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The Massage Tapestry
Our First Decade, An Era of Growth

By Bob Benson

Throughout its initial 10 years of publication, Massage & Bodywork has been observer to a intriguing period for the massage therapy profession in the United States. No, it wasn't like 1960-1985 when a new approach to bodywork seemed to migrate from Esalen to the Bay area every year, a period when today's major strands of massage and somatic therapies became established. Rather the past 10 years have witnessed more refinements and slight permutations on the technique front. Nonetheless, the 1992-2002 period included dramatic growth and the beginnings of greater structure in the profession.

What qualifies as dramatic? Consider 54,000 massage therapists in 1992 versus 175,000 today. Combined Associated Bodywork & Massage Professionals (ABMP) and American Massage Therapy Association (AMTA) membership essentially quadrupled - up from 21,850 to 86,534. National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) was just getting off the ground in 1992; today it certifies 60,000 therapists. And where did all these therapists become therapists? From one of 1,067 state-approved massage schools in 2002 versus only 240 a decade ago. Structure? Try, in addition to the emergence of national certification, 30 states now license massage therapists today versus only 16 in 1992.

This is rather stunning growth. Two others facts make it even more so. More than 95% of massage sessions were paid out of clients' own wallets during that time. And, while 175,000 women and men now practice massage or related modalities, more than another 100,000 practiced it sometime during the decade but have now dropped out of the profession.

Obviously consumers appreciate massage and it's getting plenty of trial. Abetting this process is a shift in attitudes and an increasing focus, particularly among many well-educated Americans, on taking personal responsibility for one's own health.

Health care used to consist of a family doctor and, when needed, an MD specialist to whom he or she would refer you. For most, family doctor translated to someone you trusted and who had time to listen to your concerns. That model is much more rare today in an era of HMOs, cost and time limits on doctors, and more frequent impersonal treatment.

Consumers have responded by learning about and accessing additional health care therapies and better educating themselves about nutrition (though statistics on obesity confirm that not all have taken this information to heart), vitamins and exercise. Well-being is the goal. Massage and its derivative forms are prominent in the mix.

Among new therapies tried by consumers, massage does well. It sells itself. Rare is the soul who says of a first massage session, "That didn't do much for me." Yet the full potential market remains considerably untapped: fully two-thirds of American adults have never experienced a massage or bodywork session.

Part of the challenge is the complexity of choices presented. Foremost is the distinction between relaxation and therapeutic massage - though in truth therein lies a spectrum of approaches rather than one black, one white. Then we note the differences between massage on a table or in a chair. Work done with the client fully clothed or less so. Palpation and stroking of tissues versus energy work devoid of direct skin contact. ABMP's Touch Resource Guide lists approximately 200 purportedly different modalities or techniques, reflecting the wide variety of provider interests and interventions. Add on wide variation in provider education (potentially appropriately so, depending upon the kind of work and clientele a provider chooses) and no wonder the consumer may become confused.

For all its growth and increasing professionalism, massage is still a burgeoning field. Its training, supplier and provider universe is highly atomized. Most outsiders are stunned to learn someone can receive massage education at 1,067 state-approved schools. Yet, combined enrollment at the 10 largest schools represents a bit under 12% of all current students. While some suppliers of products and services to massage therapists are larger than others, no behemoths dominate these trades. Thankfully too, even with the growth of massage in spa and medical settings, the personalism so important to massage therapy sessions is largely being sustained.

Massage's history is rooted in technique and body knowledge, but is also about heart, healing intention, and connection between therapist and client. A tension, sometimes constructive, other times uncomfortable, has been prevalent in the field between one impulse toward structure and recognition and another toward freedom and flexibility to be responsive to individual circumstances. Issues like licensing, certification, accreditation and reimbursement are the most frequent subjects around which these tensions arise.

Broad Strokes
Individual practitioners and school owners play important roles locally in the development and resolution of these issues. Looking broadly at the canvas, the broadest strokes are, however, being painted by a handful of national institutions.

The longest standing of these institutions, the AMTA, founded in 1943, has had a consistent apparent objective these past 10 years: recognition of massage therapy by the medical profession, thus opening the door to respect for practitioners and eligibility for reimbursement by health insurance companies.

Much follows from that focus. AMTA in its definitions of what constitutes massage and in its membership criteria has historically been cautious about accepting modalities which diverge substantially from its core Swedish massage tradition. In support of the medical massage orientation AMTA embraces, the organization seeks to shape images of massage professionals as working full-time and having substantial massage education. "Full-time" professional fits the image AMTA projects, even if the fact a majority of U.S. practitioners devoting fewer than 20 hours a week to massage doesn't conveniently match that desired image. While officially requiring full professional members to have at least 500 hours of massage education, AMTA and its in-house born and now independent accrediting agency - Commission on Massage Therapy Accreditation (COMTA) - encourage even more. Some local AMTA chapters have pushed for requiring as many as 1,000 hours for professionals.

To advance its apparent central objective, AMTA has looked at other health-related professions already more recognized to see how they look different to MDs and insurers. As a result, AMTA has encouraged state licensing for massage therapy, national certification of massage therapists and accreditation for massage schools. AMTA leaders believe creation of these standards will advance attainment of their goal for recognition of the massage profession by the medical community. Implementation efforts sometimes find AMTA representatives working in concert with other massage therapists in individual states; on other occasions the exercise more resembles their seeking to force a pre-determined legislative agenda.

A Different Animal
Ten years ago, ABMP was five years old and had only 6,750 members. Not being warmly embraced by AMTA, ABMP in its early years developed a certain buccaneer, "don't tread on me," quality. From its beginning, ABMP was welcoming to practitioners of a broad array of massage, bodywork and somatic modalities. Perhaps because leaders of some of the newer modalities saw their specialty as not fitting under the traditional massage banner, ABMP took positions opposing the creation of new state licensing standards and questioning the value of practitioner certification in the context of particular standards, procedures and fee structures being proposed. ABMP was, however, consistently encouraging to schools working to upgrade their curricula.

With new leadership in 1996, ABMP evolved to a more pragmatic, circumstantial examination of massage licensing proposals in each state. Representing consensus member perspectives became the watchword. In some states, the absence of any pattern of significant public harm from massage coupled with ease of setting up massage practices translated to comfort for most practitioners in working without state licensing. In other states, a growing patchwork of local city massage licensing requirements and fees became cumbersome and expensive, leading to practitioner and ABMP consensus that a uniform state licensing law is a better answer. (See sidebar for further perspective on state licensing.)

On other fronts, ABMP, through its Integrated Massage & Somatic Therapies Accreditation Council (IMSTAC), offers a pragmatic accreditation alternative for massage schools not interested in qualifying for U.S. Department of Education funding (with accompanying vast paperwork), but still wanting to go through a rigorous self-examination process and then receive feedback from ABMP staff professionals who each have visited more than 100 schools. ABMP now acknowledges some value in the National Certification Exam (NCE) credential for the express purpose of facilitating recognition of qualification to practice for individuals moving from one state to another. At the same time, ABMP continues to voice concerns about the financial burden the NCE imposes for practitioners and inconsistencies in what its proponents claim for it versus what it really provides (see article by Keith Eric Grant, "The Emperor Has No Clothes," beginning on page 46 to get further development of these perspectives).

These pragmatic approaches by ABMP - combined with emphasis on service and value - struck a chord. ABMP membership has grown to 40,440. In parallel fashion, ABMP's magazine Massage & Bodywork has evolved from a primitive, quarterly publication to what it is today - editorially and artistically advanced and now weighing in at 168 pages six times a year. ABMP has also created five Web sites, serving various constituencies, and a twice-a-year publication, Body Sense, to help massage practitioners in their client education efforts.

Other Voices
The IMA Group and at least three other parties offer professional liability insurance, but little if anything else to massage therapists. They simply aren't at the table as licensing is explored in various states or schools are being accredited.

Specialty associations, focused on a particular modality or approach, most often get involved in licensing discussions around the issue of whether their work should be covered by massage licensing requirements. Sometimes that involvement occurs as new rules are being considered; otherwise it comes after rules have been adopted (e.g., Maryland, Washington) in the form of an effort to amend legislation to exempt their specialty.

Besides membership associations, the other prominent voice on licensing issues is the NCBTMB. This organization began operations in 1992 with seed capital in the form of a $225,000-$250,000 loan1 from the AMTA. Financially, it has been highly successful: 60,000 of the current 175,000 massage practitioners have paid an initial testing fee (now $225) and face $100 renewal fees every four years. The loan has long since been paid off and NCBTMB now has a healthy cash balance.

NCBTMB was created to enhance professionalism among massage therapists by providing a uniform national credential which signified the individual had completed a core education of at least 500 hours at a recognized massage training program and then had passed a test. The implication presented in advertising and public relations releases is that someone holding the NCE credential is a knowledgeable, high quality practitioner. NCBTMB does not get involved in massage school accreditation directly, but does make decisions about which individuals and schools to include on a list of approved providers from whom certificants can obtain qualifying continuing education.

Throughout most of the 1990s, NCBTMB nominally put forward its credential for the benefit of the public and qualifying therapists with no clear agenda for its integration into state massage licensing standards. In fact, NCBTMB representatives were madly paddling under the surface for just such an end. Finally, to Neil Cross's credit during his NCBTMB stint as chairman in 2000-2001, NCBTMB "came out of the closet" and acknowledged they hoped all states would integrate a required NCE credential into their licensing standards. Small wonder - rather than go through the expense and hassle of developing their own test, 20 states now require the NCE credential and another five accept it as one way to meet their qualifications, meaning a multi-million dollar essentially guaranteed annual revenue for NCBTMB.

Monitoring these developments and sometimes commenting editorially throughout the decade have been independently owned Massage magazine, the AMTA's Massage Therapy Journal, Massage & Bodywork and a free monthly newsmagazine, Massage Today.

Interaction among these varied perspectives has resulted in steady growth in the number of states licensing massage therapists, somewhat more rapid growth in the number of NCE certificants, and quite explosive growth in both the total number of massage schools and the number accredited (138, representing 14% of all schools) by one or more of four accrediting entities.

The Insurance Game
Less changed is health insurance plan coverage of massage therapy services. Best estimates suggest only 2%-3% of massage therapists receive high dollar insurance reimbursement. Almost all their work is related to disability or accident rehabilitation. These individuals prosper because billing rates allowed are more akin to physical therapist or chiropractor billing rates than to prevalent charges for massage therapy. Ironically, if proponents of creating new coding categories specifically for massage have their way, billing rates for massage services likely will come down to "usual and customary charges" for such services.

What has not incurred in any significant dimension is financial reimbursement to consumers for massage services by mainstream health insurance plans. A number of "progressive" plans now recognize massage and even have assembled networks of approved massage therapist providers, but few of these plans reimburse therapists for massage work. Instead, as a benefit of inclusion in the insurer's network, massage therapists must promise to provide to their clients a 20% or 25% discount from their normal charge rates. Pragmatic perhaps for someone just getting started in practice; hardly a formula for prosperity when prevailing massage therapy rates remain within the $45-$60 per hour range in most U.S. communities.

Massage is not alone is this regard. Other so-called complementary and alternative medicine (CAM) health care fields also are working to secure broader recognition. Part of the solution appears to lie in seeking alliances with enlightened allopathic physicians and medical schools to pursue true integrated medicine: everyone knowledgeable and appreciative of the potentials offered by diverse therapies and a readiness to try whatever approach is effective. Another part is to work with other CAM professions in parallel pursuit and support along the quest for acceptance. The final element of public education relative to massage's potential will remain the responsibility of the massage profession itself to do good work, encourage favorable word-of-mouth by pleased clients, and seize opportunities to engage and acquaint the public.

In summary, massage remains an evolving environment. With its funding and regulatory environments not fully resolved and its multiplicity of players - schools, suppliers and therapists of many stripes - answers are not wholly predictable. Among questions or challenges still to be resolved:

• One size doesn't fit all. The diverse array of massage, bodywork and somatic services provided require different levels and kinds of education. Should we seek to mold regulatory and certification standards to appropriately reflect this diversity?

• Can the massage therapy profession become comfortable with the choice many therapists make to work part time at massage (slightly more than half of all therapists have a second job) or will some continue to stigmatize those brethren practitioners?

• Most massage schools to date have been created by experienced professionals in the field. Increasingly today, community colleges and vocational schools whose prior experience has not included massage teaching are entering the field. Will these new entrants become more dominant and will their involvement be constructive or negative?

• Most school owners feel their students are well-served by investing in a quality table, probably costing $400-$500, rather than settling for less. Will they commit to sharing that viewpoint and find effective ways to communicate it to students?

• Some proportion of the two-thirds of American adults who have never had a massage have not because they still attach a stigma to "massage." Many local law enforcement officials have the same perspective. How do we keep moving forward to get massage out of the vice pigeon-hole to being perceived instead as a respected profession?

• Will 20 states wake up to their inadvertently having ceded to NCBTMB the implicit power to revise educational requirements for individuals to practice massage in their states?

• How should we address a frustrating waste of resources and training which result from continued high attrition among massage practitioners? More than 30,000 therapists leave the profession each year - some due to temporary changes in life circumstances, more than 10,000 a year permanently. Did those leaving permanently truly make an ill-suited vocational choice? Or, more likely, did they underestimate the needs for marketing and other practice building efforts? Can anything be done about the discomfort so many otherwise well-educated and motivated massage therapists have about practice development activities?

• Given our highly mobile American society, how can we increase reciprocity to ease massage therapists' qualification to practice when they move to a new state?

• Is the massage therapist community ready to participate and to commit resources alongside other complementary health professions to improve public awareness and government support for the contributions these therapies can offer?

The articles that follow in this issue of Massage & Bodywork do not contain all the answers, or even all the viewpoints, to these questions. They do aim to provoke and spark a constructive dialogue. Your participation in that dialogue is welcomed.

Bob Benson is president of Associated Bodywork & Massage Professionals and an executive committee member of the Integrated Healthcare Policy Consortium.

Notes
1 George Kousaleos, then Chairman of NCBTMB, in an interview with Massage. Sept./Oct. 1992.

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