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Opinions and Issues

Insurance Reimbursement and the Profession of Massage
According to the ABMP 2007 Member Survey, just 14 percent of massage therapists and bodyworkers submit claims for insurance reimbursement for their services. Nearly all of this is related to disability or accident rehabilitation.

While most chiropractic and physical therapy treatments are reimbursed by health insurance, more than 90 percent of massage therapy sessions are paid out of the client's own pocket. In some cases, massage is covered only when prescribed by a physician, registered physical therapist, chiropractor or osteopath.

A number of plans have tried to meet consumer demand for massage therapy without specifically assigning medical criteria to its use. Some have assembled networks of approved massage therapist providers who provide services to eligible clients discounted by 20 percent or 25 percent in return for the plans funneling clients their way.

To many practitioners, this is a source of frustration and indignation. Especially in comparison with other treatments, such as chiropractic care and physical therapy, they wonder why massage therapy is treated as a "second-class" modality. It seems to them that the possible preventive-medicine and pain-relief aspects of massage therapy present an opportunity for cost savings to insurance plans, as well as reduced discomfort to clients. Although the hard scientific data is still less than optimum, the existing studies and anecdotal information supporting the use of massage for such conditions as pain seem enough to these professionals to warrant coverage.

Surprising to some is the fact that many massage therapists and bodyworkers don't seem interested in gaining this form of reimbursement.

As a part of the proactive wellness approach to health, rather than a symptom-based model of treatment, massage therapy is like many of its cousins in complementary and alternative medicine (CAM) in that it is countercultural, even revolutionary.

ABMP studies and anecdotal information reveal some practitioners enjoy their status and freedom outside mainstream medicine and wish to avoid the additional administrative work associated with insurance reimbursement. They seek to ensure that the "art and heart" of massage maintain important places alongside scientific and clinical research emphasis. Some modalities incorporate a spiritual or philosophical aspect to their practice, and this part of a therapy likely will never fit a Western-medicine paradigm.

Although the National Institutes of Health (NIH) developed a unit in 1999 to study many of these therapies, the field is woefully underfunded and inadequately researched even today. In relation to the number of Americans who use some form of CAM (nearly half the U.S. population, according to a National Center for Health Statistics study), medical research and medical interest lag far behind.

Consumer demand for these services, along with competitive pressure on employers in attracting and retaining staff, seems likely to drive massage therapists and insurance companies somewhat closer together. However, it is doubtful that of 250 modalities in the massage marketplace today, sufficient research will ever be conducted to validate the results of all or even most of these therapies.

The National Certification Examination

The issue of how to promote responsible and prudent regulation of massage therapy and bodywork is a controversial one. On the one hand, appropriate credentials and training are a means to greater respectability and acceptance for massage therapy, which has long been hampered by a tawdry massage-parlor image. Great strides in overcoming this image have been made, especially in the last 20 years; however, some prostitutes continue to operate under the guise of massage, tarnishing the reputation of the legitimate massage profession.

Some types of massage credentialing, in combination with scientific research, could lead to greater recognition by insurance companies as a reimbursable expense. The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB), established in 1992, has these goals:

"To establish National Certification as a recognized credential of professional and ethical standards; to promote the worth of National Certification to health, therapeutic massage and bodywork professionals, public policy makers and the general public; to assure and maintain the integrity, stability and quality of the National Certification Program; and to periodically update the program to reflect state-of-the-art practices in therapeutic massage and bodywork."

Many practitioners and profession experts argue that the National Certification Examination is far too rigid for the expanding and diverse field of massage and bodywork, reflecting a westernized and overly scientific approach to massage therapy. Others find a state-mandated requirement to pass the National Certification Exam superfluous on top of school program assessment. It also is expensive — $225 — just when someone is beginning a career. As to the National Certification supposedly offering a gateway to qualifying for insurance payments, many practitioners feel that attempting to gain insurance reimbursement is an unrealistic goal and have little desire to become part of mainstream medicine, despite the potential for more income.

Following are four articles on the pros and cons of a national credentialing standard for massage and bodywork practitioners. These articles are reprinted to stimulate thinking and dialogue: Other than the selection by an ABMP officer, they do not necessarily reflect the views of ABMP.

The National Certification Examination
Necessary to Evolution of the Profession
By Whitney Lowe

Note: Whitney Lowe is chairman of the National Certification Board for Therapeutic Massage & Bodywork. Originally published in Massage & Bodywork magazine, October/November 2002.

The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) is a nationally recognized credentialing body formed to set high standards for those who practice therapeutic massage and bodywork. It does this through a nationally recognized certification program that evaluates and attests to the core skills, abilities, knowledge and attributes expected of entry-level practitioners.

The National Certification Examination (NCE) is essential for the credibility of our industry. In order for the NCBTMB to administer the NCE, it must uphold the responsibility and strict compliance standards granted to any certifying organization "to evaluate the competence of practitioners on behalf of employers, agencies and consumers who pay for or require the services of the practitioners." While competency is a complex concept to define or measure, by using state-of-the-art psychometric principles, a thorough job task analysis, a structured prerequisite program and a well-designed examination in the formation of the NCE, NCBTMB can test the competency of each individual at the time the individual takes the exam. Maintaining competency is a lifelong challenge for every competent practitioner to perform work accurately and in the best interest of the consumer.

The development of the NCE is in strict compliance with the accreditation guidelines established by the National Commission for Certifying Agencies and the Standards for Educational and Psychological Testing (American Educational Research Association, American Psychological Association and the National Council for Measurement in Education), as well as the Equal Employment Opportunity Commission (EEOC) Guidelines on Employee Selection Procedures. Each of these organizations promulgates conventions that, in general, suggest a professional examination must reflect the practice and be supported through some type of research of the profession. From a competency standpoint, this is self-evident and only naively contested.

NCBTMB's job analyses are conducted through the cooperative efforts of NCBTMB and experts in the profession. These studies provide detailed descriptions of job-related tasks, the extent to which they are performed and their importance for entry-level practice. During NCBTMB's job analyses, a number of different methods are incorporated to maximize content validity for the examination. The concept of content-validity has to do with whether or not an examination accurately measures the appropriate domain of content associated with the inferences made using its scores. In other words, "Does the test measure what is being practiced?" And while we are not testing psychomotor skills, we are testing the skills actually needed to perform in our industry and backing this up with both quantitative and qualitative activities, which are conducted before, after and during the development of the NCE — e.g., focus groups, survey questionnaires, structural equation modeling, so that we can assure the individual has the basis to make important clinical decisions and provide safe, ethical practice to his/her clients.

Massage therapy and bodywork, as with any health practice, effectively combines science and art. The NCE does exactly what it needs to do by making sure all practitioners who take the exam have a specific body of knowledge rooted in the science aspect of our profession. To suggest we should systematize the "art" of massage therapy by testing competency in communication, business management, or general rapport with clients takes away from each individual practitioner's uniqueness and infringes upon the school's ability to prepare students for these aspects of our profession. Furthermore, these issues are covered by NCBTMB by requiring practitioners to uphold its Standards of Practice and follow its Code of Ethics as part of the credentialing process.

No recognized professional credentialing examination in any field (accounting, law, medicine, etc.) can assure clients you have the best "bedside manner."

Rather, these examinations can assure clients the practitioner has met the highest standard available in his/her profession by passing a competency examination rooted in the core components of his/her field. Most programs also require professionals ascribe to the profession's code of ethics and standards. It is this competency and adherence to ethics upon which many of us base our "buying" decision when selecting a professional to provide services, not his or her communication or business management skills.

In a world where there is still some mistrust and skepticism about the legitimacy of massage therapy and bodywork as a health practice, having a national examination, rooted in the scientific aspects of the profession, is more in tune with consumer needs and provides the right public value. The public looks to the NCBTMB to provide this assurance and we take this aspect of our role in the industry very seriously. In order to uphold this public trust, we must be able to assure them that the NCE is rooted in the right balance of prerequisites. Requiring 500 hours of formal therapeutic massage and/or bodywork education and adherence to the NCBTMB Code of Ethics and Standards of Practice, is not to simplify things administratively, rather it is to provide the assurance the public seeks from NCBTMB prior to getting massage or bodywork services.

By adhering to these strict standards, the NCBTMB can also assure the health care industry that massage and bodywork professionals should have a place in the health care system and that our industry practitioners' education and training is rooted in the scientific aspects of our profession. By providing this evidence through the NCE process, practitioners who wish to integrate their services within a medical model are well-trained, certified and capable of doing so. Many spas and other "non-medical" employers are also looking for this level of competence and assurance in the professionals they hire and the NCE equips practitioners to perform within these settings, too. When faced between hiring one of two strong candidates who have equal rapport with consumers, most employers will give the position to the one who is nationally certified, because the certification demonstrates the candidates' high level of commitment to the industry and his/her competency to deliver services. The uncertified practitioner offers none of these assurances to employers. Furthermore, the national portability of the NCTMB credential is extremely useful to practitioners and employers making it all the more valuable for employment and career advancement.

NCBTMB's prerequisite and testing structure also assures states and local regulatory bodies that use of the NCE in part or in whole for their state rules or statutes meets a rigorous standard of competency for those practicing within their jurisdiction. These employers and agencies are also relieved of the administrative burden of making their own evaluation that is legally defensible.

Because the NCE is deeply rooted by psychometric principles, a thorough job task analysis and a structured prerequisite program, it is legally defensible. This value of the NCE is extremely important and is often overlooked. Today more than ever, courts are using certified guidelines as the force of law. It is also the reason why the NCBTMB must continually update the NCE and make sure new practices based on the best science available are incorporated into the NCE and that this new science-based training becomes the guideline for certification to help protect consumers, employers and practitioners.

In order to assure that the NCE accurately reflects the needs of the industry and maintains its legally defensible position, the NCBTMB announced in June 2002 that it would be developing two new credentials, one in entry-level massage therapy and one for advanced practice in massage therapy. In addition, NCBTMB will begin researching the feasibility of developing a bodywork-specific certification program for bodywork practitioners. Into 2003 and beyond, NCBTMB will continue to offer its current combined entry-level certification in massage therapy and bodywork using the NCE, for which it is conducting its third job analysis study.

The NCE is an important and necessary part of our evolving industry. By making sure the NCE is rooted in the essential components to offer competency, the NCBTMB is uniquely capable to provide the assurances the public demands and therefore the NCE serves exactly the purpose it was intended to serve.

The National Certification Examination: "Credentialism" the Naked Emperor
By Keith Eric Grant, PhD, NCTMB

Note: Keith Eric Grant is the senior instructor and curriculum developer of the sports and deep-tissue massage program at the McKinnon Institute in Oakland, Calif. This article first appeared in Massage & Bodywork Magazine, October/November 2002.

I believe there are ways in which national certification can be helpful and also ways in which it can be quite damaging. My writing this piece reflects my belief that the use of the National Certification for Therapeutic Massage & Bodywork (NCTMB) should be based on a solid understanding both of what it is and of what it isn't, rather than on adept marketing of the NCTMB to state and local agencies.1

It also reflects my belief that state and local licensing laws requiring the NCTMB as a sole path for qualifying to practice are contrary both to current educational understanding and to good social policy. From my perspective, the uses for the NCTMB (or similar certifications) should be as a voluntary demonstration of commitment to clients, as a means of meeting employer requirements within the more medically oriented domains of massage practice, and as a sufficient criterion for enhancing professional portability between states.2

Compared to most professions, massage and bodywork are unique in breadth of application and the diversity of skills they draw into play. The foundations of massage are quite simply touch with awareness and positive intent. The basics of application are skills of verbal and nonverbal communication, empathy and rapport, trained processing and awareness of sensory input, and application of learned motor skills to touch and move a client.

As the application changes from the nurturing to the orthopedic, more knowledge of anatomy and assessment become important as do intervention planning and tracking. As the application interfaces with medical practice and otherwise ill patients, knowledge of medical terminology and protocol, as well as greater awareness of the implications of conditions and medications become important.

In contrast, if we move from basic nurturing to working with those who have experienced severe grief and trauma, understanding of how our touch and presence promotes healing and integration takes the foreground, while details of anatomy and physiology fade from our concerns. What is before us is not a single profession but a continuum of professions across a wide spectrum of application. It is not surprising that practitioners should present a similar diversity of orientations and inherent aptitudes. It is a diversity I believe we should protect within our approach to setting practice requirements for massage.

While there are health care applications of massage that require more conceptual knowledge, there are also entry-level applications almost purely based on awareness and touch. There are also domains of working with touch, presence and rapport that are simply outside the orientation and perhaps the dreams of those who created the NCTMB, yet are equally valid directions for massage. Attempting to apply an inflexible, health care-oriented bandage to massage governance has resulted not in quality but in credentialism, the promotion of formal credentials beyond the training needed to successfully practice and create benefit for clients.

Such credentialism is, unfortunately, not free from side effects. To propose that an academically oriented standard such as the NCTMB process should be the only path of qualification for practice is to undervalue our diversity. We do not all live in the same subculture and locale. The availability of positive touch is as important in an inner city neighborhood, a community of immigrants, or a rural area, as it is in a suburban or commerce zone. Credentials, however, may pose significantly higher hurdles to those coming from the former regions than from the latter. The need to recover the costs of pursuing credentials can also spur movement of professionals out of economically disadvantaged or depressed areas to higher income potential communities, thereby lowering availability of services in those less well-served.

We also are not all wired to learn and process information in the same manner. In his book, The Unschooled Mind, educational psychologist Howard Gardner captures the dual paradox of those who can successfully take tests without deeper understanding and of those who understand but are not adept at taking tests.

"Those students who exhibit the canonical (in our terms 'scholastic') mind are credited with understanding, even when real understanding is limited or absent; many people— including at times the author of this book and his daughter — can pass the test but fail other, perhaps more appropriate and more probing measures of understanding," Gardner wrote. "Less happily, many who are capable of exhibiting significant understanding appear deficient, simply because they cannot readily traffic in the commonly accepted coin of the educational realm."

Educational pediatrician Mel Levine discusses the substantial diversity in the wiring of our brains in his latest book, A Mind at a Time.

It becomes clear from Levine's descriptions there can be great variations from person to person in abilities to organize information, remember information and take in sensory information to use for planning motor responses. We do not simply know something and have its use or not know something. The realities of learning, knowing and using are far more complex. What Levine has essentially done is to provide the neurological basis for Gardner's cognitive observations.

What Levine and Gardner advocate together is that we view the ability to score well on tests with less weight and provide other means to evaluate the competency of those less suited to test-taking. The neurological and cognitive considerations imply there are simply cases for which the statistical conclusions of psychometrics don't apply. In a massage context, there is every reason to expect there will be individuals who are highly competent in interpersonal and kinesthetic intelligences, yet fare poorly when forced unnecessarily into the verbal-linguistic paradigm of the academic worlds.

Education can act as a filter, as well as a benefit. We will ultimately attract the students who match well to what we explicitly value and discourage those less able to jump our hurdles. We are well-advised to ensure that all we value in practice is equally captured in what we value in assessment and qualifying to practice.

History and Prerequisites
A major impetus for creating the NCTMB was to facilitate greater access for massage in interfacing with the U.S. health care industry, an area in which such certifications are the traffic of the realm. I concur with Whitney Lowe that a certifying agency has more credibility in these realms if, as is the case with NCTMB, it is accredited by the National Commission of Certifying Agencies (NCCA), the accrediting body of the National Organization for Competency Assurance (NOCA).

What follows from this is that the NCTMB had to match NCCA requirements for a psychometrically valid certification exam based on job surveys in order to gain NCCA approval. What also follows is that the NCTMB had to be administered by an independent organization. Both of these requirements have had important side effects.

The National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) did not spring into existence based purely on concerns of educational quality and consumer benefit. It came into being with an organizational history and agenda. The NCTMB was created by the American Massage Therapy Association (AMTA), which then, under NCCA rules, had to establish the NCTMB board as an independent agency.

However, the impact of its AMTA origins was cemented into the structure of prerequisites for sitting for the National Certification Exam (NCE). The depth of this initial connection is notable in that the AMTA immediately began using the NCTMB as a sufficient qualification criterion for its own membership. The AMTA could not have tolerated less restrictive prerequisites to sit for the NCE and still have taken this course — a course central to ensuring the early economic viability of the NCTMB.

Stated more bluntly, the initial NCBTMB Board of Directors arbitrarily decided three things:

1) A massage practitioner cannot take the NCE unless he/she completed at least a 500-hour massage school program or its equivalent.

2) The test would be positioned to state agencies as a fair measure of entry-level skills, therefore being a reasonable measure of qualifications to practice massage.

3) The NCE would be marketed to practitioners and the public as a useful discriminator between those well-qualified and those not so well-qualified to practice massage, independent of any practitioner's choice as to type of massage practice.

Partly as a result of this history, the NCE is not a competency exam open to challenge by any with a reasonable basis for taking and passing it. The NCE test gives an applicant no opportunity to demonstrate techniques or client relations skills. A highly gifted graduate of a 300-hour program isn't even eligible to take the NCE. The NCTMB process leaves the determination of kinesthetic competency to the schools (with highly variable success), while motivating those schools to place heavier stress on memorization of the conceptual material needed to pass the almost redundant NCE.

The pattern is quite analogous to the recent fashion in public schools of standardized, statewide skill-testing, with considerable resulting pressure on teachers to "teach to the test." Ironically, despite the motivation for a massage certification exam to facilitate participation in mainstream health care, the NCE is notably lacking in rigorous concepts of orthopedic assessment, medical terminology and working with ill patients that might be expected for these pursuits. For these more advanced practices, a voluntary certification with an orthopedic/medical focus would have been of better service while leaving the entry-level alone.

While marketed as an entry-level exam, the requirements of the NCTMB are of limited benefit to those entering massage only to do stress-management and spa work.

Contrary to persistent beliefs, memorization of content relevant to passing the NCE is not necessary to protect the public from harm. There are no medical reports or liability insurance statistics showing any pattern of significant harm to clients from lack of practitioner training. To the best of my knowledge, the 500-hour requirements that NCTMB inherited from the AMTA were never based on the time needed to teach specific course content determined by a detailed analysis to be essential to competent practice. The hour requirements rather seem to have been taken from the minimum course length for which a program was eligible for federally guaranteed loans and grants. As federal minimums have increased (to 720 hours for Perkins grants), schools relying on this assistance have also had to increase their program lengths.

Also ironic, although it is contrary to efficient management of federal financial assistance, most people learn best in small chunks with real-life experience in between. Requiring more education up-front does not make for better massage practitioners, just more expensive ones. No corporate training manager would demand his or her employees take courses they couldn't use in the near future. Requiring this of massage practitioners just codes bad educational and business practice into law. It does, however, facilitate the taking of a comprehensive exam at the end of an extended period of study.

I believe the NCTMB suffers from a disconnect of being motivated by health care considerations, while being aimed at entry-level work. The cause is simple economics. The NCTMB has been organized, marketed and lobbied as an entry-level certification simply because the pool of those whom it would most benefit (those interested in advanced orthopedic and medically oriented massage work) was insufficient to sustain the costs of creating and operating NCTMB. The NCE, in fact, is neither fish nor fowl; it lacks the rigor to truly separate those desiring to demonstrate advanced, medically oriented skills, yet it poses an expensive, largely redundant barrier for those deciding to do entry-level work.

The NCE and Psychometrics
The idea of the psychometric validity of a test essentially boils down to two concepts: a test should be both valid and reliable. Validity means the test measures the area of knowledge it claims to be measuring. Reliability means a person sequentially taking different variants of the test would obtain much the same score each time. Although ensuring psychometric validity is not as simple as it sounds, it is a well-established process leading to a test for which scores are considered to be defensible in courts of law. Well and good, perhaps, but still not a definitive statement of the limitations of what the NCE actually measures.

Given its format of being a multiple-choice exam, the NCE can only measure the ability of applicants to recognize correct answers to questions within the academic framework of the test. It is well known in educational literature that this is a pattern-matching skill that uses the clues and cues inherent in the academic test context along with the ability to successfully commit a multitude of unorganized facts to short-term memory. Success on the test indicates exposure to the information and the ability to retrieve it from memory (according to Levine, a hard-wired neurological function) but often has little relationship to the ability to use this information in actual practice. The disconnection from ability to use comes about from two cognitive features of the human mind. First, facts memorized without being well-connected to a framework of experience are forgotten quickly. Second, learning is most effective when done in a situation as close to that of actual use as possible. These considerations are less important in professions such as accounting, which actually requires near memorization of rules and regulations. Massage, however, is a different kind of craft and practice.

Although the NCE is a valid reflection of responses to job skill surveys, that does not imply it is free from biases of orientation, question wording or of sampling and response. As an example of orientation bias, the NCE focuses on questions of anatomy, physiology, basic ethics, business practices and overt bodywork techniques. In contrast, the NCE does not address conceptual content of verbal and nonverbal communication essential to establishing professional rapport with clients, issues of working with those experiencing grief or trauma, or the entrepreneurial issues of running a one-person business. These are not side issues. Having an understanding in these uncovered areas will have at least as great an impact on the success of those entering the massage profession as do the areas covered. Even the concept of entry-level is open to interpretation, one definition being the minimum level of training at which a practitioner can consistently provide a benefit to clients, a level the NCTMB well overshoots. Another definition is the level of training at which a majority of practitioners are entering practice, a definition that can become circular and result in an ever-raising level of entry.

To sum up, I believe the NCTMB can be useful to practitioners as a voluntary seal of accomplishment. It also provides for some portability of practice between states, a potential partly ruled out by states such as New York, Maryland and Nebraska, which either have liked another zero at the end of their requirements for round hours or have added extra stipulations such as college requirements.

I differ from the proponents of the NCTMB in viewing that, where included in statutes, it should be a sufficient rather than a necessary requirement. There should always be another path for those less adept at jumping academic hurdles, whether due to early environment or brain wiring. While I have no argument that the NCTMB is psychometrically valid and legally defensible, I don't agree that its underlying assumptions are well formed from an educational perspective. I also believe the NCTMB was created and applied as a health care-oriented bandage to a touch-oriented craft. As such, it was implemented without care for the whole system of possibilities and effects.

Lastly, we as a culture currently love credentials and certificates. Partly, given the diversity of massage methods and successful histories of practice, what the NCTMB is about is a type of gentrification of massage practice. By tying certification of massage to the entry level, rather than the advanced level, we in effect move that entry level from being a blue-collar craft into being a white-collar profession and call it gaining credibility. There's something about exclusion in that process that, as a bottom line, has never sat well with me.

1 The NCBTMB, for example, customarily has a booth at the League of Cities conventions.
2 This concept appears in the educational literature under the terms "situated learning" and "situated cognition."

Arbitrary Rules Hurt Profession
Bureaucracy Serves Itself, Not Constituents
By David Lauterstein, co-founder, Lauterstein-Conway Massage School in Austin, Texas.

Note: This article first appeared in Massage & Bodywork, June/July 2004. The new rules described in this article became effective for practitioners June 2005. David Lauterstein is the former editor of Massage Therapy Journal.

Am I going crazy? Or has the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) lost its way? You decide. Recently the NCBTMB launched a "National Massage Safety Week." The dubious and self-serving implication was that anyone who was not nationally certified was not "safe." I can scarcely imagine a more ill thought-out campaign.

I recall when former American Massage Therapy Association (AMTA) President Elliot Greene began talking to me many years ago about national certification. He had, as many of us did, a desire that the standards in our profession have some consistency from state to state. Now, however, the NCBTMB is actually promoting certified people over non-certified as more likely to be safe — we have the makings of a self-promoting bureaucracy advancing its agenda to the exclusion and detriment of the field.

In early April, my co-director and I learned from one of our students that the NCBTMB also plans to change its curriculum requirements to take the National Certification Exam. Even though we are school owners, we did not receive any type of advance notification. Unpleasantly surprised, I immediately went to the NCBTMB website, which says the plan is to change the requirements in late 2004, or in 2005.

The new requirements supposedly will be that, of the 500 hours national certification requires as a minimum (with 100 anatomy and physiology hours currently required), schools must now add an additional 40 hours of pathology and 25 additional hours of anatomy, physiology and kinesiology than are currently required. This means that schools with 500-hour programs will have to replace massage training hours with pathology and A&P hours or raise their hours and likely the tuition of their programs.

This decision, which I hope is overturned or at least modified, encapsulates the misguidance of so many trying to steer our profession these days. This editorial is an appeal to all school owners, teachers and therapists who feel as we do to contact the NCBTMB with a request to cease and desist from tunnel vision and poor timing. Following are some of the realms of concern in connection with this decision.

The NCBTMB, the Commission on Massage Therapy Accreditation (COMTA) and AMTA all claim to be holistic in their orientation. Unfortunately, this assertion has increasingly become mere lip service. There is no mention of any increase in training hours or emphasis of subjects pertaining to the art of massage. By adding pathology and A&P requirements exclusively, these organizations are contributing to the medicalization of our field.

Recent history gives no basis, other than sheer defensiveness, to these groups' claims to holism. The holistic emphasis of massage includes scientific competence, but goes beyond it, into the development of creativity, sensitivity and the evolution of massage/bodywork as a true health care modality. Massage is not primarily a medical treatment. Most state laws explicitly state so.

Nonetheless, the NCBTMB, COMTA and AMTA persist in the medical orientation and are selling out our most precious birthright — massage as a unique health care modality. Although there has been quite a bit of emphasis these days on the clinical, I have yet to teach a group of students who, when presented with a holistic vision, didn't heave an enormous sigh of relief. It's like waking from a spell. Virtually everyone in massage, when presented with a clear vision of holistic practice, prefers its scope and heart to the exclusively medical model of massage.

To be perfectly clear, I have nothing particularly against pathology and anatomy hours being required — only that hours in those subject areas be appropriately balanced by hours pertaining to the realm of health and the refinement of the therapist's sensitivity. This approach might include important subjects such as what is health; what is care; quality of touch; energetic as well as physical assessment skills; creative session design; looking more deeply at issues of pressure, rhythm; what to leave in or out for whom; how to combine modalities appropriately to address the individuality of the client; and deeper exploration of the inspirational and aesthetic dimensions of massage.

Reduction of the Diversity of Educational Approaches
The current requirements allow for 100 hours of anatomy/physiology, a minimum of 200 hours of massage and/or bodywork and the remaining hours in whatever the school chooses to complete one's massage and/or bodywork study. The new requirement will, if programs remain at 500 hours, reduce the discretionary hours by nearly one third. Currently, these hours clearly allow for a variety of approaches and diversity of education. That is not progress; this is a step backward.

Ethics and Poor Judgment
I was told by the NCBTMB that this decision was announced to the profession in January. I immediately checked with three other leaders in our field and not one of them knew about it. I had received an elaborate NCBTMB orientation box in February — the change was not mentioned. So how was this announced? It was on their website. This would be like billing my students for a new tuition while telling them it had been announced somewhere on our website.

I have also been told that schools don't have to adopt these new requirements. However, when the National Certification Exam is required by 23 states, can the NCBTMB be so naοve as to say we're free not to comply?

Our students alerted me to this decision. Reading the website, they were panicking at the published timing for the new requirements going into effect. Many schools have students enrolled in programs that do not finish until 2005. And most well-run schools plan their overall curricula and schedules at least a year in advance. This timing and the confusing language of the announcement is flabbergastingly insensitive with respect toward schools, students and therapists. It is ironically in line with the lack of heart in the new requirements.

I issue a call to the massage and bodywork profession:
  • Our profession must rise up and refuse the top-down micromanagement by the NCBTMB, COMTA and AMTA and any other organization that threatens the precious diversity within our profession.
  • The NCBTMB must withdraw its decision to add pathology and A&P hours without a corresponding strengthening of the health-promoting, right brain, imaginative and heartful side of massage. It is time our profession begins to walk again on two feet, honoring art and science, instead of just hopping on one, increasingly to the tune of insurance companies. It is time to walk the walk, not just talk it.
  • I recommend the formation of a task force to explore how the profession can proceed on both feet — emphasizing the art and the science of massage and bodywork.
  • I call upon the NCBTMB to declare a moratorium on curriculum changes mandated until this task force has been convened to explore how the profession as a whole can proceed and with the precious legacy of holism intact. It certainly can be more difficult to test people on their sensitivity than on their knowledge of anatomy.
This difficulty is perhaps our greatest challenge as a profession. Without the resolution to develop both the art and science of massage and bodywork, we will develop only the science. And, shortly, we would be little different in philosophy or practice from the allopathic health care fields.

This is our birthright — to facilitate a higher level of health in the body, mind and spirit.

Massage and bodywork do go beyond the medical. That is largely why people seek it out as an alternative, and why we need to further develop and protect it in every way we can. We hold the future of our profession in our hands. As a professional therapist and educator with more than 25 years of experience, blood, sweat, tears and joy in this profession, I urge you to stop the NCBTMB from attaching the shackles of the medico-industrial-academic complex on our profession. Returning to the issue of National Massage Safety — it may be critical at this time that the profession as a whole works together to keep itself safe from the current tendencies dominating the NCBTMB.

Massage is a freedom-loving profession. To keep it that way, let your opinion be known. Let's keep our freedom in our hands. And, by every means possible and necessary, let us keep the beautiful dream of healing through the science and art of touch alive in our hearts.

National Certification Exam Has Little Professional Credibility
By Bob Benson, ABMP President

Note: This article first appeared in the December/January 2004 issue of Massage & Bodywork magazine. Run as a publisher's note, the piece was originally titled, "Lost in Translation— The Soul of Massage Competence."

When 90 percent of respondents in a profession say your test is not reliable, it suggests that the soul of massage competence has been lost in translation.

The National Certification Exam (NCE) emperor has little credibility or support within its own profession. That's the only reasonable conclusion that can be drawn from two recent data points. A resounding 90 percent of the more than 3,300 respondents to an October 2003 online Massage Today poll answered "NO" to the question, "Do you think the National Certification Exam for Therapeutic Massage and Bodywork (NCETMB) is a reliable tool to evaluate the knowledge and skill of a massage therapist."

That's a thunderous vote of "no confidence" from the profession being evaluated. The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) touts that more than 70,000 massage therapists (Note: in May 2006 this figure is 80,000) now possess the NCE credential, inferring that those large numbers validate the credential's appeal and relevance.

A recent analysis by Associated Bodywork & Massage Professionals, however, usefully segmented that number. In the 21 states (27 in May 2006, including the District of Columbia) requiring licensed massage practitioners to take and pass the NCE (or, in some states, an equivalent exam), 77 percent (53 percent in May 2006) of licensed massage practitioners have secured an NCE credential (grandfathering provisions or selection of an alternative exam account for the remainder). By contrast, in the other 29 states (20 in May 2006), which don't require the exam, only 22 percent (14 percent in May 2006) of practitioners have passed the NCE.

Where there is a choice, in other words, massage therapists aren't flocking to sign up for a voluntary NCE credential. Does it matter that only a small portion of the profession believes the NCE fairly assesses knowledge and skill and is valuable to their careers?

If the original purpose of the NCE — to offer a consistent national voluntary individual certification — remained its sole purpose, then it wouldn't much matter. Those selecting a realm of massage practice for which they felt securing an NCE credential was valuable could choose to pursue it. The problem is that the NCE has perversely evolved into a barrier to entry into the massage profession.

Now 21 out of 33 licensing states (see notes above) require massage practitioners to pass the NCE or an equivalent exam to obtain license. As additional states add massage licensing, recent history suggests they also are likely to require the NCE. If states want a test, it's both administratively simpler and cost-free to require the NCE as opposed to creating and administering their own. The NCE shoe doesn't fit. A one-size-fits-all approach is ill-suited to the diverse massage and bodywork profession.

One or more properly constructed exams, available on a voluntary basis, may well benefit massage therapists who choose to work in close relationship with doctors and other medical professionals. Such a credential can be helpful to consumers and other health professionals in identifying massage therapists with particular credentials and skill sets. Those therapists are an important segment of the massage and bodywork profession, but hardly the only one.

The NCE is poorly matched with skills needed by an individual electing to perform basic, restorative Swedish massage, chair massage in health food stores or law offices, energy work, Asian bodywork or numerous other specialties. New variants of the NCE for basic and advanced massage may help improve fit, but still won't match the full diversity in the profession and won't address the involuntary utilization of the credentials by states.

The particular weaknesses of the NCE are well addressed by comments accompanying Massage Today poll answers. Some of the major themes are: a test of massage competence which does not include an assessment of hands-on skill is an empty test; one-size does not fit all; many questions are tossed unjustly to make sure each special interest group gets a nod ...

NCBTMB should stick to therapeutic massage and leave Asian modality certification to the American Organization for Bodywork Therapies of Asia (AOBTA); great massage therapists are more likely right-brained; tests are for the left-brained ... the NCE discriminates against kinesthetic learners;
  • Skills such as intuition, depth of touch and an ability to listen to a client are important aspects of being a competent massage therapist; the NCE test doesn't get at listening skills or other client relationship/communications abilities.
  • The art of massage requires sensitivity to the subtle energies that surround the physical palpations of muscle and flesh and the rotations and flexions of joints; the NCE doesn't assess this sensitivity.
  • Instead of helping massage therapists, it has become one more obstruction to being treated fairly and equitably in the work place.
NCBTMB's Board of Directors has heard similar complaints for years. Their response? Defensive, head-in-the-sand denial ... claiming more fiercely that their exam measures "competence" because it is based upon job content analysis, psychometric test question assessment and all the other formal steps required by their rule-setting body, the National Commission for Certifying Agencies. The problem is that, while they have done everything "by the book," as a current movie title suggests, something has been "Lost in Translation." When 90 percent of respondents in a profession say your test is not reliable, it suggests that the soul of massage competence has been lost in translation.

Massage & Bodywork and its ABMP parent organization support professionalism, sound core curricula and skill assessment at massage schools. Every practitioner should secure education appropriate to the work they subsequently choose to provide. Schools should only graduate students who are ready to begin practice.

We also encourage first-rate continuing education, whether through study of the contents of a professional magazine, refresher courses at a school or seminar participation. Voluntary standards and credentials also have a place in the field — a panoply of them to mirror diversity in the field. We would like to see additional organizations develop credentials for different parts of the massage and bodywork profession (much as the AOBTA constructively did working with the National Certification Commission for Acupuncture and Oriental Medicine).

Perhaps organizations with assessment expertise in other fields can be encouraged to partner with a new cadre of knowledgeable massage instructors to develop more reliable voluntary tests for this profession. The key word is "voluntary." Preserve flexibility and diversity in the massage profession. Respect choices individual practitioners make about types of work and how much work per week they elect to perform. Remember that a minimum required standard to obtain a massage license is quite a different matter from a voluntary certification evidencing higher-level skills. Keep licensing standards at a level sufficient to assure safe practice, but low enough to avoid screening out those individuals who choose to perform basic work. Sustain for consumers an ability to access a wide diversity of therapists whose one common bond is genuine caring for each client's health and welfare.

Do We Need a Massage-Only Credential?
By Darren Buford

Note: Darren Buford is managing editor of Massage & Bodywork magazine. This selection was originally published in Massage & Bodywork, October/November 2002.

Shakespeare wrote, "That which we call a rose by any other name would smell as sweet." In the same vein, would touch from anyone with a different moniker than "massage therapist" feel as good?

That question arises as massage and bodywork gain public currency and the public is confronted with a bewildering array of treatments, techniques and titles. Because all professionals in the field usually are deemed "massage therapists" by government officials, the press and certifying bodies, there is little room for distinction under this title. Seated massage may well require more modest training and still provide immense benefits, but "better-than-thou" attitudes have understandably developed from those with more and different levels of training, because they see an MT-only designation as not representative of or even demeaning to their skills, knowledge and quality of touch. Currently, massage professionals, movement reeducation specialists, energy therapists and Asian bodyworkers all adhere to the same moniker. Though our profession's problem is much more complex, imagine the myriad, disgruntled lawyers if paralegals were also suddenly called "lawyers." Though massage, bodywork and somatic therapies may all have similar end goals in mind, the vehicle and underlying preparation required are often very different.

Not only has this issue wounded some egos, but another, even larger problem exists because of the same-name designation. Consider that the public is probably often misled into believing anyone with the title "massage therapist" is a trained professional? How wrong that assumption is. (Think of how some unsavory types use the namesake to mask unethical practices.) Most members of the public aren't even aware there is a difference among therapists regarding education and modalities practiced. Should it then be the client's responsibility to decipher such a thing? For the public, going to a MT can be like a blind "touch" test: which is better, Massage Therapist A or B?

To say the situation is convoluted is an understatement — it's downright confusing. Perhaps, however, there is a silver lining to this cloudy horizon: tiered designation. But to get there, we must first understand how this problem came to be.

Issue of Self-Governance
Fifteen years ago, regulation of massage and bodywork through state and local governments seemed to some in the profession like the right thing to do. It was thought establishing certification and licensing of individuals and accrediting many of the massage therapy schools could help separate the profession from then public enemy No. 1 — prostitution. Second, it also could help legitimize the profession in the eyes of those in the health care field, such as physicians and insurance companies — where being accepted could help the profession get a piece of the referral and insurance reimbursement.

Among other outcomes, this avenue resulted in the creation of the now independent organization National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) in 1992 to "foster high standards of ethical and professional practice in the delivery of services through a credible, recognized credentialing program that assures the competency of practitioners of therapeutic massage and bodywork," and to promote the "worth of national certification to health, therapeutic massage and bodywork professionals, public policy makers and the general public."1

Seeking regulation, the massage field was an anomaly at state houses. Regulation of health professions is normally brought about by politicians as a way to protect the public from harm from charlatans (ie., protecting the public from untrained or improperly trained physicians). However, in the case of massage it was the opposite, because any harm massage could cause is minor compared to, say, the unguided work of an orthopedic surgeon. Therefore, legislators rarely took the initiative. Instead, regulation was sought by the profession to distinguish itself from the adult entertainment profession and the old massage parlor mystique. It became a self-governance issue (how will the field deal with itself, not how will the public deal with the field).

This issue presented another problem, however — how to package massage and its related modalities to policymakers. If regulations were to be pursued, what parameters should be set on dimensions such as scope of practice, amount and type of education, and demonstration of competence?

Because most legislators' knowledge of massage is limited, the shades of gray within the field meant very little to them. From their perspective, it's a profession problem that needs to be resolved internally. So, instead of hindering their chances at legislation, the profession took the quick route of accepting the "bait" of cramming all modalities under single standards, labeled "massage therapy," thus improving the chances for passage of legislation.

Unwittingly, regulation created a large umbrella under which everyone was forced to operate. This umbrella included everything from reflexology to Oriental modalities, from movement therapies to somatic therapies — hardly one and the same, as the variety of depth and breadth of each modality is great.

In turn, what was presented to those outside the massage field, namely the public, was that we were in fact one and the same, when we most definitely were not. This single set of standards for the different types of practice has recently led to re-examination of a tiered system of massage regulation by the NCBTMB that addresses (at least) an entry-level massage designation and an advanced massage designation.

Ray Siderius, president of the Oregon School of Massage, described the licensing and regulation that occurred in the past as uninformed decision-making, or a "dumb system." "Often we're getting involved in designing curriculum and regulatory measures where we don't have those lengthy conversations about what it is we're regulating and for what purpose, and it doesn't get discussed. Thus we have a system that's less than intelligent," he said. "A 'dumb system' doesn't address the diversity within the constituency that it purports to regulate."

Siderius added, "Intra-professional discussions and development of communication models about who we are and how our various components relate to one another are needed." Interestingly, Siderius was not the only school owner, nor the only pioneer in the profession, to express like concerns.

A Question of Semantics
The first objection from within the field came from those who did not agree with the term "therapist."2 "'Therapy' and 'therapists' are words used in the healthcare profession to mean 'treatment' or 'people who treat'," said David Palmer, owner of the TouchPro Institute in San Francisco, Calif. Palmer doesn't advocate completely dismissing the moniker altogether, but to include at least one other title which emphasizes an entry-level credential, such as "massage practitioner." "A massage therapist does massage therapy (treatment). A massage practitioner is someone who simply does massage," he said. Palmer compared this distinction to the American Massage Therapy Association namesake before 1984, when the association was called the American Massage & Therapy Association. "Then, they took out the 'and'," said Palmer. "Prior to that, there was massage and there was massage therapy. After that time, there was one thing: massage therapy. They did it for a number of seemingly innocuous reasons, however, the net effect was to make massage therapy the entry-level of our profession, and that's been a problem we've been fighting ever since."

Palmer argues the name change took the focus off touch and placed it on treatment. Instead, he is a proponent of a more preventive approach to massage, suggesting the best strategy is to keep little problems from becoming big problems rather than taking a clinical-level pathology and treating it. "It's the difference between having the ambulance at the bottom of the cliff versus having a guard rail at the top of the cliff," he said.

With those who wish to align themselves with the treatment side of the profession, Palmer advocates requiring more hours of training, basing his idea on the Ontario and British Columbia, Canada, models of 2,000 hours of training for massage therapists.3 "The idea of training someone to do medical massage in 500 hours is nothing short of absurd and irresponsible," he said. "What the massage schools are selling is self-esteem — that you'll be a junior physical therapist, that you'll be health care practitioners. The healthcare community looks at us and thinks we're a big joke because of that. They know 500 hours of training is not enough to create a competent therapist, and most people I've talked to who have graduated from 500-hour schooling know they're not competent."

Palmer is quick to state that he's not demeaning massage therapy's efficacy. "To the contrary, I think there should be whole hospitals that do nothing but massage therapy, like there are in China. I think massage therapy is incredibly efficacious and can be utilized for a broad range of conditions. My only complaint is that I'm conservative on this issue of training, and I don't think you should be presuming that level of knowledge without an equivalent level of training and experience, and 500 hours is not the equivalent level."

For Palmer, there is another solution to the problem: chair massage doesn't presume to define itself like massage therapy as a treatment and it is an obvious example of the first tier of his proposed profession. "Does it require 500 hours to create a chair massage practitioner?" asked Palmer, considered the "father of chair massage." "No. And that's one of the problems we've gotten ourselves into with this freight train of making massage therapy entry-level, because most states now have laws that require 500 hours or greater of training." Currently, if you wanted to practice chair massage or relaxation massage in New York or Nebraska, you would still need the 1,000 hours of training required by those states to do so. "What they've done is prevented the general public from the most accessible form of bodywork by forcing chair massage to be the specialty you take after getting your basic 500-hour training in table massage, rather than the other way around. It should take you 150-300 hours to learn chair massage (without any prior training), and do this first, then specialize in table massage and massage therapy after that, if you choose."

While the mainstream massage community wanted to make massage acceptable by making it a health care profession, Palmer's solution was to try to make massage accessible by lowering the cost, making it convenient. "My idea about social change is to start from the bottom up. If you can make something accessible to the broad majority of the public, then the acceptability will follow along naturally." Palmer believes the public image of massage, whether it be in a recent Time magazine article4 or in the L.A. Times, is that of chair massage making inroads into corporations, conventions, trade-shows, fitness centers, etc. "Chair massage offers an alternative approach and strategy," said Palmer. "I don't think massage therapy as a treatment will ever be mainstream massage. It's simply too expensive."

Dropping the Ball — Holism
David Lauterstein, owner of the Lauterstein-Conway Massage School in Austin, Texas, suggests two levels of designation would prolong dualistic thinking in the massage profession. "I think going to a two-tiered system would be a step backward rather than forward. For a long time there has been the idea that massage is either a cosmetic luxury or it's something you do for pain. What distinguishes modern massage is it really is a unique health modality. It lives up to the words 'health care.' Namely, it gives people the direct experience of health. It presupposes a good therapist's abilities to work with musculoskeletal tension and injury — but goes way beyond."

According to Lauterstein, massage used to be represented by the people working in beauty parlors or those who wore white coats. "That was where it was when I started in the late '70s, nationally," he said. "Unfortunately, today we have what I call 'the return of the repressed,' that it seems to be going back to that instead of stepping into the future."

Lauterstein advocates three levels of bodywork: a basic wellness level for relaxation, a medical/clinical level, and a holistic level which includes relaxation, but at a much deeper level, "where you're talking about how to work with the individual." For him, this involves moving beyond treating disease to really amplifying the health of the person. "A lot of massage schools have dropped the ball on understanding what holistic means, that a person is more than anatomy or tissues, but has emotions and thoughts, which are equally integral to health."

Lauterstein decries the current state of massage as almost one of "mass hypnosis," because so many people are using the word "treatment," when most of the state laws prevent professionals from using that word. "I've considered it a blessing that most massage therapists are forbidden to diagnose or treat. It means they are free to go the higher road, which is to work with the person."

Relating an anecdote about illustrator and writer Ann Kent Rush and her experiences at the Esalen Institute in the '70s, Lauterstein said, "She had mentioned what distinguished the institute was they were not doing it (massage) for pain, they were doing it for pleasure, which really steps out of the European model and the allopathic model that says, 'No Pain, No Gain.' They were instead saying, 'No Pleasure, No Gain,' which is still quite revolutionary for Americans to hear. However, Rush said a shift occurred when Ida Rolf came to the school. It was a step backward, she brought pain back into the equation." Today, said Lauterstein, we're still dealing with a similar conceivable setback. "Instead of really exploring the correlation between pleasure and health, many massage trainings and COMTA (Commission on Massage Therapy Accreditation) are aiming at mere allopathic competence."

State by State Approach
Deep in the Heart

Because the state of Texas only requires 300 hours of training to become a massage therapist, Lauterstein understands this is only adequate for relaxation/wellness massage. "If a client comes in needing someone to have problem-solving abilities, I don't think 300 hours is enough, so that's why we offer a 550-hour program. And then we have an additional advanced 200-hour semester that goes into craniosacral work, zero balancing, psychology of bodywork and advanced clinical work."

Imaginatively, Lauterstein said he could go far beyond this 750-hour program, but as far as he's concerned, with that much training the student is educated enough they may want to specialize in medical massage, postural work, energy therapies or Oriental medicine. In addition, Lauterstein suggests another avenue for the profession could be to formulate a wide-ranging program, where one can gain a basic 600-hour training, then rotate residencies in various programs, resembling a liberal arts education at most universities around the country. "After a good basic education, people have the right to specialize and not be hoarded into some advanced curriculum that kind of cookie-cuts us out of the variety of approaches. Any education that reduces this richness and diversity is a step backward."

Because the test far outreaches what many of their therapists are capable of passing, Texas doesn't recognize the National Certification Exam (NCE), which is designed for a student with at least 500 hours of training. Therefore, the state has developed its own testing board and exam.

The California Model
Another state with an alternative approach to a 500-hour national certification embedded in state massage regulation is California. Within the state, which currently does not have statewide massage licensing, there are a large number of schools offering 100-200 hours of training. Instead of seeing this as a hindrance to the profession, Deborra Clayton, administrator and instructor at the San Francisco School of Massage, sees it as a true benefit. The school's program offers a 608-hour program in a tiered format, comprising four courses of study, two of which are 102/103 hours and then two advanced courses that are 201 hours apiece.

"What we find is that for some students, the 100-hour courses are used as [background for] a part-time career, so they may stop their studies at this point and go to continuing education workshops for further training," said Clayton. "My sense is these people use their training to work on their friends and families, or they might get a job in a spa or with a chiropractor. Most often we find that people who stay with massage, we see them again in six months or one year, and they then take either the other basic course or they go into the advanced course."

Clayton explains the value of the shorter training is to get people interested and to begin developing their skills. Her objection to a non-tiered system is there are people who should be in the massage and bodywork field who have an extraordinary value in their quality of touch and personal presence. But if regulation is set at 500 hours, it puts training beyond the reach of people who do not have the time or the finances.

Programs offered throughout California not only offer a way in for many, but it's a way to "test" the field — weed out those who are not cut out for the work. Unlike other states, California also offers a way out without being financially destroyed by a program that says "once you've entered, you must finish the 500 hours." Clayton also emphasizes, "… and without them having to feel like a personal failure. Students leave because they discover after 100–200 hours into the training, this is not for me."

As for regulation and multi-level designations for the profession, Clayton said that in California what's changing minds is not what we call ourselves or even how long people train, but the changing perceptions of the profession. "It's not what we say, or call ourselves, it's the impact, the effect on the people we work with that is providing inroads with the medical community."

If regulation in a single-point 500-hour education requirement were to be introduced in California, the question arises whether or not this would cause the closing of many of the 100-hour programs across the state. According to Jocelyn Olivier, owner of Alive & Well in San Anselmo, Calif., the answer is no. "The 100-hour courses would simply shift to introductory courses for the public, participants just wouldn't become certified." Olivier believes her enrollment numbers wouldn't change drastically because there would still be a large percentage of the public only interested in the intro classes.

From a consumer standpoint, Olivier said she appreciates the 100-hour programs because it's made it easier for people to become introduced to the field. However, from a business standpoint, she understands a 500-hour program serves the school best economically. Her major concern with regard to regulation is instead with what she calls the "narrowing of the field." "The person who gets to define what our programs look like can restrict the breadth and scope of the practice of massage in California," she said. Olivier feels California is responsible for much of the growth in the field over the past 30 years, and regulation might deter more growth. "In the past, there's been a proliferation of modalities, approaches and knowledge about the human body, and how to work with it has expanded so much because of the openness here. If you have a clinical approach like they do in New York, it has no consciousness to it. This type of thinking narrows the field, narrows the scope, narrows how we develop, and what we think this work is about."

Times, They Are a Changin'
Much of the above discussion about which stratagem to take may soon be moot. The NCBTMB recently released a statement saying it will begin developing two new credentials, one for massage therapy and one for advanced practice in massage therapy. Christine Neiro, executive director of the NCBTMB, said, "We are currently offering the Nationally Certified Therapeutic Massage & Bodywork credential which we've offered since the program was implemented in 1992. Since then, there have been a lot of changes and developments in the whole profession. The board really pays attention, listening to its various stakeholders — schools, practitioners, certificants and customers. We were hearing there was a need for a more advanced credential."

The board determined an advanced credential in massage therapy would meet several needs: those of the practitioners who hold the current credential and who want to go to a next level, and those who need to have a higher credential for the type of work they are doing or for the setting in which they are practicing. "Practitioners are looking to increase their own body of knowledge as well, and a level of competency as they grow," said Neiro. Certification under the current credential will continue to be good for four years. "After that time, we're hoping practitioners demonstrate continued confidence and they've built on where they were four years ago when they passed the entry-level test."

Based on the new plan, it seemed only natural to the board they should also create a massage-only credential, to be developed at the entry-level. The board is also considering the feasibility of developing a bodywork specific credential for bodywork practitioners not defined by the entry-level or advanced certification. Ultimately, there could be as many as three or four levels of credentials, depending upon whether or not the board will phase out the current massage and bodywork certification.

Critics of the approach argue it's an example of top-down decision-making and again a "dumb system" because, though the profession itches for some change, the new credentials could fall short of accomplishing the desired goals of reflecting the broad diversity within the profession. Other critics express frustration that these new credential proposals have once again been announced without prior broad consultation of rank and file practitioners within the profession.

Another, harsher review of the new credentials goes as far as calling what the NCBTMB wants to create a "cash cow," because, as practitioners advance within the field and want a higher credential, they have to pay to take a second test, further tapping into practitioner's already limited budgets.5

On another note, the NCBTMB did state its willingness to work alongside state legislators, saying its new credentials "will offer more options to states that desire to separate regulations for massage and bodywork by providing more specific entry-level credentialing."6 These new NCBTMB plans raise a host of questions. Will the proposed new credentials affect the shape of potential upcoming legislation in the 20 states that remain unregulated? Will states that have regulation already on the books want to amend current standards? And will states and schools have to change their standards and curricula each time the NCBTMB introduces more credentials, such as certification for movement and posture specialists and somatic therapies? It looks like the motivation to defeat or champion such alterations will have to come from practitioners within the field after they get their first "taste" of the new credentials NCBTMB aims to implement by 2003.

Which raises an interesting point: We've spoken to school owners, to profession pioneers, to certification executives, but what about the little guy in all this — Sally Q. Therapist from Des Moines, Iowa? Do she and her peers really care about the use of monikers to distinguish the profession? Students, in theory, have a vested, non-agenda, interest in schooling. What are their feelings about the number of training hours chosen by their school and/or required by local and state governments?

In these matters, the strength of the profession is also its weakness. Many massage practitioners are attracted to the field by the prospect of helping people improve their well-being. They bring kinesthetic skills and positive emotional involvement, but don't have much interest in standards and regulation. They cede this domain to others. However, without their input, will changes continue to be made in a top-down manner by the few in power positions or can we believe that all voices in the field are, and will continue to be, heard provided an opportunity? Only time will tell.

1 NCBTMB Press Release, May 14, 2002.
2 Geoffrey Maitland's article titled "What's In a Name," featured in the Fall 1994 Massage Therapy Journal, addresses the profession's difficulties at that time in considering a professional moniker.
3 Palmer, David. "The Case for a Two-Tiered Profession." Massage. March/April 2000. 18-20.
4 Luscombe, Belinda. "Massage Goes Mainstream." Time. July 29, 2002. 48-50.
5 An August 2001 Associated Bodywork & Massage Professionals' survey found that the mean income of massage practitioners was $20,063 per year (Note: See Massage Profession Metrics for 2005 income information.).
6 NCBTMB Press Release, June 25, 2002.

Massage, bodywork and somatic therapies constitute a broad spectrum of techniques. Legislators often fail to appreciate the nuances and differences along this spectrum. As a result, they may develop legislation that subsumes all these modalities under a single regulatory scheme for touch modalities. It is probable today that probably more than 90 percent of the work performed primarily includes Swedish, deep tissue and/or neuro-muscular techniques. Nonetheless, voices representing other techniques deserve to be heard. Many such modalities merit exemptions from state massage licensing laws (and largely have been successful in gaining such exemptions). Here follow several voices from these communities.

Overbroad Licensing Wrong Fit for Bodyworkers
By Karrie Osborn, Contributing Editor, Massage & Bodywork

Note: Reprinted from Massage & Bodywork magazine, October/November 2002.

In the world of massage politics and governance, there are voices fighting to be heard. Pockets of therapists, falling across a wide spectrum of modalities, oppose the "unfair" legislation of bodywork and believe strongly that the issue of legislation is largely driven by money and a desire for control.

Mani Abreu, a licensed massage therapist, tai chi instructor, and founder of the Freedom for Bodywork online discussion group, is one of those voices. He believes the movement toward licensure is philosophically far removed from the very nature of the work he and other bodywork therapists practice. "I have discussed the issue with those on both sides of the fence more times than I can remember and have yet to see or hear any concrete evidence that would alter my belief concerning licensure — it is a movement whose primary philosophy is simply financial, having little to do with those who practice the trade."

Abreu said massage legislation is a combination of restrictive practice guidelines requiring continuing education credits at "approved" schools and a means of preventing non-licensed practitioners from exercising their skills.

"Massage legislation should concern only those who practice massage," said Abreu. "By including those who practice modalities other than massage only reinforces my belief that the primary concern of the licensure movement is simply financial in nature."

Sharon Benoliel, a Maryland shiatsu practitioner, would agree. Benoliel helped form a coalition in her state to exempt shiatsu, and eventually other forms of energy work, from the regulation recently enacted there. "I was certified in shiatsu, was well-trained and had been making a living at it for 17 years. All of a sudden, this law comes in and says to continue practicing legally, I have to take $6,000 worth of training in the totally irrelevant area of massage. I don't do massage, yet it was the injustice I was faced with," she said. Instead Benoliel chose to fight and was largely the impetus for shiatsu and other energy therapies being exempted from Maryland law.

Is it about the almighty dollar? "It's totally about money," said Benoliel, "and keeping the competition down." She said massage schools and existing practitioners are the ones who profit from all-inclusive massage regulation that doesn't take into account the variety of bodywork therapies being practiced or the educational requirements of those other therapies.

The bottom line for Benoliel is that the regulation in her state did a disservice to her and other practitioners: "It didn't honor our scope of practice."

LaRose Daniels, past president of the American Polarity Therapy Association (APTA) and current legislative coordinator for the group, said polarity therapists want title exemptions from massage governance bills, plain and simple. "Massage definitions are so broad, and they leave so much up to interpretation, that if you even touch the body you can be considered 'massage and bodywork.'" Daniels said the polarity scope of practice is very different from massage. "We feel we belong in energy medicine, not massage."

So why is it a bad thing to be included under the massage umbrella? "It's bad to be included because our education requirements are not being honored. Under many state laws, in order to ethically practice polarity, people have to go to massage school first."

She also believes special interests are often at work.

"Sometimes school owners are sitting on massage boards. It's to their financial advantage to include us. If we have to go to massage school before we can practice anything else, those school owners fill up their classes."

Daniels agreed money was at play in the issue of regulation. "The main thing is we don't want to be unfairly regulated, or be required to have an education we don't need, because we've been pulled into someone else's scope of practice. Money has a whole lot to do with it. Schools and continuing education — that's where the money is going. We just don't want to be pulled into it."

As massage legislation makes its way into more states, so does the opposition. "I don't have numbers, but in recent discussions I have heard that the AMTA (American Massage Therapy Association) could account for less than 25 percent of all active practitioners in the United States," said Abreu. "Does that give those folks the right to restrict my ability to practice massage simply because I don't want to be a card-carrying member?" Abreu speaks specifically of the AMTA because of that organization's early involvement with licensure and legislation.

As for fighting the big machine, Abreu said sometimes it simply takes an activist willing to become part of the machine in order to know the direction it is heading. "In those cases, where proposed legislation has been defeated, it has often been because those in the fight were forewarned and had sufficient time to present their own arguments to the legislative body." He said, above all else, to fight the fight, "you need people who are committed to the idea of equitable opportunities to practice our skills, whether we support the 'organization' or not."

Massage Therapy Research and Education

Research Introduction
While the last decade has witnessed an awakening in massage-therapy research, there is still much to be done. One barrier to further gains in public and medical community acceptance is the relatively modest base of research on the efficacy of massage therapy. Intuitively, many users find massage helpful, but some non-triers continue to wait for proof of scientific effectiveness.

According to Dr. Janet Kahn, a massage therapist and author of the article below, "very few people were thinking or speaking about research on therapeutic massage and bodywork ten years ago. Three institutions have emerged … to change that picture. The first was Touch Research Institute (TRI), founded in 1992 … at the University of Miami. Researchers at TRI have conducted more than 80 studies on a wide variety of potential massage applications. Most of these investigations are relatively small pilot studies. While not establishing definitive effects of massage, they have identified many areas in which massage shows potential and should be further investigated."

She notes that the 1999 convening of the Massage Research Agenda Workgroup provided a way for massage therapists and bodyworkers who may not have the training or the inclination to conduct research, to nevertheless influence the types of research being done. Kahn also notes the contributions of The National Institutes for Health Center for Complementary and Alternative Medicine (NCCAM).

Research Key to Future of Massage
By Dr. Janet Kahn, Massage Therapist, Senior Partner, Integrative Consulting, Burlington, Vt.

Note: This article first appeared in Massage & Bodywork magazine, October/November 2002. At the time of publication, Dr. Kahn was a member of the National Advisory Council for Complementary and Alternative Medicine at the National Institutes of Health.

Birthdays are great opportunities for self-reflection, for dreaming and for goal-setting. As we mark the 10th birthday of Massage & Bodywork, I have been asked to look at the field of massage research and reflect upon where our profession might hope to be 10 years from now. Ten years. What is its meaning? My dog is not quite 10 years old yet and the vet referred to him yesterday as early geriatric. I cringed. Sailing with my dad last weekend, I realized we had bought our boat almost four decades ago. It seems like yesterday. Time is a funny thing. One can imagine that 10 years might not amount to much in the life of a profession, but for the field of therapeutic massage and bodywork in general, and research specifically, the past decade was developmentally critical. I think the next decade will be at least as important. To help us understand what 10 years can mean, I will take a brief look backward, then offer some suggestions and predictions about the coming decade.

An Idea is Given Form
Ten years ago, very few people were thinking or speaking about research on therapeutic massage and bodywork. Three institutions emerged in the last decade to change that picture. The first was Touch Research Institute (TRI), founded in 1992 by Tiffany Field at the University of Miami. Researchers at TRI have conducted more than 80 studies on a wide variety of potential massage applications. Most of these investigations are relatively small pilot studies. While not establishing definitive effects of massage, they have identified many areas in which massage shows potential and should be further investigated. These studies have helped massage therapists around the globe understand the potential of research to inform our own practices, to answer our own questions and to inform others about our work. I think it is fair to Dr. Field and TRI have done much to put research on the map for massage therapists, and to put massage on the map for health care researchers. Making massage research a destination site, now that it is on these maps, is our job for the coming decade.

The American Massage Therapy Association (AMTA) Foundation was established in 1990 with the mission of bringing the benefits of massage therapy to the broadest spectrum of society through the generation, dissemination and application of knowledge in this field. The foundation began offering research grants in 1993. It has provided seed money to massage therapists and university-based researchers, allowing them to gather the kind of preliminary data needed to apply for larger grants from other sources. The AMTA Foundation has brought research closer to home. By launching the Massage Therapy Research Database (2001) it has made massage research findings more accessible to therapists.

And in convening the Massage Research Agenda Workgroup (1999), the foundation provided a way for massage therapists and bodyworkers who may not have the training or the inclination to conduct research, to nevertheless influence the types of research being done.

The third organization that warrants attention is the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH). Established as the Office of Alternative Medicine in October 1991, and reborn as NCCAM in 1998, this organization was created by legislative mandate, reflecting the public's widespread use of alternative medicine, and their demand that it be investigated as an aspect of contemporary health care. This is an important organization by virtue of its resources and its location. With a budget of more than $100 million per year and growing, it has the potential to fund significant research (although it has other responsibilities as well). The very existence of an institute devoted to alternative medicine has drawn and will draw many more conventional researchers into the field.

NIH is considered to be the pre-eminent health care research center in the world. It will likely be considered an important authority on complementary medicine, including massage. To date, therapeutic massage has not gotten its share of funding or attention from NCCAM. That is, given the number of Americans who use massage, NCCAM is not funding many studies. The responsibility for this is not all NCCAM's, since there are not many massage research proposals being submitted. In the coming decade, an important task for the field of therapeutic massage and bodywork will be to learn more about NIH, and about NCCAM in particular — to learn what funding mechanisms are available and how to successfully utilize them to advance our profession.

The past decade has also seen a nascent interest in massage research arising in this country outside of the three organizations mentioned. Where 10 years ago very little was said in our professional publications about research, today each of the three major massage periodicals covers massage research in every issue. And 10 years ago, I could not name a single massage school that taught research methods or even made reference to the massage-related research that existed at the time. As a final measure of the past decade, there are now health care administrators and practitioners who want to know what the research indicates about massage. They want to know what it is good for, what it is not good for, when they should refer, what deserves reimbursement, etc. In short, a massage research audience has begun to appear in the past decade. So where do we go from here?

Courage, Curiosity and Collaboration
Three watchwords will help us get the most out of the next decade in terms of massage and bodywork research. The words are courage, curiosity and collaboration, and the three of them must go hand-in-hand. Courage is required because we are stepping into a new arena. The mainstreaming of massage and other complementary health systems and modalities brings increased opportunity for us to be of service to more people, and it brings increased scrutiny as well. Increasingly when we make claims about the benefits of massage we are being, and will be, asked how we know that, whether there is any data to support our assertion. We must have the courage to let our work be assessed in many ways. We must have the courage to enter new contexts and work with new kinds of colleagues. Curiosity is at the heart of research. Research is designed to answer questions. We begin with hunches, clinical observations, public health needs and wonderings. We begin with curiosity about whether massage really moves fluids, can help alleviate depression, is better than surgery for people with carpal tunnel syndrome, etc. We begin with curiosity about why the premature babies in Field's studies gain more weight when they are massaged, and about what aspect of therapeutic massage treatment leads to its effectiveness in relation to persistent low-back pain as demonstrated by Cherkin and his colleagues. What is the contribution of the specific soft tissue work itself? Of generalized relaxation? Of the extent to which the client and practitioner connect? Of the client's belief in massage? Of the homework suggestions for exercise or ergonomic improvement the therapist offered to the client? Curiosity will drive the research to improve our work.

While courage and curiosity are instrumental to research, collaboration is the most important of the watchwords. Collaboration is the key to our own participation in naming the kinds of research that should be done and to mustering the resources to see it is done.

In October 1997, NCCAM awarded a $2.5 million grant to Palmer College of Chiropractic to establish the Consortial Center of Chiropractic Research (CCCR). Five chiropractic colleges joined forces to provide the infrastructure to the CCCR, offering training, database development and research opportunities. Since that time, five more chiropractic schools have joined this effort. An advisory committee composed of nationally known scientific and chiropractic experts directs the CCCR on programmatic aspects, sets research priorities and makes final decisions related to the support of selected research projects. In 2001, NCCAM gave an award to Bastyr University to establish The North American Naturopathic Medical Research Consortium with the initial goal of developing a prioritized research agenda. Again, while Bastyr is listed as the lead organization, this is a consortium that involves all five of the major accredited naturopathic colleges and universities in the United States and Canada.

In accordance, there will be a massage research consortium established in the next 10 years. It will be created by a small group of courageous and curious individuals, many of them representing exemplary massage schools. Since massage schools do not have the kinds of research experience and orientation, nor the faculty and financial resources of a Bastyr University or Palmer College, I believe this consortium will include an academic or medical center. In order to create this massage research consortium and serve our profession and the public, we will have to compete less and collaborate more. It is time for us to take on something bigger than one massage school can handle and bigger than one professional association can handle. Research doesn't exist in a vacuum. It is conceived and conducted by researchers who in turn require resources such as money, office space, access to patients, laboratories, imaging equipment, computers and the like. To be utilized, research requires an audience and vehicles through which results are made available to that audience. In the next 10 years, we need to purposefully build this infrastructure.

The Educational Role
While the creation of a consortial massage research center will be important, it is not by any means the whole picture. Massage schools are central to building the infrastructure research needs. It is their job to create massage professionals who understand research and its role in professionalization, who know how to locate and critically read the research literature, and who can adapt their practice based on research results. In 10 years time, I hope all of this will be taught in many massage schools. A smaller number of schools will also provide students who are interested in research experience — through their clinics or through internship placements at medical centers and academic institutions. All of this will require support from the faculty. In some cases, new faculty with research skills and experience will need to be hired; in other cases, faculty will need to be supported as they retrain to meet these needs. The schools should also be using research to answer pedagogical questions like how best to teach palpation, or for tracking changes in the student body, client population and treatment contexts, which could have implications for what should be taught.

We already see some students relocate to attend a massage school they believe offers superior education. In 10 years time, massage education which includes an introduction to research, at a school that has formed a partnership with a local university or medical center, will be seen as worth matriculating to. These schools will grow in size, length of program, tuition level and more. We have more than 900 (Note: In 2006 this number has grown to 1,500.)state-approved massage schools in the United States today. In 10 years time, perhaps 20–30 schools will have emerged as those offering significant research exposure. The growing number of massage programs being created in colleges will be logical sites for this education. I hope some of the established, free-standing massage schools also take on this challenge.

It is wonderful and appropriate that our magazines now report on research. It is also appropriate that we have no peer-reviewed massage journal. At this stage of our development it is important not to isolate research findings on massage, but rather to put them in the professional journals already being read by the researchers, administrators and practitioners who need to learn about our work. But in 10 years, we will be ready for a journal of massage and bodywork research. By that time, we should be generating enough research activity and audience to warrant a bi-monthly journal. And if in 10 years we get this entire infrastructure in place, what is the research we should actually be doing? There are three major categories of information a profession needs to generate in order to understand itself. The first is socio-cultural information — that which helps us to understand who we are, how we are regarded and so forth. The second arena of inquiry is information about what effects our work has. And the third is information about how that happens. This is traditionally called mechanism studies, but for now we'll refer to them as avenues of effect. Your imagination and your clinical experience will be beneficial in terms of conceiving the kinds of studies that could be done.

Socio-cultural studies could look at the demographics of student and client populations, cost-effectiveness, client-practitioner relationships, practice philosophies, regulatory issues and more. If you have any doubt about the importance of this kind of investigation, consider the impact of David Eisenberg's surveys on Americans' use of complementary and alternative medicine. When Eisenberg alerted the medical community and the public at large to the fact that more than 40 percent of Americans (Note: By 2004 a National Center for Health Statistics survey was estimating this figure at 62 percent.) were using some form of CAM every year, and that few of them were discussing this with their physicians, our field received the kind of attention it had only dreamt of before. For the field of massage, it was incredibly helpful to know that more than one-third of American adults — more than 100 million (Note: In 2006, an estimated 120 million to 135 million.) visits per year— were paid for out of pocket.

In terms of safety and efficacy studies, our attention should be steered in four directions. First, let us conduct research on the kinds of conditions we are treating. The National Alternative Medicine Ambulatory Care Study by Dan Cherkin found 63 percent of visits to massage therapists were for musculoskeletal complaints, but there is relatively little research on these conditions. Neck pain accounted for 17 percent of visits, but I know of no studies on massage for neck pain. Secondly, whereas massage research in the past 10 years has investigated at the surface level a wide range of possible applications, I encourage us to spend the next 10 years going deeper in a few areas. Consider that in the early 1990s when the Agency for Health Care Policy and Research (AHCPR) issued their consensus guidelines for Acute Low Back Problems in Adults, they recommended chiropractic care based upon the research, but could only say too little data existed to make any recommendation about therapeutic massage. We have begun to remedy that situation with multiple studies on massage and both acute and chronic low-back pain. We need to identify other areas — workplace stress or neck pain, perhaps — for which we will systematically build a body of research literature to really help us understand the potential of massage to treat these issues.

The third focus I would give to our efficacy studies is to think in terms of both primary and secondary prevention. Most of us believe that by alleviating stress, regular massage helps people avoid a whole host of conditions generated by stress. We need to design studies that can test that hypothesis. That is primary prevention. Secondary prevention means we need to conduct research that looks at the potential for massage to help people who are already diagnosed with pathologies; for instance, how to avoid a worsening of that condition. Finally, I want to suggest efficacy studies based on what practices are best for various conditions. The field of therapeutic massage and bodywork is filled with name brand treatments, but the public finds this confusing. Most names tell little about the treatment and more about the person who named it (Hellerwork, Rolfing, Alexander Technique, etc.). We need, whenever possible, to move to generic descriptors for our work and then to be willing to see whether certain kinds of bodywork are better than others for certain conditions. Are Swedish massage, myofascial techniques and neuromuscular techniques equivalently effective in relation to migraine headaches? Is there some combination of framework and techniques that is optimal? Or does method not matter because the key is the relationship between client and practitioner? We should look at such questions because when the time comes to compare massage with usual medical care, surgery, acupuncture or ayurveda, we want to make sure we are putting our best treatment forward. This search for best treatments will require the kind of courage, curiosity and collaboration discussed earlier, and I hope will lead to greater use of massage and enhanced massage education.

The next 10 years will be exciting for massage and bodywork research. As a profession we will be finding our comfort with this new enterprise. Where we have spent much time in the past decade watching, hoping and praying, in the next decade we will learn how to take the reins and see that our research agenda is being pursued.

The watchwords of courage, curiosity and collaboration apply to us as individual practitioners as well. Demand of your continuing education providers they offer opportunities for you to learn the research literacy skills that will be offered to the next decade's students in their basic education. Read the literature, think about your own practice, the questions that arise from it and might prompt a study. When you have an idea, be willing to reach out to local resources. The college or hospital nearest you may well have folks with research skills willing to collaborate with you on a study you can name, but can't design. Let it be an exciting decade for you.

1 Eisenberg, D.M., and Davis, R.B., Ettner, S.L., Appel S., Wilkey S., Van Rompay M., Kessler R.C. "Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey." Journal of the American Medical Association 1998 (280): 1569-1575.
2 Cherkin D., et al. "Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists and naturopathic physicians." Journal of the American Board of Family Practice. November 2002.

Education Introduction
As for education, the number of schools offering massage therapy training has accelerated and there has been explosive growth in the rate of new students entering massage training. There is more variety in the educational institutions that have either added massage to their curriculum, or are start-ups in massage-related training. ABMP surveys indicate more than 1,500 state-approved schools provide massage and bodywork training today.

The massage school industry continues to grow and the pie is being divided into more pieces. Massage training institutions, formerly the province of stand-alone massage-only proprietary schools, are now facing increasing competition from career (vocational) schools, and public community colleges and technical schools. Larger schools dominate the field — one fourth of schools account for more than 70 percent of graduates. One problem schools are facing is an insufficient number of qualified, experienced teachers to meet student demand.

Click here for more details from the ABMP 2004 survey of state-approved massage schools.

The State of Massage Education
By Shirley Vanderbilt, Staff Writer, Massage & Bodywork magazine.

First published in Massage & Bodywork, October/November 2002.

Note: Much has happened since 2002 when the following was published in Massage and Bodywork magazine. The number of schools offering massage therapy training has accelerated at an even faster clip. One of the dramatic trends in the profession is the explosive growth rate for new students entering massage-therapy training, and the variety and number of educational institutions that have spruced up their offerings or sprung up as independent schools to meet the demand. ABMP surveys indicate more than 1,500 state-approved schools provide massage and bodywork training today.

The massage school industry continues to grow and the pie is being divided into more pieces. Massage training institutions, formerly the province of stand-alone massage-only proprietary schools, are now facing increasing competition from career (vocational) schools, and public community colleges and technical schools. Larger schools dominate the field — one fourth of schools account for more than 70 percent of graduates. One problem schools are facing is an insufficient number of qualified, experienced teachers to meet student demand.

(Click here for more details from the ABMP 2004 survey of state-approved massage schools.)

Before the age of structured classroom settings, national exams and governmental standards, massage therapists learned their craft simply by apprenticing with a master. The healing arts were handed down from mother to daughter, father to son, or elderly shaman to some younger, tribal member possessing an extraordinary sensory perception or marked for training by surviving a cataclysmic event, such as a lightning strike. Apprenticeship, in the ancient way, was a lifetime commitment with the apprentice learning at his or her master's side for many decades before taking on the title of healer.

The growing popularity of complementary and alternative medicine (CAM) in our stress-laden society has heralded a concomitant growth in the number of massage schools — now more than a thousand in the United States alone. These schools offer a wide variety of training, from basic massage therapy to specialized modalities. Today, the opportunity to contribute to the field is open to anyone willing to pay for classes, successfully complete the required hours of training and hang out a shingle. For many, this will also include passing the National Certification Exam (NCE) or some other exam to meet requirements of state regulations.

Is apprenticeship a lost art? Is our current 21st century approach turning out well-qualified healers with the necessary hands-on experience? Does the structured classroom setting address the great diversity in learning styles of students? Does our current training system place more emphasis on passing the NCE than on preparation for actual practice? And, are students being prepared psychologically to handle the emotional and practical demands of a business?

In an effort to take a closer look at the current state of massage and bodywork education, these questions were posed to massage therapy experts across the country. The responses reflect, in a sense, the struggle of an emerging profession to fine-tune its approach to an art that has slowly made the transition from apprenticed entitlement to a legally sanctioned, legally controlled occupation of modern commerce. How the industry has handled this transformation and the proper future educational direction is the subject of much debate.

Dr. Keith Eric Grant, head of sports and deep tissue massage at McKinnon Institute in Oakland, Calif., recently wrote a white paper titled: "A Review of Issues in Massage Governance." Grant's doctorate in applied science, physics and mathematics combined with his massage-training background has earned him respect not only as an authority in massage physiology, but also as a major voice in massage politics and education. In his paper, Grant addresses a number of issues, among them current and proposed educational requirements to practice massage therapy. He wrote: "Proposals for regulation often contain entry criteria that are arbitrary in terms of educational basis and public benefit — essentially a syndrome of requiring some number of 'round hours' without basis of needed content or ultimate benefit to the consumer. These do not constitute standards in that they neither set particular performance criteria for practice nor provide a necessary and sufficient means by which criteria could be implemented and measured."

Of education itself, he wrote, "Much of what is considered to be improving the quality of massage education flies contrary to recent concepts of optimum educational methods. Cognitive research indicates that learning occurs most effectively in contexts of formal learning interspersed with practical experience and in situations of apprenticeship and mentoring."

It was, in part, Grant's writings that inspired Massage & Bodywork magazine to bring this discussion to the forefront — to examine the way things are and to ask if we can open the door for change where needed. This discussion will of necessity flow into issues of competency, regulations and requirements, but its intended focus is more on the very nature of learning itself. For Grant and others in the field, the present system doesn't exactly work for everyone, especially those whose educational backgrounds or learning styles are not compatible with empirical, textbook academics. Some students are adept at memorizing and spitting out answers on a test, but does that knowledge transfer to the massage table, especially once they are out practicing on their own? And what of the gifted massage student whose hands work like magic, but whose brain virtually freezes when faced with questions on an exam? Who we are teaching and how we are teaching is, in a sense, as vitally important as what we are teaching. As Grant noted in his paper, "Foremost, we should remember that massage, like musicianship, is primarily a kinesthetic skill coupled with supporting skills of communication, rapport building, observation and entrepreneurship."

How We Teach, How We Learn
In February 2002, Massage Today published results of a reader poll. The question, "How would you rate the training you received in massage school?" brought a response from 328 therapists. Nearly half (45.4 percent) rated their education as poor, with another 9.8 percent rating it as fair. These numbers may or may not be representative of those practicing massage across the country. And certainly they would not apply to every school. But the question has been raised, "Are we teaching students well?" Self-examination is not always easy, but it is often a necessary step to growth.

"Within the academic setting," wrote Grant, "students can learn to be successful with short-term memorization and use of 'right-answer' cues. In contrast, actual practice requires very limited memorization of facts. The massage practitioner must have the deeper understanding required to find information as needed and then to be able to use it to make therapy decisions in the face of ambiguity. Research indicates the environment that seems best able to foster the understanding leading to usability has much in common with traditional apprenticeships. In the modern cognitive apprenticeship, however, it is not just the tasks, but the thinking underlying them that must be made 'visible' and reflected upon. Such apprenticeships can be created within the context of traditional schools. A modular, tiered program can move the student into early practice, while providing resources for the ongoing training and dialogue that passes from teacher/mentors to increasingly skillful practitioners. There should be a progression of successively more difficult tasks within the conceptual scaffolding and coaching provided by mentors. Testing should not be concerned with memorization and regurgitation but with the student's ability, on being presented with relevant data, to choose among conclusions that can be drawn from it. Within the profession of massage, it is time we base our training requirements on 21st century insights into how people learn."

So we start with apprenticeship, a time-honored technique. Has this approach been lost in the shuffle of massage curriculum? Rose A. Gowdey, an organizational consultant and former director of Potomac Massage Training Institute in Washington, D.C., thinks not. "It looks different," she said. "But in any schools that continue to do practical testing where the students are working on instructors, I would call that apprenticeship, although it's not exactly precisely so. With small (student to teacher) ratios, you're doing a variation on apprenticeship. It begins to communicate what can be learned from a person when one is standing next to each other, rather than one in front of the other," said Gowdey.

On the other hand, said Pat Benjamin, dean of the Chicago School of Massage Therapy in Illinois, "It's not practical or desirable to go back to apprenticeship. There's something to be gained by an institution that has a lot of people involved in it. In an apprenticeship, you are limited by working with one person." Students get a broader view being exposed to a greater number of teachers. If the class size is small enough, the student can get individual attention.

Benjamin said the predominance of schools versus apprenticeships has shifted. "Licensing has had a big impact on that, but also the expectations of the general public about what massage therapists should know. The public is more savvy about what a good massage is," she said.

Benjamin said the Chicago School has an externship program. Students get practical experience through the in-house clinic where there is a small ratio of teachers to students, as well as working in external massage therapy settings. "That's nearer an apprenticeship. By having a more personal relationship, you do incorporate aspects of that in training."

Jack Brownfield agrees with the concept of more is better when it comes to numbers of instructors. As director of education for integrative massage and deep tissue therapy at the Atlanta School of Massage in Georgia, Brownfield is a supporter of having standards for training. "The student doesn't necessarily know what is missing when working with one person. That one teacher could have great skills or could be weak in some areas," he said recently. By offering a variety of instructors, the school provides a collective experience and creates a more well-rounded education. But, he added, "Apprenticeship is very much needed after graduation." Borrowing from the fields of psychology and counseling, Brownfield advocates a form of apprenticeship in the guise of supervision, whether individual or in a group. "It's an idea that's getting established as the profession matures."

According to Deborra Clayton, administrator of the San Francisco School of Massage in California, supervision can take the form of post-graduate coaching. "In every other physical art, coaching is such an acceptable thing," she said. "Ball players and vocalists wouldn't go without a coach, for instance. It's not about learning new things, but having someone with mastery observing from the outside." Aside from her teaching role at the school, Clayton offers private coaching services to former students. Within the school setting, students are also afforded a type of informal apprenticeship if chosen by the faculty to provide teaching assistance.

Whether we use the term apprenticeship, mentoring, or supervision, the concept of "hands-on" experience guided by an expert is essential to massage therapy training. How much of that experience students receive in their curriculum is determined by each individual school. For some students, this is a critical matter. As a kinesthetic art, massage naturally attracts many kinesthetic learners. So the question arises, are students who would otherwise emerge as highly skilled therapists being weeded out by massage school curriculum geared toward passing a national certifying exam?

Grant emphasized this issue: "There is every reason to expect that there will be those who are highly competent in interpersonal and kinesthetic intelligences yet fare poorly when forced unnecessarily into the verbal-linguistic paradigm of the academic world ... In continuing to unnecessarily push massage entry requirements into areas of psychometric testing and increased hours of book-based anatomical and physiological training to satisfy a medical model of massage, we are likely doing untold harm to those who would otherwise be highly competent practitioners from a more kinesthetic, experiential approach."

As an educator and researcher, Grant has done his homework on learning styles and the process of learning, documenting information from such leaders in the field as Howard Gardner and Mel Levine. Gardner's work points to "multiple intelligences," the brain-based differences in the learning processes of individuals. Levine's nonprofit institute, All Kinds of Minds, provides help to students, parents and educators in identifying, clarifying and working with these differences in brain wiring and learning abilities. Levine's book, A Mind at a Time, also outlines this approach and identifies the eight neurodevelopmental systems involved in learning: attention control, memory, language, spatial ordering, sequential ordering, motor, higher thinking and social thinking.1 For each individual learner, there may be strengths or weaknesses in any of these areas, and yet our formal education system has typically taken a "one size fits all" approach to classroom instruction.

Are massage schools addressing this great diversity of minds? Some schools are. At Lifestyles Learning Center in Chicago, owner Dr. Jerry Blackburn has made a point of it. A self-taught proponent of learning styles education, Blackburn has instituted a profiling process for his students to determine their learning type. He then adapts the instructional approach to address those differences. "I use it in application to myself more than anything else, techniques I have tried that actually work. It's so simple. What it does for people who have been caught in the educational problem of not being able to learn is to change their whole outlook on learning."

While not all massage schools can claim this achievement, the idea of addressing learning styles is rapidly gaining momentum in the industry. At Atlanta School of Massage, a learning skills-style inventory is used to help students understand their own learning style. "They can then take greater responsibility for their learning within the classroom," said Brownfield. In fall 2002, the school was also planning to implement a learning-styles inventory developed by Shelley Loewen called the TIPP system. "It has to do with what the person values," said Brownfield, "not only how they process information but also their character, how their personality is structured. We want to see if that yields more information." The school's instructors have also taken the inventory to gain understanding of their own learning styles, which ultimately affects how they teach. Brownfield noted that as an auditory learner tending toward verbal instruction, he also has to remember to add visual aids, to round out his approach. He expressed excitement, not only about his own school's forward movement, but that of others. "I've been going to (massage school) conferences for five years. No matter how long the schools were open, all were very interested in how to improve their schools — how they could teach better and how students could learn better. I think the majority of schools have their hearts in the right place."

Ray Siderius, president of the Oregon School of Massage, offered his take on the current state of massage education and his school's attempts for improvement. "What we found in our program was that a portion of students, those younger and/or less experienced, need more structure or guidance going through training — more focused integration. For example, they can take 100+ hours of electives (in addition to basics) in their program. Some take things that interest them and give them specific skills, but they may not be packaging their skills appropriately. Some students need the pieces woven together. Part of that is personal growth and maturity, as in any group. Has he or she been in an environment where they've had experiences developing their learning skills? Do they know their own emotional state and tensions? Maybe they can learn and not have a sense of how they've learned.

"For those of us involved in it," he asked, "are we interested in education on enough levels to recognize the diversity of cultures we work with and deal with that effectively so we can support the learning and development of our students? There are some people who work better under the apprenticeship system, who are not as adept at negotiating more formal education requirements. That's something those of us in the profession need to pay more attention to."

These school leaders recognize the diversity of ways that individual students learn most effectively and are trying conscientiously to tailor educational programs to reflect this diversity. Unfortunately, not all massage schools are so thoughtful. Too many do adopt a "one size fits all" stance, pushing students through a standardized experience, focusing laser-like on the book knowledge which must be mastered to pass the National Certification Exam.

Few school directors seem willing to challenge "the system," to ask whether our gatekeeping criteria for entry into the profession focus on the right skills and qualities. If we did, Grant would say that NCBTMB job surveys would uncover success characteristics that more effectively get at kinesthetic, observation, communication and entrepreneurial dimensions involved in establishing a practice and serving clients. And more school programs would effectively accommodate and support individuals gifted at touch but less comfortable with book-learning and test-taking.

Beyond the Academics
"I tell my students there are two kinds of massage therapists: those with clients and those without clients," said Dennis Simpson of the Colorado School of Healing Arts in Lakewood, Colo. "My question is, what makes those with clients successful? Is it the quality of education? Is it the quality of their touch? Or is it a genuine understanding, sensitivity and insight into the human condition?"

Learning to successfully apply touch for healing, and then marketing that skill goes far beyond the textbooks and classroom lectures, and even beyond the hands-on practical experience. Becoming psychologically prepared and business-savvy to practice on one's own is an issue affecting many students. Are schools doing a good job with this as well?

"I see a tremendous lack of attention to the teaching of business basics for massage therapy practice," said Blackburn, who has a marketing background. He teaches 70 hours in business and business practice plans. "I don't know any others offering so many hours. There's far too little literature and it doesn't really address the client and therapist relationship and how it's used for business." Knowing how to present oneself when the client comes through the door is important, not in a mercenary way, he noted, but in the sense of expressing pure intent to help the client.

Siderius sees variations throughout the country, depending on whether therapists gravitate toward working as an employee or establish self-employment. "There's a world of difference in being successful along those two paths," he said. "As a school leader, I think we need to evolve our ability to assess needs a little more. It has started to happen here. There's a lot of overlap, but also an additional different set of skills needed by someone with a free-standing massage practice."

Gowdey also noted a variation among schools in addressing psychological and business issues.

"There are some that have it down pat and others are still building it. I see the membership associations beginning to do some work in that area."

While some schools consider psychological issues to be a built-in part of curriculum, others deal with issues as they arise, without a systematic approach.

Despite the massage schools' best intentions, not all newly created therapists will survive the rigors of the real world. "People don't realize the work that lies behind or between the sessions," says Grant. "You have to be willing to get out there and market yourself, have self-confidence and self-esteem, and be willing to ask for advice." There's also the need for outside social interaction and non-professional relationships. "How to develop that should be touched on in schools."

Serving and Being Served
Grant points out that the question remains as to who is being served in our current educational approach. The verbal/linguistic ability to memorize information and recognize answers on a test, said Grant, "is a separate set of skills from being able to organize that information, use it in actual practice and be able to apply kinesthetic and interpersonal skills. So I think that hurdle tends to eliminate people who could be competent practitioners." What he terms the "gentrification" of massage closes the door to some. "It's almost an issue of white collar versus blue collar, making it white collar academics, while the public just wants good service."

In his white paper, Grant wrote, "In insisting on long monolithic school-based programs, we are ignoring the opportunities to use massage for community outreach and self-help." He envisions a system in which the door to massage would be open to the economically depressed or disadvantaged. "There are people who don't work well with higher education, but can learn experientially to provide touch," he said during an interview, referring to a program now being offered through McKinnon Institute's Touch Health Association. As a community service agency, the association has established a new infant massage program, based on the successes of the Touch Research Institute in Miami in working with low-income and high-risk mothers. Through this introduction to massage, it is hoped some of these women will want to continue their study through McKinnon scholarships and be placed in nonprofit organizations to provide services to those who otherwise could not access massage treatment. The concept not only addresses those who are currently deprived of massage for financial reasons, but also conquers the financial blocks for those who show potential as healers. As Grant noted, this approach could have significant impact on our current family problems with violence and inability to nurture.

In reviewing this article, Massage & Bodywork publisher Bob Benson notes that, "Most of the school leaders interviewed who see the value of internships view those as logically being capstone experiences — either the final part of school curriculum or a post-graduation experience. Perhaps the profession might benefit from a bit more openness to Gardner's and Levine's insights and to potential value from providing an internship experience perhaps half or two-thirds of the way through a structured program."

Agree to Disagree and Move On
In the final analysis, the experts all agree that cooperation is needed in determining he future of massage education and regulation. "I feel a real strong need," said Blackburn, "for associations to put their differences aside and start working on a national direction and policies so we can go forward with leadership that will take our profession in a direction that will include everybody from all types of disciplines, and not exclude anybody because of point of view."

Simpson said a colleague once told him at a convention that getting massage therapists together is like trying to herd cats. It made him laugh, but he also wondered if there might be some truth to the statement. He pointed to the many opinions on issues that face the profession. "None of the people I spoke with like the suggestive ads — that's something we all agree on." But when it comes to all the other issues, there are disagreements. "I always start out by asking: what's broke that we're trying to fix? I sincerely hope the profession moves forward in a positive manner," he said.

While speaking to national assessments and how the industry is approaching education, Grant brought up the old story of the man who was looking for his keys under the lightpost. That wasn't where he lost them, but the light was better there. Are we searching for answers in well-lit, familiar places while solutions are to be found by probing the dark unknown? The future of massage therapy education, as well as the industry itself, will be determined by the willingness of all participants to embrace self-examination and sound debate, and then to move forward with positive change.

1 Levine, Mel. "Eight Systems." Library Excerpts: A Mind at a Time.

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