By Deane Juhan
Originally published in Massage & Bodywork magazine, February/March 2007.
If you do a Google search for medical massage, you will turn up 3,210,000-plus entries. Clearly something of a large dimension is developing in this potential sector of our rapidly growing profession. And, as is the case with any broad movement, there are a variety of motives and presumed goals in play.
A largely grass roots phenomenon is beginning to institutionally encounter one of the most prosperous and prestigious—and most heavily regulated—organizations in the United States, and it seems to me that careful thought will be required as to just what this may mean.
It is obvious to everyone in the massage profession that our work very successfully addresses a wide spectrum of emotional, physical, and physiological conditions related to trauma, disease, debilitation, and recovery. A growing number of health professionals are recognizing this as well. How best to weave together often sharply divergent ways and means to accomplish mutually agreed upon ends will be a topic that is bound to absorb many minds from all sides of the issue.
I do not have a master plan. But I would like to express some thoughts concerning some of the potential—and dilemmas—that will surely be involved.
One of the backdrops against which the idea of medical massage is unfolding has to do with some disturbing trends in healthcare in this country. Our system has developed a technological and pharmacological expertise that is truly remarkable. And these developments in turn have made our healthcare by far the most expensive in the world. We spend $4,178 per capita annually on healthcare, or about 13.6 percent of our total economy. That is $2,395 more per person than the runner-up, Switzerland.
And yet, for all this lavish expense, we are far from number one when some important parameters of our system’s overall effectiveness are examined. Our infant mortality rate is 7.2 percent, the highest in all the developed industrialized nations. Our life expectancy is 70 years, ranking 24th among 191 nations studied by the World Health Organization and tying for dead last among the industrialized nations. We rank 55th among those 191 countries for fairness in the distribution of financial burdens of that care. And only 40 percent of Americans report being very or fairly satisfied with their healthcare.
In the richest nation in the history of the world, these are not celebratory numbers. And we must add to them the some 43 million Americans who have no health insurance coverage whatsoever, and the many more millions who are seeing their insurance rates and deductibles rising even as their coverage is both narrowing with regard to choices and shrinking with regard to pay outs. These are the kinds of economic pressure that spur people to start searching for ... well, “alternatives.”
And search they have. Surveys conducted by David Eisenberg, MD, reveal that as of 1997, 42 percent of the population used one or more alternative approaches to their health problems. Of this 42 percent, 96 percent were also consulting medical doctors, but the majority of them did not disclose their use of alternatives with that doctor. We certainly do not have a robust, mutually informed, cooperative, and coordinated system of integrated healthcare at this point.
More figures: the total number of visits to alternative therapists in 1997 was 628,825,000—62 percent more than the total number of visits to primary care physicians that were paid for out of pocket. And to pay for these alternatives, Americans spent a total of $27 billion, which is on a par with the $29 billion paid out of pocket for all physicians’ services. Visits to chiropractors (191,886,000) and to massage therapists (113,723,000) accounted for fully half of all visits to alternative therapists.
These kinds of figures and the popularity they represent are another kind of pressure that is pushing people to seek out our work. And, of course, to this we must also add a further attraction: a large number of those using alternative approaches claim they experienced more benefit from them than from conventional treatment. And these folks are not uninformed huddled masses. Fifty percent of them are between the ages of thirty-six and forty-nine; 51 percent of them have college educations, and 48 percent had incomes over $50,000.
The response of the medical community to these studies has been mixed. One pole of reaction has been “Oh my God, we and our patients are being illegitimately defrauded out of $27 billion a year! How do we put a stop to this charlatanism!?” Another pole has been, “Hmm, $29 billion ... customer satisfaction ... how can I utilize this in my clinic, both for my bottom line and my patients’ benefit?”
All of this suggests to me that we may well be heading toward some decisive developments in the relations between medicine and massage, and that it will inspire both enthusiastic exploration, experimentation, and cooperation in some medical quarters while inciting cries for heavy-handed regulation and restriction in others. So, how do we, as a rapidly growing and increasingly popular alternative, most effectively engage ourselves with these trends in conventional and alternative healthcare?
Therapeutic Versus Medical
A selective survey of the medical massage search (no, I did not get to all 3,210,000 of them) turns up a number of general categories of medical massage training and practice. They range, as one might guess, from the perfunctory to the useful to the exemplary.
Many standard five-hundred-hour massage certification programs are now offering an emphasis on medical massage. This emphasis is usually in the form of an expanded curriculum in anatomy, physiology, and pathology, including some clinical hours focusing on protocols and contraindications for a variety of conditions. The program descriptions of some of these schools sounds as though they are doing as responsible and inclusive a job of presenting these materials as possible given the constraints of five-hundred hours. And some of these programs sound very much like their directors have latched on to a hot buzzword in order to boost their bottom line without significantly changing their offerings. Institutional standards are never more sturdy than the personal integrity of those applying them.
But even given the highest degree of integrity, there lingers a concern that within the scope of a five-hundred-hour program there is some justification for the skeptical observation made by many in the medical profession: that an emphasis on the medical aspects of massage embedded in such a relatively brief training is not very likely (“preposterous,” some would have it) to deliver medical competence to students or their future clients. Might it not all too often lead to a little knowledge being a dangerous thing?
This is in no way to belittle the obvious benefits of this added emphasis to massage training programs. Far from it—the more knowledge the better. It is simply to observe that there is a world of difference between saying, “Our program will ground you solidly in the basics of massage, anatomy, and physiology, will give you some knowledge and experience of the wide possibilities of massage as an effective therapeutic tool, and will motivate you to continue your education and practice so that you will find yourself capable of taking on increasingly challenging clients and conditions,” and saying, “We will teach you to do medical massage.” The syllogism of “massage is therapeutic; medicine is therapeutic; therefore, massage is a form of medical practice” won’t really fly, for the simple reason that for a large portion of the medical profession there is a very wide gap between the definitions of therapeutic and medical. More on this later.
Other forums for medical massage training that have been rapidly expanding are certification programs included as a department in postsecondary adult education “colleges.” Typically these colleges offer certifications in a wide variety of career choices—X-ray technician, various forms of nursing, computer technology, and so on. This has the apparent advantage of presenting massage training on a par with a variety of well-established, mainstream careers, some of them affiliated with medical care. But again, programs are short, usually five-hundred hours, and expectations are raised. Many of these colleges advertise “guaranteed professional placement.”
Among the most substantial sounding training programs are those offered by highly experienced individuals who have been working for many years with injuries, traumas, illnesses, and rehabilitation. They do not offer basic massage training, but rather course work in addition to students’ basic training, which is highly specific and comprehensive in its content. These programs have much more the feel of an extended apprenticeship with a teacher who has had substantial success working with a wide variety of pathologies. The individuals I know who have pursued these programs strike me as well trained and knowledgeable and certainly capable of working with clients whose conditions could unquestionably be called medical.
Adding to this last point, I want to make one thing perfectly clear: it is clearly true that many, many massage practitioners have studied deeply, worked long in their fields, and have developed skills that are highly effective and therapeutic. Many, many clients have dramatically benefitted from these practitioners, often experiencing relief and recovery that had eluded them in their search for conventional treatment. It is perfectly understandable—even just and laudable—that massage therapists of high caliber would desire professional recognition for what they are able to do, and that they would want their practices to have enhanced access to insurance payment plans that fund the vast majority of healthcare costs in this country.
It is also understandable that training programs and schools would want to enhance their professional appeal and embrace the full therapeutic potential of massage as much as possible in their offerings. It is also understandable that many practitioners would hope that by splicing medical and massage together, and by adopting terminology, assessment protocols, record-keeping practices, and so on that are common to the medical world that they might be more successful in their appeals for acceptance in a broader context of healthcare.
But, I do fear that an aggressive effort to medicalize massage could be edging us toward a trip switch that could have major unintended consequences. Here is why: as I said earlier, for many in the healthcare establishment therapeutic does not equate with medical. They are willing to concede that many things are indeed therapeutic: lowered stress levels, healthy diet, vitamins, exercise, vacations, pets, supportive relationships, bodywork. But medical is quite another matter. For them, this term connotes a collection of professions whose education is long and exhaustive, that is very tightly regulated, and that commonly treads a fine line between life-saving procedures and life-threatening mistakes. They are not likely to throw open their institutional arms to us regardless of how therapeutic we can demonstrate ourselves to be. And in some quarters, they are already aggressively active in heading off any such possibility.
Early on in your medical massage search, you will find the site of the American Medical Massage Association (AMMA), whose official journal is JAMA. Any resemblance of these anagrams with AMA and JAMA are strictly uncoincidental. On this site you will find a position statement titled “Categories and Definitions of Fringe Massage Therapies.” In its opening paragraph, we discover the frightening news that “fringe massage is becoming increasingly popular in the general massage community and is occupying 25–60 percent of massage therapy curriculum.” In paragraph two, we are informed that “this is increasingly becoming an intolerable problem that begs for legislative solution.” In paragraph three, it is made clear that it is largely the five-hundred-hour programs that have become so “fringy,” teaching pseudoscience of many kinds. And further on: “The AMMA accepts that medical ethics and medical massage ethics are one and the same, and that it is unethical to promote the use and practice of fringe massage in patient care ... Some subjects taught in massage schools and practices of massage in the general community are so extreme in nature as to constitute healthcare fraud.”
And what are these offending fringes? Energy treatment, including reiki, polarity therapy, chi kung, quantum touch, and Therapeutic Touch, as well as crystal healing, craniosacral, aromatherapy, aura reading, chakra healing, five element chinese medicine, Zero Balancing, emotional balancing, unwinding, PNF, trigger point, neuromuscular therapy, and myofacial release. And this list is far from complete: “There are close to two hundred of these divergent and nonscientifically based massage theories and practice systems utilized by massage therapists ... The AMMA Board of Advisors believes that the situation regarding fringe massage education and practices within the general massage community has advanced to the point of becoming a serious problem that is adversely affecting the overall professional image and the reputation of massage therapy in the U.S.”
Now what, aside from seeing huge parts of massage therapy as we know it simply brushed off the regulatory table, is most chilling in all of this? All of their judgments concerning “fringe massage” are couched in terms of “scientific accountability,” a phrase that comes tripping in at the heels of any professional use of the term medical. “When a healthcare discipline raises to the level of a regulated healthcare profession it is incumbent upon its members to subscribe to a higher level of accountability.” Fair enough. I have been researching and writing about the scientific bases of massage for twenty-five years. But what this position paper makes clear is that by “accountability,” the AMMA specifically means the rooting out of any theory and practice that is not based solely on the physiological function of the body and the mind as currently understood by the established and accepted scientific consensus.
To me this sounds as though we might have far more to lose than regulatory control of our profession. The current medical understanding of how our bodies and minds work is far from complete; ongoing clinical research is upending many beliefs that have been regarded as physiological gospel. Those who would argue that there is and can be no such thing as energy medicine have not been listening to the physicists, who have long been telling us that there is nothing but energy in the universe. Undreamed of discoveries about how human beings function and heal are appearing at a rapid rate, as many researchers are breaking ground by learning to ask new kinds of questions that specifically challenge conventional scientific wisdom.
Our work and its empirical successes have been a large part of the accumulating evidence that has led many researchers to ask these new questions. Conservative medical regulatory boards do not hesitate to severely sanction physicians deemed to be practicing outside the box as the boards define it, utilizing curative techniques that have not been proven to their clinical satisfaction. What we could stand to lose cannot be measured as a loss of regulatory autonomy. What we could lose is the very basis of open-ended inquiry and exploration that have made us “alternatives” in the first place.
What we could lose is the definition and practice of bodywork as most of us understand them. If massage becomes medicalized, it is very likely that conservative medical experts will have the power to say what it is, who can practice it, and exactly how it is to be practiced. Legislative influence and regulatory muscle are distinctly on their side. If you think massage had to operate to a large degree underground in the past, just imagine the situation if the AMMA position statement were to become the law of our portion of the land.
We do not have to go down that road. The healthcare establishment is not the conservative monolith that the AMMA makes it and themselves out to be. Many professionals within it just want to seek out what benefits their patients, and if that turns out to be reiki or neuromuscular release, then so be it as far as they are concerned. Many of them, and more all the time, are willing to prescribe the work of alternative therapists they have come to know and trust. And more and more insurance plans are willing to pay for our work if it has been prescribed by a primary care physician.
Perhaps most encouraging of all is the recent proliferation of multidisciplinary clinics, many of which are eager to include alternative therapists on their staff. This is the kind of partnership I would far prefer for us as we become a part of the medicine of the future—a valued member of a team, each member of which brings his or her own expertise and philosophy to bear on the wellness of patients and clients. We must carefully guard against losing the essence and the uniqueness of what we have created in the interests of “belonging” (double-edged word, that) to the professional medical community.
Vive la fringe.
Deane Juhan is the author of Job’s Body: A Handbook for Bodywork and Touched by the Goddess: The Physical, Psychological, and Spiritual Power of Bodywork, both published by Station Hill Press. Juhan is a Trager Approach practitioner who taught at Esalen for many years and continues to teach for the Trager Institute. He lectures widely throughout the United States and Europe.
“The US Health Care System: Best in the World, or Just the Most Expensive?” Summary of The World Health Report 2000—Health Systems: Improving Performance, prepared by the Bureau of Labor Education, University of Maine.
Eisenberg, David et al. “Trends in Alternative Medicine Use in the United States.” Journal of the American Medical Association 280 (Nov. 11, 1998): 1569-75.
“Categories and Definitions of Fringe Massage Therapy—AMMA Position Statement,” Muskegan, Michigan, Oct. 2005.