The Fibromyalgia Client and the Pressure Request
A 55-year-old woman with fibromyalgia books a 60-minute session. She reports widespread pain, fatigue, and sensitivity to touch, and she says 'every therapist hurts me - I need really firm pressure or it doesn't count.' She is on a blood thinner for a prior clot and has a port site on her upper chest. She also has a new, raised, irregular mole on her upper back that she asks you to 'work around' without mentioning it to anyone. She wants the session to include sustained deep pressure on her upper back and neck for the full hour.
1. How do you reconcile her request for firm pressure with her fibromyalgia and blood thinner?
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You negotiate rather than comply. Fibromyalgia clients often have lowered pain thresholds and can flare after aggressive work; the therapeutic goal is gentle-to-moderate pressure with frequent check-ins, not maximum force. The blood thinner means you avoid deep compression, especially over the port site and any areas prone to bruising, and you avoid techniques that could cause hematoma. You explain the rationale, offer a graded approach (start light, increase only with consent and tolerance), and set a check-in interval. If she insists on a full hour of sustained deep pressure, you can decline that plan and offer an alternative; you are not obligated to provide a technique that is likely to harm her.
2. What are your obligations regarding the mole and the port site?
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The mole is a clinical finding outside your scope to diagnose, but you should not ignore it. You document its location and appearance, avoid working over it, and recommend she have it evaluated by a physician - you do not tell her what it is. The port site is a medical device: avoid direct pressure and work around it. Her request to 'not mention it to anyone' does not override your duty to document findings and recommend follow-up; you are not disclosing to third parties, you are advising the client. Document the conversation and her response.