked in 1265. Competition from the Hanseatic League and the spread of the Black Death weakened the country, and when the native royal house became extinct in the 1300s, Norway was gradually absorbed into a union with Denmark that lasted more than four centuries. In 1814, Norwegians adopted a constitution before being forced into a personal union with Sweden. In 1905, Norway ended the union, subsequently confirmed in a referendum, and thus over 500 years with monarchs residing outside the country. In the same year, the country confirmed the election of its own king. Despite its declaration of neutrality in World War II, Norway was occupied for 5 years by forces of Nazi Germany. In 1949 it abandoned neutrality, becoming a founding member of NATO. Discovery of oil in adjacent waters in the late 1960s boosted Norway's economic fortunes.

The People Simplicity and nature are the core of the Norwegian lifestyle. Tolerance, kindness to each other and independence are highly valued. Criticism of other people or others' systems is frowned upon. "Peace and progress" are mottos in the country that sponsors the Nobel Prizes. Norwegians treasure their landscape, outdoor activity, sailing, cross-country skiing, etc.

431 Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

When introduced for the first time, address the other by both first and last name, i.e. Mr. John Lund.

Norwegians do not use the phrases "Pleased to meet you" or "How are you?" They find these to be surface formalities with no real meaning .

Body Language There is little personal touching except between relatives and close friends.

Do not stand close to a Norwegian, back slap or put your arm around anyone.

Helpful Hints Sincerity is very important. Norwegians often consider Americans too glib and too casual.

Never lump Norwegians together with Swedes or Danes.

432

Cultural Snapshot: Your massage client from the Paraguay

Where they are from Paraguay, officially the Republic of Paraguay (Spanish: República del Paraguay), is a landlocked country in central South America, bordered by Argentina to the south and southwest, Brazil to the east and northeast, and Bolivia to the northwest. Paraguay lies on both banks of the Paraguay River, which runs through the center of the country from north to south. Due to its central location in South America, it is sometimes referred to as Corazón de América ("Heart of America").

The indigenous Guaraní had been living in Paraguay for at least a millennium before the Spanish conquered the territory in the 16th century. Spanish settlers and Jesuit missions introduced Christianity and Spanish culture to the region. Paraguay was on the periphery of Spain's colonial empire, with few urban centers and a sparse population. Following independence from Spain in 1811, Paraguay was ruled by a series of dictators who implemented isolationist and protectionist policies.

This development was truncated by the disastrous Paraguayan War (1864– 1870), in which the country lost 60 to 70 percent of its population through war and disease, and about 140,000 square kilometers (54,054 sq mi) of territory to Argentina and Brazil. Through the 20th century, Paraguay continued to endure a succession of authoritarian governments, culminating in the regime of Alfredo Stroessner, who led South America's longest-lived military dictatorship from 1954 to 1989. He was toppled in an internal military coup, and free multi-party elections were organized and held for the first time in 1993. A year later, Paraguay joined Argentina, Brazil and Uruguay to found Mercosur, a regional economic collaborative.

As of 2009, Paraguay's population was estimated to be at around 6.5 million, most of whom are concentrated in the southeast region of the country. The capital and largest city is Asunción, of which the metropolitan area is home to nearly a third of Paraguay's population. In contrast to most Latin American nations, Paraguay's indigenous language and culture, Guaraní, remains highly influential. In each census, residents predominantly identify as mestizo, reflecting years of intermarriage among the different ethnic groups. Guaraní is recognized as an official language alongside Spanish, and both languages are widely spoken in the country,

433 with around 92 percent of the general population speaking Spanish and 98 percent speaking Guaraní.

Paraguay has long been one of the region's most isolated countries, although since the turn of the 21st century, it has experienced rapid economic growth.

The People Paraguayans are traditional, conservative people who strive for tranquility (tranquilidad). Paraguay has historically been voluntarily isolated. In the 19th century, the government tried to seal the borders in an attempt to become self-sufficient. More recently, very strict government controls have isolated the people from most outside information. Inflation, foreign debt and high unemployment plague this young democracy. There is a large gap between the rich and poor. A few elite families control nearly all the resources, and economic opportunities are limited to urban dwellers.

Meeting and Greeting Men and women always shake hands when greeting, even if they have met earlier in the day.

Paraguayans kiss twice when meeting friends and family members.

Body Language Good posture is important. Try to keep your feet on the floor, and never prop them up on a piece of furniture.

A chin flick (rubbing your hand under your chin) means “I don't know.”

Helpful Hints Paraguayans are polite and soft-spoken. They do not appreciate shouting or rude behavior. Exhibit patience in all of your actions.

Paraguayans are very proud of their country and will appreciate your interest in it.

Don't give your opinion about politics.

Refer to yourself as a North American or as a citizen of the United States instead of as an American.

434

Especially for Women Machismo is strong, but women are respected. Men will go out of their way to avoid confronting or offending a woman.

435 Cultural Snapshot: Your massage client from The Philippines

Where they are from The Philippines, officially known as the Republic of the Philippines (Filipino: Repúblika ng Pilipinas), is a sovereign island country in Southeast Asia situated in the western Pacific Ocean. It consists of 7,107 islands that are categorized broadly under three main geographical divisions: Luzon, Visayas, and Mindanao. Its capital city is Manila while its most populous city is Quezon City; both are part of Metro Manila.

To the north of the Philippines across the Luzon Strait lies Taiwan; Vietnam sits west across the South China Sea; southwest is the island of Borneo across the Sulu Sea, and to the south the Celebes Sea separates it from other islands of Indonesia; while to the east it is bounded by the Philippine Sea and the island-nation of Palau. Its location on the Pacific Ring of Fire and close to the equator makes the Philippines prone to earthquakes and typhoons, but also endows it with abundant natural resources and some of the world's greatest biodiversity. At approximately 300,000 square kilometers (115,831 sq mi), the Philippines is the 64th-largest country in the world.

With a population of about 100 million people, the Philippines is the seventh-most populated country in Asia and the 12th most populated country in the world. An additional 12 million Filipinos live overseas, comprising one of the world's largest diasporas. Multiple ethnicities and cultures are found throughout the islands. In prehistoric times, Negritos were some of the archipelago's earliest inhabitants. They were followed by successive waves of Austronesian peoples. Various nations were established under the rule of Datus, Rajahs, Sultans or Lakans. Trade with Chinese, Malay, Indian, and Islamic states also occurred.

The arrival of Ferdinand Magellan in 1521 marked the beginning of Spanish colonization. In 1543, Spanish explorer Ruy López de Villalobos named the archipelago Las Islas Filipinas in honor of Philip II of Spain. With the arrival of Miguel López de Legazpi from Mexico City, in 1565; the first Spanish settlement in the archipelago was established. The Philippines became part of the Spanish Empire for more than 300 years. This resulted in the predominant religion in the country being Roman Catholicism. During this time, Manila became the Asian hub of the Manila–Acapulco galleon trade.

436 As the 19th century gave way to the 20th, there followed in quick succession the Philippine Revolution, which spawned the short-lived First Philippine Republic, and the Philippine–American War. Aside from the period of Japanese occupation, the United States retained sovereignty over the islands. After World War II, the Philippines was recognized as an independent nation. Since then, the Philippines has had an often tumultuous experience with democracy, which includes a People Power Revolution overthrowing a dictatorship. The nation's large population size and economic potential have led it to be classified as a middle power. It is a founding member of the United Nations, World Trade Organization, Association of Southeast Asian Nations, and East Asia Summit.

The People Filipinos are casual, fun loving, sensitive and hospitable people. Personal and family honor are stressed, as well as dignity and pride. Education is highly valued and families make great sacrifices to educate their children. Hiya (shame) is instilled in Filipinos at an early age. To be shamed is the greatest form of disgrace.

Meeting and Greeting Men and women shake hands with everyone present at a business meeting or social occasion and when saying "goodbye." Handshakes should be friendly and informal, but limp. Men should wait for women to extend their hand.

Body Language If Filipinos don't understand a question, they open their mouths.

Raised eyebrows signify recognition and agreement.

Laughter may convey pleasure or embarrassment; it is commonly used to relieve tension.

"Yes" is signified by a jerk of the head upward. "No" is signified by a jerk of the head down. Since the Filipinos rarely say no, the non-verbal sign for "no" is sometimes accompanied by a verbal yes, which would still indicate "no."

To Filipinos, standing with your hands on your hips means you are angry.

437 Never curl your index finger back and forth (to beckon). This is an insult.

To indicate two of something, raise your ring and pinkie fingers.

To beckon, extend arm, palm down, moving fingers in scratching motion. Touch someone's elbow lightly to attract attention. Do not tap on the shoulder.

"Eyebrow flash" -- a quick lifting of eyebrows -- is a Filipino greeting.

Helpful Hints Speak softly and control your emotions.

Don't be offended by personal questions. These are asked to show interest. Feel free to ask the same questions in return, especially about family .

Never directly criticize anyone, especially in public. Never offer insincere comments or compliments.

438 Cultural Snapshot: Your massage client from Portugal

Where they are from Portugal, officially the Portuguese, is a unitary semi-presidential republic. It is located in South-Western Europe, on the Iberian Peninsula, and it is the westernmost country of mainland Europe, being bordered by the Atlantic Ocean to the west and south and by Spain to the north and east. Aside from continental Portugal, the Portuguese Republic holds sovereignty over the Atlantic archipelagos of Azores and Madeira, which are autonomous regions of Portugal. The country is named after its second largest city, Porto, whose name derives from Latin "Portus" and Celtic "Cale".

The land within the borders of the current Portuguese Republic has been continually fought over and settled since prehistoric times. The Celts and the Romans were followed by the Visigothic and the Suebi Germanic tribes, which were themselves later invaded by the Moors. These Muslim peoples were eventually expelled during the Christian Reconquista of the peninsula. By 1139, Portugal established itself as an independent kingdom from León. In the 15th and 16th centuries, as the result of pioneering the Age of Discovery, Portugal expanded western influence and established the first global empire, becoming one of the world's major economic, political and military powers, and ultimately dividing the world with Spain.

The Portuguese Empire was the longest-lived of the modern European colonial empires, spanning almost 600 years, from the capture of Ceuta in 1415 to the handover of Macau to China in 1999 (de facto) or the granting of sovereignty to East Timor in 2002 (de jure). The empire spread throughout a vast number of territories that are now part of 53 different Sovereign States, leaving a legacy of over 250 million Portuguese speakers today (making it the sixth most spoken first language) and a number of Portuguese-based creoles. Portugal's international status was greatly reduced during the 19th century, especially following the Independence of Brazil. After 1910 revolution deposed the monarchy, the democratic but unstable Portuguese First Republic was established, itself being superseded by the "Estado Novo" right-wing authoritarian regime. Democracy was restored after the Portuguese Colonial War and the Carnation Revolution in 1974. Shortly after, independence was granted to Angola, Mozambique, São Tomé and Príncipe, East Timor, Cape Verde and Guinea-Bissau.

439 Portugal is a developed country with an advanced economy, high living standards and high-quality infrastructures, ranking 2nd in the quality of the road network and 11th overall, according to the Global Competitiveness Report. It is one of the world's most globalized and peaceful nations. It is a member of the United Nations, European Union, Eurozone, OECD, NATO, WTO, Schengen Area, and the Community of Portuguese Language Countries.

The People Portugal is a self-styled country comprised of generally reserved and understated people. The Portuguese are traditional and conservative . People do not quickly embrace change and innovation. The Catholic Church has a strong influence on people's lives. The family is the basis of Portuguese life. Life is simple, especially in rural areas. The Portuguese go home after work and entertain on weekends only.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

When meeting friends, men embrace and pat one another on the back, and women kiss both cheeks.

Body Language Portuguese do not use a lot of body gestures. Do not be overly demonstrative with hand gestures or body language.

Beckon someone with the palm of your hand down and fingers or whole hand waving (as patting someone on the head).

Never point with your finger.

Helpful Hints Portugal is not part of Spain, and the people are not Spanish, nor are they in any way similar to the Spanish in culture . They do not speak Spanish or “Brazilian”.

Cultural Snapshot: Your massage client from Russia

440 Where they are from Russia, officially known as the Russian Federation, is a country in northern Eurasia. It is a federal semi-presidential republic. From northwest to southeast, Russia shares land borders with Norway, Finland, Estonia, Latvia, Lithuania and Poland (both with Kaliningrad Oblast), Belarus, Ukraine, Georgia, Azerbaijan, Kazakhstan, China, Mongolia, and North Korea. It shares maritime borders with Japan by the Sea of Okhotsk, the US state of Alaska across the Bering Strait and Canada's Arctic islands. At 17,075,400 square kilometres (6,592,800 sq mi), Russia is the largest country in the world, covering more than one-eighth of the Earth's inhabited land area. Russia is also the world's ninth most populous nation with 143 million people as of 2012. Extending across the entirety of northern Asia and much of Eastern Europe, Russia spans nine time zones and incorporates a wide range of environments and landforms.

The nation's history began with that of the East Slavs, who emerged as a recognizable group in Europe between the 3rd and 8th centuries AD. Founded and ruled by a Varangian warrior elite and their descendants, the medieval state of Rus arose in the 9th century. In 988 it adopted Orthodox Christianity from the Byzantine Empire, beginning the synthesis of Byzantine and Slavic cultures that defined Russian culture for the next millennium. Rus' ultimately disintegrated into a number of smaller states; most of the Rus' lands were overrun by the Mongol invasion and became tributaries of the nomadic Golden Horde. The Grand Duchy of Moscow gradually reunified the surrounding Russian principalities, achieved independence from the Golden Horde, and came to dominate the cultural and political legacy of Kievan Rus'. By the 18th century, the nation had greatly expanded through conquest, annexation, and exploration to become the Russian Empire, which was the third largest empire in history, stretching from Poland in Europe to Alaska in North America.

Following the Russian Revolution, the Russian Soviet Federative Socialist Republic became the largest and leading constituent of the Soviet Union, the world's first constitutionally socialist state and a recognized superpower, which played a decisive role in the Allied victory in World War II. The Soviet era saw some of the most significant technological achievements of the 20th century, including the world's first human-made satellite, and the first man in space. Following the dissolution of the Soviet Union in 1991, the Russian SFSR reconstituted itself as the Russian

441 Federation and is recognized as the continuing legal personality of the Union state.

The Russian economy ranks as the ninth largest by nominal GDP and sixth largest by purchasing power parity in 2014. Russia's extensive mineral and energy resources, the largest reserves in the world, have made it one of the largest producers of oil and natural gas globally. The country is one of the five recognized nuclear weapons states and possesses the largest stockpile of weapons of mass destruction. Russia is a great power and a permanent member of the United Nations Security Council, a member of the G20, the Council of Europe, the Asia-Pacific Economic Cooperation, the Shanghai Cooperation Organization, the Eurasian Economic Community, the Organization for Security and Cooperation in Europe (OSCE), and the World Trade Organization (WTO), as well as being the leading member of the Commonwealth of Independent States.

The People Russia has had a long history of totalitarianism, which has resulted in a rather fatalistic approach to living. The desire to work individually under personal initiative was suppressed by the Czarist and Communist states. With the advent of perestroika (restructuring), the Soviet/Communist value system has been scrapped, but the pace of reform has been slow and many are finding it very difficult to adapt to the Western values of individualism and profit maximization. Older Russians are generally quite pessimistic and don't have much faith in a better life in the future. Younger urban Russians have adopted a more Western outlook on life.

Meeting and Greeting Initial greetings may come across as cool. Do not expect friendly smiles.

A handshake is always appropriate (but not obligatory) when greeting or leaving, regardless of the relationship. Remove your gloves before shaking hands.

Don't shake hands over a threshold (Russian folk belief holds that this action will lead to an argument).

Body Language Russians are a very demonstrative people, and public physical contact is common. Hugs, backslapping, kisses on the cheeks and other expansive

442 gestures are common among friends or acquaintances and between members of the same sex.

Russians stand close when talking.

Putting your thumb through your index and middle fingers or making the "OK" sign are considered very rude gestures in Russia.

Helpful Hints Russians are very proud of their culture and enjoy opportunities to talk about their music, art, literature and dance. Knowledge about art, music and some Russian history is appreciated.

Russians greatly appreciate any attempt by non-Russians to speak their language.

Never refer to a Russian as "Comrade."

443 Cultural Snapshot: Your massage client from Singapore

Where they are from Singapore, officially the Republic of Singapore, is a sovereign city-state and island country in Southeast Asia. It lies off the southern tip of the Malay Peninsula and is 137 kilometres (85 mi) north of the equator. The country's territory consists of the lozenge-shaped main island, commonly referred to as Singapore Island in English and Pulau Ujong in Malay, and more than 60 significantly smaller islets.[8] Singapore is separated from Peninsular Malaysia by the Straits of Johor to the north, and from Indonesia's Riau Islands by the Singapore Strait to the south. The country is highly urbanised, and little of the original vegetation remains. The country's territory has consistently expanded through land reclamation.

The islands were settled in the second century AD and subsequently belonged to a series of local empires. Modern Singapore was founded in 1819 by Sir Stamford Raffles as a trading post of the East India Company with permission from the Johor Sultanate. The British obtained sovereignty over the island in 1824, and Singapore became one of the British Straits Settlements in 1826. Occupied by the Japanese during World War II, Singapore declared independence from the United Kingdom in 1963 and united with other former British territories to form Malaysia, from which it was expelled two years later through a unanimous act of parliament. Since then, Singapore has developed rapidly, earning recognition as one of the Four Asian Tigers.

Singapore is one of the world's major commercial hubs, with the fourth- biggest financial centre and one of the five busiest ports. Its globalised and diversified economy depends heavily on trade, especially manufacturing, which represented 26 percent of Singapore's GDP in 2005. In terms of purchasing power parity, Singapore has the third-highest per capita income in the world but one of the world's highest income inequalities. It places highly in international rankings with regard to education, healthcare, and economic competitiveness. Just over five million people live in Singapore, of which approximately two million are foreign-born. While Singapore is diverse, ethnic Asians predominate: 75 percent of the population is Chinese, with significant minorities of Malays, Indians, and Eurasians. There are four official languages, English, Malay, Mandarin, and Tamil , and the country promotes multiculturalism through a range of official policies.

444 Singapore is a unitary multiparty parliamentary republic, with a Westminster system of unicameral parliamentary government. The People's Action Party has won every election since self-government began in 1959. The dominance of the PAP, coupled with a low level of press freedom and suppressed civil liberties and political rights, has led to Singapore being classified as a semi-authoritarian regime. One of the five founding members of the Association of South East Asian Nations (ASEAN), Singapore is also the host of the Asia-Pacific Economic Cooperation (APEC) Secretariat, and a member of the East Asia Summit, the Non- Aligned Movement, and the Commonwealth. Singapore's rapid development has given it significant influence in global affairs, leading some analysts to identify it as a middle power.

The People Singapore is a conglomeration of Chinese (76%), Malay (15%) and Indian (6%) cultures. In the past, this racial mixture has lead to some conflict. However, today most Singaporeans enjoy racial harmony and national unity. Each group works hard to maintain its cultural traditions while building a modern, cohesive society. Singaporeans of the younger generation think of themselves as Singaporean first, and as Chinese, Malay or Indian second.

Buddhism is the most widely practiced religion in Singapore, with 33% of the resident population declaring themselves adherents at the most recent census. The next-most practised religion is Christianity, followed by Islam, Taoism, and Hinduism. 17% of the population did not have a religious affiliation. The proportion of Christians, Taoists, and non-religious people increased between 2000 and 2010 by about 3% each, whilst the proportion of Buddhists decreased. Other faiths remained largely stable in their share of the population. An analysis by the Pew Research Center found Singapore to be the world's most religiously diverse nation.

There are monasteries and Dharma centres from all three major traditions of Buddhism in Singapore: Theravada, Mahayana, and Vajrayana. Most Buddhists in Singapore are Chinese and are of the Mahayana tradition, with missionaries having come into the country from Taiwan and China for several decades. However, Thailand's Theravada Buddhism has seen growing popularity among the populace (not only the Chinese) during the past decade. Soka Gakkai International, a Japanese Buddhist organisation, is practised by many people in Singapore, but mostly by those of Chinese

445 descent. Tibetan Buddhism has also made slow inroads into the country in recent years.

Meeting and Greeting Shake hands with everyone present at a business meeting or social occasion. Shake hands again when leaving. Your handshake should be firm.

Singaporeans may bow slightly as they shake your hand. Many Westerners are generally taller than Singaporeans, so it would be polite to give a small bow. A slight bow for Chinese or older people is polite.

Body Language Never touch a person's or child's head. The head is considered sacred.

The foot is considered the lowest part of the body, and is thought to be unclean. The foot should never be used to point at someone, and you should never show the bottom of your feet. Tapping your foot or fidgeting your legs denotes feebleness and lack of interest. When crossing your legs, do so only by placing one knee over the other.

Raise your hand to get someone's attention. Never signal or point at a person with the forefinger. Do not pound your first on an open palm; this is obscene. The forearm jerk is a rude gesture.

Helpful Hints Avoid public displays of affection.

Do not show anger or emotions or raise your voice. Remain disciplined and in control.

Avoid discussing religion or politics.

Avoid jokes until you know someone well. Few jokes will be understood or appreciated.

446 Cultural Snapshot: Your massage client from South Korea

Where they are from South Korea, officially the Republic of Korea, and commonly referred to as Korea, is a country in East Asia, constituting the southern part of the Korean Peninsula. The name Korea is derived from the Kingdom of Goryeo, also spelt as Kory ŏ. It shares land borders with North Korea to the north, and oversea borders with Taiwan to the south, Japan to the east and China to the west. South Korea lies in the north temperate zone with a predominantly mountainous terrain. Roughly half of the country's 50 million people reside in the metropolitan area surrounding its capital, the Seoul Capital Area, which is the second largest in the world with over 25 million residents.

Korea was inhabited as early as the Lower Paleolithic period and its civilization begins with the founding of Gojoseon in 2333 BC. After the unification of the Three Kingdoms of Korea in 668, Korea enjoyed over a millennium of relative tranquility under dynasties lasting for centuries in which its trade, culture, literature, science and technology flourished. It was forcibly annexed as part of the Japanese Empire in 1910 and after its defeat in 1945, Korea was divided into Soviet and U.S. zones of occupation, with the latter becoming the Republic of Korea in 1948. Although the United Nations passed a resolution declaring the Republic to be the only lawful government of Korea, a communist regime was soon set up in the North that invaded the South in 1950, leading to the Korean War that ended de facto in 1953, with peace and prosperity settling-in thereafter.

Between 1962 and 1994, South Korea's tiger economy grew at an average of 10% annually, fueled by annual export growth of 20%, in a period called the Miracle on the Han River that rapidly transformed it into a high-income advanced economy and the world's 11th largest economy by 1995. Today, South Korea is the eighth largest country in international trade, a regional power with the world's 10th largest defense budget and founding member of the G-20 and APEC. Civilian government replaced military rule in 1987 and it has since evolved into a vibrant democracy ranked second in Asia on the Democracy Index. In 2009, South Korea became the world's first former aid recipient to join the OECD's Development Assistance Committee, becoming a major donor. Its pop culture has considerable influence in Asia and expanding globally in a process called the Korean Wave.

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South Korea is a developed country ranked 15th in the Human Development Index, the highest in East Asia. In terms of average wage, it has Asia's highest income and the world's 10th highest income. It ranks highly in education, quality of healthcare, rule of law, ease of doing business, government transparency, job security, tolerance and inclusion. 64% of 25-34 year old South Koreans hold a tertiary education degree, the highest in the OECD. The most innovative country as measured by the Bloomberg Innovation Quotient, South Korea is the world's seventh largest exporter, driven by high-tech multinationals such as Samsung, Hyundai-Kia and LG. South Korea has global leadership in advanced technology such as the world's fastest Internet connection speed, ranking first in the ICT Development Index, e-Government, 4G LTE penetration and second in smartphone penetration.

The People Korea is one of the most homogeneous countries in the world, racially and linguistically. It has its own culture, language, dress and cuisine, separate and distinct from its neighboring countries. Hard work, filial piety and modesty are characteristics esteemed by Koreans. They are proud of their traditional culture and their modern economic success. Education is highly valued as the path to status, money and success.

Meeting and Greeting The bow is the traditional Korean greeting, although it is often accompanied by a handshake among men. To show respect when shaking hands, support your right forearm with your left hand.

Korean women usually nod slightly and will not shake hands with Western men. Western women may offer their hand to a Korean man.

Bow when departing. Younger people wave (move their arm from side to side).

Names and Titles It is considered very impolite to address a Korean with his or her given name. Address Koreans using appropriate professional titles until specifically invited by your host or colleagues to use their given names.

Americans should address a Korean with Mr., Mrs., Miss + family name.

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Korean names are the opposite of Western names with the family name first, followed by the two-part given name. The first of the two given names is shared by everyone of the same generation in the family, and the second is the individual's given name. Example: Lee (Family) + Dong (Shared Given) + Sung (Given). Dong Sung is the individual's given name. Address him as Mr. Lee or Lee Sonsaengnim (which means "teacher").

Body Language Koreans consider it a personal violation to be touched by someone who is not a relative or close friend .

Direct eye should be avoided. This is seen as impolite or even as a challenge.

Do not cross your legs or stretch your legs out straight in front of you.

Keep your feet on the floor, never on a desk or chair.

Always pass and receive objects with your right hand (supported by the left hand at the wrist or forearm) or with two hands.

To beckon someone, extend your arm, palm down, and move your fingers in a scratching motion. Never point with your index finger.

Helpful Hints Never use words like "fellow," "guy," "this man" or "that man." This is considered demeaning.

Koreans are not Chinese . They are distinct from other Asians in food, language and culture. Expect Koreans to ask personal questions. This is viewed as showing a polite interest in your life.

Deny a compliment . Don't say "thank you." It is impolite and shows a lack of humility.

Never expect Koreans to admit to not knowing an answer when questioned. They may give an incorrect answer or an answer they think you would like to hear to make you feel good or to save face.

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Don't talk about Koreans or their customs or culture within earshot of a Korean, even if you are saying good things. Do not talk about politics.

Especially for Women Korean women seldom shake hands. A Western woman can offer her hand to a Korean man, but should not to a Korean woman.

450 Cultural Snapshot: Your massage client from Spain

Where they are from Spain (Spanish: España), officially the Kingdom of Spain, is a sovereign state located on the Iberian Peninsula in southwestern Europe. Its mainland is bordered to the south and east by the Mediterranean Sea except for a small land boundary with Gibraltar; to the north and northeast by France, Andorra, and the Bay of Biscay; and to the west and northwest by Portugal and the Atlantic Ocean. Along with France and Morocco, it is one of only three countries to have both Atlantic and Mediterranean coastlines. Spain's 1,214 km (754 mi) border with Portugal is the longest uninterrupted border within the European Union.

Spanish territory also includes the Balearic Islands in the Mediterranean, the Canary Islands in the Atlantic Ocean off the African coast, three exclaves in North Africa, Ceuta, Melilla, and Peñón de Vélez de la Gomera that border Morocco, and the islands and peñones (rocks) of Alborán, Chafarinas, Alhucemas, and Perejil. With an area of 505,992 km2 (195,365 sq mi), Spain is the second largest country in Western Europe and the European Union, and the fifth largest country in Europe.

Modern humans first arrived in the Iberian Peninsula around 35,000 years ago. It came under Roman rule around 200 BCE, after which the region was named Hispania. In the Middle Ages, the area was conquered by Germanic tribes and later by the Moors to the south. Spain emerged as a unified country in the 15th century, following the marriage of the Catholic Monarchs and the completion of the centuries-long reconquest, or Reconquista, of the peninsula from the Moors in 1492. In the early modern period, Spain became one of history's first global colonial empires, leaving a vast cultural and linguistic legacy that includes over 500 million Spanish speakers, making Spanish the world's second most spoken first language.

Modern Spain is a democracy organized in the form of a parliamentary government under a constitutional monarchy. It is a developed country with the 13th largest economy in the world. It is a member of the United Nations, NATO, OECD, and WTO. Currently, the economic crisis became the major problem of the Spanish economy.

451 The People Personal pride and individualism are highly valued, as are character and breeding. Modesty is valued over assertiveness. Flaunting superiority, intelligence and ability is not appreciated. People strive to project affluence and social position. Personal appearance, image and human relationships are very important.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands again when leaving.

Men may embrace each other when meeting (friends and family only).

Women may kiss each other on the cheek and embrace.

Body Language Never touch, hug or backslap a Spaniard you do not know well, unless a friendly Spaniard touches you first.

Generally, Spaniards stand very close when talking.

Spaniards speak a lot with their hands. Never mimic them.

Helpful Hints Expect to be interrupted when speaking.

Be patient. Nothing is done in a hurry. Spanish trademarks are procrastination and delay.

Especially for Women Traditionally, a macho and chauvinistic behavior toward women has persisted. This has changed drastically over the last few years.

Be aware of eye contact. Returning a man's gaze may be interpreted as flirting or a show of interest.

Cultural Snapshot: Your massage client from Sweden

Where they are from

452 Sweden, officially the Kingdom of Sweden, is a Scandinavian country in Northern Europe. Sweden borders Norway and Finland, and is connected to Denmark by a bridge-tunnel across the Øresund. At 450,295 square kilometres (173,860 sq mi), Sweden is the third-largest country in the European Union by area, with a total population of about 9.6 million. Sweden has a low population density of 21 inhabitants per square kilometre (54 /sq mi) with the population mostly concentrated to the southern half of the country. About 85% of the population live in urban areas. Southern Sweden is predominantly agricultural, while the north is heavily forested.

Germanic peoples have inhabited Sweden since prehistoric times, emerging into history as the Gotar and Svear tribes and contributing to the sea peoples known as Vikings. Sweden emerged as an independent and unified country during the Middle Ages. In the 17th century, the country expanded its territories to form the Swedish Empire. The empire grew to be one of the great powers of Europe in the 17th and early 18th centuries. Most of the conquered territories outside the Scandinavian Peninsula were lost during the 18th and 19th centuries. The eastern half of Sweden, present-day Finland, was lost to Russia in 1809. The last war in which Sweden was directly involved was in 1814, when Sweden by military means forced Norway into a personal union. Since then, Sweden has been at peace, remaining a largely neutral nation. The country played a role in humanitarian efforts during World Wars I and II, taking in refugees from German-occupied Europe. With the ending of the Cold War, Sweden joined the European Union, although declined NATO membership.

Today, Sweden is a constitutional monarchy, with Carl XVI Gustaf as king, organized as a parliamentary democracy. The seat of government is the capital Stockholm, which is also the most populous city. Executive power is exercised by the Prime Minister, Fredrik Reinfeldt, and the cabinet. Sweden is a unitary state, currently divided into twenty-one counties.

It has the world's eighth-highest per capita income and ranks highly in numerous comparisons of national performance, including quality of life, health, education, protection of civil liberties, economic competitiveness, equality, prosperity and human development. Sweden has been a member of the European Union since 1 January 1995, although remains outside the Eurozone. It is also a member of the United Nations, the Nordic Council,

453 Council of Europe, the World Trade Organization and the Organisation for Economic Co-operation and Development (OECD).

The People Sweden is a predominantly middle class country with one of the most far- reaching social security systems in the world. Patriotism is important to Swedes, who are very proud of their nation, towns and regions. They speak Swedish.

Meeting and Greeting Shake hands with everyone present -- men, women, and children -- at business and social meetings. Shake hands again when leaving. Younger people generally do not shake hands when meeting friends. Older people expect a handshake when being greeted or when leaving.

If no one is available to introduce you, shake each person's hand and introduce yourself.

Body Language Generally, Swedes are reserved in body language. They do not embrace or touch often in public.

Maintain eye contact at all times while talking with someone.

Helpful Hints Knowledge about Sweden's economy, high standard of living, sports, architecture, history, etc. is appreciated.

Do not compliment lightly. Insincere comments are considered rude.

Do not expect them to be anymore familiar with a “Swedish” massage than your typical client from the USA.

454 Cultural Snapshot: Your massage client from Switzerland

Where they are from Switzerland is a federal parliamentary republic consisting of 26 cantons, with Bern as the seat of the federal authorities, the so-called Bundesstadt ("federal city"). The country is situated in Western and Central Europe, where it is bordered by Italy to the south, France to the west, Germany to the north, and Austria and Liechtenstein to the east. Switzerland is a landlocked country geographically divided between the Alps, the Swiss Plateau and the Jura, spanning an area of 41,285 km2 (15,940 sq mi). While the Alps occupy the greater part of the territory, the Swiss population of approximately 8 million people is concentrated mostly on the Plateau, where the largest cities are to be found. Among them are the two global cities and economic centres of Zürich and Geneva.

The establishment of the Swiss Confederation is traditionally dated to 1 August 1291, which is celebrated annually as Swiss National Day. It has a long history of armed neutrality—it has not been in a state of war internationally since 1815—and did not join the United Nations until 2002. It pursues, however, an active foreign policy and is frequently involved in peace-building processes around the world. Switzerland is also the birthplace of the Red Cross and home to numerous international organizations, including the second largest UN office. On the European level, it is a founding member of the European Free Trade Association and is part of the Schengen Area – although it is notably not a member of the European Union, nor the European Economic Area. Switzerland comprises four main linguistic and cultural regions: German, French, Italian and the Romansh-speaking valleys. Therefore, the Swiss, although predominantly German-speaking, do not form a nation in the sense of a common ethnic or linguistic identity; rather, the strong sense of identity and community is founded on a common historical background, shared values such as federalism and direct democracy, and Alpine symbolism.

Switzerland has the highest nominal wealth per adult (financial and non- financial assets) in the world according to Credit Suisse and eighth-highest per capita gross domestic product on the IMF list. However, Switzerland is also the most expensive country in the world to live in, as measured by the price level index.

455 Swiss citizens have the second-highest life expectancy in the world on the UN DESA list. Switzerland is tied with the Netherlands for the top rank on the Bribe Payers Index indicating very low levels of business corruption. Moreover, for the last five years the country has been ranked first in economic and tourist competitiveness according to the Global Competitiveness Report and the Travel and Tourism Competitiveness Report respectively, both developed by the World Economic Forum. Zürich and Geneva have each been ranked among the top cities with the highest quality of life in the world, with the former coming second globally according to Mercer. However, Mercer also rates those two cities as the fifth- and sixth- most expensive cities in the world to live in.

The People The Swiss value cleanliness, honesty, hard work, and material possessions. Motto: "Unity, yes; Uniformity, no." They are very proud of their environment and have a long tradition of freedom. They value sobriety, thrift, tolerance, punctuality and a sense of responsibility. They are very proud of their neutrality and promotion of worldwide peace. The Swiss have a deep-rooted respect for saving and the material wealth it brings.

Switzerland has four official languages ! In 2011, the languages most spoken at home among permanent residents aged 15 and older were: Swiss German (4,027,917, or 61.1%); French (1,523,094, 23.1%); Standard German (637,439, 9.7%); Italian (545,274, 8.2%).

Meeting and Greeting Shake hands with everyone present -- men, women, and children -- at business or social meetings. Shake hands again when leaving.

Handshakes are firm with eye contact.

Allow the hosts to introduce you at parties.

Use last names and appropriate titles until specifically invited by your Swiss hosts or colleagues to use their first names. Academic and professional titles are used frequently.

First names are reserved for very close friends and family.

456 Body Language Poor posture is frowned upon. Do not stretch or slouch in public.

Do not point your index finger to your head. This is an insult.

Helpful Hints

Be punctual.

Show great respect for elderly.

Refrain from putting your hands in your pockets while talking with people.

Never put your feet on a desk, chair or table.

457 Cultural Snapshot: Your massage client from Taiwan

Where they are from Taiwan, officially the Republic of China, is a state in East Asia. The Republic of China, originally based in mainland China, now governs the island of Taiwan, which makes up over 99% of its territory, as well as Penghu, Kinmen, Matsu, and other minor islands. Neighboring states include the People's Republic of China to the west, Japan to the east and northeast, and the Philippines to the south. Taipei is the seat of the central government. New Taipei, encompassing the metropolitan area surrounding Taipei proper, is the most populous city.

The island of Taiwan (formerly known as "Formosa") was mainly inhabited by Taiwanese aborigines until the Dutch and Spanish settlement during the Age of Discovery in the 17th century, when Han Chinese people began immigrating to the island. In 1662, the pro-Ming loyalist Koxinga expelled the Dutch and established the first Han Chinese polity to rule on the island, the Kingdom of Tungning. The Qing Dynasty of China later conquered Taiwan in 1683. By the time Taiwan was ceded to Japan in 1895, the majority of Taiwan's inhabitants were Han Chinese either by ancestry or by assimilation. The Republic of China (ROC) was established in China in 1912. At the end of World War II in 1945, Japan surrendered Taiwan to ROC military forces on behalf of the Allies. Following the Chinese civil war, the Communist Party of China took full control of mainland China and founded the People's Republic of China (PRC) in 1949. The ROC relocated its government to Taiwan, and its jurisdiction became limited to Taiwan and its surrounding islands. In 1971, the PRC assumed China's seat at the United Nations, which the ROC originally occupied. International recognition of the ROC has gradually eroded as most countries switched recognition to the PRC. Only 21 UN member states and the Holy See currently maintain official diplomatic relations with the ROC, though it has unofficial ties with most other states via its representative offices.

Constitutionally, the ROC government has claimed sovereignty over all of "China," in a definition that includes mainland China and Outer Mongolia, but has not made retaking mainland China a political goal since 1992. However, the government's stance on defining its political position of relation with China largely depends on which political coalition is in charge. Meanwhile, the PRC also asserts itself to be the sole legal representation of China and claims Taiwan as its 23rd province to be under its

458 sovereignty, denying the status and existence of ROC as a sovereign state. The PRC has threatened the use of military force as a response to any formal declaration of Taiwanese independence, or if it deems peaceful reunification no longer possible. Cross-strait relations as well as issues of national identity within the country are important factors in Taiwanese politics and a cause of social and political division among political parties and their respective supporters.

During the latter half of the 20th century, Taiwan experienced rapid economic growth and industrialization and is now an advanced industrial economy. In the 1980s and early 1990s, Taiwan evolved into a multi-party democracy with universal suffrage. Taiwan is one of the Four Asian Tigers and a member of the WTO and APEC. The 19th-largest economy in the world, its high-tech industry plays a key role in the global economy. Taiwan is ranked highly in terms of freedom of the press, health care, public education, economic freedom, and human development.

The People The people of Taiwan value hard work, patience, humility, friendliness and respect for others. They are highly motivated and centered around the extended family, their most important economic resource. They dislike loud, showy and unrefined behavior. Bringing shame on anyone ("loss of face") brings shame to the entire family.

Meeting and Greeting A nod of the head or a slight bow is considered polite for the first meeting.

Handshakes are generally only for males who are friends. Introductions are important.

Do not introduce yourself. Instead, have a third person introduce you.

Body Language Do not touch anyone, especially a baby, on top of the head.

Affection for the opposite sex is not shown in public.

Never use your feet to move an object or to point at an object. Feet are considered dirty.

459 Place your hands in your lap when sitting.

Men should not cross their legs, but rather place both feet on the floor.

Putting an arm around another's shoulder, winking and pointing with your index finger are all considered rude gestures. Point with an open hand .

Palm facing outward in front of face moving back and forth means "no".

Placing your right hand over your left fist and raising both hands to your heart is a greeting of respect for the elderly.

Helpful Hints Speaking even a few words of Chinese is greatly appreciated.

Revere the elderly. Hold doors, rise when the elderly enter a room, give the elderly your seat, etc.

Refer to the People's Republic of China (PRC) as "Mainland China."

460 Cultural Snapshot: Your massage client from Thailand

Where they are from Thailand, officially the Kingdom of Thailand, formerly known as Siam, is a country at the center of the Indochina peninsula in Southeast Asia. It is bordered to the north by Burma and Laos, to the east by Laos and Cambodia, to the south by the Gulf of Thailand and Malaysia, and to the west by the Andaman Sea and the southern extremity of Burma. Its maritime boundaries include Vietnam in the Gulf of Thailand to the southeast, and Indonesia and India on the Andaman Sea to the southwest.

Thailand is a monarchy headed by King Bhumibol Adulyadej, Rama IX and governed by a military junta that took power in May 2014. The king is the ninth of the House of Chakri, and has reigned since 1946 as the world's longest-serving current head of state and the country's longest-reigning monarch. The King of Thailand's titles include Head of State, Head of the Armed Forces, Adherent of Buddhism, and Upholder of religions. Although a constitutional system was established in 1932, the monarchy and military have continued to intervene periodically in politics.

With a total area of approximately 513,000 km2 (198,000 sq mi), Thailand is the world's 51st-largest country. It is the 21st-most-populous country in the world, with around 65 million people. The capital and largest city is Bangkok, which is Thailand's political, commercial, industrial, and cultural hub. About 75–95% of the population is ethnically Tai, which includes four major regional groups: Central Thai, Northeastern Thai (Khon [Lao] Isan), Northern Thai (Khon Müang); and Southern Thai. Thai Chinese, those of significant Chinese heritage, are 14% of the population, while Thais with partial Chinese ancestry comprise up to 40% of the population. Thai Malays represent 3% of the population, with the remainder consisting of Mons, Khmers and various "hill tribes". The country's official language is Thai and the primary religion is Buddhism, which is practised by around 95% of the population.

Thailand experienced rapid economic growth between 1985 and 1996, becoming a newly industrialized country and a major exporter. Manufacturing, agriculture, and tourism are leading sectors of the economy. Among the ten ASEAN countries, Thailand ranks second in quality of life and the country's HDI had been rated as 'high'. Its large

461 population and growing economic influence have made it a middle power in the region and around the world.

The People Thais are tolerant of individualism, but find comfort and security in being part of a group. Mai Pen Rai (never mind) is the Thai expression which characterizes the general focus of life - "it is to enjoy." Thais are productive and hard working while at the same time happy with what they are and what they have materially. They are smiling, pleasant, humble and patient people who laugh easily, speak softly, are slow to anger, and never try to cause anyone to lose face. Thais are very proud of their cultural heritage and enjoy talking about it with visitors. Thais are proud that they have never been ruled by a Western power.

Meeting and Greeting When being introduced or greeting someone, men say Sawatdee-krap and women say Sawatdee-kah.

Thais greet each other with a "wai." Foreigners are not expected to initiate the wai gesture, but it is an insult not to return the wai. If a wai is not offered to you, shake hands with men and smile and nod to women. A Thai businessperson may shake hands with a foreigner. Offer a wai only to a person of equal or greater status. Subordinates should offer a wai first.

Wai (why) - a person places the palm of his or her hands together, with their fingers extended at chest level close to their body and bows slightly. The higher the hands are placed, the more respect is shown. Subordinates might raise their fingers as high as their nose. However, the tips of their fingers should never be above eye level.

A wai can mean "Hello," "Thank you," "I'm sorry," or "Goodbye." A wai is not used to greet children, servants, street vendors or laborers. Never return a wai to a child, waiter, clerk, etc. Simply nod and smile in response.

Thais say "Where are you going" rather than "Hello." A polite response is "Just down the street."

Introductions are common only in a formal situation. Introduce yourself by your first name. Feel free to introduce yourself or ask for someone's name.

462 When introducing your business partner to an important Thai, mention your partner's name first.

The inferior or lower-status person is always addressed first in an introduction. Thus, a child is introduced before its parents, a secretary is introduced before her boss.

Names and Titles Thais address one another by first names and titles and reserve last names for very formal occasions and written communications. Last names have been used in Thailand for only the past fifty years and are difficult even for Thais to pronounce. Two people with the same last name are almost certainly related.

Foreigners are often addressed by their given names because it is easier for Thais; it does not imply familiarity. Thais will probably call you Mr. Joe or Mrs. Mary.

Titles, rank and honor are very important. Introductions require only the given name and title. Mr., Mrs., or Miss + family name are appropriate for visitors to use in formal situations.

Thai given names are preceded by Khun (Mr. Mrs. or Miss), unless they carry a higher degree, such as doctor. Khun is used for men and women, married or single. If you don't know a person's name, address them as Khun. Example: Anuwat (Given) + Wattapongsiri (Family) is Khun Anuwat.

Body Language Touching between people of the same sex is more common in Thailand than in many other Asian countries.

However, touching someone of the opposite sex is taboo. Do not show affection in public.

Never touch or pass anything over anyone's head. The head is considered sacred in Thailand and must be respected.

Never point your feet at anyone or use your feet to move anything or touch anyone. Feet are regarded as unclean and symbolically (as well as physically) the lowest part of the body.

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Do not put your hands in your pockets while talking to someone.

Never put your arm over the back of the chair in which someone is sitting.

A smile is often used for many different emotions. It may be an apology, a thank-you, a greeting, or to show embarrassment. Be aware: A Thai's smiling assurance does not mean you will in fact get what you want, when you want it. It simply reflects the Thai appreciation of harmony and their "never mind" attitude.

Don't wave your hands about as you talk, giving Thais the impression that you are angry. Never pass anything with your left hand. Never point with your hand and never, never with one finger.

Do not cross your legs in the presence of the elderly or monks.

Helpful Hints Step over the threshold, not on it, when going through a doorway. Thais believe a spirit resides in the threshold.

Use your right hand only for passing, eating, touching, etc.

Do not speak in a loud voice. Do not show your temper. Never criticize anyone publicly.

Traditional Thais believe a woman can lose face if a man touches her in public.

464 Cultural Snapshot: Your massage client from Turkey

Where they are from Turkey, officially the Republic of Turkey, is a contiguous transcontinental parliamentary republic, with its smaller part in Southeastern Europe and its larger part in Western Asia (i.e. the Balkans and Anatolia, respectively). Turkey is bordered by eight countries: Bulgaria to the northwest; Greece to the west; Georgia to the northeast; Armenia, Iran and the Azerbaijani exclave of Nakhchivan to the east; and Iraq and Syria to the southeast. The Mediterranean Sea is to the south; the Aegean Sea to the west; and the Black Sea to the north. The Sea of Marmara, the Bosphorus and the Dardanelles (which together form the Turkish Straits) demarcate the boundary between Thrace and Anatolia; they also separate Europe and Asia. Turkey's location at the crossroads of Europe and Asia makes it a country of significant geostrategic importance.

Turkey has been inhabited since the paleolithic age, including various Ancient Anatolian civilizations, Aeolian and Ionian Greeks, Thracians and Persians. After Alexander the Great's conquest, the area was Hellenized, which continued with the Roman rule and the transition into the Byzantine Empire. The Seljuk Turks began migrating into the area in the 11th century, starting the process of Turkification, which was greatly accelerated by the Seljuk victory over the Byzantines at the Battle of Manzikert in 1071. The Seljuk Sultanate of Rûm ruled Anatolia until the Mongol invasion in 1243, upon which it disintegrated into several small Turkish beyliks.

Starting from the late 13th century, the Ottomans united Anatolia and created an empire encompassing much of Southeastern Europe, Western Asia and North Africa, becoming a major power in Eurasia and Africa during the early modern period. The empire reached the peak of its power between the 15th and 17th centuries, especially during the reign of Suleiman the Magnificent (r. 1520–1566). After the second Ottoman siege of Vienna in 1683 and the end of the Great Turkish War in 1699, the Ottoman Empire entered a long period of decline. The Tanzimat reforms of the 19th century, which aimed to modernize the Ottoman state, proved to be inadequate in most fields, and failed to stop the dissolution of the empire. The Ottoman Empire entered World War I (1914–1918) on the side of the Central Powers and was ultimately defeated. During the war, major atrocities were committed by the Ottoman government against the Armenians, Assyrians and Pontic Greeks. Following WWI, the huge

465 conglomeration of territories and peoples that formerly comprised the Ottoman Empire was divided into several new states. The Turkish War of Independence (1919–1922), initiated by Mustafa Kemal Atatürk and his colleagues in Anatolia, resulted in the establishment of the modern Republic of Turkey in 1923, with Atatürk as its first president.

Turkey is a democratic, secular, unitary, constitutional republic with a diverse cultural heritage. The country's official language is Turkish, a Turkic language spoken natively by approximately 85% of the population. About three quarters of the population are ethnic Turks and about a fifth ethnic Kurds. The vast majority of the population is Muslim. Turkey is a member of the UN, NATO, OECD, OSCE, OIC and the G-20. After becoming one of the first members of the Council of Europe in 1949, Turkey became an associate member of the EEC in 1963, joined the EU Customs Union in 1995 and started full membership negotiations with the European Union in 2005. Turkey's growing economy and diplomatic initiatives have led to its recognition as a regional power.

The People Turks are extremely patriotic. They are proud of their ancestors and of the achievements of their modern society. The family is the most important social unit. Each person is dependent upon and loyal to the family. Rural life is still traditional, but in cities women frequently work outside the home.

Meeting and Greeting Shake hands with everyone present--men, women and children--at a business or social meeting. Shake hands with elders first. Shake hands again when leaving.

It is common for Turkish men and women to cheek-kiss one another when meeting and parting.

Body Language "Yes" is a slight downward nod of the head. "No" is a slight upward nod of the head while making a quick, sucking sound through your two front teeth (like "tsk").

Turks generally have a small area of personal space and may stand closer than most foreigners are used to.

466 Never point the sole of your foot toward a person.

Turks, most of whom are devout Muslims , may avoid looking into your eyes in a display of humble behavior.

Do not stand with your hands on your hips when talking to others, especially older people or superiors, or put your hands in your pockets.

In Turkey, putting your thumb between your first two fingers is the equivalent to raising your middle finger in the United States.

The “O.K.” sign in Turkey means that someone is homosexual.

Helpful Hints Turks ask even casual acquaintances what Americans consider to be very personal questions (age, salary, etc.). However, do not ask such personal questions until a friendship has been established.

Especially for Women In general, conservative attitudes toward women exist in Turkey, but Turkish men tend to be very respectful.

Keep in mind that many are Muslims and as such may have a preference for massage therapists of the same gender.

467 Cultural Snapshot: Your massage client from Uruguay

Where they are from Uruguay, officially the Oriental Republic of Uruguay, is a country in the southeastern region of South America. It is bordered by Argentina to its west and Brazil to its north and east, with the Atlantic Ocean to the south and southeast. Uruguay is home to 3.3 million people, of whom 1.8 million live in the metropolitan area of its capital and largest city, Montevideo. With an area of approximately 176,000 square kilometres (68,000 sq mi), Uruguay is geographically the second-smallest nation in South America after Suriname.

Uruguay remained largely uninhabited until the establishment of Colonia del Sacramento, one of the oldest European settlements in the country, by the Portuguese in 1680. Montevideo was founded as a military stronghold by the Spanish in the early 18th century, signifying the competing claims over the region. Uruguay won its independence between 1811 and 1828, following a four-way struggle between Spain, Portugal, Argentina and Brazil. It remained subject to foreign influence and intervention throughout the 19th century, with the military playing a recurring role in domestic politics until the late 20th century. Modern Uruguay is a democratic constitutional republic, with a president who serves as both head of state and head of government.

Uruguay is ranked first in Latin America in democracy, peace, lack of corruption, quality of living, e-Government, and equally first in South America when it comes to press freedom, size of the middle class, prosperity and security. On a per capita basis, Uruguay contributes more troops to United Nations peacekeeping missions than any other country. It ranks second in the region on economic freedom, income equality, per capita income and inflows of FDI. Uruguay is the third best country on the continent in terms of HDI, GDP growth, innovation and infrastructure. It's regarded as a high income country (top group) by the UN, the only one in Latin America alongside Chile. Uruguay is also the 3rd best ranked in the world in e-Participation. Uruguay is an important global exporter of combed wool, rice, soybeans, frozen beef, malt and milk.

The People The majority of the people are middle class; the extremes of wealth and poverty found in most other South American countries don't exist.

468 Uruguayans take a pragmatic, utilitarian and materialistic approach to life. They have an inherent trust of people and a strong belief in social justice. A great deal of emphasis is placed on education. Uruguay has the best- educated workforce on the continent. People enjoy easy access to a good education, compulsory for nine years and free through post-graduate studies. The literacy rate is 96%, one of the highest in South America.

Meeting and Greeting Greetings are warm and accompanied by a firm handshake.

Friends kiss once on the right cheek when meeting.

People do not greet strangers when passing on the street. Greeting or smiling at a stranger may be misunderstood.

Body Language Uruguayans stand very close when conversing, both socially and in business.

People touch shoulders and hold arms while they talk to each other.

Never sit on or put your feet up on a ledge, desk or table.

The North American “O.K.” sign is extremely rude.

Helpful Hints Uruguayans are extremely political people. Ask about politics.

Ask questions about Uruguay. People are very proud of their country.

Don't confuse Paraguay and Uruguay.

469 Cultural Snapshot: Your massage client from Venezuela

Where they are from Venezuela, officially called the Bolivarian Republic of Venezuela. Venezuela is a country on the northern coast of South America. Venezuela's territory covers around 916,445 square kilometres (353,841 sq mi) with an estimated population of approximately 29,100,000. Venezuela is considered a state with extremely high biodiversity, with habitats ranging from the Andes Mountains in the west to the Amazon Basin rainforest in the south, via extensive llanos plains and Caribbean coast in the center and the Orinoco River Delta in the east.

Venezuela was colonized by Spain in 1522 amid resistance from indigenous peoples. In 1811 it became one of the first Spanish-American colonies to declare independence, which was not securely established until 1821, when Venezuela was a department of the federal republic of Gran Colombia. It gained full independence as a separate country in 1830. During the 19th century Venezuela suffered political turmoil and autocracy, remaining dominated by regional caudillos (military strongmen) until the mid-20th century. Since 1958, the country has had a series of democratic governments. Economic shocks in the 1980s and 1990s led to several political crises, including the deadly Caracazo riots of 1989, two attempted coups in 1992, and the impeachment of President Carlos Andrés Pérez for embezzlement of public funds in 1993. A collapse in confidence in the existing parties saw the 1998 election of former coup-involved career officer Hugo Chávez and the launch of the Bolivarian Revolution, beginning with a 1999 Constituent Assembly to write a new Constitution of Venezuela.

Venezuela is a federal presidential republic consisting of 23 states, the Capital District (covering Caracas), and Federal Dependencies (covering Venezuela's offshore islands). Venezuela also claims all Guyanese territory west of the Essequibo River, a 159,500 square kilometres (61,583 sq mi) tract dubbed Guayana Esequiba or the Zona en Reclamación (the "zone being reclaimed").

Venezuela is among the most urbanized countries in Latin America; the vast majority of Venezuelans live in the cities of the north, especially in the capital, Caracas, which is also the largest city in Venezuela. Since the discovery of oil in the early 20th century, Venezuela has the world's largest

470 oil reserves and been one of the world's leading exporters of oil. Previously an underdeveloped exporter of agricultural commodities such as coffee and cocoa, oil quickly came to dominate exports and government revenues. The 1980s oil glut led to an external debt crisis and a long-running economic crisis, which saw inflation peak at 100% in 1996 and poverty rates rise to 66% in 1995 as (by 1998) per capita GDP fell to the same level as 1963, down a third from its 1978 peak.

The recovery of oil prices after 2001 boosted the Venezuelan economy and facilitated social spending which significantly reduced inequality and poverty, although the fallout of the 2008 global financial crisis saw a renewed economic downturn. In February 2013, Venezuela devalued its currency due to the rising shortages in the country. Shortages of items included toilet paper, milk, flour and other necessities. As of June 2014, Venezuela's inflation has increased to 62%. This was one of the main causes of the 2014 Venezuelan protests.

The People Venezuelans respect leadership and are a tolerant and loving people. Extended family and friends are very important, and one should avoid doing anything that might shame them. The upper class dominates the economic structures of commerce and industry, but the middle class dominates politics. People are emotionally attached to the church (96% Roman Catholic), which gives them a sense of stability, but religion is not a strong force in daily life. Venezuelans are very proud of the fact that religious freedom is guaranteed by their constitution.

Meeting and Greeting Greetings are warm and friendly. People kiss business acquaintances on the cheek once and personal friends twice.

Handshakes are common among strangers.

Body Language Venezuelans stand very close when speaking. Do not back away.

Seating posture is important. Try to keep both feet on the floor, and avoid slouching. Don't put your feet on furniture.

Casual touching is common among males.

471

The North American “O.K.” sign is extremely rude.

Pointing with your index finger can be considered rude. Motioning with your entire hand is more polite.

Always maintain eye contact when talking.

Helpful Hints Learn about Venezuelan history, and ask questions. Venezuelans are proud of their country and will appreciate your interest. However, don't talk about local unrest and inflation, or give your opinion on local politics.

People call each other names like Negro (“black”), Gordo (“fatso”), Chino (“Chinaman”), etc. These nicknames are meant to show friendship, fondness and fun and are not meant to be demeaning.

Privacy is not valued in the same way it is in North America.

472 Cultural Snapshot: Your massage client from Vietnam

Where they are from Vietnam, officially the Socialist Republic of Vietnam, is the easternmost country on the Indochina Peninsula in Southeast Asia. With an estimated 90.0 million inhabitants as of 2013, it is the world's 13th-most-populous country, and the eighth-most-populous Asian country. The name Vietnam translates as "Southern Viet" (synonymous with the much older term Nam Viet); it was first officially adopted in 1802 by Emperor Gia Long, and was adopted again in 1945 with the founding of the Democratic Republic of Vietnam under Ho Chi Minh. The country is bordered by China to the north, Laos to the northwest, Cambodia to the southwest, and the South China Sea to the east. Its capital city has been Hanoi since the reunification of North and South Vietnam in 1976.

Vietnam was part of Imperial China for over a millennium, from 111 BC to 938 AD. The Vietnamese became independent from Imperial China in AD 938, following the Vietnamese victory in the Battle of B ạch Đằ ng River. Successive Vietnamese royal dynasties flourished as the nation expanded geographically and politically into Southeast Asia, until the Indochina Peninsula was colonized by the French in the mid-19th century. Following a Japanese occupation in the 1940s, the Vietnamese fought French rule in the First Indochina War, eventually expelling the French in 1954. Thereafter, Vietnam was divided politically into two rival states, North and South Vietnam. Conflict between the two sides intensified, with heavy intervention from the United States, in what is known as the Vietnam War. The war ended with a North Vietnamese victory in 1975.

Vietnam was then unified under a Communist government but remained impoverished and politically isolated. In 1986, the government initiated a series of economic and political reforms which began Vietnam's path towards integration into the world economy. By 2000, it had established diplomatic relations with most nations. Since 2000, Vietnam's economic growth rate has been among the highest in the world, and, in 2011, it had the highest Global Growth Generators Index among 11 major economies. Its successful economic reforms resulted in its joining the World Trade Organization in 2007.

473 However, regardless of the advancements that have been made in recent years, the country still experiences high levels of income inequality, disparities in access to healthcare, and a lack of gender equality.

The People A long struggle for independence has given the Vietnamese a deep sense of national pride. Vietnamese value their independence and history and offended by people who ignore or violate either. Most Vietnamese have an interest in all things American. They believe all past hostilities were part of the natural defense of their national territory. Families are very strong and help each other in all needs.

Meeting and Greeting The Vietnamese generally shake hands both when greeting and when saying good-bye.

Shake with both hands, and bow your head slightly to show respect. Bow to the elderly who do not extend their hand. Vietnamese women are more inclined to bow their head slightly than to shake hands.

When greeting someone, say “xin chao” (seen chow) + given name + title. The Vietnamese are delighted if a Westerner can properly say “xin chao” (because Vietnamese is a tonal language, “xin chao” can have six different meanings, only one of which is "Hello").

Body Language Summoning someone with a curled index finger, as is done in the West, is only done by the boss. To beckon someone, extend your arm, palm down, and move your fingers in a scratching motion. Only beckon someone who has a "lower" status than you.

Men and women do not show affection in public. However, members of the same sex may hold hands while walking.

Always use both hands when passing an object to another person. Touching children on the head is only done by parents, grandparents, etc.

474 Summary As with any client you see in your practice, the best results come from a trusting therapeutic relationship between practitioner and client. There are many things that clients have in mind when coming to see a massage therapist and in order to cover all of the client’s concerns, it is important to understand a little about where they are coming from. Appreciate that while it may not be hard for some clients to discuss personal information, it can be very difficult for others, especially those not familiar with massage therapy in the United States.

Being familiar with different cultural backgrounds will help you to understand the varying beliefs of your clients. Also, using effective communication will be critical in getting the information you need, while not offending clients from different cultures. Together, sensitivity, listening skills, and cultural awareness can help to form the trusting relationship you need to help your client and encourage them to share information with you.

Remember… ♦ Empathize with your client ♦ Do not stereotype ♦ Be educated about the types of populations you might be seeing ♦ Communicate effectively ♦ Be understanding ♦ Listen

475 Section 4: Transference and Countertransference in Massage

Instructions Thanks for taking this Somatic Arts and Sciences continuing education course. You are on the home stretch now, the last section. When you finish this one you will have completed all 12 hours.

Taking the quiz To take the quiz you can click the link on the website below this book.

Target audience This continuing education course has been designed to meet the educational needs of massage therapists.

Degree of Difficulty Beginner/Entry Level

Course description This course will present detailed information about the psychological phenomenon known as transference and countertransference and how it applies to the client practitioner relationship in therapeutic massage.

Educational objectives Upon completion of this home study continuing education course, the massage practitioner should be able to: Define the terms transference and countertransference as it applies to massage therapy. Describe by what means negative transference can be redirected. List potential warning signs of negative transference and countertransference in a therapeutic relationship.

Introduction This course is presented for educational purposes only. It was developed and marketed specifically for massage therapists that are required to obtain continuing education hours for licensing purposes. The author is not giving medical, legal or other professional advice.

This course is classified as “ Cognitive ” learning, meaning that there is no hands on portion.

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Chapter 1: Introduction to Transference and Counter Tansference Transference is a phenomenon characterized by unconscious redirection of feelings from one person to another. One definition of transference is "the inappropriate repetition in the present of a relationship that was important in a person's childhood 53 ." Another definition is "the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object 54 ." Still another definition is "a reproduction of emotions relating to repressed experiences, especially of childhood, and the substitution of another person ... for the original object of the repressed impulses." Transference was first described by Sigmund Freud, who acknowledged its importance for psychoanalysis for better understanding of the patient's feelings. The inclusion of "inappropriate" in the first definition notwithstanding, transference is normal and does not constitute underlying a breach of professional ethics in itself; it is only inappropriate when patterns of transference lead to maladaptive thoughts, feelings or behaviours.

It is common for people to transfer feelings from their parents to their partners or children (i.e., cross-generational entanglements). For instance, one could mistrust somebody who resembles an ex-spouse in manners, voice, or external appearance, or be overly compliant to someone who resembles a childhood friend.

In The Psychology of the Transference, Carl Jung states that within the transference dyad both participants typically experience a variety of opposites, that in love and in psychological growth, the key to success is the ability to endure the tension of the opposites without abandoning the process, and that this tension allows one to grow and to transform 55 .

Only in a personally or socially harmful context can transference be described as a pathological issue. A modern, social-cognitive perspective

53 Kapelovitz, Leonard H. (1987). To Love and To Work/A Demonstration and Discussion of Psychotherapy . p. 66. 54 Webster's New Collegiate Dictionary (8th ed. 1976). 55 Jung, Carl C. The Psychology of the Transference, Princeton University Press, ISBN 0-691-01752-2

477 on transference, explains how it can occur in everyday life. When people meet a new person that reminds them of someone else, they unconsciously infer that the new person has traits similar to the person previously known. This perspective has generated a wealth of research that illuminated how people tend to repeat relationship patterns from the past in the present.

Transference and countertransference is a fairly common phenomenon that occurs in massage therapy. In the context of massage therapy transference refers to redirection of a client's feelings for a significant person in their current life or past to the massage therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms.

Countertransference is defined as redirection of a massage therapist's feelings toward a client, or more generally, as a massage therapist's emotional entanglement with a client. A massage therapist's attunement to their own countertransference is nearly as critical as understanding the transference. Not only does this help the massage therapists regulate their emotions in the therapeutic relationship, but it also gives massage therapists valuable insight into what clients are attempting to elicit in them. For example, a massage therapist who is sexually attracted to a client must understand the countertransference aspect (if any) of the attraction, and look at how the client might be eliciting this attraction. Once any countertransference aspect has been identified, the massage therapist can ask the client what his or her feelings are toward the massage therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.

In any human relationship there is a transference of feelings, thoughts and attitudes. All of our present interactions are colored and shaped by the interactions of our past. The relationship between a massage therapist and their client is no different.

Empathy v s Energy transfer For many years massage schools have taught (and still teach) that a clients negative energy can be transferred to the massage therapist during the massage and that the massage therapists energy can travel likewise to the client.

478 While it is not our intent to refute this, an important distinction must be made here. This is not transference and countertransference.

Transference and countertransference are a function of the mind. The feelings we have towards our clients originate in us; they are not drawn from the client.

Part 1: Transference (the client side)

Transference in therapeutic massage Every massage therapist has dealt with a client that has shared a past massage experience, both good and bad. Every client brings with them a perception of massage in some way shaped by these past experiences. But what about the client’s other past experiences with touch? These too are brought to the massage table to a greater or lesser degree. Some clients will direct the feelings of these past experiences toward their therapist. This is known as transference 56 .

For the most part this phenomenon is harmless. It becomes an issue of concern when the touch is associated with thoughts and feelings that could interfere with the therapeutic process.

Some massage modalities are undeniably sensual in nature. Swedish, Ayurvedic, even Lymphatic Drainage can all bring to mind past experiences of intimate, romantic touch.

56 Howard A. Wishnie Working in the Countertransference: Necessary Entanglements Jason Aronson (January 2005)

479 patients in long term rehabilitation. As the patient works through painful exercise routines with the physical therapist he may begin to transfer feelings of resentment (of the pain/injury) to the physical therapist, who is then seen as a manifestation of that pain. Many physical therapists have been called “sadistic”, “bully” and even “torturer” through gritted teeth by a patient they are helping back to health 57 .

A third form of transference can develop when a client begins to see their massage therapist as a psychological rescuer .

The Drama Triangle The Drama Triangle is a graphic representation of a social dynamic involving three people in the distinctive roles of victim, persecutor, and rescuer.

In massage therapy, the client would be the victim in the scenario. They receive massage therapy for relief from the stress caused by the

57 Michael A. Pagliarulo Introduction to Physical Therapy Mosby; 3 edition (July 31, 2006) 58 The Three Faces of Victim: An Overview of the Drama Triangle web article By Lynne Forrest http://lynneforrest.com/html/the_faces_of_victim.html

480 persecutor (husband, wife, mother, boss, etc), which makes the massage therapist the rescuer.

A practical example: During the massage the client “unburdens” himself by describing a fight with his wife. The therapist listens to his side of the story during the massage, and the client feels better afterwards.

While this scenario may sound familiar to many massage therapists, it is surprising how many do not realize that they are being slowly but inexorably drawn into a conflict that they do not belong in.

By passively listening to the client when they vent about their spouse they are, in effect, bolstering the clients beliefs, which may not be accurate or

481 healthy. After venting to someone for an hour that does not disagree with them or offer different points of view they will naturally believe that they are totally correct in their assertion that it is “all the other persons fault” or that they really are “being treated unfairly”. This could lead them to exasperate the situation further-which causes them to need the rescuer even more.

Identifying negative transference in clients As stated previously, transference is natural and is part of any human interaction. The practitioner need only be concerned with negative transference , which in this context means it could lead the client to develop feelings or attitudes that are harmful to the therapeutic relationship. If the massage practitioner is able to identify the warning signs of these feelings and attitudes early enough they can be redirected.

Romantic/erotic transference This is perhaps the most familiar to massage therapists as it is generally addressed in the core training.

Romantic/erotic transference warning signs The following list of possible indicators of romantic/erotic transference is gender neutral (applies to men or women) and is intended as a reference only. Some of these could be purely innocent, but if more than one occurs with the same individual there is a good chance they are developing inappropriate feelings in your therapeutic relationship.

Does your client: Come to the massage appointment “dressed up”.

482 Bring you small, thoughtful gifts for no reason. Asks you to attend purely social functions. Makes persistent inquires into your social life. Undrape themselves ‘accidentally’ in session.

Redirecting romantic/erotic transference Should you believe that your client is experiencing romantic/erotic transference it is your ethical responsibility to attempt to redirect this thought or cease treatment, referring the client to another therapist.

This should be done tactfully and professionally. In many cases, a straightforward conversation may be all that is needed to redirect the situation.

The emphasis on separating professional and private life leaves no ambiguity. While it may sound a little rude, it clearly defines the boundaries while gently pointing out to the client that they are attempting to cross them. If done early enough, this may redirect any thoughts the client may have, and while transference may still occur, you are not facilitating it.

483 In any of these situation the massage therapist should immediately end the session and have a very frank discussion of boundaries. Let the client know that you will no long be able to serve him or her effectively and make a referral to another massage professional.

Remember, it is unethical for you to have a romantic or sexual relationship with a client-and to do so would put your license at risk.

Pain/resentment in transference More common with physical therapists but still a factor for massage practitioners, clients can transfer feelings of pain and resentment to their therapist when they are dealing with treatments that are uncomfortable.

Pain/resentment transference warning signs This type of transference will be apparent in the attitude and language of your client.

Does your client: Make sarcastic remarks during your sessions. Ask if the treatment is necessary. Accuse you of using more pressure then necessary.

Redirecting pain/resentment transference If you are feeling hostility from your client and you believe that the cause of it is Pain/Resentment Transference you can address it by educating your client on the nature of the physical condition you are treating. As this type of massage is most frequently done in rehabilitation centers or physical therapy offices this could be as easy as sitting down with the client’s file and reviewing the information with him/her. Remind them that it is actually the injury that is causing their discomfort and that you are in fact helping them recover from it. This may have to be done several times, but this type of verbal redirection can help them realign their thoughts. Remember that transference occurs on an unconscious level, and that by bringing it to the forefront of their mind you are making them aware of the issue.

Countertransference and the Drama Triangle If you have a client that routinely talks out his/her stress while on the table and more often then not the source of that stress is another person you are being drawn into the drama triangle . This only becomes a problem when

484 the client begins to see the massage practitioner as a person they can turn to outside of the massage session.

The Drama Triangle Warning Signs This type of transference will be apparent if your client displays the following behaviors.

Breaking out of the Drama Triangle If you find yourself in this situation the first step is to take yourself out of the triangle, the second is to reestablish the boundaries.

If your client has agreed to relax during their session and not talk about their stressor you have succeed in taking yourself out of the triangle. The

485 next step is to reestablish the boundaries of your client practitioner relationship.

Part 2: Countertransference (the massage practitioners side)

Countertransference in therapeutic massage Up to now we have been examining the potential unconscious thoughts and feelings that a client may bring into the session, but massage practitioners also have these thoughts and feelings that can be directed towards our clients. It is just as important to recognize these feelings in us and to deal with them appropriately.

Countertransference occurs when the massage therapist begins to direct unconscious thoughts and feelings toward their client.

As stated previously, transference and countertransference is a normal human psychological phenomenon-it happens to all of us to a greater or lesser degree. It only becomes a problem when we allow it to distort or interfere with our professional therapeutic relationships. The most important factor in avoiding negative countertransference issues is self- awareness . If we are aware of our feelings and thoughts about our clients we are able to maintain proper boundaries at all times.

Assess your feelings As a massage therapist you are going to have feelings about your clients. You will have clients you like, and clients that you do not. That is natural and unavoidable, and it happens to all of us.

To avoid countertransference issues you should assess your feelings toward your clients. Be honest with yourself, your feelings are natural and

486 a part of you-even if you do not like them, it’s all right to have them. Recognizing them is the key to managing them. Use the tools on the following pages to perform an assessment of two of your clients, one you like and one you do not. (If you do not have a client that you do not like you are a very lucky massage therapist!)

Do you do anything different for the client you like or do not like? Be honest!

It is not uncommon to give extra time, discounts or similar preferential treatment to clients we like and to not do the same for clients we do not like. Is this wrong? Not necessarily, after all, there is nothing wrong with rewarding a good client by giving them extra time on the table, but you need to be aware of your feelings and to bring them to the conscious part of your mind.

Client Feeling Assesment Tool

Client I like: ______Client I don’t like: ______

Reasons why Reasons why

1)______1)______

2)______2)______487

3)______3)______

Romantic/erotic Countertransference As stated in part 1, many people associate the sensual and nurturing touch of massage with romance and eroticism. Even though we are professional body workers we are still human and as such are naturally subject to sexual attraction.

It is important that we recognize these thoughts and feelings early and make a deliberate effort to not dwell on them.

You do not have to deny your attraction to a client, but you should be aware that your Romantic/Erotic feelings could have a subtle influence on your professional judgment.

Familial Countertransference

488 Of course not all countertransference issues stem from Romantic/Erotic feelings. It is just as easy to feel strongly toward a client that reminds you of a beloved family member, a good friend or a former mentor. Could these feelings be leading you to compromise your judgment by offering unreasonable discounts, agreeing to therapy that might be contraindicated so as to not disappoint them, etc?

Ineffectiveness and Counteransference There are many physical conditions that are beyond the ability of the massage therapist to treat and this can cause frustration for the practitioner.

A similar source of frustration is with the client that continually injures the same area, as with professional athletes.

When we are working with someone who repeatedly causes damage to their body it is easy for us to resent that on an unconscious level.

Remember, it’s ok to have positive or negative feelings toward your clients, that is what makes you human . Behaving in a consistent manner with both, and not letting it interfere with your treatment is what makes you a professional .

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490 Chapter 2: Sensory memory and emotions There can be no doubt that massage therapy is a sensual experience. It’s not just the touch and feel of a therapist manipulating the tissues, most of the other senses are stimulated to a lesser degree as well.

Your massage room has an atmosphere, an environment that can trigger memories in your client, either consciously or subconsciously. Each of our senses has a memory of it’s own, it’s called sensory memory (SM) and it can trigger emotional reactions by association.

During every moment of a person’s life, sensory information is being taken in by sensory receptors and processed by the nervous system. The information people received which is stored in sensory memory is just long enough to be transferred to short-term memory. Humans have five main senses: sight, hearing, taste, smell, touch. Sensory memory allows individuals to retain impressions of sensory information after the original stimulus has ceased. A common demonstration of SM is a child's ability to write letters and make circles by twirling a sparkler at night. When the sparkler is spun fast enough, it appears to leave a trail which forms a continuous image. This "light trail" is the image that is represented in the visual sensory store known as iconic memory. The other two types of SM that have been most extensively studied are echoic memory, and haptic memory; however, it is reasonable to assume that each physiological sense has a corresponding memory store. Children for example have been shown to remember specific "sweet" tastes during incidental learning trials but the nature of this gustatory store is still unclear.

SM is considered to be outside of cognitive control and is instead an automatic response. The information represented in SM is the "raw data" which provides a snapshot of a person's overall sensory experience. Common features between each sensory modality have been identified; however, as experimental techniques advance, exceptions and additions to these general characteristics will surely evolve. The auditory store, echoic memory, for example, has been shown to have a temporal characteristic in which the timing and tempo of a presented stimulus affects transfer into more stable forms of memory. Four common features have been identified for all forms of SM:

The formation of a SM trace is independent of attention to the stimulus.

491 The information stored in SM is modality specific. This means for example, that echoic memory is for the exclusive storage of auditory information, and haptic memory is for the exclusive storage of tactile information. Each SM store represents an immense amount of detail resulting in very high resolution of information.

Each SM store is very brief and lasts a very short period of time. Once the SM trace has decayed or is replaced by a new memory, the information stored is no longer accessible and is ultimately lost. All SM stores have slightly different durations which is discussed in more detail on their respective pages.

It is widely accepted that all forms of SM are very brief in duration; however, the approximated duration of each memory store is not static. Iconic memory for example has an average duration of 500 ms which tends to decrease with age. The SM is made up of spatial or categorical stores of different kinds of information, each subject to different rates of information processing and decay. Genetics also play a role in SM capacity; mutations to the brain-derived neurotrophic factor (BDNF), a nerve growth factor, and N-methyl-D-aspartate (NMDA) receptors, responsible for synaptic plasticity, decrease iconic and echoic memory capacities respectively.

Types of Sensory Memory Iconic memory (What we see) Olfactory memory (What we smell) Echoic memory (What we hear) Haptic memory (What we feel)

Iconic Memory Iconic memory is the visual sensory memory (SM) register pertaining to the visual domain and a fast-decaying store of visual information. It is a component of the visual memory system which also includes visual short- term memory (VSTM) and long-term memory (LTM). Iconic memory is described as a very brief (<1000 ms), pre-categorical, high capacity memory store. It contributes to VSTM by providing a coherent representation of our entire visual perception for a very brief period of time. Iconic memory assists in accounting for phenomena such as change blindness and continuity of experience during saccades. Iconic memory is no longer thought of as a single entity but instead, is composed of at least two distinctive components. Classic experiments including Sperling's partial

492 report paradigm as well as modern techniques continue to provide insight into the nature of this SM store.

The occurrence of a sustained physiological image of an object after its physical offset has been observed by many individuals throughout history. One of the earliest documented accounts of the phenomenon was by Aristotle who proposed that afterimages were involved in the experience of a dream. Natural observation of the light trail produced by glowing ember at the end of a quickly moving stick sparked the interest of researchers in the 1700s and 1800s. They became the first to begin empirical studies on this phenomenon which later became known as visible persistence. In the 1900s, the role of visible persistence in memory gained considerable attention due to its hypothesized role as a pre-categorical representation of visual information in VSTM. In 1960, George Sperling began his classic partial-report experiments to confirm the existence of visual sensory memory and some of its characteristics including capacity and duration. It was not until 1967 that Ulric Neisser termed this quickly decaying memory store iconic memory. Approximately 20 years after Sperling’s original experiments, two separate components of visual sensory memory began to emerge: visual persistence and informational persistence. Sperling’s experiments mainly tested the information pertaining to a stimulus, whereas others such as Coltheart performed directs tests of visual persistence. In 1978, Di Lollo proposed a two-state model of visual sensory memory. Although it has been debated throughout history, current understanding of iconic memory makes a clear distinction between visual and informational persistence which are tested differently and have fundamentally different properties. Informational persistence which is the basis behind iconic memory is thought to be the key contributor to visual short term memory as the precategorical sensory store.

The two main components of iconic memory are visible persistence and informational persistence. The first is a relatively brief (150 ms) pre- categorical visual representation of the physical image created by the sensory system. This would be the "snapshot" of what the individual is looking at and perceiving. The second component is a longer lasting memory store which represents a coded version of the visual image into post-categorical information. This would be the "raw data" that is taken in and processed by the brain. A third component may also be considered which is neural persistence: the physical activity and recordings of the

493 visual system. Neural persistence is generally represented by neuroscientific techniques such as EEG and fMRI.

Visible persistence is the phenomenal impression that a visual image remains present after its physical offset. This can be considered a by- product of neural persistence. Visible persistence is more sensitive to the physical parameters of the stimulus than informational persistence which is reflected in its two key properties:

1. The duration of visible persistence is inversely related to stimulus duration. This means that the longer the physical stimulus is presented for, the faster the visual image decays in memory.

2. The duration of visible persistence is inversely related to stimulus luminance. When the luminance, or brightness of a stimulus is increased, the duration of visible persistence decreases. Due to the involvement of the neural system, visible persistence is highly dependent on the physiology of the photoreceptors and activation of different cell types in the visual cortex. This visible representation is subject to masking effects whereby the presentation of interfering stimulus during, or immediately after stimulus offset interferes with one’s ability to remember the stimulus.

Different techniques have been used to attempt to identify the duration of visible persistence. The Duration of Stimulus Technique is one in which a probe stimulus (auditory "click") is presented simultaneously with the onset, and on a separate trial, with the offset of a visual display. The difference represents the duration of the visible store which was found to be approximately 100-200 ms. Alternatively, the Phenomenal Continuity and Moving Slit Technique estimated visible persistence to be 300 ms. In the first paradigm, an image is presented discontinuously with blank periods in between presentations. If the duration is short enough, the participant will perceive a continuous image. Similarly, the Moving Slit Technique is also based on the participant observing a continuous image. Only instead of flashing the entire stimulus on and off, only a very narrow portion or "slit" of the image is displayed. When the slit is oscillated at the correct speed, a complete image is viewed.

Underlying visible persistence is neural persistence of the visual sensory pathway. A prolonged visual representation begins with activation of

494 photoreceptors in the retina. Although activation in both rods and cones has been found to persist beyond the physical offset of a stimulus, the rod system persists longer than cones. Other cells involved in a sustained visible image include M and P retinal ganglion cells. M cells (transient cells), are active only during stimulus onset and stimulus offset. P cells (sustained cells), show continuous activity during stimulus onset, duration, and offset. Cortical persistence of the visual image has been found in the primary visual cortex (V1) in the occipital lobe which is responsible for processing visual information.

Information persistence represents the information about a stimulus that persists after its physical offset. It is visual in nature, but not visible. Sperling's experiments were a test of informational persistence. Stimulus duration is the key contributing factor to the duration of informational persistence. As stimulus duration increases, so does the duration of the visual code. The non-visual components represented by informational persistence include the abstract characteristics of the image, as well as its spatial location. Due to the nature of informational persistence, unlike visible persistence, it is immune to masking effects. The characteristics of this component of iconic memory suggest that it plays the key role in representing a post-categorical memory store for which VSTM can access information for consolidation.

Although less research exists regarding the neural representation of informational persistence compared to visual persistence, new electrophysiological techniques have begun to reveal cortical areas involved. Unlike visible persistence, informational persistence is thought to rely on higher-level visual areas beyond the visual cortex. The anterior superior temporal sulcus (STS), a part of the ventral stream, was found to be active in macaques during iconic memory tasks. This brain region is associated with object recognition and object identity. Iconic memory’s role in change detection has been related to activation in the middle occipital gyrus (MOG). MOG activation was found to persist for approximately 2000ms suggesting a possibility that iconic memory has a longer duration than what was currently thought. Iconic memory is also influenced by genetics and proteins produced in the brain. Brain-derived neurotrophic factor (BDNF) is a part of the neurotrophin family of nerve growth factors. Individuals with mutations to the BDNF gene which codes for BDNF have been shown to have shortened, less stable informational persistence.

495 Iconic memory provides a smooth stream of visual information to the brain which can be extracted over an extended period of time by VSTM for consolidation into more stable forms. One of iconic memory's key roles is involved with change detection of our visual environment which assists in the perception of motion.

Iconic memory enables integrating visual information along a continuous stream of images, for example when watching a movie. In the primary visual cortex new stimuli do not erase information about previous stimuli. Instead the responses to the most recent stimulus contain about equal amounts of information about both this and the preceding stimulus. This one-back memory may be the main substrate for both the integration processes in iconic memory and masking effects. The particular outcome depends on whether the two subsequent component images (i.e., the “icons”) are meaningful only when isolated (masking) or only when superimposed (integration).

The brief representation in iconic memory is thought to play a key role in the ability to detect change in a visual scene. The phenomenon of change blindness has provided insight into the nature of the iconic memory store and its role in vision. Change blindness refers to an inability to detect differences in two successive scenes separated by a very brief blank interval, or interstimulus interval (ISI). As such change blindness can be defined as being a slight lapse in iconic memory. When scenes are presented without an ISS, the change is easily detectable. It is thought that the detailed memory store of the scene in iconic memory is erased by each ISS, which renders the memory inaccessible. This reduces the ability to make comparisons between successive scenes.

It has been suggested that iconic memory plays a role in providing continuity of experience during saccadic eye movements. These rapid eye movements occur in approximately 30 ms and each fixation lasts for approximately 300 ms. Research suggests however, that memory for information between saccades is largely dependent on VSTM and not iconic memory. Instead of contributing to trans-saccadic memory, information stored in iconic memory is thought to actually be erased during saccades. A similar phenomenon occurs during eye-blinks whereby both automatic and intentional blinking disrupts the information stored in iconic memory.

496 The development of iconic memory begins at birth and continues as development of the primary and secondary visual system occurs. By 6 months of age, infants' iconic memory capacity approaches adults' By 5 years of age, children have developed the same unlimited capacity of iconic memory that adults possess (ref needed). The duration of informational persistence however increases from approximately 200 ms at age 5, to an asymptotic level of 1000 ms as an adult (>11 years). A small decrease in visual persistence occurs with age. A decrease of approximately 20 ms has been observed when comparing individuals in their early 20's to those in their late 60's. Throughout one’s lifetime, mild cognitive impairments (MCIs) may develop such as errors in episodic memory (autobiographical memory about people, places, and their contex), and working memory (the active processing component of STM) due to damage in hippocampal and association cortical areas. Episodic memories are autobiographical events that a person can discuss. Individuals with MCIs have be found to show decreased iconic memory capacity and duration. Iconic memory impairment in those with MCIs may be used as a predictor for the development of more severe deficits such as Alzheimer's disease and dementia later in life.

Olfactory memory Olfactory memory refers to the recollection of odors. Studies have found various characteristics of common memories of odor memory including persistence and high resistance to interference. Explicit memory is typically the form focused on in the studies of olfactory memory, though implicit forms of memory certainly supply distinct contributions to the understanding of odors and memories of them. Research has demonstrated that the changes to the olfactory bulb and main olfactory system following birth are extremely important and influential for maternal behavior. Mammalian olfactory cues play an important role in the coordination of the mother infant bond, and the following normal development of the offspring. Maternal breast odors are individually distinctive, and provide a basis for recognition of the mother by her offspring.

497 Alzheimer's disease and dementia. These individuals lose the ability to distinguish smells as their disease worsens. There is also research showing that deficits in olfactory memory can act as a base in assessing certain types of mental disorders such as depression as each mental disorder has its own distinct pattern of olfactory deficits.

An odorant is a physiochemical molecule that binds to a specific receptor protein. In mammals, each olfactory receptor protein has one type of molecule that it responds to, known as the one-olfactory-one-neuron rule, and approximately one thousand kinds of which have been identified. Structure and complexity constitute an odorant’s features, with changes resulting in altered odorant quality. An odorant’s features are detected by the olfactory system’s glomeruli and mitral cells which can be found in the olfactory bulb, a cortical structure involved in the perceptual differentiation of odorants. The olfactory bulb itself affects how odors come to be encoded through its temporal structure and firing rate, which in turn influences the likelihood of an odorant being remembered.

Neuromodulation exists in the olfactory system and is responsible for neural plasticity and behavioral change in both mammals and insects. In the context of olfactory memory, neuromodulators regulate storage of information in a way that maintains the significance of the olfactory experience. These systems are highly dependent on norepinephrine and acetylcholine, which affect both implicit and explicit memory. Studies involving the noradrenergic system of mice demonstrate elimination of habitual learning when areas involving this system are lesioned, and subsequent restoration of habitual learning abilities when noradrenaline is injected into the olfactory bulb. The importance of cholinergic systems has been demonstrated in studies of rats and the effects of scopolamine, with acetylcholine being involved in initial learning stages and more specifically in the reduction of interference between stored memories.

Implicit memories of stimuli do not require conscious recollection of the initial encounter of the stimulus. In regards to olfactory memory, deliberate recollection of an odor experience is not necessary in order for implicit memories of odors to form in the brain. Techniques used to study implicit olfactory memory are considered to be applicable to both humans and animals. In tests of implicit memory, memory of a stimulus is shown to be aided by previous exposure to that same stimulus. Evidence of the formation of implicit memory is found in tests of habituation, sensitization,

498 perceptual learning and classical conditioning. In olfaction there exists a strong tendency for habituation, which is discussed further in the following paragraph. By evaluating memory performance of tasks involving one of these ‘subsets’ of implicit memory, the effect of previous odor stimulus experience not involving conscious recollection can be measured. Further knowledge can be gained about implicit memory of odor through the study of the implications of cognitive deficits. The effects of brain injury on odor memory can be investigated through the use of these implicit memory measures leading to further overall understanding of the brain.

Habituation involves decreased levels of attention and responsiveness to a stimulus that is no longer perceived as being novel. In the realm of olfactory memory, habituation refers to a decrease in responsiveness to an odor as a result of prolonged exposure (restricted to a certain repeated stimulus), which involves adaptation of cells in the olfactory system. Receptor neurons and mitral cells located in the olfactory system adapt in response to odors. This includes the involvement of piriform cortical neurons which adapt rapidly, more completely and selectively to novel odors and are also thought to play a very important role in the habituation of odors. Norepinephrine is considered to have an effect on the functioning of the mitral cells by increasing their responsiveness. Acetylcholine is also regarded as an important neurotransmitter involved in the habituation of olfactory stimulus, though the exact means through which it operates are not yet clear.

Explicit, unlike implicit memory for odors, is thought by some to be a phenomenon that is exclusive to humans. Explicit memory refers to memories that are remembered with conscious awareness of doing so. In olfaction, explicit memory refers to attributing associative meaning to odors. Through the assignment of associations to odors as well as non-odor stimuli, olfactory stimuli can gain meaning. Explicit memories of odors include information which can be used to process and compare other encountered odors. Attention focused on odors aids in the functioning of everyday life as well as the engagement of proper responses to experienced events. Evidence of explicit olfaction memory is seen through behaviours in tasks involving a working memory component. The two most commonly used tests for explicit odor memory are odor identification and odor recognition, which are discussed in greater detail below.

499 Odor recognition is the most common and direct means used to measure odor memory. In an odor recognition test participants are asked whether or not they recognize an odor. More specifically, a participant is subjected to a certain olfactory-related stimulus, and after a delay period is asked to decide if a probe (a stimulus that could or could not be the same as the initial stimulus) is the same as the one he/she initially encountered. Memory accuracy is assessed by the amount of correct recognition decisions that are made. A potential problem with this measure involves the generation of verbal labels that may enhance memory for olfactory stimuli. There are various ways of measuring the effect of verbal labeling, which include comparison of odors and odor names, as well as the speed and accuracy with which lexical decisions are made regarding odor names. It has been suggested that odor recognition testing should be considered as a measure that involves both memory for perceptual information as well as potentially confounding memory due to the generation of verbal labels.

Odor identification requires the specific labeling of presented olfactory stimuli, unlike odor recognition. The ability of humans to verbally identify odors is very restricted despite the ability to differentiate hundreds of odors. It has been hypothesized that such poor odor identification performance is due to a weak link between odors and language. However, it is possible that this poor connection is not due to limitations imposed by the human olfactory system, but by the way odors are gradually learned and because no formal education exists for the naming of odors as does for visually identifiable stimuli. The difficulty in identifying and giving a label to olfactory stimuli is known as verbal-semantic processing, and is thought to grow increasingly worse with age, consequently affecting odor recognition.

Although bilateral activation of the brain has been seen with unilateral stimulation (accomplished by placing a stimulus under one nostril only), the activation seen is not exactly equal in both hemispheres. Different parts of the brain are involved in olfactory memory, depending on what type of memory is being processed (e.g. implicit memory-habituation or explicit memory-recognition) and this is evident in the results of explicit and implicit tasks of memory. Studies have shown that the left hemisphere is activated during verbal semantic retrieval of odor-related memories, while the right hemisphere shows activation during non-verbal retrieval of semantic odor- related information. Much overlap does occur between regions, however. Information of odors of a semantic nature is distributed across both sides of the brain, although the right hemisphere is more involved in the processing

500 of odor quality and previous encounter of the stimulus than the left. Neural plasticity is also an important part of olfaction, as different experiences may result in alterations of both cortical and subcortical circuitry in the brain.

The amygdala is a complex set of nuclei situated in the anterior temporal lobe and lies beneath the primary olfactory cortex. The amygdala is involved in the formation of memories of emotional experiences, particularly those associated with fear, flight, and defense. It is connected by various pathways to other parts of the brain, but most notably to the basal forebrain which contains magnocellular cells which provide extensive input into the neocortex and hippocampus. There are also direct projections to the hippocampus from the amygdala, which are involved in the integration of various sensations into memory. Neuropsychological research has suggested that this pathway is vital for the development of olfactory memories. The primary olfactory cortex and the hippocampus have extensive connections with the amydgala through both indirect and direct pathways. It is important for an animal to create memories of olfactory stimuli which threaten its survival. Without a properly functioning amygdala, olfactory memories would not be able to form which could put an animal at risk of dangerous stimuli in its environment due its lack of memory of such stimuli.

Studies demonstrate that the changes to the olfactory bulb and main olfactory system following birth are extremely important and influential for maternal behavior. Pregnancy and childbirth result in a high state of plasticity of the olfactory system that may facilitate olfactory learning within the mother. Neurogenesis likely facilitates the formation of olfactory memory in the mother, as well as the infant. A significant change takes place in the regulation of olfaction just after birth so that odors related with the offspring are no longer aversive, allowing the female to positively respond to her babies. Research with a variety of animals suggest the role of norepinephrine in olfactory learning, in which norepinephrine neurons in the locus coeruleus send projections to neurons in the main and accessory olfactory bulbs. This is significant in the formation of olfactory memory and learning.

The main olfactory bulb is one of the neural structures that experiences profound change when exposed to offspring odors at the time of childbirth. Human neuroimaging studies suggest that activation of the medical prefrontal cortex (mPFC) occurs during tests of olfactory memory. The

501 medial prefrontal cortex receives extensive olfactory projections, which are activated immediately after birth in correspondence with primary olfactory processing regions. Although there is no functional specificity for the main or accessory olfactory systems in the development of maternal behaviors, it has been shown that the main olfactory system is affected when individual odor discrimination of the offspring is required; this system experiences significant change following exposure to offspring odors after giving birth. Changes in synaptic circuitry also contribute to the level of maternal responsiveness and memorization to these odors.

Olfactory cues play an important role in the coordination of the mother infant bond, and the following normal development of the offspring. The offspring of several different mammals are attracted to the odor of amniotic fluid, which helps to calm and adapt the infant to the novel environment outside of the womb. Sheep form olfactory recognition memory for their lambs within 2–4 hours of giving birth, which causes the mother to subsequently reject advances from unfamiliar lambs and scents. This bond is thought to be enhanced by olfactory cues that cause enhanced transmission across synapses of the olfactory bulb. After the birth of the offspring, there is a shift in the value of the infant’s odors to the mother, which causes change in neural structures such as the olfactory bulb. These changes contribute to maternal responsiveness and memorization of these odors. Olfactory cues from the baby lamb are important in establishing maternal behavior and bonding. After birth, the smell of amniotic fluid (which was previously disgusting) becomes attractive for ewes.

Amniotic fluid is one of the primary olfactory cues that the ewe is exposed to after birth, allow her to be attracted to any newborn lamb associated with that amniotic fluid. The amniotic fluid produces olfactory cues, and a response from the ewe that cause her to be attracted to the newborn lamb. When newborn lambs were washed with soap (or even water) it greatly reduced the degree of licking behavior by the maternal ewe, and consequently prevented her from displaying acceptance behavior towards the newborn. The main olfactory system in sheep is quite significant in the developing appropriate maternal behaviors in sheep.

Physiological, behavioral and anatomical evidence show that some species may have a functioning olfactory system in utero. Newborn infants respond positively to the smell of their own amniotic fluid, which may serve as evidence for intrauterine olfactory learning. Mammals’ sense of smell

502 becomes mature at an early stage of development. Fetal olfactory memory has been demonstrated in rats, for example. This is shown by rat pups, who avoid odors that they experienced in association with a noxious stimulus prior to birth. While animal studies play an important role in helping discover and learn olfaction memory of humans, it is important to pay attention to the specifics of each study, as they cannot always be generalized across all species.

Research studies provide evidence that the fetus becomes familiar with chemical cues in the intrauterine environment. Intrauterine olfactory learning may be demonstrated by behavioral evidence that newborn infants respond positively to the smell of their own amniotic fluid. Infants are responsive to the olfactory cues associated with maternal breast odors. They are able to recognize and react favorably to scents emitted from their owns mother’s breasts, despite the fact that they also may be attracted to breast odors from unfamiliar nursing females in a different context. The unique scent of the mother (to the infant) is referred to as her olfactory signature. While breasts are a source of the unique olfactory cue of the mother, infants are also able to recognize and respond with familiarity and preference to their mother’s underarm scent.

Olfactory cues are widespread within parental care to assist in the dynamic of the mother-infant relationship, and later development of the offspring. In support of fetal olfactory learning, newborn infants display behavioral attraction to the odor of amniotic fluid. For example, babies would more often suck from a breast treated with an amount of their own amniotic fluid, rather than the alternative untreated breast. Newborns are initially attracted to their own amniotic fluid because that odor is familiar. Although exposure to amniotic fluid is eliminated after birth, breast fed babies have continued contact with cues from the mother’s nipple and areola area. This causes breast odors to become more familiar and attractive, while amniotic fluid loses its positive value. Maternal breast odors are individually distinctive, and provide a basis for recognition of the mother by her offspring.

As demonstrated by animals in the wild (the great apes, for example), the offspring is held by the mother immediately after birth without cleaning and is continually exposed to the familiar odor of the amniotic fluid (making the transition from the intrauterine to extrauterine environment less overwhelming). In newborn mammals, the nipple area of the mother is significant as the sole source of necessary nutrients. The maternal olfactory

503 scent that is unique to the mother becomes associated with food intake, and newborns who do not gain access to the mother’s breasts would die shortly after birth. As a result, it seems natural selection should favor the development of a means to help in maintain and establish effective breast feeding. Maternal breast odors signal the presence of a food source for the newborn. These breast odors bring forth positive responses in neonates from as young as 1 hour or less through to several weeks postpartum. The mother’s olfactory signature is experienced with reinforcing stimuli such as food, warmth and tactile stimulation; enhancing further learning of that cue.

While infants are generally attracted to the odors produced by lactating women, infants are particularly responsive to their mother’s unique scent. These olfactory cues are used in mammals during maternal care for coordination of mother-infant interaction. Familiarization with odors that will be encountered after birth may help the baby adapt to the otherwise unfamiliar environment. Neural structures such as the olfactory bulb undergo extensive changes when exposed to infantile odors; providing a starting point for individual recognition by the mother. odors from the breasts of lactating women serve as attractants for neonates, regardless of feeding history of the infant. Maternal olfactory learning occurs due to the high state of plasticity and flux within the olfactory system during pregnancy and childbirth.

Studies of the mammalian brain have discovered that the excess of cerebral neurons is a phenomenon of mainly animals which had to seek and capture food. These neurons have become a large part of the olfactory system throughout evolution to allow higher mammals such as primates to have a better chance for survival through more advanced methods of hunting and finding food. For example, the vulture has a large part of its brain committed to olfactory senses. This allows for it to be able to detect food at long ranges without being able to see it. Having memory for various types of food aids in survival by allowing the animals to remember which scent it edible and which is not.

Olfactory memory has also been developed throughout evolution to help animals recognize other animals. It is suggested that smell allows for young infants to identify with their mothers or for humans to identify between males and females. Olfaction cues were also used, and are still used, by many animals to mark territory, protecting themselves from other threats to their survival. While the development of other sensory systems, such as the

504 visual system and auditory systems, has decreased how reliant some animals are on the olfactory system, these is still evidence that shows these animals’ olfactory systems still have a strong influence on their social interactions. The memory for specific odorants gives the animal an opportunity to communicate with members of the same species and allows for lack of communication between species that do not have the proper receptor systems for the odor. These chemical signals can also be sensed in the dark or even under water.

Olfaction is a very important aspect in sexual reproduction throughout evolution because it triggers mating behavior in many species. Pheromones as olfactory chemical signals allow for members of the same species to perceive when other members are ready for reproduction. It can also lead to the synchronization of menstrual cycles in females within the species and influence sexual attraction between members within the species. Having an unconscious memory for such processes has allowed for species to survive 59 .

The development of a sense of smell is also thought to have arisen to function as an arousal system. Once an odor enters into conscious memory, it can signal the presence of a threat, like the smell of gas or smoke. However, odor memory can also be an implicit or unconscious process. This ability to respond automatically to a warning stimulus is much like pre-attentive processes in other sensory systems which involve the use of automatic forms of memory. These response patterns have evolved over time and involve a wide variety of motor and autonomic responses which are integrated into the behaviour pattern of reacting to a warning stimulus. odor-induced anxiety can be caused when an animal senses a predator. A study conducted on rats showed that when a rat was exposed to cat odors, there was increased anxiety-related behaviour in the rat. The cat odor induced an inhibition of the endocannabinoid system in the amygdala which has been suggested to induce anxiety-related responses.

Olfactory memory deficits can be significant indications of a number of things going on within the brain. There is evidence to suggest that certain mental disorders produce olfactory deficits and olfactory deficits can in turn be a significant predictor of mental disorders. An example of two mental disorders that have significant deficits in olfactory memory are Alzheimer's

59 Goldstein, Bruce E. 2002. Sensation and Perception: 6th Edition. Pacific Grove CA: Wadsworth Group. P 475.

505 disease and Dementia. Some other olfactory deficits have been discovered in vascular dementia, dementia with Lewy bodies, Parkinson's disease, and Huntington's disease. There is also evidence to suggest that certain brain altering drugs such as anti-depressants produce deficits in olfactory memory.

Many tests have been developed to test olfactory memory in patients with mental disorders such as the Brief Smell Identification Test where participants with dementia underwent a twelve-part smell identification test which found that as dementia worsens so does the ability to distinguish smells. In testing the effects of anti-depressants on olfactory sensitivity in mice, the “mice were tested in a Y-maze with a choice between an odorant (butanol) or distilled water before and during 3 weeks of dailyintra- peritoneal injection of either citalopram or clomipramine. Their performance was compared with those of a control group injected with a saline solution” and the results were that significant olfactory deficits were found during the three-week period of testing.

Olfactory deficits have been found in patients suffering from mental disorders and there is evidence suggesting that olfactory deficits can be a predictor of mental illness and disease. Research suggests that olfactory memory deficits can be good predictors of several mental disorders such as depression, dementia and neurodegeneration, as each disorder has its own distinct features leading to specific predictions about what type of mental disorder a person may have 60 .

In a massage practice: For those of you that use Aromatherapy and/or scented candles in your massage practice, be aware that strong scents can elicit strong memories associated with them.

The same goes for perfume or cologne. What if the perfume you are wearing is the favorite of your massage client’s ex-wife? Or what if the cologne you are wearing is the same one favored by a young ladies abusive boyfriend?

60 Atanasova. B, 2008. Olfaction: A potential cognitive marker of psychiatric disorder. Neuroscience and Biobehavioral Reviews 32 (2008) 1315–1325.

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Echoic Memory Echoic memory is one of the sensory memory registers; a component of sensory memory (SM) that is specific to retaining auditory information. The sensory memory for sounds that people have just perceived is the form of echoic memory. Unlike visual memory, in which our eyes can scan the stimuli over and over, the auditory stimuli cannot be scanned over and over. Overall, echoic memories are stored for slightly longer periods of time than iconic memories (visual memories). Auditory stimuli are received by the ear one at a time before they can be processed and understood. For instance, hearing the radio is very different from reading a magazine. A person can only hear the radio once at a given time, while the magazine can be read over and over again. It can be said that the echoic memory is like a "holding tank" concept, because a sound is unprocessed (or held back) until the following sound is heard, and only then can it be made meaningful. This particular sensory store is capable of storing large amounts of auditory information that is only retained for a short period of time (3–4 seconds). This echoic sound resonates in the mind and is replayed for this brief amount of time shortly after the presentation of auditory stimuli. Echoic memory encrypts only moderately primitive aspects of the stimuli, for example pitch, which specifies localization to the non- association brain regions.

Shortly after George Sperling’s partial report studies of the visual sensory memory store, researchers began investigating its counterpart in the auditory domain. The term echoic memory was coined in 1967 by Ulric Neisser to describe this brief representation of acoustic information. It was initially studied using similar partial report paradigms to those utilized by Sperling; however, modern neuropsychological techniques have enabled the development of estimations of the capacity, duration, and location of the echoic memory store. Using Sperling's model as an analogue, researchers continue to apply his work to the auditory sensory store using partial and whole report experiments. They found that the echoic store has a duration of up to 4 seconds, and in the absence of interference has been shown to last up to 20 seconds. However, different durations have been proposed for the existing echo once the hearing signal has been presented. Guttman and Julesz suggested that it may last approximately one second or less, while Eriksen and Johnson suggested that it can take up to 10 seconds.

507 Baddeley's model of working memory consists of the visuospatial sketchpad which is related to iconic memory, and a phonological loop which attends to auditory information processing in two ways. The first is a phonological store which has the capacity to retain information for 3-4 seconds before decay, which is a much longer duration than iconic memory (which is less than 1000ms). The second is a sub-vocal rehearsal process to keep refreshing the memory trace by the using one’s "inner voice". However, this model fails to provide a detailed description of the relationship between the initial sensory input and ensuing memory processes.

A short-term memory model proposed by Nelson Cowan attempts to address this problem by describing a verbal sensory memory input and storage in more detail. It suggests a pre-attentive sensory storage system that can hold a large amount of accurate information over a short period of time and consists of an initial phase input of 200-400ms and a secondary phase that transfers the information into a more long term memory store to be integrated into working memory that starts to decay after 10-20s.

Following Sperling's (1960) procedures on iconic memory tasks, future researchers were interested in testing the same phenomenon for the auditory sensory store. Echoic memory is measured by behavioural tasks where participants are asked to repeat a sequence of tones, words, or syllables that were presented to them, usually requiring attention and motivation. The most famous partial report task was conducted by presenting participants with an auditory stimulus in the left, right, and both ears simultaneously. Then they were asked to report spatial location and category name of each stimulus. Results showed that spatial location was far easier to recall than semantic information when inhibiting information from one ear over the other. Consistent with results on iconic memory tasks, performance on the partial report conditions were far superior to the whole report condition. In addition, a decrease in performance was observed as the interstimulus interval(ISI) (length of time between presentation of the stimulus and recall) increased.

Auditory backward recognition masking (ABRM) is one of the most successful tasks in studying audition. It involves presenting participants with a brief target stimulus, followed by a second stimulus (the mask) after an (ISI). The amount of time the auditory information is available in memory is manipulated by the length of the ISI. Performance as indicated by

508 accuracy of target information increases as the ISI increased to 250 ms. The mask doesn’t affect the amount of information obtained from the stimulus, but it acts as interference for further processing.

A more objective, independent task capable of measuring auditory sensory memory that does not require focused attention are mismatch negativity (MMN) tasks, which record changes in activation in the brain by use of electroencephalography (EEG). This records elements of auditory event- related potentials (ERP) of brain activity elicited 150-200ms after a stimulus. This stimulus is an unattended, infrequent, "oddball" or deviant stimulus presented among a sequence of standard stimuli, thereby comparing the deviant stimulus to a memory trace.

Auditory sensory memory has been found to be stored in the primary auditory cortex contralateral to the ear of presentation. This echoic memory storage involves several different brain areas, due to the different processes it is involved in. The majority of brain regions involved are located in the prefrontal cortex (PFC) as this is where the executive control is located, and is responsible for attentional control. The phonological store and the rehearsal system appear to be a left-hemisphere based memory system as increased brain activity has been observed in these areas. The major regions involved are the left posterior ventrolateral prefrontal cortex (VLPFC), the left premotor cortex (PMC), and the left posterior parietal cortex (PPC). Within the VLPFC, Broca’s area is the main location responsible for verbal rehearsal and the articulatory process. The dorsal PMC is used in rhythmic organization and rehearsal, and finally the PPC shows a role in localizing objects in space.

The cortical areas in the brain believed to be involved with auditory sensory memory exhibited by MMN response have not been localized specifically. However results have shown comparative activation in the superior temporal gyrus (STG) and in the inferior temporal gyrus (ITG).

Age-related increases in activation within the neural structures responsible for echoic memory have been observed showing that with age comes increased proficiency in the processing auditory sensory information.

Findings of a (MMN) study, also suggest that the duration of auditory sensory memory increases with age, significantly between the ages of two and six years old from 500-5000ms. Children 2 years of age exhibited an

509 MMN response in ISI between 500ms and 1000ms. Children 3 years old have a MMN response from 1 to 2 seconds, 4 year olds over 2 seconds, and 6 year old children from 3 to 5 seconds. These developmental and cognitive changes and that occur at a young age, and extends into adulthood until eventually decreasing again at old age.

Researchers have found shortened echoic memory duration in former late talkers (LT’s), children with Precordial catch syndrome (PCS), and oral clefts, with information decaying before 2000 ms. However this reduced echoic memory is not predictive for language difficulties in adulthood.

In a study, it was found that when words were presented to both younger subjects and adult subjects, that the younger subjects out perform the adult subject as the rate in which the words are presented is increased

Affect echoic memory capacity seems to be independent of age.

Children with deficits in auditory memory have been shown to have developmental language disorders. These problems are difficult to assess since performance could be due to their inability to understand a given task, rather than a problem with their memory.

People with attributed unilateral damage to the dorsolateral prefrontal cortex and temporal-parietal cortex after experiencing a stroke were measured using the a MMN test. For the control group the MMN amplitude was largest in the right hemisphere regardless if the tone was presented in the right or left ear.

MMN was greatly reduced for temporal-parietal damaged patients when the auditory stimulus was presented to the contralateral ear of the lesion side of the brain. This adheres to the theory of auditory sensory memory being stored in the contralateral auditory cortex of ear presentation. Further research on stroke victims with a reduced auditory memory store has shown that listening to daily music or audio books improved their echoic memory. This shows a positive effect of music in neural rehabilitation after brain damage.

I had a touching personal experience with echoic memory related transference in my massage practice. I had a client that was a regular; she came in once a week for a one hour Swedish massage. She was a bank

510 manager, very professional and highly composed. She was a boss and a powerful lady-always in a rush when she came in and she always left quietly afterwards, she wasn’t the kind of client that liked to sit around and “waste time”.

One day she began to cry softly in the middle of her massage. I fetched her some tissue and asked her if she would like to stop the massage or if there was anything I could do and she replied no-she said she became very sad and she didn’t know why. She was not an emotional person by nature and was a little confused.

We continued the massage and when she finished dressing afterwards she sat down with me in my lobby and explained that she figured out why she started crying. The music CD I was playing (your typical Massage/Meditation new age type of music) was the exact same CD the funeral home played in the background at the viewing and memorial service for her father. She figured it out toward the end of the massage.

Haptic Memory Haptic memory is a form of sensory memory that refers to the recollection of data acquired by touch after a stimulus has been presented. Haptic memory is used regularly when assessing the necessary forces for gripping and interacting with familiar objects. It may also influence one’s interactions with novel objects of an apparently similar size and density. Similar to visual iconic memory, traces of haptically acquired information are short lived and prone to decay after approximately two seconds. Haptic memory is best for stimuli applied to areas of the skin that are more sensitive to touch. Haptics can be classified as a type of perceptual system which involves two subsystems; cutaneous and kinesthetic. The former refers to anything that is skin related, whereas the latter is muscle sense. Haptics involves active, manual examination and is quite capable of processing the material traits of surfaces or objects.

Perhaps the first experiment conducted to study the phenomenon of haptic memory was that of Bliss, Crane, Mansfield, and Townsend who investigated the characteristics of immediate recall for brief tactile stimuli applied to the hand. The results obtained showed a haptic memory store remarkably similar to the visual memory store suggested by Sperling in 1960, with a capacity of approximately four to five items. Similar to tests of visual sensory memory, it was also found that haptic memory performance

511 was significantly improved with the use of partial report procedures. This particular finding is consistent with more recent research by Gallace in 2008. Bliss et al. interpreted this difference in partial report versus whole report as a sensory form of memory for passively presented tactile stimuli with a high capacity and short duration. Additional support for the short duration of haptic memory comes from studies by Gilson and Baddeley in 1969. According to these studies, memory for stimuli applied to the skin is resilient for approximately ten seconds after removal of the stimulus, even when the individual is engaged in tasks that inhibit verbal rehearsal. After this delay, the memory trace becomes vulnerable to forgetting as it decays from the haptic memory store and begins to rely on a more central memory store. Similar findings were later reported by Miles and Borthwick in 1996, who emphasized the role of tactile interference on discriminability of the target location and the role of central processing resources in consolidation of haptic memory. More recent experimental procedures and technologies such as minielectrode recording devices and transcranial magnetic stimulation have allowed for mapping of brain areas involved in the storage of tactile memories. Implicated in most of these studies is the primary somatosensory cortex. More recent studies have also investigated a broader selection of participants, allowing for the discovery of an intact haptic memory in infants.

Tactile memories are organized somatotopically, following the organization of the somatosensory cortex. This means that areas close on the body surface receive nervous signals from areas that are close together on the brain surface. Several distinct areas of the parietal lobe are responsible for contributing to different aspects of haptic memory. Memory for the properties of stimuli such as roughness, spatial density, and texture involves activation of the parietal operculum. Properties of stimuli such as size and shape, as detected by touch receptors in the skin, are stored in the anterior part of the parietal lobe. Memory for spatial information such as the location of stimuli involves the right superior parietal lobule and temporoparietal junction. Additional neuroimaging data has been provided by studies using microelectrodes implanted in the somatosensory cortex of monkeys. When performing a delayed match to sample task with objects of identical dimensions but different surface features, activity is observed in somatosensory neurons during perception and in the short-term memory for tactile stimuli.

512 According to a study done by Bruce V. DiMattia, Keith A. Posley and Joaquin M. Fuster, it was found that monkeys were quite capable of concurrent Visual-to-Haptic as well as Haptic-to-Visual crossmodal matching of objects by size, shape and texture. It was also discovered that they were more adept at performing cross modal matching in the Visual-to- Haptic direction.

Memory is important in infancy as it forms the basis for more complex procedures such as learning and reasoning. Studies of haptic memory in infants is particularly useful because it allows researchers to study the more perceptual representation of information as opposed to verbal or semantic aspects. Haptic abilities develop in stages in infants: The last two decades have allowed researchers to study the sensory system of infants which gives an insight to the initial stages of thinking, deciding and reasoning in a human brain.

Newborn: Haptic ability develops in the mouth, as it is essential for feeding.

1 month of age: Recognition of texture and shape

2 months of age: Recognition of familiar objects after 30 second delay

4 months of age: Recognize familiar objects after 2 minute delay

Evidence of haptic memory was discovered in infants as young as two months by Myriam Lhote and Arlette Streti, who demonstrated that haptic habituation occurs asymmetrically between the hands of infants, and that differences in haptic memory exist between sexes. For instance, in 2- month-old infants, haptic habituation was found in both the right and the left hand. Babies were able to encode haptically some characteristics or features of objects without visual control with their left hand as well as with their right hand. In the experiment, haptic habitutation was formed through an occurred stimuli and at the end, it has seen that even though stimuli was not present, infants still carry on their stimuli habit. It was also shown that infantile haptic memory is robust in that it is somewhat resistant to delays (especially in males). These findings support earlier results by Catherwood, which stated that 8-month-old infants were able to recognize a familiar shape after a five minute delay. Studies by Millar on congenitally blind and blindfolded children have revealed the importance of movement and body-

513 centered cues in haptic memory. While these cues are important in all individuals, blind children tend to rely on them heavily.

Furthermore, it is proven that our haptic cues and memory affects our visual experience and the two experiences are linked for us to comprehend our surroundings.

Implicit memory can be referred to as the unconscious recollection of previously presented information. This type of memory influences one’s actions and behaviors without the individual having any awareness of its availability for explicit recall. Implicit memory has been linked to phenomena such as skill acquisition, priming, and classical conditioning. In some cases, tactile information is also remembered implicitly. Evidence for this comes from patients with damage to the right cerebral hemisphere, who, due to their brain damage, are unable to explicitly report any of the qualities of objects held in their left hand when another object is simultaneously presented in their right hand. Despite this fact, when the patients are asked to compare the characteristics of objects presented to either hand, their judgements are influenced by objects previously held in their right hand. This suggests that the patients have some memory for the properties of objects recently removed from their right hand that they are not consciously aware of, and that this memory is affecting their accuracy on subsequent tasks. Similar evidence has been found in healthy individuals of varying ages, and in patients with Alzheimer’s disease.

SM is not involved in higher cognitive functions such as consolidation of memory traces or comparison of information. Likewise, the capacity and duration of SM cannot be influenced by top-down control; a person cannot consciously think or choose what information is stored in SM, or how long it will be stored for. The role of SM is to provide a detailed representation of our entire sensory experience for which relevant pieces of information can be extracted by short-term memory (STM) and processed by working memory (WM). STM is capable of storing information for 10–15 seconds without rehearsal while working memory actively processes, manipulates, and controls the information. Information from STM can then be consolidated into long-term memory where memories can last a lifetime. The transfer of SM to STM is the first step in the Atkinson–Shiffrin memory model which proposes a structure of memory.

514 Flashbacks A flashback, or involuntary recurrent memory, is a psychological phenomenon in which an individual has a sudden, usually powerful, re- experiencing of a past experience or elements of a past experience. These experiences can be happy, sad, exciting, or any other emotion one can consider. The term is used particularly when the memory is recalled involuntarily, and/or when it is so intense that the person "relives" the experience, unable to fully recognize it as memory and not something that is happening in "real time".

Flashbacks are the "personal experiences that pop into your awareness, without any conscious, premeditated attempt to search and retrieve this memory" These experiences occasionally have little to no relation to the situation at hand. Flashbacks to those suffering posttraumatic stress disorder can be so disruptive as to seriously affect day-to-day living.

Memory is divided into voluntary (conscious) and involuntary (unconscious) processes that function independently of each other. Theories and research on memory dates back to Hermann Ebbinghaus, who began studying nonsense syllables. Ebbinghaus classified three distinct classes of memory: sensory, short term, and long-term memory. Sensory memory is made up of a brief storage of information within a specific medium (the line you see after waving a sparkler in your field of vision is created by sensory memory). Short term memory is made up of the information currently in use to complete the task at hand. Long term memory is composed of the systems used to store memory over long periods. It enables one to remember what happened two days ago at noon, or who called last night.

Miller (1962–1974) declared that studying such fragile things as involuntary memories should not be done. This appears to have been followed since very little research has been done on flashbacks in the cognitive psychology discipline. Flashbacks have been studied within a clinical discipline however, and they have been identified as symptoms for many disorders, including post traumatic stress disorder.

Due to the elusive nature of involuntary recurrent memories, very little is known about the subjective experience of flashbacks. However, theorists agree that this phenomenon is in part due to the manner in which memories of specific events are initially encoded (or entered) into memory, the way in which the memory is organized, and also the way in which the

515 individual later recalls the event. Overall, theories that attempt to explain the flashback phenomenon can be categorized into one of two viewpoints. The special mechanism view is clinically oriented in that it holds that involuntary memories are due to traumatic events, and the memories for these events can be attributed to a special memory mechanism. On the other hand, the basic mechanism view is more experimentally oriented in that it is based on memory research. This view holds that traumatic memories are bound by the same parameters as all other every-day memories. Both viewpoints agree that involuntary recurrent memories result from rare events that would not normally occur.

These rare events elicit strong emotional reactions from the individual since it violates normal expectations. According to the special mechanisms view, the event would lead to fragmented voluntary encoding into memory (meaning that only certain isolated parts of the event would be encoded), thus making the conscious subsequent retrieval of the memory much more difficult. On the other hand, involuntary recurrent memories are likely to become more available, and these are more likely to be triggered by external cues. In contrast to this, the basic mechanism view holds that the traumatic event would lead to enhanced and cohesive encoding of the event in memory, and this would make both voluntary and involuntary memories more available for subsequent recall.

What is currently an issue of controversy is the nature of the defining criteria that makes up an involuntary memory. Up until recently, researchers believed that involuntary memories were a result of traumatic incidents that the individual experienced at a specific time and place, but the temporal and spatial features of the event are lost during an involuntary recollection episode. In other words, people who suffer from flashbacks lose all sense of time and place, and they feel as if they are re-experiencing the event instead of just recalling a memory. This is consistent with the special mechanism viewpoint in that the involuntary (unintended) memory is based on a different memory mechanism than its voluntary (intended) counterpart. Furthermore, the initial emotions experienced at the time of encoding are also re-experienced during a flashback episode, and this can be especially distressing when the memory is of a traumatic event. It has also been demonstrated that the nature of the flashbacks experienced by an individual are static in that they retain an identical form upon each intrusion. This occurs even when the individual has learned new

516 information that directly contradicts the information retained in the intrusive memory.

Upon further investigation, it was found that involuntary memories are usually derived from either stimuli (i.e. anything that causes a change in behaviour) that indicated the onset of a traumatic event, or from stimuli that hold intense emotional significance to the individual simply because these stimuli were closely associated with the trauma in terms of timing. These stimuli then become warning signals that if encountered again, serve to trigger a flashback. This has been termed the warning signal hypothesis. For example, a man experiences a flashback upon seeing sun spots on his lawn. This happens because he associates the sun spots with the headlights of the vehicle that he collided with, causing a horrific car accident. According to Ehlers and Clark, traumatic memories are more apt to induce flashbacks simply because of faulty encoding in that the individual fails to take contextual information into account, as well as time and place information that would usually be associated with every-day memories. These individuals become more sensitized to stimuli that they associate with the traumatic event which then serve as triggers for a flashback (even though the context surrounding the stimulus may be unrelated; such as sun spots being unrelated to headlights). These triggers may have elicited an adaptive response during the time of the traumatic experience, but they soon become maladaptive if the person continues to respond in the same way in situations in which no danger may be present.

The special mechanism viewpoint would add to this further by suggesting that these triggers activate the fragmented memory of the trauma, but protective cognitive mechanisms function to inhibit the recall of the original memory of the traumatic event. Dual representation theory enhances this idea by suggesting two separate mechanisms that account for voluntary and involuntary memories; the first of which is called the verbally accessible memory system and the latter is referred to the situationally accessible memory system.

In contrast to this, theories belonging to the basic mechanism viewpoint hold that there are no separate mechanisms that account for voluntary and involuntary memories. The recall of memories for stressful events do not differ under involuntary and voluntary recall. Instead, it is the retrieval mechanism that is different for each type of recall. In involuntary recall, the external trigger creates an uncontrolled spreading of activation in memory,

517 whereas in voluntary recall, this activation is strictly controlled and is goal- oriented.

Several brain regions have been implicated in the neurological basis of flashbacks. The medial temporal lobes, the precuneus, the posterior cingulate gyrus and the prefrontal cortex are the most typically referenced with regards to involuntary memories.

The medial temporal lobes are commonly associated with memory. More specifically, the lobes have been linked to episodic/declarative memory and thus damage to these areas of the brain result in disruptions to declarative memory system. The hippocampus, located within the medial temporal regions, has also been highly related to memory processes. There are numerous functions in the hippocampus; these functions also include aspects of memory consolidation. Brain imaging studies have shown flashbacks activate areas associated with memory retrieval. The precuneus, located in the superior parietal lobe and the posterior cingulate gyrus have also been implicated in memory retrieval. In addition, studies have shown activity in areas of the prefrontal cortex to be involved in memory retrieval.

Thus, the medial temporal lobe, precuneus, superior parietal lobe and posterior cingulate gyrus have all been implicated in flashbacks in accordance to their roles on memory retrieval.

Memory has typically been divided into sensory, short term, and long term processes. According to Rasmuseen & Berntsen, 2009, "long-term memory processes may form the core of spontaneous thought". Thus the memory process most related to flashbacks is long term memory. As well, studies by Rasmuseen & Berntsen, 2009, have shown that long term memory is also susceptible to extraneous factors such as recency effect, arousal and rehearsal as it pertains to accessibility. Compared to voluntary memories, involuntary memories show shorter retrieval times and little cognitive effort. Finally, involuntary memories arise due to automatic processing, which does not rely on higher-order cognitive monitoring, or executive control processing. Voluntary memory is normally associated with contextual information, which is what allows for correspondence between time and place, this is not true of flashbacks. According to Brewin, Lanius et, al, 2009, flashbacks, are disconnected from contextual information, and as a result are disconnected from time and place.

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To date, the specific causes of flashbacks have not yet been confirmed. Several studies have proposed various potential factors. Gunasekaran et al., 2009, indicate there may be a link between food deprivation and stress on the occurrence of flashbacks. Neurologists suggest temporal lobe seizures may also have some relation.

On the reverse side, several ideas have been discounted in terms of their causing flashbacks. Tym et al., 2009, suggest this list includes medication or other substances, Charles Bonnet syndrome, delayed palinopsia, hallucinations, dissociative phenomena, and depersonalization syndrome.

A study of the persistence of traumatic memories in World War II prisoners of war investigates through the administration of surveys the extent and severity of flashbacks that occur in prisoners of war. This study concluded that the persistence of severely traumatic autobiographical memories can last upwards of 65 years. Until recently, the study of flashbacks has been limited to participants who already experience flashbacks, such as those suffering from posttraumatic stress disorder, restricting researchers to observational/exploratory rather than experimental studies.

Neuroimaging techniques have been applied to the investigation of flashbacks. Using these techniques, researchers attempt to discover the structural and functional differences in the anatomy of the brain in individuals who suffer from flashbacks compared to those who do not. Neuroimaging involves a cluster of techniques, including computerized tomography, positron emission tomography, magnetic resonance imaging (including functional), as well as magnetoencephalography. Neuroimaging studies investigating flashbacks are based on current psychological theories that are used as the foundation for the research, and one such theory that is consistently investigated is the difference between explicit and implicit memory. This distinction dictates the manner in which memories are later recalled, namely either consciously (voluntarily) or unconsciously (involuntarily).

These methods have largely relied on subtractive reasoning in which the participant voluntarily recalls a memory and then the memory is again recalled, but this time through involuntary means. Involuntary memories (or flashbacks) are elicited in the participant by reading an emotionally-charged script to them that is designed to trigger a flashback in individuals who

519 suffer from post-traumatic stress disorder. The investigators record the regions of the brain that are active during each of these conditions, and then subtract the activity. Whatever is left is assumed to underpin the neurological differences between the conditions.

Flashbacks are often associated with mental illness as they are a symptom and a feature in diagnostic criteria for posttraumatic stress disorder (PTSD), acute stress disorder, and obsessive-compulsive disorder (OCD). Flashbacks have also been observed in people suffering from manic depression, depression, homesickness, near-death experiences, epileptic seizures, and drug abuse. Some researchers have suggested that the use of some drugs can cause a person to experience flashbacks; users of lysergic acid diethylamide sometimes report "acid flashbacks". While other studies show that the use of drugs, specifically cannabis, can help reduce the occurrence of flashbacks in people with PTSD.

The strong connection between emotions and memory Emotion can have a powerful impact on memory. Numerous studies have shown that the most vivid autobiographical memories tend to be of emotional events, which are likely to be recalled more often and with more clarity and detail than neutral events.

The activity of emotionally enhanced memory retention can be linked to human evolution; during early development, responsive behavior to environmental events would have progressed as a process of trial and error. Survival depended on behavioral patterns that were repeated or reinforced through life and death situations. Through evolution, this process of learning became genetically embedded in humans and all animal species in what is known as flight or fight instinct.

Artificially inducing this instinct through traumatic physical or emotional stimuli essentially creates the same physiological condition that heightens memory retention by exciting neuro-chemical activity affecting areas of the brain responsible for encoding and recalling memory. This memory- enhancing effect of emotion has been demonstrated in a large number of laboratory studies, using stimuli ranging from words to pictures to narrated slide shows, as well as autobiographical memory studies. However, as described below, emotion does not always enhance memory.

520 One of the most common frameworks in the emotions field proposes that affective experiences are best characterized by two main dimensions: arousal and valence. The dimension of valence ranges from highly positive to highly negative, whereas the dimension of arousal ranges from calming or soothing to exciting or agitating.

Most studies so far focused on the arousal dimension of emotion as the critical factor contributing to the emotional enhancement effect on memory. Different explanations have been offered for this effect, according to the different stages of memory formation and reconstruction.

Even though the majority of studies have focused on the arousal dimension, a growing body of research is dedicated to the emotional valence dimension and its effects on memory. It has been claimed that this is an essential step towards a more complete understanding of emotion effects on memory. The studies that did investigate this dimension have found that emotional valence alone can enhance memory, that is, nonarousing items with positive or negative valence can be better remembered than neutral items.

From an information processing perspective, encoding refers to the process of interpreting incoming stimuli and combining the processed information. At the encoding level the following mechanisms have been suggested as mediators of emotion effects on memory:

Easterbrook's (1959) cue utilization theory predicted that high levels of arousal will lead to attention narrowing, defined as a decrease in the range of cues from the stimulus and its environment to which the organism is sensitive. According to this hypothesis, attention will be focused primarily on the arousing details (cues) of the stimulus, so that information central to the source of the emotional arousal will be encoded while peripheral details will not.

Accordingly, several studies have demonstrated that the presentation of emotionally arousing stimuli (compared to neutral stimuli) results in enhanced memory for central details (details central to the appearance or meaning of the emotional stimuli) and impaired memory for peripheral details. Also consistent with this hypothesis are findings of weapon focus effect, in which witnesses to a crime remember the gun or knife in great detail but not other details such as the perpetrator’s clothing or vehicle. In

521 laboratory replications it was found that participants spend a disproportionate amount of time looking at a weapon in a scene, and this looking time is inversely related to the likelihood that individuals will subsequently identify the perpetrator of the crime. Other researchers have suggested arousal may also increase the duration of attentional focusing on the arousing stimuli, thus delaying the disengagement of attention from it. Ochsner (2000) summarized the different findings and suggested that by influencing attention selectivity and dwell time, arousing stimuli are more distinctively encoded, resulting in more accurate memory of those stimuli.

While these previous studies focused on how emotion affects memory for emotionally arousing stimuli, in their arousal-biased competition theory, Mather and Sutherland (2011) argue that how arousal influences memory for non-emotional stimuli depends on the priority of those stimuli at the time of the arousal. Arousal enhances perception and memory of high priority stimuli but impairs perception and memory of low priority stimuli. Priority can be determined by bottom-up salience or by top-down goals.

Emotional items also appear more likely to be processed when attention is limited, suggesting a facilitated or prioritized processing of emotional information. This effect was demonstrated using the attentional blink paradigm in which 2 target items are presented in close temporal proximity within a stream of rapidly presented stimuli.

The typical finding is that participants often miss the second target item, as if there were a “blink” of attention following the first target’s presentation, reducing the likelihood that the second target stimulus is attended. However, when the second target stimulus elicits emotional arousal (a “taboo” word), participants are less likely to miss the target’s presentation, which suggests that under conditions of limited attention, arousing items are more likely to be processed than neutral items.

Additional support for the Prioritized processing hypothesis was provided by studies investigating the visual extinction deficit. People suffering from this deficit can perceive a single stimulus in either side visual field if it is presented alone but are unaware of the same stimulus in the visual field opposed to the lesional side, if another stimulus is presented simultaneously on the lesional side.

522 Emotion has been found to modulate the magnitude of the visual extinction deficit, so that items that signal emotional relevance (e.g., spiders) are more likely to be processed in the presence of competing distractors than nonemotional items (e.g., flowers).

In addition to its effects during the encoding phase, emotional arousal appears to increase the likelihood of memory consolidation during the retention (storage) stage of memory (the process of creating a permanent record of the encoded information). A number of studies show that over time, memories for neutral stimuli decrease but memories for arousing stimuli remain the same or improve.

Others have discovered that memory enhancements for emotional information tend to be greater after longer delays than after relatively short ones. This delayed effect is consistent with the proposal that emotionally arousing memories are more likely to be converted into a relatively permanent trace, whereas memories for nonarousing events are more vulnerable to disruption.

A few studies have even found that emotionally arousing stimuli enhance memory only after a delay. The most famous of these was a study by Kleinsmith and Kaplan (1963) that found an advantage for numbers paired with arousing words over those paired with neutral words only at delayed test, but not at immediate test. As outlined by Mather (2007), the Kleinsmith and Kaplan effects were most likely due to a methodological confound. However, Sharot and Phelps (2004) found better recognition of arousing words over neutral words at a delayed test but not at an immediate test, supporting the notion that there is enhanced memory consolidation for arousing stimuli. According to these theories, different physiological systems, including those involved in the discharge of hormones believed to affect memory consolidation, become active during, and closely following, the occurrence of arousing events.

Another possible explanation for the findings of the emotional arousal delayed effect is post-event processing regarding the cause of the arousal. According to the post stimulus elaboration (PSE) hypothesis, an arousing emotional experience may cause more effort to be invested in elaboration of the experience, which would subsequently be processed at a deeper level than a neutral experience. Elaboration refers to the process of

523 establishing links between newly encountered information and previously stored information.

It has long been known that when individuals process items in an elaborative fashion, such that meaning is extracted from items and inter- item associations are formed, memory is enhanced. Thus, if a person gives more thought to central details in an arousing event, memory for such information is likely to be enhanced. However, these processes could also disrupt consolidation of memories for peripheral details. Christianson (1992) suggested that the combined action of perceptual, attentional, and elaborative processing, triggered by an emotionally arousing experience, produces memory enhancements of details related to the emotion laden stimulus, at the cost of less elaboration and consolidation of memory for the peripheral details.

The processes involved in this enhancement may be distinct from those mediating the enhanced memory for arousing items. It has been suggested that in contrast to the relatively automatic attentional modulation of memory for arousing information, memory for non-arousing positive or negative stimuli may benefit instead from conscious encoding strategies, such as elaboration. This elaborative processing can be autobiographical or semantic.

Autobiographical elaboration is known to benefit memory by creating links between the processed stimuli, and the self, for example, deciding whether a word would describe the personal self. Memory formed through autobiographical elaboration is enhanced as compared to items processed for meaning, but not in relation to the self.

Since words such as "sorrow" or "comfort" may be more likely to be associated with autobiographical experiences or self-introspection than neutral words such as “shadow”, autobiographical elaboration may explain the memory enhancement of non-arousing positive or negative items. Studies have shown that dividing attention at encoding decreases an individual's ability to utilize controlled encoding processes, such as autobiographical or semantic elaboration.

Thus, findings that participants’ memory for negative non-arousing words suffers with divided attention, and that the memory advantage for negative, non-arousing words can be eliminated when participants encode items

524 while simultaneously performing a secondary task, has supported the elaborative processing hypothesis as the mechanism responsible for memory enhancement for negative non-arousing words.

Retrieval is a process of reconstructing past experiences; this phenomenon of reconstruction is influenced by a number of different variables.

Contextual effects occur as a result of the degree of similarity between the encoding context and the retrieval context of an emotional dimension. The main findings are that the current mood we are in affects what is attended, encoded and ultimately retrieved, as reflected in two similar but subtly different effects: the mood congruence effect and mood-state dependent retrieval.

The mood congruence effect refers to the tendency of individuals to retrieve information more easily when it has the same emotional content as their current emotional state. For instance, being in a depressed mood increases the tendency to remember negative events.

This effect has been demonstrated for explicit retrieval as well as implicit retrieval.

Another documented phenomenon is the mood-state dependent retrieval, a type of context-dependent memory. The retrieval of information is more effective when the emotional state at the time of retrieval is similar to the emotional state at the time of encoding.

Thus, the probability of remembering an event can be enhanced by evoking the emotional state experienced during its initial processing. These two phenomena, the mood congruity effect and mood-state dependent retrieval, are similar to the context effects which have been traditionally observed in memory research (Baddeley, 1993) It may also relate to the phenomena of state-dependent memory in neuropsychopharmacology.

A somewhat different contextual effect stemmed from the recently made distinction between thematical and sudden appearance of an emotionally arousing event, suggesting that the occurrence of memory impairments depends on the way the emotional stimuli are induced. Laney et al. (2003) argued that when arousal is induced thematically (i.e., not through the sudden appearance of a discrete shocking stimulus such as a weapon but

525 rather through involvement in an unfolding event plot and empathy with the victim as his or her plight becomes increasingly apparent), memory enhancements of details central to the emotional stimulus need not come at the expense of memory impairment of peripheral details.

Laney et al. (2004) demonstrated this by using an audio narrative to give the presented slides either neutral or emotional meaning, instead of presenting shockingly salient visual stimuli. In one of the experiments, participants in both the neutral and emotional conditions viewed slides of a date scenario of a woman and man at a dinner date. The couple engaged in conversation, then, at the end of the evening, embraced. The event concluded with the man leaving and the woman phoning a friend.

The accompanying audio recording informed participants in the neutral condition that the date went reasonably well, while participants in the emotional condition heard that, as the evening wore on, the man displayed some increasingly unpleasant traits of a type that was derogatory to women, and the embrace at the end of the evening was described as an attempt to sexually assault the woman.

As expected, the results revealed that details central to the event were remembered more accurately when that event was emotional than when neutral, However, this was not at the expense of memory for peripheral (in this case, spatially peripheral or plot-irrelevant) details, which were also remembered more accurately when the event was emotional. Based on these findings it has been suggested that the dual enhancing and impairing effects on memory are not an inevitable consequence of emotional arousal.

Many researchers use self-report measures of felt emotion as a manipulation check. This raises an interesting question and a possible methodological weakness: are people always accurate when they recall how they felt in the past? Several findings suggest this is not the case. For instance, in a study of memory for emotions in supporters of former U.S. presidential candidate Ross Perot, supporters were asked to describe their initial emotional reactions after Perot’s unexpected withdrawal in July 1992 and again after the presidential election that November.

Between the two assessment periods, the views of many supporters changed dramatically as Perot re-entered the race in October and received nearly a fifth of the popular vote. The results showed that supporters

526 recalled their past emotions as having been more consistent with their current appraisals of Perot than they actually were.

Another study found that people’s memories for how distressed they felt when they learned of 9/11 terrorist attacks changed over time and more so, were predicted by their current appraisals of the impact of the attacks (Levine et al., 2004). It appears that memories of past emotional responses are not always accurate, and can even be partially reconstructed based on their current appraisal of events.

Studies have shown that as episodic memory becomes less accessible over time, the reliance on semantic memory to remember past emotions increases. In one study Levine(2009) primes of the cultural belief of women being more emotional than men had a greater effect on responses for older memories compared to new memories. The long term recall of emotions was more inline with the primed opinions showing that long term recall of emotions was heavily influenced by current opinions.

An interesting issue in the study of the emotion-memory relationship is whether our emotions are influenced by our behavioral reaction to them, and whether this reaction—in the form of expression or suppression of the emotion—might affect what we remember about an event. Researchers have begun to examine whether concealing feelings influences our ability to perform common cognitive tasks, such as forming memories, and found that the emotion regulation efforts do have cognitive consequences. In the seminal work on negative affect arousal and white noise, Seidner found support for the existence of a negative affect arousal mechanism through observations regarding the devaluation of speakers from other ethnic origins."

In a study of Richards and Gross (1999), participants viewed slides of injured men that produced increases in negative emotions, while information concerning each man was presented orally with his slide. The participants were assigned to either an expressive suppression group (where they were asked to refrain from showing emotion while watching the slides) or to a control group (where they were not given regulatory instructions at all). As predicted by the researchers, suppressors showed significantly worse performance on a memory test for the orally presented information. Several related studies have reached similar results. It was demonstrated that the effects of expressive suppression on memory

527 generalize to emotionally positive experiences and to socially relevant contexts.

One possible answer to the question "why does emotion suppression impair memory?" might lay in the self monitoring efforts invested in order to suppress emotion (thinking about the behavior one is trying to control). A recent study found heightened self- monitoring efforts among suppressors relative to control participants.

That is, suppressors were more likely to report thinking about their behavior and the need to control it during a conversation. Increases in self- monitoring predicted decreases in memory for what was said, that is, people who reported thinking a lot about controlling their behavior had particularly impoverished memories. However, additional research is needed to confirm whether self-monitoring actually exerts a causal effect on memory.

Emotionally arousing stimuli can lead to retrograde amnesia for preceding events and anterograde amnesia for subsequent events. This has been demonstrated in lab studies with lists of words or pictures, in which people show impaired memory for stimuli appearing before or after arousing stimuli.

Memory recall tends to be congruent with one's current mood, with depressed people more likely to recall negative events from the past In addition, depression is often associated with poor memory in general, as outlined here.

Several studies have demonstrated emotional memory enhancement in Alzheimer's patients suggesting that emotional memory enhancement might be used in the daily management of Alzheimer's patients. One study found that objects are recalled significantly better in Alzheimer's patients if they were presented as birthday presents to AD patients.

The enhancing effects of emotional arousal on later memory recall tend to be maintained among older adults and the amygdala shows relatively less decline than many other brain regions. However, older adults also show somewhat of a shift towards favoring positive over negative information in memory, leading to a positivity effect.

528 Emotional memory and sleep has been a well-researched association. Emotional memories are consolidated greater during sleep, rather than neutral memories. Studies have investigated high valence and arousing words, in comparison to neutral words. Sleep enhances the consolidation of the high valence and arousing words and therefore these are remembered more post-sleep. This concept has been demonstrated in many studies using a variety of media such as pictures, film clips and words.

Memories of 'future relevance' are also consolidated greater during sleep. In a study by Wilhelm et al., 2011, memories of items that participants knew were needed for the future (for the testing session) were remembered more after sleep. Sleep consolidated these memories of future relevance to a greater extent. Memories that are emotionally significant and relevant for the future are therefore preferentially consolidated during sleep. This can translate to mean that memories that are more meaningful or valuable to a person are consolidated more.

The concept of emotional memory and sleep can be applied to real-life situations e.g. by developing more effective learning strategies. One could integrate the memorization of information that possesses high emotional significance (highly salient) with information that holds little emotional significance (low salience), prior to a period of sleep.

In regards to transference and countertransference When your client enters your massage room they are bringing with them a host of memories that can be triggered by one or more forms of sensory memory.

When you combine that with the general association of touch and emotions you can see why the feelings they develop towards you can seem so powerful. It’s important for you to recognize where they might be coming from.

The Florence Nightingale effect The Florence Nightingale effect is a situation where a caregiver develops romantic and/or sexual feelings for his/her client, even if very little communication or contact takes place outside of the care given. Feelings may fade once the client is no longer in need of care.

529 The effect is named for Florence Nightingale, a pioneer in the field of nursing in the second half of the 19th century. Due to her dedication to patient care, she was dubbed "The Lady with the Lamp" because of her habit of making rounds at night, previously not done. Her care would forever change the way hospitals treated patients. Most consider Nightingale the founder of modern nursing. There is no record of Florence Nightingale having ever fallen in love with one of her patients. In fact, despite multiple suitors, she never married for fear it might interfere with her calling for nursing. Albert Finney referred to the effect as the "Florence Nightingale syndrome" in a 1982 interview, and that phrase was used earlier to refer to health workers pursuing non-tangible rewards in their careers.

Florence Nightingale effect is not recognized as a medical condition; rather, it is a pop-culture name given to a situation. It is generally considered unprofessional in the medical industry for a caregiver to become involved with a patient.

Many often misunderstand the term to mean the opposite; that is, a patient falling in love with the caregiver as a result of interpreting an amiable bedside manner as affection. The correct term, for that situation is, as you know, transference.

Massage therapists are not immune to the Florence Nightingale effect, so be cognizant of your feelings toward your clients at all times.

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Chapter 3: Prevention of Sexual Misconduct Upon completion of this chapter, the massage practitioner should be able to:

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves.

An excerpt from the Hippocratic oath, 5 th Century BC

The passage above was taken from the original Hippocratic oath and demonstrates that healthcare practitioners have grappled with sexual temptation with their patients from the earliest days of medicine.

Sexual Misconduct defined Sexual misconduct is a broad category of offenses; it basically describes a behavior used to obtain sexual gratification against another persons will or at the expense of another person. At the expense of another person is an important term; because sexual misconduct complaints often involve willing participants-but that doesn’t make it less wrong.

There are different types of sexual misconduct. The term includes sexual harassment, sexual assault, and any conduct of a sexual nature that is without consent, or has the effect of threatening or intimidating the person against whom such conduct is directed.

When we think of massage therapists and sexual misconduct there are generally two images that come to mind:

531 1) The prostitute that is using massage therapy as a cover, usually (but not always) a female.

2) The sexual predator that is taking advantage of clients, usually (but not always) a male.

To be fair, the reason why these two images immediately spring to mind is because that is what the media reports happening the most frequently.

Most incidents of sexual misconduct involving massage therapists are related to one of those two categories of misconduct. Unfortunately if we limit our thinking on sexual misconduct to those two examples we are putting ourselves in danger, because it’s a much broader category than that.

When Consent doesn’t Matter Having sexual relations with a person that is also your massage client is sexual misconduct, even if they are an adult and a willing participant. Even when they initiate the sexual encounter, and even when the sexual relations take place outside of your work.

We live in an age where sexual norms are being challenged all the time, and the familiar defense of the challenge is always “What does it matter if the participants are consenting adults?”

Our society will give you a pass for just about any kind of sexual weirdness as long as all parties are adults and give their consent, or in other words, are willing participants. This graciousness on the part of our culture has created a false sense of propriety in our minds whenever consenting adults are involved.

Compare these two hypothetical scenarios:

Scenario A A 35-year-old male high school teacher is discovered to be having sexual relations with a 17-year-old female student. Despite the fact that the young women repeatedly admitted to initiating the encounter and that she was a willing participant, the man is fired, loses his license to teach and is charged with a crime (statutory rape).

532 Scenario B A 35-year-old male Jr. College teacher is discovered to be having sexual relations with an 18-year-old female student. The young woman admits the relationship was consensual, but this is still against the colleges no fraternization policy; he is officially reprimanded and although he keeps his job he has a disciplinary record and told future incidents would lead to his termination.

In both of these examples sexual misconduct occurred. Scenario A was treated far more harshly because the person involved was a minor, making it a crime. The fact that she gave consent was nullified by the fact that she was not of legal age to give consent.

In scenario B the woman involved was not a minor, but sexual misconduct still occurred, despite the fact that she was a willing participant. So why was it considered sexual misconduct if she was legally an adult and was a willing participant? Because the power differential involved in the student- teacher relationship makes their sexual relationship potentially harmful.

The definition of sexual misconduct I gave earlier included the term at the expense of another person .

What if the affair between the college professor and the young adult student took a turn for the worse and ended poorly? She would not only be in danger of a broken heart, he might also fail her out of spite, wrecking her GPA, causing her to lose her scholarship or not graduate with her degree on time. The college has rules against teachers and students having sexual relationships because the power differential puts the student at risk of being harmed-even if they are consenting adults.

We spent a lot of time in the last chapter talking about the power differential that exists in massage therapy-it’s a big one. The person on our table is in a very vulnerable position, both physically and psychologically.

This is why massage therapists are held to high standard when it comes to relationships with our clients. The intimate nature of our work creates a deeply personal connection between the client and therapist and is particularly vulnerable to the phenomenon of transference, especially of the romantic/erotic kind.

533 For this reason it’s not surprising that sexual misconduct is the number one type of lawsuit claim lodged against massage therapists 61 .

As I stated in the beginning of the chapter, sexual misconduct is a broad category, it’s not limited to just sexual intercourse with a client. It can include an inappropriate comment, flirtatious behavior, suggestive looks or the giving of inappropriate gifts. This type of misconduct can harm the client in many ways and has major repercussions for us as practitioners. These repercussions can include damage to our professional reputation as well as that of our employers, costly lawsuits, and ultimately losing our licenses and massage practices.

The statistics for sexual misconduct show that 70 percent of sexual misconduct complaints are filed by female clients against male professionals and 20 percent are from female clients complaining about female professionals. The remaining 10 percent are spilt evenly between men and women lodging complaints against female professionals 62 .

Females make up about 90 percent of the victims of sexual misconduct, and 25 percent of the alleged perpetrators. Most experts believe that these numbers are skewed because traditionally male victims of sexual misconduct underreport 63 .

Well-Maintained Boundaries Help Prevent Misconduct We spent time going over the different types of boundaries in the last chapter for a reason. Well-established and maintained boundaries are your first defense against slipping into sexual misconduct.

From a legal standpoint the most important boundary is physical, in regards to massage therapy that means what part of the body you are touching. Most state laws give clear parameters about what areas are off limits for massage therapists, namely the genitals. Some states may specifically require a medical rationale documented in an informed consent form to work on the female breast.

Of course you are a professional massage therapist, so you know that.

61 According to the American Massage Council, a provider of liability insurance coverage for massage therapists http://www.massagecouncil.com/index.html 62 Redleaf, Angelica, Behind Closed Doors: Gender, Sexuality, and Touch in the Doctor/Patient Relationship. 63 Gonsiorek, John C., Perpetrators, in Breach of Trust: Sexual Exploitation by Health Care Professionals and Clergy, John C. Gonsiorek, ed. (Thousand Oaks, CA.; Sage Publications, Inc., 1995), 131.

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Proper draping, or rather the lack of it, is the number one sexual misconduct complaint levied against massage therapists. This means we need to take extra care to not only keep our clients properly covered, but to make sure they feel properly covered.

One of the best ways to do this is to take a moment before the massage to explain how the draping works, and then during the massage make sure the client feels the linens securely on their skin at all times. You also want to make sure the client has enough time to change before and after the massage.

In addition to proper draping you will want to make sure your client feels comfortable communicating with you. The way this is accomplished is by listening attentively to them during your initial assessment and intake period and throughout the massage. Never assume that a client understands why you are doing what you are doing, always keep them informed of what your intentions are while you are doing it, to avoid misunderstandings.

Remember that you are the professional and it’s your responsibility to set the tone of any conversations that take place in your massage practice. From the moment you first meet your client you need to make an effort to speak and comport yourself as a professional in order to set proper boundaries. This means you should abstain from using slang or inappropriate speech, and you should definitely avoid gossiping about any of your other clients.

You should be dressed professionally, which means in a manner that is not sexually provocative and clearly designates you as a professional. In other words, if your client were to walk in and see you, dressed as you are, it should be clear that you work in the establishment and aren’t there visiting.

Through creating and maintaining these boundaries you will promote your business, your professional image, and you will keep you and your clients safe.

If you are the owner of a massage business that employs other therapists you will want to take steps to ensure that everyone working for you (or renting space from you) is taking similar steps to protect themselves and

535 your business. Here are some steps you can take to set the tone in your workplace:

1) Develop a Clients Bill of Rights and post it in the waiting room. 2) Teach your staff what behavior is unacceptable. 3) Improve communication with clients by asking for evaluations. 4) Address client complaints and dissatisfaction quickly. 5) Always lead by example-demonstrate correct behavior yourself.

Differentiating between Sexual Misconduct and Sexual Crimes Remember the example I gave of the teacher and the student relationship? One was a high school teacher; the other a college teacher and both had a sexual relationship with a student. Both of them were guilty of sexual misconduct, but obviously the high school teacher was also guilty of a crime, because the person he was having the affair with was a minor.

Not all cases of sexual misconduct are crimes, but all of them are grounds for license revocation. It’s important to know the difference between sexual misconduct and crimes of a sexual nature.

Sexual Misconduct involves a boundary violation with a massage client, and this includes willing participants. Because of the power differential and the phenomenon of transference and countertransference it is never appropriate for a massage therapist to have a sexual relationship with a client, even if the client is a consenting adult.

Please note that “sexual relationship” is not limited to sexual intercourse, It also includes inappropriate talk or touching, or unnecessary examinations or treatments.

Sexual Crimes include things like sexual harassment , sexual assault , and prostitution , all of which are very serious and are mentioned here specifically because massage therapists have been charged with these crimes far more often than you might believe.

Let’s look at each category and how it relates to massage therapy.

Sexual Harassment This is generally a workplace issue; it involves the behavior of a supervisor, manager, employer or employee toward staff at the same or a lower level

536 of power. It can also apply to a business owner that rents space to a massage therapist.

It generally involves one person having some kind of power over another person, this can be related to their employment, money, grades or advancement, and the abuse of that power. It can also refer to harassment by a co-worker of equal rank, but is of a sexual nature. There are two commonly recognized forms of sexual harassment:

1) Quid pro quo a demand for sexual favors in exchange for job benefits;

2) Hostile work environment unwelcome acts such as physical or verbal conduct, or visual displays, that makes the individuals’ job difficult 64 .

The U.S. Equal Employment Opportunity Commission (EEOC) defines sexual harassment as unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature when:

- Submission to such conduct is made a term or condition of an individuals employment, either implicitly or explicitly;

- Submission to, or rejection of, such conduct is used as a basis for employment decisions affecting such individual;

-Such conduct has the purpose or effect of unreasonably interfering with an individuals work performance or creating an intimidating, offensive, or hostile work environment.

Harassment can come in the form of physical abuse, such as touching, hugging and stroking. It can also be verbal abuse, which includes inappropriate ways of addressing a person, use of sexually explicit language, or use of words that refer to an individuals body parts.

It’s important to remember that it doesn’t matter if the intent of the statement or actions was to be abusive or offensive, it is the nature of the comment or action itself that is viewed by a jury .

64 Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense, a seminar handout (Providence, RI: Litch & Semenoff, Attorneys at Law, May 2, 1995).

537 In cases where it can be proved that the perpetrator did intent to offend, heavier penalties may be assigned.

A finding of quid pro quo in sexual harassment requires that a plaintiff prove that receiving job benefits or protection from job detriments was dependent upon his or her submission to a supervisors unwelcome sexual demands. Remember that this can apply to the owner of a massage business or spa that rents out space to other massage therapists, do not think that just because you don’t have any “employees” that this doesn’t apply to you.

A hostile work environment exists when an employee experiences workplace harassment and fears going to work because of the offensive, intimidating, or oppressive atmosphere generated by the harasser.

A hostile work environment may also be created when management acts in a manner designed to make an employee quit in retaliation for some action. For example, if an employee reported safety violations at work, was injured, attempted to join a union, or reported regulatory violations by management, then their response might be to harass and pressure the employee to quit. Employers have tried to force employees to quit by imposing unwarranted discipline, reducing hours, cutting wages, or transferring the complaining employee to a distant work location. The employer and the employee often mistakenly believe that if the employee quits his or her job due to the hostile work environment, the employee cannot get unemployment benefits and cannot sue the employer.

In many states within the USA, this is true; but in others neither is true.

The United States Supreme Court stated in Oncale v. Sundowner Offshore Services, that Title VII is "not a general civility code." Thus, federal law within the USA does not prohibit simple teasing, offhand comments, or isolated incidents that are not extremely serious. Rather, the conduct must be so objectively offensive as to alter the conditions of the individual's employment. The conditions of employment are altered only if the harassment culminates in a tangible employment action or are sufficiently severe or pervasive.

538 Sexual assault Sexual assault is any involuntary sexual act in which a person is threatened, coerced, or forced to engage against their will, or any sexual touching of a person who has not consented . This includes groping , which is where massage therapists that let their hands roam over forbidden areas are charged with.

When used in a sexual context, groping is touching or fondling another person in a sexual way using the hands; it generally has a negative connotation, and is considered sexual assault in most states. The term 'frotteurism' may be applied when a person rubs up against another person, typically using their sexual parts.

Touching a client's body during massage is not considered groping unless the touching involves inappropriate areas. Areas of the body most frequently groped include the buttocks, breasts, and thighs on a woman, and the penis, testicles and buttocks on a man. Gropers might use their hands, but pressing any part of their body against another person can be considered groping.

The Gluteus Muscles and Breast Tissue There are of course, medically valid reasons why the breasts and buttocks could be worked during a massage. This must be for a medically valid reason, and when a proper informed consent form has designated the medical reason and the client has signed it to designate their consent.

Unscrupulous practitioners have used “blank” informed consent forms to molest their clients. This means that they included a generic informed consent form in their intake paperwork, with the medical rationale for specific treatment blank, so it can be filled out by them after the client has signed it. This is obviously an unethical practice and an attempt to protect them from charges of impropriety. Thankfully it doesn’t work, courts are aware of this sort of deception.

If you are a massage therapist and your client has a legitimate reason for wanting their breast tissue or gluteus muscles worked you should ask them to fill in the medical rationale on the form in their own handwriting. It doesn’t have to be fancy, just a simple statement like “I am recovering from a mastectomy or breast augmentation and I would like massage on my

539 breast tissue to help reduce formation of scar tissue.” Or “I am a runner and I need my gluteus muscles massages.”

The medical rationale for massaging these areas should not be filled out by the therapist to avoid an appearance of impropriety.

A sample state law: Title 14, criminal law RS 14:43.1;§43.1. Sexual battery: A. Sexual battery is the intentional touching of the anus or genitals of the victim by the offender using any instrumentality or any part of the body of the offender, or the touching of the anus or genitals of the offender by the victim using any instrumentality or any part of the body of the victim, when any of the following occur: (1) The offender acts without the consent of the victim 65 .

Massage therapists, both male and female, can be charged with sexual battery if they touch the genitals or anus of their client without their consent, and are definitely guilty of sexual misconduct and can lose their license even if they do have the clients consent.

Prostitution Prostitution is defined as the practice of engaging in sexual activity, usually with individuals other than a spouse or friend, in exchange for immediate payment in money or other valuables. Prostitutes may be of either sex and may engage in either heterosexual or homosexual activity, but historically most prostitution has been by females with males as clients 66 .

I have not included the legal definition because it varies slightly from state to state, but I will say that each one of them includes the manual manipulation of the genitals with the hands for the purpose of sexual gratification in exchange for payment.

I would love to tell you that the majority of articles that came up in our Internet search of “Massage therapists arrested” were actually prostitutes posing as massage therapists, that they weren’t actually people that went to massage school and went through the steps to become certified and receive a state license.

Unfortunately I can’t say that, because it’s not true.

65 http://law.justia.com/codes/louisiana/2006/146/78532.html 66 Concise Encyclopedia: www.merriam-webster.com/browse/concise/a.htm

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It is true that many of the cases involve “massage parlors” which are just thinly veiled brothels, often staffed by women that are victims of human trafficking. Thankfully these are easy to spot and shut down. The more consistent problem for our industry is the trained massage professional that offers “extra services” for a higher fee.

It might seem mind boggling to think that after spending thousands of dollars to attend a massage school and hundreds of hours studying anatomy and pathology and taking a national certification test to get a license that a person would risk it all to provide sexual favors in exchange for money.

There are hundreds of online articles from News Papers across the country detailing legitimately credentialed massage therapists being arrested for prostitution in states with high standards for licensing.

Doesn’t the requirement for education and certification prevent legitimate massage therapists from committing acts of prostitution?

Unfortunately the answer is an emphatic no, state licensing laws and national certification do not prevent legitimate massage therapists from committing acts of prostitution. It does make it more difficult for prostitutes with no actual massage education or training to pose as massage therapists, but they still manage it. In a 2014 sting operation in Florida several police agencies and the Florida Department of Health Board of Massage Therapy shut down massage parlors that are fronts for prostitution. The board ruled in January to revoke 19 massage licenses and voted to accept the voluntary surrender of 55 massage therapists' licenses. The majority of the cases involved women who obtained their state licenses fraudulently by submitting fake credentials 67 .

If people are planning on breaking the law in a profession, they’re obviously not opposed to breaking a law to get into the profession, and this means faking school certificates and even national certification board or state licensing board tests.

67 Three women arrested at Hallandale Beach massage parlor April 4, 2013|By Wayne K. Roustan, Sun Sentinel

541 But even legitimately credentialed massage therapists succumb to the temptation to make extra money easily. We must never make the mistake of assuming that just because laws and regulations exist to make it difficult to obtain a position or profession that it somehow makes those in that profession free from the temptation of wrong doing.

How often have we heard of a doctor or lawyer being indicted for committing a crime? They have to go to school for much longer than us, and obviously medical school and law school cost much more than massage school, and yet they are not immune to the lure of illicit activity.

What about politicians and corporate CEOs? People that attain positions of respect and power that take a lifetime of work to get, risk losing it all just to make more money. Education and certifications do not remove the temptation, which is why it keeps happening.

Ethical arguments against offering sexual services We can tell you that performing sex acts in exchange for money is wrong all day, but the bottom line is that our society is one that doesn’t like to be told what they can and can’t do in regards to sexual conduct. It comes back to that argument about “Consenting adults” and the idea that two people who are adults should be free to do what they want.

We’ve already discussed why sexual relations of any kind are potentially harmful to the client (the power differential, transference and countertransference, etc) and all of those reasons still apply, even if the client is offering to pay for the sex acts.

The Categorical Imperative and Prostitution Kant’s categorical imperative tells us that prostitution is wrong because it involves putting one’s emotions aside to provide a sexual service in exchange for financial compensation. Prostitutes allow their bodies to be used for sex possibly countless times, which is degrading oneself for the benefit of another. Prostitution, by definition, violates the second form of the categorical imperative by allowing the client to use the prostitute purely as a “means to an end”-and people should never be treated as a means to an end.

542 The Deontological theory and Prostitution As we stated earlier in this course, deontological arguments relate to our duties. In this regard our duty as a massage therapist extends beyond our relationship with our client. As a massage therapist you have a duty to every other massage therapist as well, and when a massage therapist engages in an illegal activity they are not just hurting themselves and their client, they are hurting me, you, and every other massage therapist that is affected by the negative perception it creates with the public. For this reason alone there is a deontological reason to not engage in prostitution.

The Social Contract argument and Prostitution Social contract theory is the idea that persons’ moral and/or political obligations are dependent upon a contract (agreement) among all the people in the society in which they live.

Basically it’s the idea that people collectively agree to behave morally and lawfully as a way to reduce social chaos and create peace.

One of those laws that we agree to when we live in our society is that we will not perform sexual favors in exchange for money. It doesn’t matter if you agree with the law or not, you are bound by the social contract to follow it. If you think the law is bad then you should work to get it changed, but until it is you need to obey it.

The Virtue ethics argument and Prostitution Virtue ethics emphasize the importance of character and virtue in moral philosophy, elevating it above doing one’s duty or performing actions based on their intended consequences. A person that practices virtue ethics approaches each decision by asking himself or herself “What would a virtuous person do in this situation?” and then do what they believe a virtuous person would do.

So would a virtuous person break the law in order to make extra money? No they wouldn’t.

An economical argument against prostitution I would like to end the section on prostitution with a simple look at the long- term economics of prostitution and massage therapy. Many of the articles we read in researching this course included police reports of licensed

543 massage therapists that were arrested for performing sexual acts. We can only assume that money is the motivation for most of these people.

The temptation to earn money quickly through illicit practices is almost always the result of short-term thinking. If the massage therapist succumbs to offering “extra services” in exchange for a $100 tip they are only thinking of the money they are making right now.

They are not considering the long-term costs involved when they are eventually arrested in an undercover sting. Add up the cost of losing a license, massage school tuition wasted, all the licensing and certification fees, and not to mention the actual costs of the arrest, bail, fines, etc.

In the long term offering “extras” to clients will end up costing the therapist far more than they can hope to make. So even if they lacked the moral center and ethical grounding to make the right decision, hopefully they will consider the economical ramifications and stick to providing legitimate massage services.

In this chapter we looked what constitutes sexual misconduct in a massage practice. We looked at what efforts we can take as individual therapists to create and maintain healthy boundaries with our clients, as well as looking at some basic strategies that managers of massage businesses can employ to influence their staff. We learned that communication with our clients is critically important, as is addressing any complaints quickly and efficiently.

We also looked at the difference between sexual misconduct in the general sense and specific sex related crimes that massage therapists have been known to plague the massage industry. Specifically we examined sexual harassment, sexual assault (including groping and sexual battery), and prostitution.

The most important factors in preventing sexual misconduct is to be proactive in establishing your boundaries. This means always making sure your clients know that you are a professional and that you are not interested in anything other than being a great massage therapist. It also means not assuming that you are above temptation, because most human beings are not, despite what they might think of themselves. The best way

544 to resist temptation to do something wrong is to avoid putting yourself in a position to be tempted in the first place.

And lastly, always remember how much you have invested in your massage career as far as time and money spent in schooling and licensing fees.

Chapter 4: Reviewing professional boundaries Most of this course deals with the specifics of how you should guide your actions and your decision-making at work. It’s definitely not our place to tell you how to live your personal life.

The simple example that I used to give my students was the one below. We are going to call it Scenario A.

Monday morning you are back and work and your first appointment, a new client, comes in. 545

It’s your dance partner from Saturday night.

Well now, this is awkward .

Maybe it’s just a coincidence. If you live in a smaller community this can easily happen. We discuss it later in the section on Managing Dual Relationships.

It has a lot to do with how you behaved yourself at the club.

But we don’t live in a perfect world, do we?

To illustrate that point, here is Scenario B.

Scenario B You are relaxing in the park on your day off. You see a man walking a dog on a leash. The dog sees a squirrel and starts to pull against the leash because he wants to chase it. The man becomes very angry and jerks the leash back, making the dog yelp in pain. 546 He then takes the upper part of the leash and starts to beat the cringing dog with it like it’s a whip, all the while cursing angrily. He then walks way, dragging the abused dog behind him.

So how comfortable are you with this guy drilling in your mouth?

Can you separate the dentist from the man walking the dog?

Now invariably some of you are wondering why I have included this section on professional image and public perception of massage therapy in an ethics course.

In Scenario A the ethical question is how do you conduct yourself with the person once they have shown up as your client, not how you conducted yourself at the club on Saturday night. It’s important to recognize that fact, but it’s equally important to recognize that how you conduct your personal life will greatly influence what kind of ethical challenges you face in your professional life. The two can only be separated by so much; after all you are just one person.

547 The purpose of an ethical code Massage therapists have a need for ethical principles to guide decision making when values are in conflict . In a perfect world, we would not need an ethical code. We need one because the world is not perfect.

Industry leaders recognize the impact that ethical values, behaviors and practices can have on our profession, your personal reputation and your massage businesses bottom line.

A code of ethics is a set of guidelines that defines acceptable behavior for members of an organization or group. Ideally, an organization tailors its code of ethics to its needs and values.

A good code of ethics can serve as a guide when you face an unusual situation and you are not sure what the right thing to do is.

“It's not hard to make decisions when you know what your values are.” ― Roy Disney

On the following pages there is a copy of the Code of Ethics for the National Certification Board for Therapeutic Massage and Body Work.

The NCBTMB Code of Ethics NCBTMB certificants and applicants for certification shall act in a manner that justifies public trust and confidence, enhances the reputation of the profession, and safeguards the interest of individual clients. Certificants and applicants for certification will:

I. Have a sincere commitment to provide the highest quality of care to those who seek their professional services.

II. Represent their qualifications honestly, including education and professional affiliations, and provide only those services that they are qualified to perform.

548 III. Accurately inform clients, other health care practitioners, and the public of the scope and limitations of their discipline.

IV. Acknowledge the limitations of and contraindications for massage and bodywork and refer clients to appropriate health professionals.

V. Provide treatment only where there is reasonable expectation that it will be advantageous to the client.

VII. Conduct their business and professional activities with honesty and integrity, and respect the inherent worth of all persons.

VIII. Refuse to unjustly discriminate against clients and/or health professionals.

XI. Respect the client's right to refuse, modify or terminate treatment regardless of prior consent given.

XII. Provide draping and treatment in a way that ensures the safety, comfort and privacy of the client.

XIII. Exercise the right to refuse to treat any person or part of the body for just and reasonable cause.

XIV. Refrain, under all circumstances, from initiating or engaging in any sexual conduct, sexual activities, or sexualizing behavior involving a client,

549 even if the client attempts to sexualize the relationship unless a pre-existing relationship exists between an applicant or a practitioner and the client prior to the applicant or practitioner applying to be certified by NCBTMB.

XV. Avoid any interest, activity or influence which might be in conflict with the practitioner's obligation to act in the best interests of the client or the profession.

XVII. Refuse any gifts or benefits that are intended to influence a referral, decision or treatment, or that are purely for personal gain and not for the good of the client.

550 On the following pages there is a copy of the Code of Ethics for the American Massage Therapy Association.

Massage therapists/practitioners shall:

Demonstrate commitment to provide the highest quality massage therapy/bodywork to those who seek their professional service.

Acknowledge the inherent worth and individuality of each person by not discriminating or behaving in any prejudicial manner with clients and/or colleagues.

Demonstrate professional excellence through regular self-assessment of strengths, limitations, and effectiveness by continued education and training.

Acknowledge the confidential nature of the professional relationship with clients and respect each client’s right to privacy within the constraints of the law.

Project a professional image and uphold the highest standards of professionalism.

Accept responsibility to do no harm to the physical, mental and emotional well-being of self, clients, and associates.

Rules of Ethics. The Rules of Ethics are mandatory and direct specific standards of minimally-acceptable professional conduct for all members of

551 the association. The Rules of Ethics are enforceable for all association members, and any members who violate this Code shall be subject to disciplinary action.

Massage therapists/practitioners shall:

Conduct all business and professional activities within their scope of practice and all applicable legal and regulatory requirements.

Refrain from engaging in any sexual conduct or sexual activities involving their clients in the course of a massage therapy session.

Be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

Refrain from using AMTA membership, including the AMTA name, logo or other intellectual property, or the member’s position, in any way that is unauthorized, improper or misleading.

Refrain from engaging in any activity which would violate confidentiality commitments and/or proprietary rights of AMTA or any other person or organization.

Effective Date May 1, 2010

Central to the nature of the therapeutic relationship is the belief that what is done is by the practitioner (in our case, the massage therapist) is done with

552 the goal of helping or healing. So it is right to assume that nothing harmful should arise out of the relationship. While this may seem simplistic and even obvious, it is a profound truth and needs to be recognized and used as a lens through which to examine all of our actions within the role of our profession.

The Clients Expectations A client enters into the Therapeutic Relationship with certain expectations. These expectations help form the boundaries of the relationship from the client’s perspective.

It is important to remember that the benefits of Massage can only be gained when a Client is able to place themselves in one of the most vulnerable positions imaginable.

553 Reviewing Basic Ethical Concepts

The Right of Refusal also applies to you as a massage practitioner. You can end a session at any time, for any reason.

554 Boundaries A Boundary is a space within a perimeter that may be a physical, emotional or mental space. There are many different boundaries, spatial, legal, physical and emotional, etc.

This is a boundary crossing; you and your client are now moving beyond the boundaries of your therapeutic relationship and are entering a Dual Relationship .

555 Different boundaries

Spatial boundaries The spatial boundary is the invisible “three feet of personal space” that most Americans claim as their comfort zone 68 . This is why strangers in the movie theater will usually leave an empty seat between them, or why people boarding a bus will sit in an empty row before choosing to sit in an empty seat beside a total stranger. We like a buffer between us and people we do not know well.

When your client is in the waiting room, or completing intake information in your massage room, you should be observing a respectable distance.

Even though he is about to touch you and palpate areas you usually do not make available to strangers, they are still observing the spatial boundary by sitting on a stool or standing a few feet away.

It could be easy for massage therapists to forget that just because they routinely cross the spatial boundary with a client in the massage room, this boundary does exist and needs to be recognized.

68 I say Americans because this is not universal! People from other countries may have entirely different spatial boundaries. This is described in more detail in EPS003 Cultural Sensitivity for Massage Therapists.

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In the traditional 69 treatment setting, only the hands, forearms and elbows should be making contact with the client. These parts of our body are permitted to cross the spatial boundary during the massage. The client should not feel other parts of our body during the massage if it can be avoided.

Therapeutic Massage never includes any type of sexual touch. That being said, how does one differentiate between two closely related types of touch?

If you have ever shaken hands with a car salesman you know what I am talking about, their mouth says “pleased to meet you” but their hands say “hello commission!”

69 I am referring to Swedish massage, certain modalities, such as Thai Massage, require much more physical contact between the practitioner and the client, which is one of the reasons why they are done fully clothed!

557 therapeutic massage. Ever. Throughout the history of Massage Therapy there have been people who have tried to reintroduce inappropriate sexual touch through various systems and modalities that claim legitimacy but are in fact only thinly veiled acts of prostitution.

558 room, especially if the person is nervous or distressed and you need to convey empathy and trust.

Another variant is the shoulder-handshake. When shaking hands with a client you can demonstrate empathy and trust by placing a hand on their shoulder.

These are two examples of appropriate therapeutic touch outside of the massage room. Human beings need to be touched; we are wired give and receive physical affection. Both of these methods cross the spatial boundary in a safe and socially acceptable way.

I have often found that a well timed offer of a handshake is a great deterrent to other forms of physical greetings that may present themselves, which brings us to…

559

I will not go on record stating that a massage therapist should never hug a client. I myself had a 70-year-old widow that would give me a hug every time she left my office. In this case I could find no legitimate reason to refuse the hug, the intent was clear and non-threatening. She lived with persistent pain and I helped her deal with it, she was grateful.

Even though there is a wide variation, some things are universal to massage and these can be addressed here.

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External Manipulation Only Every set of laws that I have seen governing massage practice in the United states defines massage as being manipulation of the outside of the body only. While this may seem like common sense to us there are many massage therapists that are practicing techniques for treatment of Temporomandibular Joint Disorder (TMJD) that requires you to work the muscles of the jaw from inside the mouth. This is a practice which is illegal in many areas, and practitioners should consult their state and local ordinances before engaging in this practice. If the ordinance states “external parts of the body” this technique is off limits for you.

561 Thankfully avoiding this mistake is just as easy as making it. We are professional body workers and we do want to facilitate the healing of our clients. If you are working with someone that you believe has a medical condition that they are unaware of, all you need to do is talk to them in straightforward and candid terms.

In the above example, if you are massaging an individual with Ischemia you can have a conversation with them afterwards regarding your suspicions. That conversation could sound something like this:

562 predisposed to believing any claim that may offer relief. In addition to this, the massage therapist, by virtue of our credentials and education, carry an aura of “Expert Knowledge” which makes people even more likely to believe us when we tell them that something will take away their pain.

Keep that in mind before you recommend any product you are selling.

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To avoid violating this boundary in the therapeutic relationship you must take care to avoid assumptions about people’s lack of modesty. Never tell yourself that they must be comfortable with being undraped if they are getting a massage. Explain all procedures, including draping, before starting each massage with a new client.

In addition to concerns about modesty some clients are uncomfortable with certain techniques, types of product or other methodology that is regular practice for the practitioner.

Emotional boundaries The most difficult boundaries to determine are emotional boundaries. Emotional boundaries come in to play when dealing with issues of Transference and Countertransference.

Self-disclosure Self-disclosure is a process of communication through which one person reveals himself or herself to another. It comprises everything an individual chooses to tell the other person about himself or herself, making him or her known. The information can be descriptive or evaluative and can include thoughts, feelings, aspirations, goals, failures, successes, fears, dreams as well as one's likes, dislikes, and favorites.

According to social penetration theory, there are two dimensions to self- disclosure: breadth and depth. Both are crucial in developing a fully intimate relationship. The range of topics discussed by two individuals is the breadth of disclosure. The degree to which the information revealed is private or personal is the depth of that disclosure. It is easier for breadth to be expanded first in a relationship because of its more accessible features; it consists of outer layers of personality and everyday lives, such as occupations and preferences. Depth is more difficult to reach, given its inner location; it includes painful memories and more unusual traits that we

564 might try to hide from most people. This is why we reveal ourselves most thoroughly and discuss the widest range of topics with our spouses and loved ones.

Self-disclosure is an important building block for intimacy; intimacy cannot be achieved without it. We expect self-disclosure to be reciprocal and appropriate. Appropriate is the key word here people!

Self-disclosure can be assessed by an analysis of cost and rewards, which can be further explained by social exchange theory. Most self-disclosure occurs early in relational development, but more intimate self-disclosure occurs later.

Social penetration theory states that the development of a relationship is closely linked to systematic changes in communication. Relationships generally begin with the exchange of superficial information and gradually move on to more meaningful conversations. In order to develop a more intimate relationship partners must increase the breadth and depth of their conversations. Breadth includes the variety of topics two people discuss and depth is the personal significance of these topics.

Altman and Taylor use a wedge to explain this theory. In this example, the beginning of a relationship is represented by a narrow and shallow wedge because only a few topics are discussed. However, as the relationship goes on the wedge should become broader and deeper because more topics are discussed that have more personal significance. This wedge must drive through three layers in order for intimacy to develop. The first layer is the superficial layer where couples make “small talk.” These conversations usually provide little personal information about the speakers. The next layer is the intimate level where the couple increases the breadth and depth of their conversations and share more personal details until the wedge reaches the very intimate level where extremely private information is shared

Intimacy in these relationships can only develop if both partners reciprocate disclosures. Intimacy will not develop if only one partner discloses and the other continues to reveal only superficial information. According to this theory, this process of reciprocity needs to be gradual and partners need to match the intimacy of the disclosures. Saying something too personal too soon creates an imbalance in the relationship which can make the other

565 partner very uncomfortable. This gradual process varies from relationship to relationship and can depend on the specific partner one is communicating with.

Reciprocity is a positive response from the person with whom one is sharing information, whereby the person who was received the disclosure self-discloses in turn. Self-disclosure usually influences whether two people will want to interact again. Research has shown that when one person self- discloses, another person is more likely to self-disclose. Initially, the process is started by one partner's reveal of personal information to the other partner. In return, the other will disclose something and behave in such a way so as to be responsive to the initial disclosure's content, while also conveying a degree of understanding and validation for what was revealed.

Research has found that people who consider themselves to be high in disclosure are likely to be good at eliciting more disclosure from those with whom they interact. Three theories describe reciprocity: The social attraction-trust hypothesis, social exchange theory and the norm of reciprocity. The social attraction-trust hypothesis says that people disclose to one another because they believe the person who disclosed to them likes and trusts them. Social exchange theory explains that people attempt to maintain equality in self-disclosure because an imbalance in this makes them uncomfortable. The third explanation, the norm of reciprocity, argues that reciprocating disclosure is a social norm and violating it makes a person uncomfortable.

There are two types of reciprocity: turn-taking reciprocity and extended reciprocity. Turn-taking is when partners immediately self-disclose with one another and extended is when disclosure happens over a period of time, in which one partner may be the only one disclosing while the other just listens. Those who engage in turn taking reciprocity are shown to like their interaction partners more than those who engage in extended reciprocity. Turn taking partners are also shown to feel closer and similar to each other and to enjoy the other’s company more than extended pairs. This can be explained by the social attraction-trust hypothesis because the partners perceive the discloser as liking and trusting them because they disclosed personal information. Those who engage in extended reciprocity are affected by the social exchange theory and the norm of reciprocity which can account for the lower degree of liking. Since extended reciprocity limits

566 reciprocating disclosure it creates an imbalance in disclosure which violates both of these theories. That said, people usually report that they themselves are disclosing more than is the other partner. This is called perceived partner reciprocity, and it is critical to the self-disclosure process in developing relationships.

Two key components for intimacy are disclosure and partner responsiveness. It is extremely important that when a speaker discloses personal information their partner also discloses something personally relevant. It is also essential that the listener understand, validate and care about what the speaker is disclosing. If the speaker does not feel accepted by the listener then they may not disclose something to them in the future, which stops the development of intimacy. Emotional disclosures are also shown to foster intimacy more than factual disclosures. Factual disclosures reveal facts and information about the self (e.g., “I am divorced from my husband.”) while emotional disclosures reveal a person’s feelings, thoughts and judgments (e.g., “My divorce was so painful it has made it difficult for me to trust a romantic partner again”). Emotional disclosures can increase intimacy because they allow the listener to confirm and support the discloser’s self-view. The transition from sharing impersonal to personal facts is crucial to the building of an intimate relationship. One must feel accepted in order to feel comfortable enough to self-disclose. Without acceptance, one partner will withdraw and fail to reveal personal facts within the relationship. Sharing our selves also brings us out of our imaginary worlds and allows us to see the realities of the world we live in. We are most comfortable sharing with those whom we like and feel like us. There is also evidence that someone who introduces himself with more intimacy is more likely to facilitate self-disclosure and intimacy with the recipient. Thus, self-disclosure breeds intimacy. This is why reveal ourselves most and discuss the widest range of topics with our spouses and loved ones.

We often perceive our own self-disclosure as higher than our partner's, which can lead to ill feelings. It is hard for humans to accurately judge how fully another is disclosing to them.

Self-monitoring is a form of impression management in which a person examines a situation and behaves accordingly. Although self-monitoring is measured on a continuous scale, researchers often group individuals into two types: high and low self-monitors. Someone who is a high self-monitor

567 tends to examine a situation more closely and adjusts their behavior in order “fit in” with others in the scenario. High self-monitors tend to behave in a friendlier and extroverted manner in order to be well liked by peers. A low self-monitor does not do this and tends to follow their own emotions and thoughts when behaving in public. Since they are more attuned to social cues, high self-monitors are generally better at assessing the level of intimacy a partner is disclosing. By noticing these cues, high self-monitors tend to reciprocate equally in their self-disclosures.

This can be explained by the norm of reciprocity because the high self- monitors can pick up on these cues easily and know that they need to respond with their own disclosure. It can also be explained by social exchange theory. Research shows that high self-monitors are more uncomfortable when paired with a low self-monitor because low self- monitors do not tend to disclose intimate details so the balance in the conversation is uneven. High self-monitors are also shown to be the “pace- setters” of the conversation and generally initiate and maintain the flow of a conversation.

Those in a positive mood have been found to disclose more intimately than those in a negative mood. This may be because of informational effects whereby happy people tend to access more positive information which leads them to behave in a more optimistic and confident manner. Unhappy people tend to access more negative information which increases the likelihood of cautious, pessimistic and restrained communications.

This may also be due to processing effects, in particular assimilation and accommodation effects. Assimilation effects rely on an individual’s prior knowledge to guide their behavior in a situation and accommodation effects rely on careful monitoring of a situation and a greater attention to concrete information. Assimilative processing is ideal for safe, routine situations while accommodative processing is for problematic situations. Happy people tend to use assimilative processing, which leads to more daring and direct disclosures, while unhappy people use accommodative processing, which leads them to be more cautious in their disclosures. These accommodating effects for unhappy people tend to increase reciprocity because these individuals will match the level of disclosure from their partner but will not go beyond that.

568 However, it can also be said that being distressed, anxious, or fearful (which would be classified as negative mood states) can accelerate disclosure as well. The exception to this is loneliness, for lonely individuals have shown decreased rates of self-disclosure.

Whether or not one sex shares more readily is a heated debate in social psychology, but sex-role identities play a large part in the amount one chooses to reveal to another.

Research findings on gender differences in self-disclosure are mixed. Women self-disclose to enhance a relationship, while men self-disclose relative to their control and vulnerabilities. Men initially disclose more in heterosexual relationships. Women tend to put more emphasis on intimate communication with same-sex friends than men do.

In relationships, there are still other factors that contribute to the likelihood of disclosure. In men, self-disclosure and the level of disclosure they perceive from their wives is positively correlated with their self-esteem. For both genders, the state of a relationship and the feelings associated with it are major contributors to how much each spouse reveals himself or herself. Husbands and wives in a relationship marked with satisfaction, love, and commitment rate their own levels of disclosure highly as well as their perceptions of their spouses' disclosures.

Being shy decreases self-disclosure. Among men, those who are or appear more "tough" are less likely to disclose and express themselves.

Motivation for disclosure is also critical: does the individual need to present himself or herself in a certain way in order to gain certain benefits, and does the self-disclosure match the person's sense of ideal self? We like to present ourselves in ways that we feel are congruent with our own self- concepts, and what we tell others about ourselves often becomes how we actually are.

Social exchange theory Social exchange theory is a social psychological and sociological perspective that explains social change and stability as a process of negotiated exchanges between parties. Social exchange theory posits that human relationships are formed by the use of a subjective cost-benefit analysis and the comparison of alternatives. The theory has roots in

569 economics, psychology and sociology. Social exchange theory features many of the main assumptions found in rational choice theory and structuralism.

Social exchange theory was introduced in 1958 by the sociologist George Homans with the publication of his work "Social Behavior as Exchange". He defined social exchange as the exchange of activity, tangible or intangible, and more or less rewarding or costly, between at least two persons. After Homans founded the theory, other theorists continued to write about it, particularly Peter M. Blau and Richard M. Emerson, who in addition to Homans are generally thought of as the major developers of the exchange perspective within sociology. Homans' work emphasized the individual behavior of actors in interaction with one another. Although there are various modes of exchange, Homans centered his studies on dyadic exchange. John Thibaut and Harold Kelley are recognized for focusing their studies within the theory on the psychological concepts, the dyad and small group. Lévi-Strauss is recognized for contributing to the emergence of this theoretical perspective from his work on anthropology focused on systems of generalized exchange, such as kinship systems and gift exchange.

Homans summarizes the system in three propositions success, stimulus, deprivation–satiation proposition.

1. Success proposition: When one finds they are rewarded for their actions, they tend to repeat the action.

2. Stimulus proposition: The more often a particular stimulus has resulted in a reward in the past, the more likely it is that a person will respond to it.

3. Deprivation–satiation proposition: The more often in the recent past a person has received a particular reward, the less valuable any further unit of that reward becomes.

Peter Blau focused his early writings on social exchange theory more towards the economic and utilitarian perspective. Whereas Homans focused on reinforcement principles which believe individual's base their next social move on past experiences, Blau's utilitarian focus encouraged the theorist to look forward as in what they anticipated the reward would be in regards to their next social interaction. Blau felt that if individuals focused too much on the psychological concepts within the theory, they would

570 refrain from learning the developing aspects of social exchange. Blau emphasized technical economic analysis whereas Homans concentrated more on the psychology of instrumental behavior.

Richard Emerson's early work on the theory intertwined with both Homans and Blau's ideas. From Homan's ideas, he believed social exchange theory was based on reinforcement principles. According to Emerson, Exchange is not a theory but a framework of from which other theories can converge and compared to structural functionalism. Emerson's perspective was similar to Blau's since they both focused on the relationship power had with the exchange process. Emerson says that social exchange theory is an approach in sociology that is described for simplicity as an economic analysis of noneconomic social situations. Exchange theory brings a quasi- economic more of analysis into those situations.

Self-interest and interdependence are central properties of social exchange. These are the basic forms of interaction when two or more actors have something of value to each other, and they have to decide whether to exchange and in what amounts. Homans uses the concepts of individualism to explain exchange processes. To him, the meaning of individual self-interest is a combination of economic and psychological needs. Fulfilling self-interest is often common within the economic realm of the social exchange theory where competition and greed can be common. In social exchange, self-interest is not a negative thing; rather, when self- interest is recognized, it will act as the guiding force of interpersonal relationships for the advancement of both parties’ self-interest" — Michael Roloff (1981) Thibaut and Kelley see the mutual Interdependence of persons as the central problem for the study of social behavior. They developed a theoretical framework based on the interdependence of actors. They also highlighted social implications of different forms of interdependence such as reciprocal control. According to their interdependence definition, outcomes are based on a combination of parties’ efforts and mutual and complementary arrangements.

Social exchange theory views exchange as a social behavior that may result in both economic and social outcomes. Social Exchange Theory has been generally analyzed by comparing human interactions with the marketplace. The study of the theory from the microeconomics perspective is attributed to Blau. Under his perspective every individual is trying to maximize his wins. Blau stated that once this concept is understood, it is

571 possible to observe social exchanges everywhere, not only in market relations, but also in other social relations like friendship. Social exchange process brings satisfaction when people receive fair returns for their expenditures. The major difference between social and economic exchange is the nature of the exchange between parties. Neoclassic economic theory views the actor as dealing not with another actor but with a market and environmental parameters, such as market price. Unlike economic exchange, the elements of social exchange are quite varied and cannot be reduced to a single quantitative exchange rate. According to Stafford, social exchanges involve a connection with another person; involve trust and not legal obligations; are more flexible; and rarely involve explicit bargaining.

Simple social exchange models assume that rewards and costs drive relationship decisions. Both parties in a social exchange take responsibility for one another and depend on each other. The elements of relational life include:

Costs are the elements of relational life that have negative value to a person, such as the effort put into a relationship and the negatives of a partner. (Costs can be time, money, effort etc.)

Rewards are the elements of a relationship that have positive value. (Rewards can be sense of acceptance, support, and companionship etc.)

As with everything dealing with the social exchange theory, it has as its outcome satisfaction and dependence of relationships. The social- exchange perspective argues that people calculate the overall worth of a particular relationship by subtracting its costs from the rewards it provides.

Worth = Rewards – Costs

If worth is a positive number, it is a positive relationship. On the contrary, a negative number indicates a negative relationship. The worth of a relationship influences its outcome, or whether people will continue with a relationship or terminate it. Positive relationships are expected to endure, whereas negative relationships will probably terminate. In a mutually beneficial exchange, each party supplies the wants of the other party at lower cost to self than the value of the resources the other party provides.

572 In such a model, mutual relationship satisfaction ensures relationship stability.

Outcome = Rewards – Costs

Homans based his theory on behaviorism to conclude that people pursue rewards to minimize costs. The “satisfactory-ness” of the rewards that a party gains from an exchange relationship is judged relative to some standard, which may vary from party to party.

Ivan Nye came up with twelve theoretical propositions that aid in understanding the exchange theory.

Individuals choose those alternatives from which they expect the most profit.

Cost being equal, they choose alternatives from which they anticipate the greatest rewards.

Rewards being equal, they choose alternatives from which they anticipate the fewest costs.

Immediate outcomes being equal, they choose those alternatives that promise better long- term outcomes.

Long-term outcomes being perceived as equal, they choose alternatives providing better immediate outcomes.

Costs and other rewards being equal, individuals choose the alternatives that supply or can be expected to supply the most social approval (or those that promise the least social disapproval).

Costs and other rewards being equal, individuals choose statuses and relationships that provide the most autonomy.

Other rewards and costs equal, individuals choose alternatives characterized by the least ambiguity in terms of expected future events and outcomes.

573 Other costs and rewards equal, they choose alternatives that offer the most security for them.

Other rewards and costs equal, they choose to associate with, marry, and form other relationships with those whose values and opinions generally are in agreement with their own and reject or avoid those with whom they chronically disagree.

Other rewards and costs equal, they are more likely to associate with, marry, and form other relationships with their equals, than those above or below them. (Equality here is viewed as the sum of abilities, performances, characteristics, and statuses that determine one's desirability in the social marketplace.)

In industrial societies, other costs and rewards equal, individuals choose alternatives that promise the greatest financial gains for the least financial expenditures.

Even though Homans took an individualistic approach, a major goal of his work was to explicate the micro-foundations of social structures and social exchange. By studying such forms of behavior he hoped to illuminate the informal sub-institutional bases of more complex social behavior, typically more formal and often institutionalized. According to Homans, social structures emerge from elementary forms of behavior. His vision of the underpinnings of social structure and institutional forms is linked to the actions of individuals, for example to their responses to rewarding and punishment circumstances.

Homans developed five key propositions that assist in structuring individuals' behaviors based on rewards and costs. This set of theoretical ideas represents the core of Homans's version of social exchange theory.

The first proposition: the Success Proposition states that behavior that creates positive outcomes is likely to be repeated.

The second proposition: the Stimulus Proposition believes that if an individual's behavior is rewarded in the past, the individual will continue the previous behavior.

574 The third proposition: the Value proposition believes that if the result of a behavioral action is considered valuable to the individual, it is more likely for that behavior to occur.

The fourth proposition: the Deprivation-satiation proposition believes that if an individual has received the same reward several times, the value of that reward will diminish.

The fifth proposition discusses when emotions occur due to different reward situations. Those who receive more than they expect or do not receive anticipated punishment will be happy and will behave approvingly.

Social exchange theory is not one theory but a frame of reference within which many theories can speak to another, whether in argument or mutual support. All these theories are built upon several assumptions about human nature and the nature of relationships. Thibaut and Kelley have based their theory on two conceptualizations: one that focuses on the nature of individuals and one that describes the relationships between two people. Thus, the assumptions they make also fall into these categories. The assumptions that social exchange theory makes about human nature include the following: Humans seek rewards and avoid punishments. Humans are rational beings.

The standards that humans use to evaluate costs and rewards vary over time and from person to person.

The assumptions social exchange theory makes about the nature of relationships include the following: Relationships are interdependent. Relational life is a process.

The prisoner's dilemma is a widely used example in game theory that attempts to illustrate why or how two individuals may not cooperate with each other, even if it is in their best interest to do so. It demonstrates that while cooperation would give the best outcome, people might nevertheless act selfishly. All relationships involve exchanges although the balance of this exchange is not always equal. We cannot achieve our goals alone so as humans sometimes we have to become actors. In the world today we

575 see actors as unemotional people but that is not the case once we reach our goals in the end.

Social exchange includes "both a notion of a relationship, and some notion of a shared obligation in which both parties perceive responsibilities to each other" John Thibaut and Harold Kelley proposed two comparison standards to differentiate between relationship satisfaction and relationship stability. This evaluation rests on two types of comparisons: Comparison Level and Comparison Level for Alternative. According to Thibaut and Kelley, the Comparison Level (CL) is a standard representing what people feel they should receive in the way of rewards and costs from a particular relationship. An individual's comparison level can be considered the standard by which an outcome seems to satisfy the individual. The Comparison Level for Alternative (CLalt) refers to “the lowest level of relational rewards a person is willing to accept given available rewards from alternative relationships or being alone” In other words, when using this evaluation tool, an individual will consider other alternative payoffs or rewards outside of the current relationship or exchange. CLalt provides a measure of stability rather than satisfaction. If people see no alternative and fear being alone more than being in the relationship, Social Exchange Theory predicts they will stay.

According to Kelley and Thibaut, people engage in Behavioral Sequence, or a series of actions designed to achieve their goal. This is congruent with their assumption that human beings are rational. When people engage in these behavioral sequences, they are dependent to some extent on their relational partner. In order for behavioral sequences to lead to social exchange, two conditions must be achieved: "It must be oriented towards ends that can only be achieved through interaction with other persons, and it must seek to adapt means to further the achievement of these ends". The concept of reciprocity also derives from this pattern. The reciprocity principle refers to the mutual reinforcement by two parties of each other's actions. The process begins when at least one participant makes a “move,” and if the other reciprocates, new rounds of exchange initiate. Once the process is in motion, each consequence can create a self-reinforcing cycle. Even though the norm of reciprocity may be a universally accepted principle, the degree to which people and cultures apply this concept varies.

576 Several definitions of power have been offered by exchange theorists. For instance, some theorists view power as distinct from exchanges, some view it as a kind of exchange and others believe power is a medium of exchange. However, the most useful definition of power is that proposed by Emerson, who developed a theory of power-dependence relations. According to this theory, the dependence a person has on another brings up the concept of power. Power differentiation affects social structures by causing inequalities between members of different groups, such as an individual having superiority over another. Power within the theory is governed by two variables : the structure of power in exchange networks and strategic use.

According to Thibaut and Kelley, there are two types of power: fate control and behavior control. Fate control is the ability to affect a partner’s outcomes. Behavior control is the power to cause another’s behavior to change by changing one’s own behavior.

People develop patterns of exchange to cope with power differentials and to deal with the costs associated with exercising power. These patterns describe behavioral rules or norms that indicate how people trade resources in an attempt to maximize rewards and minimize costs. Three different matrices have been described by Thibaut and Kelley to illustrate the patterns people develop. These are given matrix, the effective matrix and the dispositional matrix.

The given matrix represents the behavioral choices and outcomes that are determined by a combination of external factors (environment) and internal factors(the specific skills each interactant possesses).

The effective matrix “which represents an expansion of alternative behaviors and/or outcomes which ultimately determines the behavioral choices in social exchange”.

The dispositional matrix represents the way two people believe that rewards ought to be exchanged between them.

There are three forms within these matrices: Reciprocity, Generalized Exchange, and Productive Exchange. In a direct exchange, reciprocation is confined to the two actors. One social actor provides value to another one and the other reciprocates. There are three different types of reciprocity:

577 Reciprocity as a transactional pattern of interdependent exchanges Reciprocity as a folk belief Reciprocity as a moral norm

A generalized exchange involves indirect reciprocity between three or more individuals. For example, one person gives to another and the recipient responds by giving to another person other than the first person. Productive exchange means that both actors have to contribute for either one of them to benefit. Both people incur benefits and costs simultaneously.

Another common form of exchange is negotiated exchange which focuses on the negotiation of rules in order for both parties to reach a beneficial agreement. Reciprocal exchanges and negotiated exchanges are often analyzed and compared to discover their essential differences. One major difference between the two exchanges is the level of risks associated with the exchange and the uncertainty these risks create (ref). Negotiated exchange can consist of binding and non-binding negotiations. When comparing the levels of risk within these exchanges, reciprocal exchange has the highest level of risk which in result produces the most uncertainty. An example of a risk that could occur during the reciprocal exchange is the factor that the second party could end up not returning the favor and completing the reciprocal exchange. Binding negotiated exchanges involve the least amount of risks which will result the individuals feeling low levels of uncertainty. Whereas non-binding negotiated exchanges and their level of risks and uncertainty fall in between the amount of risks associated with reciprocal and binding negotiated exchanges. Since there is not a binding agreement involved, one party involved in the exchange could decide to not cooperate with the agreement.

Reciprocity Reciprocity refers to responding to a positive action with another positive action, rewarding kind actions. As a social construct, reciprocity means that in response to friendly actions, people are frequently much nicer and much more cooperative than predicted by the self-interest model; conversely, in response to hostile actions they are frequently much more nasty and even brutal.

People categorize an action as kind by viewing its consequences and also by the person's fundamental intentions. Even if the consequences are the same, underlying intentions can cause an action to be reciprocated

578 differently. Reciprocity is considered as a strong determining factor of human behavior. Positive reciprocal actions differ from altruistic actions as the former only follow from other positive actions and they differ from social gift giving in that those are not actions taken with the hope or expectation of future positive responses. The focus of reciprocity is centered more on trading favors than making a negotiation or a contract with another person. With reciprocity, a small favor can produce a sense of obligation to a larger return favor. This feeling of obligation allows an action to be reciprocated with another action. Because there is a sense of future obligation with reciprocity it can help to develop and continue relationships with people. Reciprocity works because from a young age people are taught to return favors and to disregard this teaching will lead to the social stigma of being an ingrate.

Reciprocity as a form of social obligation calling for future acts kindness can be seen in the Japanese word for thank you, "sumimasen," which means "this will not end" It is also presented in the Bulgarian word for thank you "blagodariya”, which means "Good I'll Give".

Cooperative reciprocal tendencies i.e. inclinations to give back in a cooperative manner, are called positive reciprocity. On the other hand, retaliatory aspects i.e. the aspects of trying to get back and cause harm, are known as negative reciprocity. Unlike "cooperative" or "retaliatory" behavior in repeated interactions, reciprocity is an in-kind response to beneficial or harmful acts with no material gains expected by the actor.

Some examples of positive reciprocity include smiling waitresses getting tipped much more than less friendly ones (Tidd and Lochard, 1978), calls for contributions to charities being accompanied by small gifts, use of free samples of a certain product in a supermarkets (Cialdini, 1993).

Reciprocal actions are important to social psychology as they can help explain the maintenance of social norms. Reciprocity is so strong that a person will feel obligated to return a favor regardless of whether they like the person who originally gave the favor and even if they did not want the favor, as was demonstrated in an experiment by Dennis Regan in 1971. Regan had subjects believe they were in an “art appreciation” experiment with a partner, who was really Regan’s assistant. In the experiment the assistant would disappear for a two-minute break and bring back a soft drink for the subject. After the art experiment was through, the assistant

579 asked the subject to buy raffle tickets from him. In the control group the assistant behaved in exactly the same manner, but did not buy the subject a drink. The subjects who had received the favor, a soft drink, bought more raffle tickets than those in the control group despite the fact that they hadn’t asked for the drink to begin with. Regan also had the subjects fill out surveys after they finished the experiment and found that whether they personally liked the assistant or not had no effect on how many tickets they bought. One problem of reciprocity, however, focuses on the unequal profit obtained from the concept of reciprocal concessions. The emotional burden to repay bothers some more than others, causing some to overcompensate with more than what was given originally. In the Regan study, subjects paid more money for the tickets than the cost of the (un-requested) soft drink.

How self-disclosure and Reciprocitys relate to this subject The massage therapist client relationship is already an intimate one, evenwhen it is professional. We are bound by rules of confidentiality, and we conduct our interactions behind closed doors. We spend a great deal of time touching our clients and seeing them in varying stages of undress. Unlike other medical professionals that administer exams or procedures, our service can (and often are) sought out purely for pleasure or release of tension.

That being said, our amount of self-disclosure, is the first line of defense against allowing the client to form an inappropriate attachment to us.

In regards to transference it makes little difference. The client is transferring feelings they have for someone else to you; largely due to the way you are touching them-so they can develop feelings for you regardless of how much of yourself you choose to share.

Even though it will not prevent it, keeping your self-disclosure to a minimum will help you deal with the advances of a client that is experiencing transference. If you have kept your self-disclosure to a minimum you can point out to them that what they are feeling isn’t truly directed at you because they don’t know you. You will not have that option if your client knows a lot about you.

580 Summary of Transference & Countertransference in Massage Therapy Transference and countertransference is a fairly common phenomenon that occurs in massage therapy. In the context of massage therapy transference refers to redirection of a client's feelings for a significant person in their current life or past to the massage therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms.

The Drama Triangle The Drama Triangle is a graphic representation of a social dynamic involving three people in the distinctive roles of victim, persecutor, and rescuer.

581 In massage therapy, the client would be the victim in the scenario. They receive massage therapy for relief from the stress caused by the persecutor (husband, wife, mother, boss, etc), which makes the massage therapist the rescuer.

Transference is natural and is part of any human interaction. The practitioner need only be concerned with negative transference , which in this context means it could lead the client to develop feelings or attitudes that are harmful to the therapeutic relationship. If the massage practitioner is able to identify the warning signs of these feelings and attitudes early enough they can be redirected.

Romantic/erotic transference This is perhaps the most familiar to massage therapists as it is generally addressed in the core training.

582 Redirecting romantic/erotic transference Should you believe that your client is experiencing romantic/erotic transference it is your ethical responsibility to attempt to redirect this thought or cease treatment, referring the client to another therapist.

Pain/resentment transference warning signs This type of transference will be apparent in the attitude and language of your client.

Does your client: Make sarcastic remarks during your sessions. Ask if the treatment is necessary. Accuse you of using more pressure then necessary.

583 As helpers and nurturers it is easy for us to “be there” for our clients when they need someone to talk to, but if they are calling you to vent outside of the massage session they are crossing an important boundary.

The Drama Triangle Warning Signs This type of transference will be apparent if your client displays the following behaviors.

Breaking out of the Drama Triangle If you find yourself in this situation the first step is to take yourself out of the triangle, the second is to reestablish the boundaries.

584 If your client is calling you to talk about their stressor outside of the massage session this needs to stop immediately. You must let your client know that professional boundaries must be maintained and that any calls should be regarding massage services, not venting or emotional support. While your client may need these things, it is outside of your scope of practice to provide them and you should refer him/her to the appropriate professional (psychologist, marriage and family counselor, social worker, clergy, etc).

Countertransference in therapeutic massage Countertransference occurs when the massage therapist begins to direct unconscious thoughts and feelings toward their client.

As stated previously, transference and countertransference is a normal human psychological phenomenon-it happens to all of us to a greater or lesser degree. It only becomes a problem when we allow it to distort or interfere with our professional therapeutic relationships. The most important factor in avoiding negative countertransference issues is self- awareness . If we are aware of our feelings and thoughts about our clients we are able to maintain proper boundaries at all times.

Romantic/erotic Countertransference Many people associate the sensual and nurturing touch of massage with romance and eroticism. Even though we are professional body workers we are still human and as such are naturally subject to sexual attraction.

585 It is important that we recognize these thoughts and feelings early and make a deliberate effort to not dwell on them.

You do not have to deny your attraction to a client, but you should be aware that your Romantic/Erotic feelings could have a subtle influence on your professional judgment.

Ineffectiveness and Counteransference There are many physical conditions that are beyond the ability of the massage therapist to treat and this can cause frustration for the practitioner.

A similar source of frustration is with the client that continually injures the same area, as with professional athletes.

When we are working with someone who repeatedly causes damage to their body it is easy for us to resent that on an unconscious level.

586 If you find that there are some clients that you do not look forward to seeing you should examine your feelings toward them. You may discover that you have feelings about your clients you were completely unaware of.

Sensory memory and emotions There can be no doubt that massage therapy is a sensual experience. It’s not just the touch and feel of a therapist manipulating the tissues, most of the other senses are stimulated to a lesser degree as well.

Types of Sensory Memory Iconic memory (What we see) Olfactory memory (What we smell) Echoic memory (What we hear) Haptic memory (What we feel)

Iconic memory involves the memory of visual stimuli. It is how the brain remembers an image you have seen. For example, look at an object in the room you are in now, and then close your eyes and visualize that object. The image you "see" in your mind is your iconic memory of that visual stimuli.

Iconic memory is part of the visual memory system in addition to long-term memory and visual short-term memory. It is a type of sensory memory that lasts very briefly before quickly fading.

Olfactory memory refers to the recollection of odors. Studies have found various characteristics of common memories of odor memory including persistence and high resistance to interference. Explicit memory is typically the form focused on in the studies of olfactory memory, though implicit forms of memory certainly supply distinct contributions to the understanding of odors and memories of them. Research has demonstrated that the changes to the olfactory bulb and main olfactory system following birth are extremely important and influential for maternal behavior. Mammalian olfactory cues play an important role in the coordination of the mother infant bond, and the following normal development of the offspring. Maternal

587 breast odors are individually distinctive, and provide a basis for recognition of the mother by her offspring.

Olfactory memory was developed throughout evolution for various reasons. Among the most notable reasons are those related to the survival of the species and the development of early communication. Even in humans and animals today, these survival and communication aspects are still functioning. There is also evidence suggesting that there are deficits in olfactory memory in individuals with brain degenerative diseases such as Alzheimer's disease and dementia. These individuals lose the ability to distinguish smells as their disease worsens. There is also research showing that deficits in olfactory memory can act as a base in assessing certain types of mental disorders such as depression as each mental disorder has its own distinct pattern of olfactory deficits.

Echoic memory is one of the sensory memory registers; a component of sensory memory (SM) that is specific to retaining auditory information. The sensory memory for sounds that people have just perceived is the form of echoic memory. Unlike visual memory, in which our eyes can scan the stimuli over and over, the auditory stimuli cannot be scanned over and over. Overall, echoic memories are stored for slightly longer periods of time than iconic memories (visual memories). Auditory stimuli are received by the ear one at a time before they can be processed and understood. For instance, hearing the radio is very different from reading a magazine. A person can only hear the radio once at a given time, while the magazine can be read over and over again. It can be said that the echoic memory is like a "holding tank" concept, because a sound is unprocessed (or held back) until the following sound is heard, and only then can it be made meaningful. This particular sensory store is capable of storing large amounts of auditory information that is only retained for a short period of time (3–4 seconds). This echoic sound resonates in the mind and is replayed for this brief amount of time shortly after the presentation of auditory stimuli. Echoic memory encrypts only moderately primitive aspects of the stimuli, for example pitch, which specifies localization to the non- association brain regions.

Haptic memory is a form of sensory memory that refers to the recollection of data acquired by touch after a stimulus has been presented. Haptic memory is used regularly when assessing the necessary forces for gripping and interacting with familiar objects. It may also influence one’s interactions

588 with novel objects of an apparently similar size and density. Similar to visual iconic memory, traces of haptically acquired information are short lived and prone to decay after approximately two seconds. Haptic memory is best for stimuli applied to areas of the skin that are more sensitive to touch. Haptics can be classified as a type of perceptual system which involves two subsystems; cutaneous and kinesthetic. The former refers to anything that is skin related, whereas the latter is muscle sense. Haptics involves active, manual examination and is quite capable of processing the material traits of surfaces or objects.

Flashbacks A flashback, or involuntary recurrent memory, is a psychological phenomenon in which an individual has a sudden, usually powerful, re- experiencing of a past experience or elements of a past experience. These experiences can be happy, sad, exciting, or any other emotion one can consider. The term is used particularly when the memory is recalled involuntarily, and/or when it is so intense that the person "relives" the experience, unable to fully recognize it as memory and not something that is happening in "real time".

589 Massage therapists are not immune to the Florence Nightingale effect, so be cognizant of your feelings toward your clients at all times.

When we think of massage therapists and sexual misconduct there are generally two images that come to mind:

3) The prostitute that is using massage therapy as a cover, usually (but not always) a female.

4) The sexual predator that is taking advantage of clients, usually (but not always) a male.

To be fair, the reason why these two images immediately spring to mind is because that is what the media reports happening the most frequently.

We live in an age where sexual norms are being challenged all the time, and the familiar defense of the challenge is always “What does it matter if the participants are consenting adults?”

590 created a false sense of propriety in our minds whenever consenting adults are involved.

Not all cases of sexual misconduct are crimes, but all of them are grounds for license revocation. It’s important to know the difference between sexual misconduct and crimes of a sexual nature.

Sexual Misconduct involves a boundary violation with a massage client, and this includes willing participants. Because of the power differential and

591 the phenomenon of transference and countertransference it is never appropriate for a massage therapist to have a sexual relationship with a client, even if the client is a consenting adult.

Please note that “sexual relationship” is not limited to sexual intercourse, It also includes inappropriate talk or touching, or unnecessary examinations or treatments.

Let’s look at each category and how it relates to massage therapy.

Sexual Harassment This is generally a workplace issue; it involves the behavior of a supervisor, manager, employer or employee toward staff at the same or a lower level of power. It can also apply to a business owner that rents space to a massage therapist.

1) Quid pro quo a demand for sexual favors in exchange for job benefits;

2) Hostile work environment unwelcome acts such as physical or verbal conduct, or visual displays, that makes the individuals’ job difficult 70 .

- Submission to such conduct is made a term or condition of an individuals employment, either implicitly or explicitly;

70 Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense, a seminar handout (Providence, RI: Litch & Semenoff, Attorneys at Law, May 2, 1995).

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- Submission to, or rejection of, such conduct is used as a basis for employment decisions affecting such individual;

-Such conduct has the purpose or effect of unreasonably interfering with an individuals work performance or creating an intimidating, offensive, or hostile work environment.

Sexual assault Sexual assault is any involuntary sexual act in which a person is threatened, coerced, or forced to engage against their will, or any sexual touching of a person who has not consented . This includes groping , which is where massage therapists that let their hands roam over forbidden areas are charged with.

593 them from charges of impropriety. Thankfully it doesn’t work, courts are aware of this sort of deception.

71 Concise Encyclopedia: www.merriam-webster.com/browse/concise/a.htm

594 The Deontological theory and Prostitution As we stated earlier in this course, deontological arguments relate to our duties. In this regard our duty as a massage therapist extends beyond our relationship with our client. As a massage therapist you have a duty to every other massage therapist as well, and when a massage therapist engages in an illegal activity they are not just hurting themselves and their client, they are hurting me, you, and every other massage therapist that is affected by the negative perception it creates with the public. For this reason alone there is a deontological reason to not engage in prostitution.

Basically it’s the idea that people collectively agree to behave morally and lawfully as a way to reduce social chaos and create peace.

So would a virtuous person break the law in order to make extra money? No they wouldn’t.

595 massage therapists that were arrested for performing sexual acts. We can only assume that money is the motivation for most of these people.

596 to resist temptation to do something wrong is to avoid putting yourself in a position to be tempted in the first place.

Reviewing professional boundaries Most of this course deals with the specifics of how you should guide your actions and your decision-making at work. It’s definitely not our place to tell you how to live your personal life.

Industry leaders recognize the impact that ethical values, behaviors and practices can have on our profession, your personal reputation and your massage businesses bottom line.

A code of ethics is a set of guidelines that defines acceptable behavior for members of an organization or group. Ideally, an organization tailors its code of ethics to its needs and values.

Central to the nature of the therapeutic relationship is the belief that what is done is by the practitioner (in our case, the massage therapist) is done with the goal of helping or healing. So it is right to assume that nothing harmful should arise out of the relationship. While this may seem simplistic and even obvious, it is a profound truth and needs to be recognized and used

597 as a lens through which to examine all of our actions within the role of our profession.

The Clients Expectations A client enters into the Therapeutic Relationship with certain expectations. These expectations help form the boundaries of the relationship from the client’s perspective.

It is important to remember that the benefits of Massage can only be gained when a Client is able to place themselves in one of the most vulnerable positions imaginable.

Reviewing Basic Ethical Concepts Informed Consent Informed consent is a legal condition whereby a person can be said to have given consent based upon a clear appreciation and understanding of the facts, implications and future consequences of an action. In terms of

598 massage therapy this means that they understand what treatments are going to be performed and the purpose and goals of each.

The Right of Refusal also applies to you as a massage practitioner. You can end a session at any time, for any reason.

Boundaries A Boundary is a space within a perimeter that may be a physical, emotional or mental space. There are many different boundaries, spatial, legal, physical and emotional, etc.

599 This is a boundary crossing; you and your client are now moving beyond the boundaries of your therapeutic relationship and are entering a Dual Relationship .

Different boundaries

Spatial boundaries The spatial boundary is the invisible “three feet of personal space” that most Americans claim as their comfort zone 72 . This is why strangers in the movie theater will usually leave an empty seat between them, or why people boarding a bus will sit in an empty row before choosing to sit in an empty seat beside a total stranger. We like a buffer between us and people we do not know well.

When your client is in the waiting room, or completing intake information in your massage room, you should be observing a respectable distance.

Medical doctors usually demonstrate this principle rather well. Think about the last time you visited a doctor for a medical exam. There you are sitting

72 I say Americans because this is not universal! People from other countries may have entirely different spatial boundaries. This is described in more detail in EPS003 Cultural Sensitivity for Massage Therapists.

600 on the table wearing that ridiculous paper gown. The doctor comes in and greets you, and then sits down on a stool to discuss your condition, or symptoms, etc.

Even though he is about to touch you and palpate areas you usually do not make available to strangers, they are still observing the spatial boundary by sitting on a stool or standing a few feet away.

It could be easy for massage therapists to forget that just because they routinely cross the spatial boundary with a client in the massage room, this boundary does exist and needs to be recognized.

In the traditional 73 treatment setting, only the hands, forearms and elbows should be making contact with the client. These parts of our body are permitted to cross the spatial boundary during the massage. The client should not feel other parts of our body during the massage if it can be avoided.

73 I am referring to Swedish massage, certain modalities, such as Thai Massage, require much more physical contact between the practitioner and the client, which is one of the reasons why they are done fully clothed!

601 Therapeutic Massage never includes any type of sexual touch. That being said, how does one differentiate between two closely related types of touch?

If you have ever shaken hands with a car salesman you know what I am talking about, their mouth says “pleased to meet you” but their hands say “hello commission!”

In regards to geography, all massage therapists learn in school that certain areas of the body are always off limits. This is important enough to be repeated. The genitals and the anus are never stimulated during a therapeutic massage. Ever. Throughout the history of Massage Therapy there have been people who have tried to reintroduce inappropriate sexual touch through various systems and modalities that claim legitimacy but are in fact only thinly veiled acts of prostitution.

602 their comfort level they will tense up, causing an intensification of the ‘pain- spasm-pain’ cycle instead of interrupting it, which is our desired goal.

603 tired of living with discomfort they have finally “worked up the nerve” to try it out.

In addition to concerns about modesty some clients are uncomfortable with certain techniques, types of product or other methodology that is regular practice for the practitioner.

Emotional boundaries The most difficult boundaries to determine are emotional boundaries. Emotional boundaries come in to play when dealing with issues of Transference and Countertransference.

604 Reciprocity Reciprocity refers to responding to a positive action with another positive action, rewarding kind actions. As a social construct, reciprocity means that in response to friendly actions, people are frequently much nicer and much more cooperative than predicted by the self-interest model; conversely, in response to hostile actions they are frequently much more nasty and even brutal.

That being said, our amount of self-disclosure, is the first line of defense against allowing the client to form an inappropriate attachment to us.

605 Maintaining a correct ethical posture in this profession requires us to continually assess our thoughts and feelings and to develop our sense of self-awareness and to constantly be in tune with it.

To stay grounded you can repeatedly ask yourself the following questions during your work:

• Am I focusing on the therapeutic relationship ?

• Are my personal issues intruding into this treatment?

• Are my reactions blurring ethical boundary lines?

606 Certificate of Completion and Transcript In order to receive your certificate of completion and an updated transcript for this course you must complete and pass the quiz.

Once we have received your quiz we will generate your certificate and transcript and both will be emailed to you. If you completed the last quiz during our business hours (Monday-Friday 8:00 am-5:00 pm Pacific Standard Time) it should be emailed to you within a few minutes.

If you complete the last quiz after business hours, or on a weekened it will still be emailed to you as quickly as possible. We check the system every hour until midnight most days so it should go out within an hour of you taking it.

If you take the last quiz after midnight you will probably have to wait until the next morning, we do sleep.

Please give us a full 24 hours before you call us if you have not received your certificate and transcript. We pride ourselves on being very fast, but if there is a condition beyond our control (the Internet Service Provider is down, etc) it may take us longer than usual.

Also please be aware that many people wait until the last minute to do their courses. For this reason, the last few days of the month (28 th , 29 th , 30 th , etc) are usually very, very busy times for us so our turn around time may be a little slower-but it should still be within 24 hours.

If it has been more than 24 hours and you still have not received your emailed certificate, by all means call us! The number is (209) 777-6305.

Lost Certificates and Transcripts If you need another copy of your documents emailed to you we will gladly do that for free at any time, just go to the contact page on our website and ask for it.

607 Course Evaluation We would like to hear some feedback form you. You can complete the evaluation online by clicking this link: http://www.sasionline.com/courseevaluation.html

If you are using the “embedded” version of this course you will not be able to click the link above but there should be one you can access on the webpage itself.

Thanks for taking our course; we really appreciate your business and we hope you come back to us next time you need continuing education hours.

We would also love it if you would “Like us” on facebook, you can find us at www.facebook.com/beyondmassageschool .

Errata If you found a typo PLEASE LET US KNOW what page it is on and the paragraph and we will fix it ASAP. This book has 45,000 words in the course content alone. Some of those are going to be misspelled. We’re not perfect, but we strive to be- so help us out.

Help and Technical Support We have worked hard to make this course as easy to use as possible, but it does rely on technology and sometimes there are factors that are out of our control (like your local internet provider, your computer, your browser version, the device you are using etc).

If for some reason you are not able to access the quiz you can call us and let us know, and we will problem solve it for you. We have office hours, Monday-Friday 8:00 am-5:00 pm PST but you can call or email for help at any time after hours, I monitor the system every hour until I go to sleep, so call if you need to and I will do my best to help you. The number is (209) 777-6305.

608 Bibliography

Section 1: Massage Therapy Roles and Boundaries Introduction to Massage Therapy By Mary Beth Braun, Stephanie J. Simonson, Debra C. Howard, Marybetts Sinclair

The Ethics of Touch: The Hands-on Practitioner's Guide to Creating a Professional, Safe and Enduring Practice by Cherie M Sohnen-Moe, Ben E Benjamin

Ethics for Massage Therapists by Terrie Yardley-Nohr

Informed Consent: Heart of Bodywork By Nina McIntosh Massage & Bodywork magazine, February/March 2007

Boundaries in the Therapeutic Relationship article by Marjorie L. Rand Ph.D.

Section 2: Ethics in Massage Marketing Introduction to Massage Therapy By Mary Beth Braun, Stephanie J. Simonson, Debra C. Howard, Marybetts Sinclair

Theory and Practice of Therapeutic Massage 4 th edition by Mark F. Beck

Massage Therapy Principles and Practice 3 rd edition by Susan G. Salvo

Ethics for Massage Therapists by Terrie Yardley-Nohr

How Advertising Works by colin Mcdonald NTC Publications Ltd

Made You Look: How Advertising Works and Why You Should Know by Shari Graydon

The Placebo Effect: An Interdisciplinary Exploration. Cambridge, by Anne Harrington. MA: Harvard University Press, 1999.

The Powerful Placebo: From Ancient Priest to Modern Physician. Shapiro, Arthur K., and Elaine Shapiro. Baltimore, MD: John Hopkins University Press, 1997.

609 Section 3: Cultural Sensitivity for Massage Therapists Recognizing the power of diversity Gardenswartz, L., & Rowe, A. (1993). Physician Executive, 19(6), 64-67.

The art of leading with grace Kerfoot, K. (1999). MEDSURG Nursing, 8(3), 217-218.

Enriching our practice through culturally competent care. Jean M. Nardini

The Healthcare Professional's Guide to Clinical Cultural Competence by Rani Srivastava

Cultural Competence in Health Care by Wen-Shing Tseng and Jon Streltzer

InfoTrac Article: Cultural Competence: A Primer for Educators by Jerry Diller and Jean Moule

"Put Your Best Foot Forward" by Mary Murray Bosrock.

Section 4: Transference and Countertransference in Massage Beck, Mark F Theory and Practice of Therapeutic Massage. Milady 4 edition (2007)

Susan G. Salvo Massage Therapy: Principles and Practice Saunders; 3 edition (May 3, 2007)

Schaeffer, Judith A. Transference and countertransference in non-analytic therapy; double-edged swords . University Press of America; 1 edition (December 28, 2006)

Howard A. Wishnie Working in the Countertransference: Necessary Entanglements Jason Aronson (January 2005)

A. Alexandris, G. Vaslamatis Countertransference: Theory, Technique, Teaching Karnac Books; 1 edition (May 1992)

Michael A. Pagliarulo Introduction to Physical Therapy Mosby; 3 edition (July 31, 2006)

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When your feelings aren’t your own: understanding transference and countertransference an article in the Massage Therapy Journal, Issue WI06 page 82 Published by the AMTA.

Kapelovitz, Leonard H. (1987). To Love and To Work/A Demonstration and Discussion of Psychotherapy. p. 66. Webster's New Collegiate Dictionary (8th ed. 1976).

Jung, Carl C. The Psychology of the Transference, Princeton University Press, ISBN 0-691-01752-2

Howard A. Wishnie Working in the Countertransference: Necessary Entanglements Jason Aronson (January 2005)

Michael A. Pagliarulo Introduction to Physical Therapy Mosby; 3 edition (July 31, 2006)

The Three Faces of Victim: An Overview of the Drama Triangle web article By Lynne Forrest http://lynneforrest.com/html/the_faces_of_victim.html

Goldstein, Bruce E. 2002. Sensation and Perception: 6th Edition. Pacific Grove CA: Wadsworth Group. P 475.

Atanasova. B, 2008. Olfaction: A potential cognitive marker of psychiatric disorder. Neuroscience and Biobehavioral Reviews 32 (2008) 1315–1325.

Redleaf, Angelica, Behind Closed Doors: Gender, Sexuality, and Touch in the Doctor/Patient Relationship.

Gonsiorek, John C., Perpetrators, in Breach of Trust: Sexual Exploitation by Health Care Professionals and Clergy, John C. Gonsiorek, ed. (Thousand Oaks, CA.; Sage Publications, Inc., 1995), 131.

Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense, a seminar handout (Providence, RI: Litch & Semenoff, Attorneys at Law, May 2, 1995). http://law.justia.com/codes/louisiana/2006/146/78532.html

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Concise Encyclopedia: www.merriam-webster.com/browse/concise/a.htm

Sexual Harassment in the Workplace: Corporate Strategies for Protection and Defense, a seminar handout (Providence, RI: Litch & Semenoff, Attorneys at Law, May 2, 1995).

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