Instrument-assisted soft-tissue mobilisation (Graston and others)

1. Introduction

Version followed: Graston Technique (Graston Technique, LLC) as its training and FAQ pages describe it, read alongside the 2025 international Delphi consensus on IASTM precautions and contraindications (Cheatham, Baker, Loghmani, Schleip). Other branded IASTM systems and gua sha are described more briefly. This guide is written for a psychotherapist. Psychotherapists do not deliver IASTM. They suggest it, refer, prepare clients, and work with what clients bring back from it.

What it is. Instrument-assisted soft-tissue mobilisation (IASTM) means treating soft tissue with hard tools. Seffrin et al. (2019) define it as "the use of hard tools to manipulate soft tissue" and trace it to Cyriax cross-friction massage. Branded systems include Graston Technique, ASTYM, Fascial Abrasion Technique and HawkGrips. Instruments differ in material and design, and strokes differ in direction, force and pattern [source: Seffrin et al. 2019]. Graston Technique uses a set of stainless-steel instruments. Only clinicians who have completed the company's entry course may buy the instruments and use the technique on patients [source: Graston FAQ].

Core idea of how change happens, as the developers state it. Graston Technique, LLC says the technique breaks down collagen cross-links and stretches connective tissue and muscle fibres. It also says the technique changes reflexes in chronic muscle-holding patterns, alters spinal reflex activity, increases blood flow through new vessel growth, and raises fibroblast and mast-cell activity. The company calls the support for these mechanisms "empirical and anecdotal" [source: Graston FAQ]. It also says it has historically seen positive results in 75–90% of the conditions treated. That figure comes from the company and has not been independently checked [source: Graston FAQ; uncertain: not verified]. Seffrin et al. (2019) note that earlier work proposed fibroblast proliferation and collagen remodelling, but their review did not test these mechanisms.

Evidence status (brief, because reader safety depends on it).

Seffrin et al. 2019 (systematic review with effect sizes): IASTM improved range of motion in uninjured people and improved pain and/or self-reported function in injured patients. It did not improve strength in injured participants. Evidence quality was moderate, with poor blinding and allocation concealment. Effect sizes came from pre/post data rather than comparisons with controls [source: Seffrin et al. 2019].
Tang et al. 2024 (meta-analysis of nine RCTs): IASTM produced small gains in range of motion. Certainty was very low to low (GRADE) [source: Tang et al. 2024].
What has not been shown: No source supports IASTM as a treatment for any psychological condition or systemic disease. Do not present it to clients that way [synthesis].

Gua sha (related East Asian practice, attributed to its tradition). Nielsen, Kligler and Koll (2012) describe gua sha as a procedure of traditional East Asian medicine. It is used in integrative clinics and in family settings, and they define it as "instrument assisted mechanical stimulation of the body surface". It deliberately produces "therapeutic petechiae and ecchymosis", which is why it differs from most IASTM practice, where petechiae are treated as a sign to adjust. Because blood can come through the skin, the authors propose hospital-standard bloodborne-pathogen protocols [source: Nielsen et al. 2012]. Explanatory concepts from the tradition belong to the tradition and are not stated here as fact. How the tradition explains its effects is not covered here [uncertain: not verified].

2. Framework

IASTM has no phases in the psychotherapy sense. It is a manual-therapy tool used inside another clinician's plan of care. The framework below has two parts. The first is the clinical sequence as published. The second is the psychotherapist's parallel role before, during and after a course of treatment.

A. Clinical sequence as published (delivered by the treating clinician).

Screening: The clinician checks for precautions and contraindications, educates the patient, discusses any conditions found, and obtains informed consent. Where a precaution applies, technique or dosage is modified. Where a contraindication applies, a safe alternative is chosen [source: Cheatham et al. 2025].
Session content: One practice article describes a light warm-up, gentle scanning with the instrument to find tenderness or texture change, and strokes such as sweep, fan or strum at a pressure the patient tolerates. Treatment is reassessed often, and progressive exercise follows straight away [source: Medbridge 2025]. Graston Advanced training adds movement, resistance, weight-bearing, provocation and therapeutic exercise, and reviews "eight fundamental strokes" [source: Graston CEU information]. Session timings, pressures and exercise parameters are the treating clinician's decisions and are left out here on purpose.
Course length: Studies varied widely, from single sessions to about a dozen, and IASTM was usually combined with stretching, strengthening, eccentric or balance exercise. Reviewers call for more consistent protocols [source: Seffrin et al. 2019]. No standard session count is published in the sources here [uncertain].
Moving on or stopping: Progress is judged by changes in symptom irritability and motion [source: Medbridge 2025]. Stopping and referral criteria beyond the precaution/contraindication framework are not published in the sources here [uncertain]. Sensible stop points are new red flags, intolerable pain, or no change in the agreed outcomes [synthesis].

B. Who may deliver it and how they are credentialed.

Graston Essential Training: 12 hours, with a cap on class size and a set faculty-to-student ratio. It covers the instruments, indications and contraindications (relative and absolute), soft-tissue healing and technique for the major body regions [source: Graston CEU information].
Eligible for Essential: acupuncturists, chiropractors, dentists, physicians, occupational and physical therapists and their assistants, osteopaths, podiatrists, veterinarians, certified hand therapists, athletic trainers, Canadian massage therapists, and final-year students in these programmes. US massage therapists must meet extra conditions: a current licence, a listed exam or work under a licensed PT, DC or ATC, and minimum education and hands-on hours [source: Graston CEU information; Graston FAQ].
Advanced Training: 14 hours, for clinicians who have completed Essential [source: Graston CEU information]. The FAQ's eligibility lists do not fully match each other. One list adds personal trainers, CrossFit trainers and strength-and-conditioning specialists [source: Graston FAQ; uncertain: sources conflict].
GTS specialist credential: Graston Technique Specialist (GTS) certification by examination began in 2017. More than 1,000 clinicians are certified, and the credential is renewed every two years [source: Graston CEU information; Graston FAQ].
Regulation: IASTM is a technique, not a regulated profession. The practitioner's own licence governs it, for example their state physical-therapy, chiropractic, athletic-training or massage board in the US, or the equivalent professional regulator elsewhere. The names and remits of these regulators are not set out in the sources here [uncertain: not verified]. A company course certificate is not a licence [synthesis].
Gua sha: practised in traditional East Asian medicine and acupuncture settings and in families. The authors say national acupuncture standards do not adequately cover its safety [source: Nielsen et al. 2012].

C. The psychotherapist's parallel role (all [synthesis]).

Before: Notice when a client's musculoskeletal complaint could be assessed by a licensed clinician. Check whether trauma history, body-image concerns or skin-related distress might make instrument work hard to tolerate. Agree how the client will use consent and stop signals.
During the course: Review briefly, session by session, how the client experienced the treatment. With the client's written consent, coordinate with the treating clinician.
After: Integrate what the client felt in their body. Monitor reactions to marks or soreness. Pass reported adverse effects to the treating clinician or, where needed, to the client's physician. Support complaints if a boundary was crossed.

3. Guiding principles

Stay in your scope. You do not apply instruments. Hands-on or instrument work is combined with psychotherapy only where your own professional code allows it and you hold the training. Mainstream codes (BACP, UKCP, BPS, HCPC, APA, AAMFT) contain no explicit touch provision but require competence and prohibit sexual contact, and body-psychotherapy codes (USABP, EABP) regulate touch directly [source: BACP 2018; UKCP 2019; BPS 2009; HCPC 2023; APA; AAMFT 2015; USABP Code VIII; EABP 2020] [synthesis for the application].
Screening comes first. Experts recommend checking risk factors before IASTM, educating the patient and getting informed consent [source: Cheatham et al. 2025]. Practically, encourage clients to disclose medications and conditions to the treating clinician.
Know the contraindications as published. The 2025 Delphi panel's strong contraindications include: unhealed or unstable fracture; thrombophlebitis or osteomyelitis; acute inflammatory skin conditions; open wounds, scrapes or blisters; insect bites of unexplained origin; allergy to metals, emollients or latex; and acute systemic infection, fever or contagious illness. Moderate-grade contraindications include myositis ossificans, bleeding disorders, severe skin hypersensitivity, rash, and treatment around a pacemaker or insulin pump [source: Cheatham et al. 2025]. Practically, a client who mentions one of these should raise it with the clinician first.
Know the precautions as published. These include blood-thinning medications, hormone replacement or fluoroquinolone antibiotics, rheumatoid or psoriatic arthritis, and fibromyalgia with nervous-system sensitivity. They also include abnormal skin sensation, medications that alter sensation, burn scars, severe pain, inability to position the body, and a "psychological condition that would affect a patient's response to treatment" [source: Cheatham et al. 2025]. Practically, the last item makes the psychotherapist a legitimate informant. With consent, tell the clinician what helps the client tolerate treatment.
Watch the unclassified conditions closely. The panel could not agree whether these are precautions or contraindications: cancer and malignancy, high-risk pregnancy, lupus, peripheral vascular disease or varicose veins, healing surgical scars, Dupuytren's contracture, unhealed stress fracture, and inability to communicate because of language or cognitive issues. For these the panel advises close monitoring during and after treatment [source: Cheatham et al. 2025]. A patient-facing page adds high blood pressure, certain kidney disorders, blood thinners, spinal compression fractures, and pregnancy, with avoidance over the spine, pelvis and abdomen [source: Spine-health]. A clinician education article lists uncontrolled hypertension, DVT and anticoagulation risk [source: Medbridge 2025]. Osteoporosis is named elsewhere as a general soft-tissue caution, but that is not verified for IASTM [uncertain: not verified]. Practically, clients with these conditions need medical clearance or a clinician who documents the decision.
Bruising and petechiae have different meanings in different traditions. In gua sha, petechiae and ecchymosis are the intended effect [source: Nielsen et al. 2012]. In one IASTM practice article, transient redness is expected and "petechiae is a signal to adjust stroke, pressure, or dosage" [source: Medbridge 2025]. The Delphi experts dropped petechiae from their final list of conditions, so it is not a settled screening item [source: Cheatham et al. 2025]. Practically, ask clients which approach they are receiving, and treat unexpected or extensive bruising as something to report.
Consent is continuous. Consent is given before treatment and can be withdrawn at any moment. The client can stop at any time, ask for a chaperone or a trusted person, and decline an area. Touch is never sexual. Treatment near intimate areas belongs only with regulated clinicians, discussed in clinical terms [synthesis].
Trauma-informed adaptation. Instrument work can involve scraping, strong pressure and visible marks, any of which can recall assault or medical trauma. Prepare clients, agree stop signals, and adjust pacing [synthesis].
Attribute claims. Company outcome and mechanism claims are reported as company claims, with the evidence status beside them. Gua sha's explanatory concepts are attributed to its tradition [synthesis].
Collaborate with consent. Share information with the treating clinician only with the client's written consent, and only the minimum needed [synthesis].

[source for section 3: Cheatham et al. 2025; Medbridge 2025; Spine-health; Nielsen et al. 2012; principles marked synthesis are the guide's own]

4. Intervention inventory

Part A describes what the treating clinician does, so you can explain it accurately and prepare clients. These are not instructions for you to perform. Part B covers what you do as the psychotherapist. Example language throughout is illustrative.

A1. Clinician screening, education and informed consent (delivered by the treating clinician)

Purpose: Identifies precautions and contraindications before treatment and secures informed consent [source: Cheatham et al. 2025].
Steps, as published: The clinician reviews risk factors such as skin conditions, fractures, infection, bleeding disorders, blood-thinning and other listed medications, implanted devices, metal, emollient or latex allergy, sensation changes, and psychological factors that affect response. They educate the patient and discuss any condition found. Where a precaution applies, they modify technique or dosage. Where a contraindication applies, they choose a safe alternative. They then obtain informed consent [source: Cheatham et al. 2025]. The Delphi authors call their list "a starting point and not all-inclusive" [source: Cheatham et al. 2025].
Example language (illustrative, for you): "Before your first session, the clinician should ask about your medications, skin, and any conditions such as bleeding problems. Would it help to make a list together now?"
Watch for: Clients who plan to leave out anticoagulants, a recent fracture, an implanted device or a skin condition because they feel embarrassed or want to be a "good patient". It is working when the client reports that the clinician asked these questions and the client answered fully.

A2. Scanning and instrument strokes (delivered by the treating clinician)

Purpose: Locates and treats areas of soft-tissue restriction or tenderness with a hard-edged tool [source: Seffrin et al. 2019; Medbridge 2025].
Steps, as published (descriptive only): An emollient is applied; Graston sells its own [source: Graston trigger-finger course page, product links]. A light warm-up comes first. The clinician scans gently with the instrument to find tenderness or texture change. They then use strokes such as sweep, fan or strum, choosing an instrument edge that fits the body contour, at a pressure the patient tolerates. They reassess often [source: Medbridge 2025]. Graston teaches a set of fundamental strokes in its training [source: Graston CEU information]. Pressures and timings are the clinician's decision and are left out here.
Example language (illustrative): "The clinician will move a smooth steel tool along the skin with lotion. You may feel scraping or grainy sensations and some discomfort. You can ask for less pressure or for a stop at any time."
Watch for: Clients who describe pain they did not feel able to stop, or who froze or dissociated during strokes. It is working when the client describes the treatment as tolerable and felt in control.

A3. Integration with exercise (delivered by the treating clinician)

Purpose: IASTM is typically paired with active care. Studies combined it with stretching, strengthening, eccentric or balance exercise [source: Seffrin et al. 2019]. One practice source says progressive exercise should follow it immediately [source: Medbridge 2025]. Graston Advanced training includes movement, resistance, weight-bearing, provocation and therapeutic exercise [source: Graston CEU information].
Steps: The clinician sets any home programme. You do not give exercise instructions.
Example language (illustrative): "Your clinician will probably give you exercises to go with the tool work. What did they suggest, and how do you feel about fitting them into your week?"
Watch for: Non-adherence driven by avoidance, depression or fear of pain. Address the motivation, and send exercise questions back to the clinician. It is working when the client reports doing the agreed programme or raising barriers with the clinician [synthesis].

A4. After-effects: redness, petechiae, bruising, soreness (clinician-led, monitored by you)

Purpose: Helps clients understand which skin changes are expected and which need reporting.
What sources say: One clinician article expects transient redness (erythema) and treats petechiae as a signal to adjust stroke, pressure or dosage [source: Medbridge 2025]. Graston's training mentions possible "reactivity" to IASTM, therapeutic and adverse, without detail [source: Graston CEU information]. The Delphi panel dropped petechiae from its final list [source: Cheatham et al. 2025]. In gua sha, petechiae and ecchymosis are intentional [source: Nielsen et al. 2012]. How long marks usually last is not stated in these sources [uncertain: not verified].
Steps: Ask whether marks were explained in advance. Ask the client to report extensive, unexpected, worsening or slow-to-fade bruising, and any bruising while on blood thinners, to the treating clinician or a physician [synthesis].
Example language (illustrative): "Some redness is common. Your clinician also sees spotty marks as a sign to ease off. If you get bruising you weren't told to expect, please tell them."
Watch for: Bruising in clients on anticoagulants or with bleeding disorders, both listed in the published contraindications and precautions [source: Cheatham et al. 2025]. Watch also for distress about marks: shame, body image, or others assuming abuse or self-harm [synthesis].

A5. Gua sha session (delivered within traditional East Asian medicine practice)

Purpose, as attributed: Gua sha is a traditional East Asian medicine procedure of instrument-assisted press-stroking that intentionally produces petechiae and ecchymosis [source: Nielsen et al. 2012]. Traditional explanations belong to that tradition [uncertain: not verified].
Steps: The practitioner strokes the skin with a tool. Because blood may come through the skin, the authors propose hospital-standard infection control and bloodborne-pathogen protocols [source: Nielsen et al. 2012]. Contraindications specific to gua sha are not covered here [uncertain: not verified]. Use the IASTM contraindications as a minimum screen [synthesis].
Example language (illustrative): "Gua sha is meant to leave marks, so it helps to know that beforehand. Ask your practitioner how they clean their tools and what they check before they start."
Watch for: Marks on children or dependent adults from family use. Ask calmly, without assuming abuse, and follow local safeguarding procedures if the explanation or the pattern raises concern. Watch also for skin breaks with no infection control [synthesis; source for infection risk: Nielsen et al. 2012].

B1. Deciding when to suggest a musculoskeletal assessment

Purpose: Clients sometimes ask about "scraping" or Graston for pain or stiffness. Your job is to send them to a licensed clinician for assessment, not to recommend a specific technique [synthesis].
Steps:
1. Note the physical complaint and anything the client has already tried.
2. Name the evidence status plainly. Reviews find gains in range of motion and some improvement in pain and function, but certainty is low to moderate [source: Seffrin et al. 2019; Tang et al. 2024].
3. Suggest assessment by a licensed physical therapist, chiropractor, athletic trainer or physician, or another eligible licensed profession [source: Graston CEU information].
4. Suggest the client check the practitioner's licence with their regulator and, if they want, their Graston training or GTS status.
Example language (illustrative): "Instrument techniques can help some people move more easily, but the research is still limited. A licensed physio or similar clinician can assess whether it suits you or whether something else would be better."
Watch for: Clients hoping body treatment will resolve emotional pain, or using treatment-seeking to avoid therapy work. It is working when the client goes for assessment with realistic expectations [synthesis].

B2. Pre-referral safety conversation

Purpose: Helps the client arrive ready to disclose relevant conditions. You are not making a medical judgement [synthesis].
Steps:
1. Briefly ask about bleeding problems, blood thinners, skin conditions, recent fractures or surgery, implanted devices, metal or latex allergy, current infection or fever, pregnancy, cancer, and conditions that change sensation. These come from the published lists [source: Cheatham et al. 2025; Spine-health].
2. Anything raised goes to the treating clinician or the client's physician for medical clearance. Do not decide eligibility yourself.
3. Record that you advised disclosure.
Example language (illustrative): "I'm not the person to judge whether this is safe for you, but some things matter to the clinician: blood thinners, skin problems, recent fractures, a pacemaker or insulin pump. Is there anything like that you'd want to mention?"
Watch for: Minimisation, especially in clients with eating disorders or medical neglect, or clients who fear being refused. It is working when the client reports disclosing fully [synthesis].

B3. Preparing a trauma-affected client for instrument work

Purpose: The Delphi panel lists a psychological condition affecting treatment response as a precaution [source: Cheatham et al. 2025]. Preparation lowers the risk of re-traumatisation [synthesis].
Steps (all [synthesis]):
1. Explore what scraping sensations, steel tools, lying still, visible marks or a closed room might evoke.
2. Help the client write a consent plan: areas that are off-limits, a stop word or hand signal, a request to be told before each new area, a chaperone or trusted person present, clothing preferences, and the door left open where possible.
3. Rehearse saying "stop" or "less pressure" aloud in session.
4. Practise a grounding skill the client already knows, to use on the table.
5. With written consent, give the clinician a brief note: "needs advance explanation and check-ins", not trauma details.
Example language (illustrative): "You're allowed to stop the treatment at any second, even halfway through a stroke. Let's practise how you'd say it so it's ready if you need it."
Watch for: Freeze responses, people-pleasing, or the client saying they "couldn't" stop. Such reports should lead to renegotiating with the clinician or pausing the course. It is working when the client used, or felt able to use, the plan [synthesis].

B4. Coordinating with the treating clinician

Purpose: Aligns care while respecting confidentiality and scope [synthesis].
Steps:
1. Get written consent and specify what will be shared.
2. Share only what affects tolerance and consent, such as pacing needs and stop signals.
3. Ask what after-effects the clinician expects, so you can reinforce accurate information.
4. Agree who the client should call about physical reactions: the clinician or the physician, not you.
Example language (illustrative, to the clinician): "With my client's permission, I'm letting you know they do best when each step is explained beforehand and they're reminded they can pause."
Watch for: Over-sharing of trauma history, or the clinician asking you for medical opinions. It is working when the client experiences consistent messages from both of you [synthesis].

B5. Debriefing and integrating the body experience

Purpose: Uses what the client noticed in their body during and after treatment as material for therapy. Many clients notice new sensations, emotions or memories [synthesis].
Steps (all [synthesis]):
1. Ask open questions about sensations, emotions and images during and after treatment.
2. Track what happened when discomfort came up. Did the client speak up, freeze or comply?
3. Link this to the client's existing goals, such as assertiveness, interoception or relating to pain.
4. Do not interpret marks or sensations as "released trauma" or stored emotion. No source here supports that.
Example language (illustrative): "When the tool was on your shoulder and it got intense, what did you notice: in your body, your thoughts, your urge to speak up?"
Watch for: Emerging trauma memories that need pacing, and clients attributing psychological change to the tool. It is working when the client can describe the experience with curiosity rather than threat.

B6. Responding to visible marks

Purpose: Petechiae or bruising (and intentional marks in gua sha) can trigger shame or body-image distress. Others may also mistake them for abuse or self-harm [source for marks: Medbridge 2025; Nielsen et al. 2012; consequences: synthesis].
Steps (all [synthesis]):
1. Ask how the client feels about the marks.
2. Plan what they will say if others ask.
3. For clients with a self-harm history, check whether the marks are reminders or triggers, and review the safety plan.
4. Unexpected or extensive bruising goes to the clinician (see A4).
Example language (illustrative): "Some people feel self-conscious about these marks, or they bring up old memories. How has it been for you?"
Watch for: Concealment, or marks the client cannot explain or whose pattern does not fit the reported treatment. In that case, assess calmly for other causes and follow safeguarding procedures where indicated.

B7. Recognising and passing on adverse effects

Purpose: Gets physical reactions to the right clinician quickly [synthesis].
Steps:
1. Ask briefly after each treatment about pain beyond what was expected, bruising, skin breaks or signs of infection, numbness or tingling, swelling, and fever.
2. Prompt the client to contact the treating clinician. Use urgent medical services for red flags such as calf swelling or pain with possible DVT, spreading redness with fever, or chest symptoms [synthesis; DVT/thrombophlebitis as contraindications: Cheatham et al. 2025; Medbridge 2025].
3. Document what you advised.
Example language (illustrative): "That swelling and warmth isn't something I can assess. Please call the clinician today, and if it gets worse or you feel unwell, get urgent medical care."
Watch for: Clients who downplay symptoms to avoid "bothering" anyone. It is working when the client contacts the clinician and comes back with a plan.

B8. Boundary violations and complaints

Purpose: Helps clients recognise and report inappropriate touch or conduct by a practitioner [synthesis].
Steps (all [synthesis]):
1. Name the boundaries clearly. IASTM never involves sexual touch. Intimate areas are not part of routine treatment. The client may refuse any area, ask for a chaperone, and stop at any time.
2. If the client describes a violation, believe them, assess safety, and explain the routes: the practitioner's licensing board or regulator, the clinic, and the police where a crime may have occurred.
3. Support the client's own decision about reporting, within your mandatory-reporting duties.
4. Remember that a training-company certificate is not a licence. Complaints go to the regulator of the practitioner's licensed profession. The names of these regulators are not set out here [uncertain: not verified].
Example language (illustrative): "What you describe isn't part of this treatment. You have the right to complain to the board that licenses them, and I can help you think through the steps."
Watch for: Self-blame, freezing, or confusion about what was "clinical". It is working when the client feels believed and knows their options.

5. Handling problems

The published sources cover screening and contraindications, not psychological difficulties. Guidance below is [synthesis] unless a source is named.

The client is stuck: no physical change after several sessions.
- Encourage them to raise it with the clinician. Reviews report modest effects, so a lack of change is plausible [source: Seffrin et al. 2019; Tang et al. 2024].
- Explore what an unchanged complaint means to them: hopelessness, or confirmation of a belief that "nothing works".
- Example (illustrative): "It sounds disappointing. What would it mean to ask the clinician whether a different approach makes sense?"
Resistance to referral: fear of pain or of being touched.
- Validate the fear.
- Offer the option of a consultation only, without treatment.
- Remind the client that other treatments exist and that IASTM is optional.
- Do not push.
Overwhelm or dissociation during treatment.
- Debrief using B5, then revise the consent plan from B3.
- Consider pausing the course until regulation skills are stronger.
- With consent, ask the clinician for slower pacing, more explanation, or a different technique.
- The Delphi precaution on psychological conditions supports this conversation [source: Cheatham et al. 2025].
Non-adherence to the home programme.
- Work on motivation and barriers such as depression, avoidance or chaotic routines.
- Send all questions about exercise content, intensity or frequency to the clinician.
Rupture: the client feels you "sent them" somewhere that hurt them.
- Acknowledge the experience without defending the referral or the clinician.
- Repair, then help the client decide whether to complain, stop, or renegotiate care (B8).
Unexpected bruising, skin injury or a medical symptom.
- Follow B7.
- Petechiae are treated as a signal to adjust in at least one IASTM source [source: Medbridge 2025]. Clients on blood thinners or with bleeding disorders need particular caution [source: Cheatham et al. 2025; Spine-health].
Conflicting messages about whether marks are "good".
- Explain that gua sha intends marks [source: Nielsen et al. 2012], whereas some IASTM practice treats petechiae as a sign to ease off [source: Medbridge 2025].
- Encourage the client to ask their own practitioner which approach they follow.
The client expects psychological or detox effects.
- Gently correct this. Neither the company's mechanism claims nor the reviews cover psychological effects [source: Graston FAQ; Seffrin et al. 2019].
The client wants you to do it.
- Decline. Psychotherapists do not apply instruments, and combining hands-on work with psychotherapy requires both permission under your code and proper training [synthesis; source: UKCP 2019 item 23; BACP 2018 para 13; USABP Code VIII].
- Offer the referral routes in B1.
Unlicensed or poorly trained provider.
- Suggest the client check the provider's professional licence. Graston restricts instrument use to clinicians who have completed its training [source: Graston FAQ], but other tools are sold without such restrictions [uncertain: not verified].
Cultural or family gua sha practice comes up.
- Explore it respectfully. Attribute the explanatory concepts to the tradition.
- Apply safeguarding procedures only where the pattern or the account raises concern, not because marks are present (A5).

Sources

Web pages:

Not verified: the full Graston contraindication list, which the company covers in training [uncertain: not verified]; gua sha-specific contraindications and the tradition's explanatory concepts [uncertain: not verified]; the names and remits of professional regulators [uncertain: not verified].

Professional codes cited above:

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