Introduction

Domestic and family violence (DFV) is “any violent, threatening, coercive or controlling behaviour that occurs in current or past family, domestic or intimate relationships that causes the person experiencing the behaviour to feel fear” (Department of Familes Fairness and Housing. 2018; Victorian Government, 2021). Family, domestic and sexual violence is a major health and welfare issue (Family, domestic and sexual violence in Australia, 2018, 2018). Some individuals are at a higher risk of experiencing DFV and include people with a disability (Krnjacki et al., 2016), older adults (Knight & Hester, 2016), women (McCauley et al., 2017), women who are pregnant (Campo, 2015) and other vulnerable populations. Domestic and family violence is “one of the leading causes of death, illness and injury in Australian women aged between 18 to 34 with a disease burden of 5.1 per cent” (Charlton et al., 2022). Multiple professions are involved in supporting individuals who have experienced DFV including specialist DFV services, government organisations, educational organisations, the justice system, religious organisations and healthcare providers. Healthcare workers, especially doctors, nurses, midwives and carers, are frontline responders to individuals who have experienced violence (McLindon et al., 2022) although any healthcare worker may interact with individuals experiencing DFV (Hollingdrake et al., 2023). The role of healthcare practitioners in supporting and empowering people experiencing DFV to access healthcare, safety and support is well established (Hollingdrake et al., 2023; The World Health Organisation., 2021). Individuals experiencing DFV more frequently attend and interact with health services for needs both related and un-related to their abuse either as a result of an injury or thought associated mental trauma such as anxiety, depression (Hollingdrake et al., 2023; Ison et al., 2022; McCauley et al., 2017). While massage therapy is a part of healthcare, massage therapists are not generally frontline responders and therefore they have a different role to play in supporting DFV in their workplace.

Domestic violence has life-long negative implications (McCauley et al., 2017) for physical (chronic pain, migraines (McCauley et al., 2017) and mental health (anxiety, depression, substance abuse, post-traumatic stress disorder) (Department of Health & Human Services., 2020; McCauley et al., 2017). Massage therapy may benefit many of the physical and psychological symptoms that occur directly or indirectly as a result of DFV such as anxiety, depression, stress, muscle pain, chronic pain, injuries (Lynch et al., 2022; Mazza et al., 2021). Given the above reasons for seeking massage and that women are over represented as massage therapists and massage consumers (Balogun & Kennedy, 2020; Cherkin et al., 2002; Ooi et al., 2018; Jonathan L. Wardle et al., 2015a, 2015b), the massage treatment space is one in which it is highly likely that massage therapists will “come into contact with a client who either is or has been subjected to domestic violence” (Razo, 2009). The massage treatment space is one in which a supportive therapeutic relationship is cultivated through trust, rapport, safety, listening, and empathy over repeated visits (Baskwill et al., 2021; Fogarty et al., 2013; Smith et al., 2009). Safety is an important aspect and influencer in the decision to disclose with individuals more likely to disclose DFV if they feel safe (Spangaro et al., 2011) and as massage is a place where safety is imbedded into the treatment and consultation, the massage space might be a place where consumers might disclose DFV. The importance of safety and the therapeutic relationship in DFV has been demonstrated in beauty salons and hairdressers where disclosures of DFV have occurred (Beebe et al., 2018; DiVietro et al., 2016; McCann & Myers, 2023; McLaren et al., 2010; Page et al., 2022) and hairdressers and salon providers have been recruited and trained as ‘natural helpers’ (being a place where service providers or therapists provide advice, support and empathy social support especially around DFV) (Beebe et al., 2018; DiVietro et al., 2016; McCann & Myers, 2023; McLaren et al., 2010; Page et al., 2022). Potentially, the massage environment may be a more appropriate place than hairdressers for DFV disclosure given hairdressers often work in open spaces. Victims of DFV have also indicated a preference for informal helpers over professionals as a source of support (Anderson et al., 2010) increasing the likelihood that massage therapists may be a health professional that clients discloses DFV to. Massage therapy often requires partial disrobing, and this may provide massage therapists the opportunity to identify physical signs of DFV that might be hidden to other healthcare providers. Given the potential for identification or disclosure of DFV to or by massage therapists, it is important that massage therapists are comfortable and confident about responding to or identifying DFV. Therefore, it is important we understand the attitudes of massage therapists regarding DFV. A small number of trade publications and educational material briefly discuss asking about and responding to disclosures of DFV. (Mathiesen & Clark, 2016; Mines, 2001; Razo, 2009). However, there is very little evidence to help guide massage therapists if they should ask about DFV or how to respond to a disclosure. Thus, the objective of this research was to investigate massage therapists’ attitudes, the consultation processes, and confidence to respond to situations involving DFV in clinical practice.

Method

An online survey research study was conducted. The study was approved by Western Sydney University Human Ethics Committee (approval number H14636) on 22 November 2021.

Inclusion Criteria, Sample and Recruitment

Massage therapists in Australia were recruited using convenience sampling (Harrell, 2009). The study sample was massage therapists from Australia, Inclusion criteria was massage therapists who are currently practicing or have recently ceased practising in Australia and who are able to read and understand English and over 18 years of age.

Massage therapists were invited to participate through email and social media. An invitation was sent to members of the Association of Massage Therapists (AMT) in Australia which included approximately 3200 therapists. The study was also advertised on six Facebook groups (Massage Champions Private Group, Pregnancy Massage Australia Q&A, Massage, Soft Tissue Therapy & Myotherapy Australia, Stuart Hinds Results driven therapists, Firm n Fold and CUE/CPD for Remedial Massage/Soft Tissue Therapy/Myotherapy in Australia) which combined have 14,797 followers.

The study was hosted on the Qualtrics online survey platform and was open for participation for 6 months from 15th March to 15th September 2022. Massage therapists who responded within the time frame became the sample. Consent was implied by participants undertaking the survey. No incentive was offered for survey completion.

Survey Design and Data Collection

A survey was developed to ascertain massage therapist’s knowledge and confidence to recognize, respond and refer in situations involving DFV in clinical practice. Demographic questions were informed by a previous survey of the massage therapy profession (Baskwill, 2014). The survey options included tripartite scales such as yes, unsure, or no, rating scales (mostly Likert scales in a matrix format with a single answer per row), open ended-questions and multiple-choice questions. The survey was difficult to validate due to the descriptive nature of the questions and as such principal component analysis was unable to be undertaken.

The final survey included 64 questions in 3 sections: 1) Demographics, 2) Recognize Family and Domestic Violence, and 3) Respond to domestic and family violence (with 4 subsections; i) disclosures, ii) referrals, iii) further education, and iv) final comments). Details about the study were included at the beginning of the survey including information about the purpose of the study, anonymity, what participants were required to do, instructions, perceived benefits for the research, contact details for study researchers and contact details for 24/7 community domestic violence support services in case participants experienced discomfort or stress during or after the completion of the survey.

Analysis

Data were screened for non-consenting and missing responses. Respondents who did not meet the inclusion criteria or those that did not answer any of the domestic violence questions were removed. Descriptive statistics of demographic information are presented as means and standard deviations for continuous data and frequency distributions for discrete data (percentages). Chi-square tests of independence were used to test frequency of distribution of dependent variables (the agreement with statements) with the independent variable (personal experience of DFV). A Fisher’s Exact test was used where there were cells with values less than 5. The threshold for significance was p ≤ 0.05. For those variables with significant differences a post hoc test for each subset of possible paired comparisons was undertaken, including a Bonferroni’s correction, to reduce the chance of a type I error occurring (Portney & Watkins, 2009). Data analysis were undertaken using SPSS (IBM Corp., 2020). The open-ended questions were analysed using inductive content analysis. The first author (SF) read the data and created codes directly from the open-ended survey responses. The codes were then condensed into meaningful categories and themes.(Elo & Kyngäs, 2008).

Results

Two-hundred and thirty-six massage therapists started the survey and after removal of those that did not meet the inclusion criteria (n = 2) and those that only completed demographic information (n = 19), responses from 217 respondents were included in the analysis. The survey took participants an average of 8.5 min (SD 7.7) to complete. Unless stated otherwise, all results are from respondents’ answers to dichotomous scale questions, rating, or multiple-choice questions. Almost half of the respondents (n = 104, 49.5%) had personal experience of DFV.

Demographics

The majority of the respondents identified as female (> 80%) from New South Wales (n = 92, 42.4%) or Queensland (n = 44, 20.3%) and with a mean age of 48 years (SD 12.4). See Table 1. The majority had a diploma qualification in massage (n = 165, 76.0%) and were members of the Association of Massage Therapists (n = 188, 86.6%). Respondents were, on average, in active practice for 10.8 years (SD 8.7). Respondents who identified as female were significantly more likely to have had a personal experience of DFV (p = 0.049). See Table 1.

Table 1 Demographics of participants
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The majority of respondents were self-employed (n = 170, 78.3%). Two thirds of respondents worked in an urban location (n = 145; 66.8%) and almost two thirds identified as a sole practitioner (n = 139, 64.1%). Forty percent worked in a home-based practice (n = 87), 27.2% in a multi-disciplinary practice (n = 59) and 10.6% in a multi-massage practice (n = 23). Chronic pain (n = 140), sports people/athletes (n = 111) and the elderly (n = 107) were the most common focus of respondents’ practice. Significantly more respondents who had a personal experience of DFV had pregnancy massage (5.178 (1, 217), p = 0.023), working with children (4.598 (1, 217), p = 0.032) and or clients with low socioeconomic status (11.27 (1, 217), p < 0.001) as a focus of their clinical practice. (Table 1). No other types of focus of clinical practice were significantly different (See Supplementary Material Table 1).

Massage Consultations and Treatments

Asking Clients About DFV: Confidence, Comfortability, and Knowledge

Five respondents collectively asked their clients, in some way, if they were experiencing DFV (n = 1, 0.9% routinely asks all clients, n = 1, 0.9% routinely asks only new clients and n = 3; 2.8% asks if in an at-risk population). See Table 2. Respondents with a personal experience of DFV were significantly more comfortable and confident to ask clients if they are experiencing DFV than those with no personal experience. See Table 3. Despite the differing levels of comfortability and confidence between participants with and without a personal experience of DFV, both groups wanted more training about DFV including on how to ask about DFV and how to deal with the response before they would feel comfortable asking about DFV. See Table 3.

Table 2 Asking about domestic and family violence: practice, confidence, comfortability, and knowledge
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Table 3 Asking about domestic and family violence: confidence, comfortability, and knowledge
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Responding to Domestic and Family Violence Disclosure in Practice

Respondents with a personal experience of DFV were significantly more likely to have a client disclose DFV than those with no personal experience. For those who had experienced a disclosure, those with a personal experience of DFV were significantly more likely to feel they were adequately equipped when responding to the disclosure. See Table 4. A number of open-ended questions explored the actions/responses respondents undertook when a disclosure occurred and a referral to police, General Practitioners (GP), counsellors, and DFV services were the most common actions (n = 34) followed by listening (n = 23). Traits in treatment such as being sympathetic, compassionate, empathetic and or kind were commonly used (n = 16) and respondents often provided verbal support through affirming the violence and providing clients with an opportunity to speak about it (n = 12). Nine respondents checked if the client was safe. A small number of respondents indicated that they felt their response to the disclosure was not ideal with respondent 37 (personal experience of DFV) indicating they “just said oh my goodness that is horrible I am so sorry, I hope you have received support for it and left it at that as I was very uncomfortable”. The majority of respondents (n = 58, 70.7%) indicated that they would not change anything about the way they responded to a DFV disclosure in their workplace. The things that they would change about how they responded to prior disclosures of DFV was having a better toolbox of resources including more professionals they could refer clients to, asking the client/victim what support they need, allowing the client to talk more if needed, and calling someone for the client. A few respondents did not know exactly what they would change but recognised their lack of knowledge impacted their ability to change how they responded in future instances.

Table 4 Responding to domestic and family violence disclosure in practice
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Support and Safety

Significantly, respondents who had no personal experience of DFV were unsure about whether they would be comfortable referring clients to DFV services (p = 0.044). See Table 5. Respondents with a personal history of DFV were significantly more likely to know what they would be prepared to do to support client/s disclosing a history of DFV, how they would manage their client’s safety after a disclosure and how they would manage their own safety. Respondents with a personal history of DFV were significantly more likely to know what questions to ask to determine the level of risk to their client (10.417 (2,217) p = 0.005) and significantly more likely to know of national (14.877 (2, 217) p < 0.001), state 8.785 (2,217) p = 0.012) and local (6.470 (2, 217) p = 0.39) DFV services they could refer their clients to. Bespoke DFV services (DFV services especially for a particular person, organization, or purpose such a Moorditj Yorga (Strong Women) domestic violence support) were not correlated to personal experience of DFV. See Table 5.

Table 5 Support and safety
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An open-ended question gained information about the types of questions respondents would ask to determine a level of risk for the client who had disclosed DFV. Many respondents asked about immediate risk to life, or immediate risk for harm (physical or mental health and well-being). They asked about safety including if clients felt safe to go home or “do you feel your life is in danger” as well as “if they have a safe place to go to”, “do you have a safety plan”, “is it safe to contact you by phone or text”, and “can you leave quickly if you have to?”. A few respondents mentioned they would ask about the frequency of the violence e.g., was it escalating, and the nature of abuse with a few mentioning they would ask about strangulation. Asking clients what supports they have in place was also a frequent question respondents asked. A couple of respondents asked questions about any Apprehended Domestic/Personal Violence Orders in place and whether or not the perpetuator have access to weapons of any kind, clearly assessing the level of risk to their client. A number of the respondents asked client-centred questions regarding emotional safety of clients such as do you want/need intervention, have you spoken to anyone else about it, would you like to make a phone call to report your abuse, would you be open to counselling, and do you need help/support with reporting this.

A Contrast of Professional Beliefs About the Role of DFV in Massage

Respondents were asked if they had any additional thoughts about massage therapy and their involvement in DFV in an open-ended question. The main theme from the analysis of the open-ended responses was a contrast of professional beliefs about the role of DFV in massage. The subthemes were DFV has no place in massage therapy and DFV is part of massage therapy which were largely patterned by prior experience with DFV. Respondents with no experience of DFV contributed more to the not relevant to massage therapists, and respondents with experience of DFV contributed more to the acknowledging DFV might be relevant in the massage space and wanting to be prepared.

The themes illustrate the diametrically opposed attitudes and professional beliefs expressed by massage therapists in relation to DFV in clinical practice. Many massage therapists articulated that they did believe that DFV was an area relevant to massage therapists citing lack of prevalence in their practice, the massage space not being where individuals experiencing DFV would frequent, and not being a place for DFV conversations. On the opposite side, many therapists recognised that DFV was integrated into massage therapy and that the massage environment was conducive to discussing DFV. These respondents wanted to be prepared and more knowledgeable to support their clients.

DFV has no Place in Massage Therapy

Many massage therapists expressed an ethos that there is “no connection between massage therapy and domestic violence” (Respondent 227, no personal experience of DFV) and that they “never thought domestic violence would be involved in massage” (Respondent 149, no personal experience of DFV). There were a number of reasons given for this perspective including believing that someone experiencing DFV would not seek a massage.

“I’d be extremely surprised to learn that a person in an abusive environment would come in for a massage- that, to me, seems like an extremely unlikely headspace for a victim to have.” (Respondent 60, no personal experience of DFV)

“I wonder how many people suffering domestic and family violence would actually be able/allowed/comfortable to get a massage whilst it is a current situation and not part of their history”. (Respondent 203, no personal experience of DFV)

“I kind of assume that victims of domestic and family violence a) don’t have the income to be getting massages and b) might not have the trust in others to remove clothing and have someone give them a massage”. (Respondent 107, no personal experience of DFV)

Integrating DFV into massage practice was perceived by respondents as irrelevant as they felt that “massage therapists wouldn’t be exposed to many clients experiencing domestic violence in the time of the consultation” (Respondent 56, no personal experience of DFV) and reinforced by many practitioners who had seen no evidence of DFV in all their years of practice.

“In ten years, I’ve never encountered a client who has shown any physical signs of abuse, nor brought the subject up in reference to a current relationship” (Respondent 60, no personal experience of DFV)

“If this area is extremely relevant and important within the massage industry then I’m happy to learn more but in my experience...[it] hasn’t ever come up.” (Respondent 172, no personal experience of DFV)

Many therapists expressed beliefs that indicated their professional values did not include DFV being in the realm of massage therapists. Some respondents felt that the massage space was not a time for talking, especially about personal problems and discussing DFV in the massage space was viewed as an unwanted intrusion.

[DFV is] “a very sensitive topic and people do not want to be interrogated about their life” (Respondent 178, no personal experience of DFV).

“Clients can seek professional help from people who are trained in domestic violence. Often clients come in for a massage, hardly any time to talk let alone telling us their personal problems to a complete stranger.” (Respondent 227, no personal experience of DFV)

Furthermore, respondents felt that discussions about DFV in the massage space might be inappropriate and therefore detrimental to either themselves or the client such as respondent 162 (no personal experience of DFV) who felt that therapists “should help respecting their [client’s] integrities and not outing them in extra danger”. Other respondents felt that it was not the role or place for therapists to be providing information about DFV:“I’m not sure it is the role of a massage therapist to provide information to people of potential domestic violence.” (Respondent 108, no personal experience of DFV). For a few respondents DFV was “not a subject that I wish to deal with personally” (Respondent 200, no personal experience of DFV).

DFV is Part of Massage Therapy

Respondents indicated that they had a strong philosophy for DFV being an aspect of clinical massage practice. Therapists believe that they are “in a unique position to recognize and support victims of domestic abuse” (Respondent 156, no personal experience of DFV) and that they “build rapport and trust with clients and it may offer that doorway to action and get help” (Respondent 182, personal experience of DFV). Respondents deemed that the massage treatment space was a place where a disclosure of DFV may occur and where the therapist could have a positive impact.

“I can see that we have an uncommon opportunity for privacy with our clients given that we are alone in a room with them, away from violent abusers. This puts us in a good position to discretely help them in whatever way we can”. (Respondent 112, personal experience of DFV)

Respondents considered that the nature of massage treatment and the therapeutic relationship that is built between the practitioner and the client allowed the therapist to observe both physical and emotional signs of DFV and to sensitively ask questions.

“Because we engage with people at a very intimate level, we are in a position to observe physical signs of injury, emotional signs and language signs and we have a position of trust to reflect concerns and ensure client safety”. (Respondent 98, personal experience of DFV)

“I have strong relationships with my clients which places me in a unique position to provide access to services my client may not know about. I can recognize changes to my client which, with correct gentle questioning, may be what they need to seek help. (Respondent 155, personal experience of DFV)

Despite considering that DFV is a part of the massage consultation and care, respondents did indicate that they had some concerns about discussing DFV in the massage space and the potential negative response from a client. Therapists were worried that “upfront questioning may stop them [clients] returning” (Respondent 41, personal experience of DFV) and that “it is difficult to say something as you risk turning the client away” (Respondent 175, personal experience of DFV). They were also worried about the client and their feelings about responding to a question or discussion about DFV and that “even though I [the practitioner] might be comfortable to ask but not all my clients are comfortable to answer” (Respondent 89, no personal experience of DFV).

Several respondents acknowledged the importance of being prepared to support clients who may be experiencing DFV by “researching support contacts that might be helpful and I would pass those on and or contact someone myself for advice” (Respondent 140, personal experience of DFV). The philosophy of support and resourcing clients was viewed as an integral part of the care that massage therapists provide as demonstrated by respondent 69 (personal experience of DFV) who indicated that “we are often the first port of disclosure, so it is our duty to provide as much support and refer to the correct services”. Respondents felt that they “should all have a better understanding of domestic violence in all its forms and know how to put our clients in touch with the support they need asap” (Respondent 109, personal experience of DFV). However, respondents indicated that they had some DFV knowledge and skill gaps that they felt hindered their capacity to provide the support they would have liked for their clients experiencing DFV. This included not knowing enough to help such as respondent 151 (personal experience of DFV) who “never thought Domestic Violence would be involved in massage but it is part of the society, so yes, I would love to learn and have some awareness of domestic violence” and not feeling skilled enough to recognize DFV: “it terrifies me that it is so prevalent and that I have potentially treated more than one client who is a victim of domestic and family violence and yet I didn’t have the skills to recognize it”. (Respondent 42, no personal experience of DFV) Some therapists expressed that “the fear of getting it wrong or making things worse may prevent some of us from being as proactive as we should be” in incorporating DFV into their clinical practice. (Respondent 156, no experience of DFV).

Duty of care was a concern for respondents who believed that DFV should be integrated in massage therapy, especially how to meet the duty of care to clients but stay within the limitations of being a massage therapist. Specific concerns were raised around providing professional care but not taking on too much and keeping themselves safe.

“As a therapist we have a duty of care to all our clients, and it is vital we provide a safe space but are also aware of our limitations so must be aware of when it is relevant to refer on to specialist services.” (Respondent 99, no personal experience of DFV)

“We should know the best referral centres for help but it can be very messy and others are trained to deal with this so we should only take on a level we can handle and remain safe ourselves.” (Respondent 109, personal experience of DFV)

Discussion

The study found that having a personal experience of DFV significantly impacted the way that respondents felt about and managed DFV in their clinic. The study found there was a contrast of professional beliefs about the place of DFV in massage that was largely patterned by prior experience with DFV. Respondents who had personal experience of DFV were more knowledgeable about DFV, more confident to ask their clients about DFV, more likely to have a client disclose DFV, feel better equipped with information to manage a disclosure, and believe that DFV had a place in massage than those with no experience of DFV. It is unclear how much the personal DFV experience preceded and influenced beliefs about DFV and massage, or if the professional beliefs and philosophical underpinnings of what massage may offer preceded and influenced their belief about massage and DFV. Further, this may be a bidirectional relationship.

Professional identity is ‘‘the values and beliefs held by [a professional] that guide their thinking, actions, and interactions with the patient’ (Fagermoen, 1997). Professional identities provide a lens through which to understand oneself and the professional community, (Fraser-Arnott, 2019) and are influenced by identity constituting beliefs, which are ‘‘[beliefs] that is fundamental to one’s sense of self, one’s place in the world, and one’s purpose’’ (Weber & Gray, 2017). It is unclear if it is beliefs about DFV and or beliefs about what it means to be a massage therapist (or a bit of both), that are the nexus of the conviction that DFV has no place in massage therapy. Trying to engage therapists with these convictions to undertake DFV and massage training is unwise as doing so might create a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist leading to distress and disengagement (Baskwill et al., 2019; Fogarty et al., 2024). Professional identity is developed through socialisation and is interrelated with personal identity (Schubert et al., 2023) and thus, providing a fertile workplace for exploring values, attitudes, beliefs, and practices that support professional identity growth are integral to changing professional identity. Previous DFV literature indicates that strategies that address the broader community beliefs and values around DFV are needed (McCann & Myers, 2023) as well as addressing DFV at a micro level and together they may have greater impact in changing the belief that DFV has no place in massage therapy.

Massage therapists predominately identify as healthcare practitioners (Baskwill et al., 2019, 2021; Fogarty et al., 2022). The role of healthcare practitioners in supporting and empowering people experiencing DFV to access healthcare, safety and support (Hollingdrake et al., 2023) is well established. In some healthcare settings, screening for DFV is advised or required (Aljomaie et al., 2022; Creedy et al., 2021). Research into healthcare settings where screening for DFV is advised of required have found that “there is no consistency in screening across healthcare services, and those that have implemented routine inquiry often do so without adequate ongoing training, processes and available resources” (Creedy et al., 2021). The massage therapy industry in Australia is self-regulated and there is no clear direction or guidelines from professional massage associations, government or health departments for massage therapists in Australia about where, or even if, DFV fits within the massage space. Many respondents in our study indicated that they wanted to support a client experiencing DFV. Respondents articulated that they wanted targeted education that would help them learn more about DFV, ask about and respond to DFV disclosures, and provide clarity about the scope of practice of the massage therapist in relation to DFV. More resources and direction are needed for massage therapists about their role in DFV and how to support a client experiencing DFV. The hairdressing industry, which has similar development of safe client-therapist relationships, could provide a model for the massage therapy industry to emulate specifically the collaborations with DFV organisations (FVREE, 2022) and nationwide training (Hamilton-Smith, 2021).

Individuals experiencing DFV want their healthcare provider to discuss DFV and are happy for the healthcare provider to initiate the conversation (Silva et al., 2022). While no single health professional discipline can adequately address domestic and family violence, (Hollingdrake et al., 2023) the massage therapy model of care has a lot of positives that help to facilitate disclosure. Good interpersonal relationships, (Heron et al., 2022), feeling safe (Heron et al., 2022), validation from health care professionals, (Heron et al., 2022) and supportive and trusting relationships (McCauley et al., 2017; Rose et al., 2011) have all been found to be facilitators to disclosure. Given that our study found a similar rate of disclosure of DFV (39.2%) to other healthcare professionals (Australian Institute of Health & Welfare, 2019; Heron & Eisma, 2021; McCloskey et al., 2005), it appears that massage therapists are providing the environment for a disclosure, even without specific DFV training. Therapists who have an experience of DFV were significantly more likely to have a client disclose DFV and this may be a combination of the therapist being more aware of the signs and symptoms of DFV, being more comfortable with a conversation about DFV and or the client recognising a kindred experience (Dheensa et al., 2023). Given that women are highly represented both in the massage workforce in Australia and as massage consumers (Cherkin et al., 2002; Ladanyi et al., 2020; J. L. Wardle et al., 2015a, 2015b) and in DFV statistics (Australian Institute of Health & Welfare, 2024), it is important to consider novel ways the industry can upskill therapists who do not have experiences of DFV. Interpersonal transfer of knowledge and learning in social contexts (peers, work colleagues and/or mentors) are effective ways methods of adult learning (De Felice et al., 2022; Moskaliuk et al., 2016). One potential option is using a peer mentoring model to facilitate the sharing of knowledge and experiences of DFV. While there are peer mentoring models in massage to provide guidance, support and transfer of knowledge and skills from experienced mentors to mentees in the context of massage skills and business building, no such program occurs for understanding DFV for massage therapists. The peer mentoring model could be used to upskill therapists and improve their confidence to have discussions around DFV and ideally could include therapists with and without personal experience of DFV. Supporting therapists with a personal experience of DFV in any mentoring program is essential to ensure that sharing their experiences is not distressing or stress is minimised (Dheensa et al., 2023).

Community understanding of DFV is a concept that involves a macro level of recognition of DFV and its social context, support services including both the health and justice systems (Coumarelos et al., 2021). The attitudes and social norms towards DFV and response to DFV is influenced by community understanding of DFV (Coumarelos et al., 2021). The massage community demonstrated mixed DFV understandings which was influenced by personal experience of DFV. Several of the therapists who had no personal experience of DFV considered individuals experiencing DFV would not want to undress due to injuries and that individuals experiencing DFV would not have the income to pay for a massage. Such views demonstrate a lack of understanding and knowledge, leading to assumptions such as DFV constitutes physical violence only and DFV only occurs in homes with a lower income. As well as the misconceptions about DFV that were voiced, there were therapists who expressed antithetical attitudes about the role of DFV in massage. Massage therapists raised several concerns and anxieties in relation to DFV in the massage space. This included concerns about the appropriateness of talking about DFV in the massage space, worry or fear about making things worse or responding in the ‘wrong’ way, worry that they would put their clients in danger, and a feeling of not knowing enough about the DFV and its consequences to help or what to do if a client disclosed DFV. Similar barriers have been identified by other healthcare providers (Creedy et al., 2021; Heron & Eisma, 2021; Ison et al., 2022; McCauley et al., 2017; Rose et al., 2011). Strategies that have been used in other healthcare settings such as increased undergraduate education (Doran & van de Mortel, 2022) and postgraduate online education (Zaher et al., 2014) may be useful for the massage industry to consider given the increase in knowledge and attitudes seen in these programs. Being caring and empathetic are common traits of massage therapists (Smith et al., 2009) and these traits “increase social understanding, lessen social conflict and motivate pro-social behaviour” (Berardi et al., 2020). These traits may engender greater participation in DFV education programs (Desrumaux et al., 2018). Evidence shows that workplace training changes on behaviour and attitudes deteriorate over time (Bezrukova et al., 2016; Kuntz & Searle, 2022) and strategies to decrease behaviour and attitude deteriorations over time are needed in any DFV and massage education program.

Limitations

The sample of respondents is a convenience sample and may not be representative of all massage therapists because of self-selection bias. The sample did not specifically determine nonbinary gender thus it is unclear if the study results represents the experiences of nonbinary gender. Massage therapists who were non-English literate were not able to participate in the survey limiting the applicability of the study findings to culturally and linguistically diverse massage therapists.

Conclusion

This study identified massage therapists’ attitudes, the consultation processes, and confidence to respond to situations involving DFV in clinical practice. Respondents who had personal experience of DFV were more likely to feel more knowledgeable about DFV, be more confident to ask their clients about DFV, more likely to have a client disclose DFV, feel better equipped with information to manage a disclosure, and believe that DFV had a place in massage than those with no experience of DFV. There were contrasting professional beliefs about the place of DFV in massage that was largely patterned by prior experience with DFV. Respondents with no personal experience of DFV were more likely to express the belief that DFV has no part of massage therapy. It is important to upskill and educate massage therapists, particularly those with no personal experience, to improve their confidence to have discussions around DFV and to respond to DFV disclosures as well as challenging their professional beliefs about the role of DFV in the massage space. Utilising learnings from other areas of healthcare is imperative to provide effective opportunities for learning and change.