David Palmer

David Lauterstein

Jocelyn Olivier

Tiers of Joy?
The Efficacy of a Multi-level Designation

By Darren Buford

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 a 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 industry'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 industry get a piece of the referral and insurance reimbursement.

Among other outcomes, this avenue resulted in the creation of the now independent organization National Cetification 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 industry 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 an industry 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 weÕre 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 health care 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 health care 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 in-roads 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 backwards; 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 which 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 nor 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 industry, 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 industry. "It's not what we say, or call ourselves, it's the impact, the effect on the people we work with that is providing in-roads 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 regards 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 industry. 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 their willingness to work alongside state legislators, saying their 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 industry 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.

Footnotes
1 www.ncbtmb.com/Press_releases/10th_Anniversary.htm
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.
6 www.ncbtmb.com/Press_releases/new_credential.htm.

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