Organizations that support professional massage therapy:
A Study of Industry Professionalization
Luann D. Fortune
Charles Seashore – Faculty Assessor
School of Human and Organization Development
Fielding Graduate University
March 19, 2009
As a massage therapist for over fifteen years, as well as an instructor to those aspiring to the profession, I believe in the potential impact of massage as a practice and intervention. In recent years, I have furthermore witnessed a shift in the way that massage is practiced, purchased, and perceived by related service providers. Whether in response to a changing marketplace, or under the impetus of various stakeholders in and near the massage therapy field, the industry is growing and going mainstream. Parallel to that growth runs a trend to professionalize the profession, for myriad predictable reasons. However, this move to professionalism carries inherent, and possibly unforeseen, implications for the practitioner and ultimately for the consumer.
This paper describes this movement to professionalism in massage through the perspective of the environmental factors and stakeholders that are orchestrating and implementing it. Specifically, the paper focuses on associations that support massage therapy and how their visions and actions are directing industry change. In the spirit of hermeneutic inquiry, particular groups are analyzed with progressively deeper layers of consideration. The more intimate insights were collected through individual, private interviews with association directors and key administrators. Embedded in this presentation are repeated revisits to the published data and an ongoing search for substantiation from non self-referential sources. The discussion portion considers various perspectives for understanding the data and the professionalization movement through organizational theory and parallels in other industries. Finally, alternative outcomes are considered, with speculations on possible impacts.
Professionalization of Massage
Massage is gaining increasing prominence in North America as an intervention to promote wellness as well as rehabilitation. Massage was previously more accepted in the spas of Europe (Cherkin, 1998), the protocols of Chinese medicine (Carlson, 2006, p. 5), and the procedures of Ayurvedic medicine (Johari, 1996). Massage recently became more popular in the U.S. Frequently cited surveys (Eisenberg, et. al, 1993; Barnes, Bloom & Nahin, 2008) estimate that over a third of the U.S. population purchases alternative treatments for wellness, including massage therapy. Other estimates claim that 24 percent of adult Americans get a massage at least once a year (AMTA, 2007). Massage is now commonly employed to address a wide range of needs and symptoms, across populations that vary from the very aged to the very young (Field, 2001, p. 131). There is not just one channel for this impact, and in fact, there are many ways to practice this skill and art. There are estimated to be over 250 types and modalities of massage from which to chose (ABMP, 2008), and equally as many reasons for people to purchase the various types of treatments.
In the US, most professional massage is purchased by adults who self pay for the service (Field, 2001, p. 91) outside conventional health care channels (AMTA, 2006; Field, 2001, p. 91) at an average of $60 per session (AMTA, 2007). In 2004, massage therapy was projected to be a $6 to $11 billion a year industry (Barnes, Powell-Griner, McFann, Nahin, 2004). In 2008, estimates increased to $11 to 16 billion per year (ABMP, 2008). Some argue that the service might be recession proof (McGinn & Sterling, 2008) as increasingly stressed, debilitated, dysfunctional, and otherwise needy people seek out the service for the various remedies it offers (Kent, 2008, p.18).
Massage therapy as a profession is growing beyond the national average, at an estimated 20 percent per year (Bureau of Labor, 2007). Currently, there are an estimated 265,000 to 300,000 massage therapists and massage school students in the United States (AMTA, 2007). The number of state approved schools increased from 637 to 1,529 between 1998 and 2007 (ABMP, 2008).
With wider public acceptance and consumption of alternative wellness methods, (AMTA, 2006; Field, 2001, p. 91) massage delivery channels are changing. Surveys of one national association membership (ABMP, 2008) claim that the therapist’s private office is the most common venue in which to purchase massage. The percentage of massage therapists who work in spa settings is dropping, from 41.8 percent in 2003 to 28.9 percentage in 2007 (ABMP). Perhaps this shift to a more therapy-based setting is demonstrated in the increased presence of licensing. In 1980, nine states regulated massage (AMTA, 2009a). Today, 42 states and DC regulate the practice of massage therapy (Crownfield, et. al, 2008, p. 1; AMTA, 2009). With increased regulation comes a focus on tighter standards and other measures of professional conduct.
An in-depth investigation of organizations that support professional massage therapy offers insight into the development of the market and the profession. In the past ten years a formal movement has developed amongst industry stakeholders to “professionalize” (Kahn, 2002, p. 2) the business of massage. One strategy of the movement involves standardizing the cornerstones of regulation and examination, certification, research, and education. At the forefront of that movement are a handful of professional associations.
An important aspect of the movement involves expanding research and introducing “evidence based practice” (Kahn, 2002; Bondurant, 2008, p. 1) into the process of massage. There is a new focus to fund and develop research that provides evidence of efficacy for various massage indications, protocols, and conditions (Bondurant, p. 3). The studies are primarily situated in the context of empirical research, similar to that found in medical science (Kahn, 2002a, p. xv-xvi). Research topics vary from examining efficacy of specific techniques for particular structural rehabilitation, to protocols for supporting systemic disorders such as cancer or ADHD (Field, 2001, p. 134-136), to more generalized explanations as to why massage helps relieve stress (Field, 2001, p. 87-89). A related project is presently being launched to prescribe “body of knowledge” (MTBOK, 2009) standards for training and practice. Underlying the call for evidence is the suggestion that proof will not only validate the field of massage but also direct individual treatments, as practice protocols based on the evidence become the standard.
In most practices, I think the application and interpretation of massage therapy is highly individual, variable with the therapist as well as the client, and can be considered through many coexisting metaphors (Morgan, 1997). Medical science’s empirical research offers only one such metaphor. Are the demands for evidence-based practice coming from the market, the therapists, or some other force? In depth consideration of the market perspective is beyond the scope of this paper. The impact of the movement to professionalize massage is a likely topic for my own dissertation. But the role of the associations could prove to be key. This investigation focuses on who are the stakeholders driving this movement to professionalize, what is the place of evidence-based practice in their vision, and where do their marching papers come from.
Professional Massage Associations
This study is not an expose. It does not purport to reveal what the associations actually do with their constituency, but rather what the associations report that they do. Therefore, it assumes that vision and perception guide the evolution of the associations, and potentially of the industry. Working hermeneutically (Bentz & Shapiro, 1998, p. 40) based on published text and interviews, the following sections present in successive layers: first the material details and the vision of the association, and next the underlying arguments and philosophies that propel the foremost associations.
In selecting which associations are most influential, membership size was first considered. Also, longevity and scope of presence among therapists as well as consumers is considered. A balance of purposes, ranging from educational to regulatory, is embodied in the complement of associations discussed. Some of these organizations are relatively young but serve an important role or function, especially in how they interact with the changing industry climate.
This paper identifies several national associations that are influential in North America, particularly in the US. Almost all practicing massage therapists are directly impacted by at least one of these organizations, either through training, licensure, certification, or association membership that also provides professional insurance. There are several professional support groups, the larger two being the Associated Bodywork and Massage Professionals (ABMP), and the American Massage Therapy Association (AMTA), which includes various influential committees such as the Council of Schools. Two smaller groups, the International Massage Association (IMA), and the American Organization of Bodywork Therapies of Asia (AOBTA) are mentioned superficially, as they are more limited in their membership and scope of influence.
There is an independent research foundation dedicated to massage, the Massage Therapy Foundation (MTF). The specialty certifier of massage schools is the Commission on Massage Therapy Accreditation (COMTA). The national certifying group is the National Certification Board of Therapeutic Massage and Bodywork (NCBTMB), which was initially the sole examining organization. However, the Federation of State Therapeutic Massage Boards (FSTMB) has recently introduced its own proprietary exam and is replacing NCBTMB in that role.
Professional Support Association Profiles
Approximately 40 percent of practicing massage therapists subscribe to one of two professional associations (ABMP, 2009a), the ABMP or the AMTA. There is no prohibition against dual membership, though this is seldom done. The primary objective of membership, insurance coverage, is satisfied with a single subscription. Although insurance coverage is a concern for practitioners, I can find no malpractice legal cases filed against a massage therapist. Yet, the National Practitioner Databank, a tracking mechanism for complaints, lists six medical malpractice reports regarding massage therapists in the US from 1990 to 2004 (NPDB, 1992-2004, as cited in “Massage Therapy”, nd). Nonetheless, the threat of malpractice, both on behalf of consumers and as a precaution for therapists, is one motivator for professionalization tactics.
Associated Bodywork and Massage Professionals
The privately owned ABMP reports approximately 71,000 members (ABMP, 2009; England, 2007), the largest professional membership of the associations. ABMP was founded in 1987, and has steadily increased its domestic membership each year (ABMP). A foundational tenet of the organization, which continues today, is to accept a wide range of practitioners with “diverse practice choices” (ABMP, 2009a), most of who work at massage part-time (ABMP, 2009).
ABMP offers a range of membership options, according to varying educational and practice-related standards. Approximately 22 percent of their membership (Massage Today, 2005) subscribe to the highest professional category, Certified, although other options do not require continuing education or local licensing. Annual fees range from $199 to $229 per year (ABMP, 2009). Membership benefits vary with membership level, and include professional and liability insurance, subscription to ABMP publications, and marketing support. In the past two years, ABMP has also expanded its offerings of educational programs (Bondurant, 2007), including its Massage Schools Alliance geared to massage educators (ABMP). Although 31.6 percent of members have taken the National Certification exam and remain certified, as explained below, another 64.2 percent have never taken the exam (ABMP).
ABMP conducts regular membership surveys. In 2007, ABMP sent out 4,962 electronic invitations to its then 67,432 membership (ABMP, 2009). They received 976 responses, or 19.7 percent, which were used to construct the bi-annual membership profile data (ABMP, 2008). It is not clear from the published findings how respondents were selected, although “invitation” (ABMP, 2008) connotes less than random selection. Survey results represent 1.4 percent of their member population, and thus, the statistical significance and viability is not clear.
Based on this 2007 data, ABMP suggests a profile for their typical ABMP member. She works part-time in massage, supplements her income with another job for at least 25 hours per week, and is an independent practitioner motivated by “genuine desire to improve the well-being and healthfulness of their clients” (ABMP, 2009a). Some 83 percent of these therapists are women, the majority of whom are married, with a median age of 45 (ABMP). She has a college degree 56.5 percent of the time. She reports working in various settings, although primarily in her own private office (ABMP). She is less likely to work in a medical office now than in 2005, down from an incidence of 32.9 percent to 24.3 percent (AMBP). She uses a variety of techniques and modalities, primarily deep tissue massage some 33.1 percent of the time, but also Swedish, reflexology, and “energy” work (ABMP). Her client contact hours are dropping, averaging 14.4 per week, down from 15.4 in 2005 (ABMP). Most of her clients result from personal referrals, and she wishes that she had more of them (ABMP). The top five reasons listed for seeking massage were “stress management, relaxation, relief from acute pain, management of chronic pain, and rehabilitation from injury” (ABMP).
American Massage Therapy Association
The AMTA is a non-profit organization, and operates under a complex set of governance bylaws and chapter-supported volunteerism. It was founded in 1943 and claims approximately 56,000 members in the US and 27 other countries (ABMP, 2009; AMTA, 2009). Until several years ago, when it was overtaken by ABMP, it led in membership numbers. It offers similar benefits as the ABMP: professional and liability insurance, publications, and marketing support. Fees are similar; annual membership fees are approximately $255, varying slightly according to local chapter supplemental dues. However, professional membership is not offered in different levels: all members are required to meet a single set of criteria similar to ABMP’s strictest standards, including accredited training, certification, and licensing. AMTA members are required to hold valid licenses in states that regulate massage. Although not identical measurements, this demonstrates a difference in the ABMP membership where only 31.6 percent have taken the exam required for licensure. In contrast, AMTA’s vision is integral to promoting higher standards of practice.
AMTA last published their membership demographics in 2006 (AMTA, 2006), They annually publish an industry Fact Sheet based on data compilations from various sources (AMTA, 2009) that appear quite similar to the ABMP data (ABMP, 2008). The demographic profile suggested by the 2006 data is almost an exact parallel to the ABMP’s members: 85 percent are women, has a median age of 44, and works part-time as a massage therapist, spending a median of 12 hours per week massaging. The AMTA average prototype is slightly less likely, about 15 percent, to have a college degree than the ABMP member. As with the ABMP data, the method and sources are not clearly explained or transparent.
AMTA is also dedicated to industry development, as stated in its mission: “…to serve AMTA members while advancing the art, science and practice of massage therapy” (AMTA, 2009). AMTA authored its first code of ethics in 1960 (AMTA, 2009), changed its publication name in 1986 from Massage Journal to Massage Therapy Journal, and employs a large professional staff to provide regulatory advocacy and lobbying, encourage education principles, develop practice standards, create demand for massage in the public sector, and more recently, promote massage therapy research (AMTA, 2009). AMTA’s strategic plan includes proactive pursuit of licensure in every state, and promoting brand name consumer preference for AMTA members (AMTA, n.d.a).
In 1982, AMTA established a branch, the Council of Schools, to take a leadership role in support and development of massage training institutes. Member schools must adhere to curriculum standards and meet legal requirements in their jurisdiction. In 2008, there were about 300 member schools (AMTA, 2008), down from 350 in 2001 (Barrett, 2006). AMTA’s interest in elevating industry standards is manifest in the formation of separate entities to accredit, certify, and examine. Offshoots of the AMTA, which now operate as stand-along organizations, are discussed below.
International Massage Association
The IMA is a proprietary organization based near Washington, DC. Annual fees are $199, also offered for $149 without insurance coverage. Established in 1984 as an alternative to the large associations for providing affiliation and insurance, it claims that its membership numbers are in the tens of thousands (IMA, n.d.). But industry experts (Sweeney, 2008) estimate that IMA membership is a small fraction of the ABMP or AMTA. The actual counts remain proprietary information.
American Organization of Bodywork Therapies of Asia
Founded in 1989, the AOBTA has approximately 1,500 members (Spuller, 2008). Members practice some form of oriental bodywork, such as Japanese Shiatsu or Chinese Tuina. The practice paradigms foundational to AOBTA are different from western massage, and the role of the association is to protect their membership’s scope of practice and right to work. AOBTA has been effective in getting non-western techniques included in national exams. AOBTA provides insurance and marketing support to its membership.
Accreditation Agency: Commission on Massage Therapy Accreditation
In 1989, AMTA established the Commission on Massage Therapy Accreditation Approval (COMTAA) (Barrett, 2006) in order to “improve the quality of education through an accreditation process “ (Osendorf, 2006, p. 7). COMTAA eventually transitioned to independence as COMTA and is the only accrediting agency dedicated to massage therapy education (COMTA, 2008). In 2002, the US Department of Education granted COMTA federal authority to accredit massage programs including those offered in conjunction with associate degrees (OEDb, n.d.). COMTA employs a small staff, and is governed by a twelve member volunteer Board of Commissioners (COMTA, n.d.). Competency standards that were adopted in 2003 (Ostendorf, 2006, p. 1) direct the examiners; they are based on a grass roots orientation of “what do these people need to know and what do they need to be able to do to be successful” (Ostendorf, 2006, p. 6).
COMTA’s role is to ensure that schools meet industry “competency-based standards” (Hymel, 2003) for basic training. COMTA includes in its curriculum standards a research competency component (Hymel, 2005) in order to “call the profession to a potentially heightened level of credibility” (Hymel, 2003, p. 194). Of approximately 1,300 domestic schools or programs in massage (PubMed, 2009), COMTA has accredited only a small fraction, approximately 100. This proportion is in part due to the rapid increase in massage training programs in non-dedicated schools, such as those now part of college offerings.
National Certification Board of Therapeutic Massage and Bodywork
In 1992, AMTA created the NCBTMB in order to promote national standards and certification, specifically through licensing. Over 91,000 massage therapists are now certified through NCBTMB (NCBTMB, 2007). NCBTMB, a non-profit organization, separated from AMTA and established its own charter in 2007 (NCBTMB, 2007a). It is currently recognized by the National Commission of Certifying Agencies (NCCA) (Barrett, 2006; NCBTMB, 2007).
NCBTMB promotes higher standards of “ethical and professional practice through national certification” (NCBTMB, 2008). They advertise a pledge with four tenets: safe conduct, confidentiality, professionalism, and ethics and accountability (NCBTMB, 2008), and claim an important role in setting standards “to protect consumers, employers, and the profession” (NCBTMB, 2007). They promote this role as enabling increased national mobility for the professional massage therapist. They also provide a grievance process for investigating complaints.
In order to take NCBTMB’s exam, applicants must complete a minimum 500-hour accredited massage training program. After passing the initial exam, credentials must be renewed every four years. Criteria for certification renewal include an annual minimum of 200 hours of massage therapy contact (Bureau of Labor, 2007) and 48 hours of continuing education over a four year period (NCBTMB, 2007).
Until last year, NCBTMB’s examination was the standard requirement for licensure in most states. However, an examination recently introduced by the FSTMB is quickly being adopted as the preferred vehicle for licensure. In seeking to retain some segment of the business, NCBTMB is positioning itself as the certifying body. According to one local massage licensing board member (Casperson, 2009), NCBTMB’s future could include certifying in advanced techniques or modalities, but at the moment the situation presents a quandary. Since NCBTMB is currently the only certifying option, any massage therapists wishing to be certified must first take the NCBTMB exam. Yet many states are now asking for the new FSTMB exam in order to license.
Regulation: Federation of State Therapeutic Massage Boards
In 2005, a handful of state regulators initiated the formation of the FSTMB to support member massage therapy licensing bodies. Their intention was to establish compatible requirements and cooperative procedures between jurisdictions, and also share data, such as that related to disciplinary history (FSMTB, n.d.). Of the 43 states that regulate massage today, 39 and the District of Columbia and Puerto Rico are members.
Consistent with other regulated professions, states require that applicants have passed a recognized examination in order to be licensed as massage therapists. In 2008, FSTMB introduced its own examination of entry-level competence, the Massage & Bodywork Licensing Examination (MBLEx). It has already been adopted by 17 states. The MLBEx, is likely to become the national standard for the industry.
Research: Massage Therapy Foundation
In 1990, the AMTA established a separate research arm, the MTF that transitioned to a separate 501c3 non-profit corporation. Today, it has an annual operating budge of about $250K, four dedicated staff, and is governed by a volunteer board of 11 trustees. Despite fiduciary independence, MTF still shares its executive director with AMTA, being allotted about ten percent of the director’s time (Thompson, 2008).
MTF raises independent funds, and distributes grants to massage therapy dedicated research, education, and community outreach. The AMTA is still their largest contributor (Thompson, 2008). Since 1993, MTF has granted $245,000 for community service projects, and $441,000 in research grants (MTF, 2008). MTF recently introduced a program to teach massage educators to incorporate research literacy into their curriculum (AMTA, 2009c). In addition, MTF provides a massage therapy research database with over 5,000 entries (World Massage Forum, 2007), and last year launched a quarterly peer review journal, the International Journal of Therapeutic Massage & Bodywork (IJTMB), which is offered free from an online platform. IJTMB is only one of two scholarly journals to focus on massage and bodywork, the other being the Journal of Bodywork and Movement Therapies.
MTF funds projects based on an established research agenda that has evolved since 1999 (Cassidy, 1998/1999) and is further articulated in the Massage Research Agenda (Kahn, 2002). Fundable research is based in the empirical medical science paradigm, and focuses primarily on disease or dysfunction (Thompson, 2008). MTF plans a symposium in May of 2010 to update the agenda.
Spiraling deeper into the professional stakeholders
In keeping with the hermeneutic method employed for this study, a review of the published information identified threads for deeper inquiry. This resulted in a series of interviews with principals of key stakeholder organizations. Since AMTA is seminal to most of the entities, a pivotal interviewee was AMTA Executive Director Liz Lucas. Related threads of investigation lead to interviews with Diane Thompson, MTF President, Glenn Hymel, IJTMB Editor, John Gosse, Acting Director of COMTA, and Les Sweeney, Executive Director of ABMP. Interviews were tape recorded when possible, and are transcribed in Appendix 1. Gosse also provided additional COMTA reports documenting interviews conducted in 2006 with prior commissions and directors. These appear in citations in the text and the reference section. Finally, a locally assembled group of massage therapists shared their insights as to how they see their work. Notes from the discussion (2009) appear in Appendix 2.
AMTA’s Agenda: Four Cornerstones of Professionalism
Based on their mission and formational role in advancing a fellowship of support organizations, the AMTA is an orchestrator of the movement to professionalism (Lucas, 2006). A personal interview with Executive Director Liz Lucas (October, 2008) confirmed and elaborated this position. Lucas considers the domestic pool of currently practicing massage therapists to be roughly 260,000. AMTA represents about a quarter of the practitioners, but Lucas implies that her organization interprets to and promotes with the entire marketplace (Lucas, 2008).
According to Lucas, AMTA is not simply driving the movement but reacting to changes in the environment. The information age has fed maturation of the marketplace; demand for massage, which is mostly urban, increases as it is better appreciated and understood (Lucas, 2008). As demand proliferates, employment opportunities increase creating the potential for slipping standards as a byproduct of rapid growth. Subsequently, there is a “cry from regulators” (Lucas) for consistency in entry-level education. Lucas suggests a model for incorporating the key industry stakeholders into Four Cornerstones of Professionalism: licensure, certification, accreditation, and research.
Licensure
AMTA’s goal is for licensure in all states, an objective supported by 90 percent of AMTA members (Lucas, 2006). Forty-two states and DC are now regulated. However, in other jurisdictions right to work remains an issue for therapists concerned with practice restrictions. In some venues, regulated practice now allows protection for massage therapists to practice their trade legally where affiliated professions previously challenged their legality (Greene, 1997, p. 87). Those turf battles are now maturing within regulated systems, although levels of professional recognition through license requirements remain contested (Eisenberg, Cohen, et al., 2002, p. 965). AMTA is positioned to play a role in shaping how regulation is executed, and supports FSMTB as a partner in this function.
FOUR CORNERSTONES OF MASSAGE INDUSTRY PROFESSIONALISM
On the lobbying side, AMTA and its regulatory advocacy program and support staff continue to play a key role in attaining uniform and domestic licensure in every state. Although the FSMTB has an intrinsic interest in regulatory penetration, it is not a lobbying group. Instead, it fulfills a regulatory coordination role, exerting influence to impose consistence standards. It supports national mobility for practitioners, now more able to move from state to state and become licensed. One exam will lend consistency, and though “NCBTMB has temporarily filled a gap, we need to look at other regulated professions as models” (Lucas, 2008). FSTMB does not support the use of dual exams: “having a choice becomes a moot point because the MBLEx is clearly the only appropriate exam” (FSTMB, n.d.).
Although superficially this argument is practical, endorsement of a single exam by the examiner smacks of commercial or political self-interest. Also, the organic need of the proposed mobility is questionable based on the demographic data. Since the majority of massage therapists practice as a part-time pursuit, most are not jeopardizing livelihood in moving to another jurisdiction since for most therapists, another job is their major income source. This point does not diminish the value of professional mobility, but raises the question of whether the concern is actual or projected based on stakeholder’s visions.
Certification
As the FSTMB becomes the examiner of choice, the viability of the NCBTMB arises. Lucas’ cornerstone model endorses a distinction between licensure and certification. Licensure should be the minimum standard for competency (Lucas, 2008). Advanced credentials and continuing education are certifying issues. NCBTMB is currently filling that role, but Lucas points out that this function could also be assumed through the FSMTB. In fact, the introduction of the new FSMTB exam creates a paradox for newly examined therapists who want to establish certification. They would have to take another exam, the one offered by NCBTMB, in order to obtain renewal certification. This situation is the result of stress between stakeholders, and likely to spark further debate.
NCBTMB has a history of controversy in its management, operations, and dealings with fellow associations (Razzo, 2005; NCBTMB, 2007b; Bondurant, 2009). Besides having a reputation for mismanagement and internal chaos, its contentious relations with fellow associations were apparent to the public by 2005 (Razzo). NCBTMB initially opposed the formation of the independent Federation in 2005. Its reported unresponsiveness to FSMTB’s requested changes to NCBTMB’s examination prompted FSMTB to introduce its own exam, the MBLEx. This subsequently removed NCBTMB’s virtual monopoly on this market. Currently, both AMTA and ABMP have endorsed the MBLEx as the preferred and sole professional exam (Bondurant, 2009). Hawaii and New York continue to offer their own proprietary exams.
A pre-requisite for taking any of the state exams is completion of an accredited program in massage therapy. Recent trends in providing this adult education are changing these offerings with consequences that affect the key stakeholders (Lucas, 2008; Sweeney, 2008; Gosse, 2008).
Accreditation
Massage education that consistently conveys standards is a critical cornerstone. While schools and programs have increased, including those accredited by COMTA, AMTAs Council of Schools membership decreased approx 18 percent (AMTA, 2008; Barrett, 2006). This is attributed to two factors. First, there is a move towards corporate ownership of schools (Lucas, 2008), e.g., the ten-location chain owned by Cortiva (Schwartz, 2006, p. 2). “what you’re seeing…is this consolidation with these big companies such as Cortiva” (Freeman, 2006, p. 8). Thus, multiple locations now count as one school. Second, many massage training programs are now contained in colleges or broader based vocational schools (Gosse, 2008). In these cases, many of the programs are accredited by a generic agency and less foundationally intertwined with the AMTA and its agenda for uniform, higher standards.
A goal of the AMTA is to have all massage therapy schools and programs accredited by a “USDE recognized agency specializing in massage therapy education standards” (AMTA, n.d.). At present, COMTA is the only such agency. COMTA is still young in its own standardization process, having adopted detailed procedures only in the past five years. Establishing a clear and consistent internal process has itself been a struggle (Gosse, 2008; Thomas, 2006). It took years to move into being a “proper accreditation agency” (Gosse, 2008).
Despite the recent focus on evidence-based practice, COMTA’s intial standards were practitioner driven. “What accreditation should really be concerned with is what can the people do on the way out, not how many people they’ve been associated with who have Ph.D.’s or how many books there are” (Freeman, 2006, p.11). But in addition, standards lay the ground work for evidence-based practice: “coordinating the various curricular, instructional, organizational, and resource areas (is) essential to advancing massage therapy research competencies” (Hymel, 2003).
A former COMTA commissioner argues that standards are important for the employer: “…the massage industry was growing so rapidly without standards that it was important for us (COMTA) to make a stance to show employers that, hey, if your applicant has graduated from a COMTA accredited school, then you know they have X,Y, and Z competencies…. we constantly have employee retention issues, so you have to really be wise how you interview people and we need to look to the resources that are providing the right education to the therapists.” (Trieste, 2006, p. 2). This interest might not be meaningful to most massage therapists, who as noted above, are largely self-employed (AMTA, 2005; ABMP, 2009).
Greater uniformity is a likely by-product of massage school ownership consolidation. “… The extent to which more schools are owned by a smaller group of owners there’s going to be a tendency toward standardization within those institutions” (Freeman, 2006, p 8). Uniform standards also appeal to corporate reframing of massage product offerings. Larger concerns are likely to have the financial resources required to influence developments (Schwartz, 2006, p. 5).
Even if standardization is successful, there are downsides. “standardizing high quality gives you high quality. But it does lessen the opportunity to try new things…so to the extent that creativity and diversity was a value in developing the profession’s educational processes that could be lost” (p. 8). But accreditation standards help to improve credibility outside the massage community. Massage therapy is “far more acceptable in the healthcare profession even than it was 10 years ago. I know absolutely COMTA played a part in that” (Schwartz, 2006, p. 6).
The intertwined relationship between COMTA and AMTA continues to influence vision and practice e.g., “AMTA was HUGE in…ongoing financial support” (Ostendorf, 2006). Financial support is also linked to competitive considerations. One former commissioner claimed that COMTA’s evolution from AMTA committee to nationally recognized accrediting body was a result of AMTAs concern for competitive advantage over ABMP. “We were faced with a competitor that was an outgrowth of ABMP—I don’t know what that acronym stands for I’m sorry to say…so the commission made a decision to move forward.” (Ostendorf).
COMTA faces many challenges, including competition from the primary accrediting agencies Academy of Clinical Close Encounter Therapies (ACCET) and Accrediting Commission of Career Schools and Colleges of Technology (ACCSCT) (Trieste, 2006, p.2) . In addition, there are concerns related to evaluating the teaching of fundamentally kinesthetic skills in increasingly techno-centric learning environments. “It’s really going to be a challenge for COMTA to find the appropriate response to Distance Education….(but) just think of the ramifications if you don’t have control of the actual environment of learning” (Ostendorf, 2006, p. 7). That the COMTA commissioners are considering such complexities speaks to its inherent industry-based perspective. Accordingly, COMTA has potential to consider training elements from a more meaningful position than educators with little understanding of the massage process. However, the question remains as to whether COMTA can exert influence quickly enough to command critical mass of the massage program market. (Schwartz, 2006, p. 5).
Research
Through certification and accreditation, “nationally uniform credentialing are necessary to ensure…more generalizable clinical research” (Eisenberg, Cohen, et. al., 2002). As massage use increases, and is increasingly positioned as a complimentary and alternative medicine (CAM) practice, allied health care professionals are calling for “accessible high-quality evidence from clinical trials to show which CAM therapies work best and for which conditions” (Manheimer & Berman, 2004, p. 268). Research is a keystone to professionalization as an adjunct medical service, although it begs the question of the overall impact of that positioning.
The MTF’s entry into the research arena is only one of recent developments. Until about 15 years ago, scientific research of massage was rare. One early proponent of touch research, T. Field, gained national attention and funding due to her early work with premature infants (Field, 2001). Field went on to form a dedicated organization, the Touch Research Institute (TRI). Today, TRI has conducted over 100 studies on massage and touch, many focusing on infants (Field, 1999). The National Institutes of Health established their National Center for Complimentary and Alternative Medicine (NCCAM) in 1998 (NCCAM, 2009a). In 2008, NCCAM’s total appropriation was $121,577,000. Although only a fraction of that amount was allotted to massage dedicated studies, “the scientific evidence base for integrative medicine will rest on data from both clinical trials and basic research that elucidates biological mechanism” (Briggs & Turman, 2008).
One indication of how CAM is gaining wider acceptance is that a conventional medical professional suggested it in 33 percent of the cases (PubMed, 2009). But lack of empirical research makes some allied health care professionals nervous (Cherkin, et. al, 2002, p. 378). Research, specifically that situated in the medical science paradigm, “gives credibility to massage, because Western medicine wants research-based evidence. Massage is moving in that direction” (Schwartz, 2006, p. 7). Some scholars have acknowledged that the medical model is limited in its ability to capture the full range of benefits from massage, suggesting that a psychotherapy perspective of efficacy would be more meaningful (Moyer, Rounds & Hannum, 2004). However, critics from the more conventional perspective continue to label some modalities or techniques embedded with massage therapy as “quackery” (Barrett, 2006).
In addition to benefiting allied providers, massage research will help “all our stakeholders: insurance companies, referring care givers, pharmaceutical industry, researchers, the educators” (Thompson, 2006). Research will also force a standardization of language. Thompson asserts that currently the terms used differ amongst therapists, as well as between massage and other health care providers. Primarily, the consumer will benefit. Research will help better answer consumer questions: “should I be getting massage, how will it make me feel differently, how does this work with my medication, how does this work with my relationship with my health care provider” (Thompson). Ultimately, it will inform the therapist as to how to work more effectively, i.e. “how we can give the best care possible” (Thompson).
Thompson expresses another underlying agenda more relevant to individual practitioners: insurance reimbursement such as that provided in Washington State (2008). Research, as well as minimum professional standards, will support insurance reimbursement (Cohen, et al, 2005). “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” (Juhan, 2007, p.5). However, numerous debates now active in the health care industry dispute whether insurance reimbursement is an advantage, given the move to health care cost containment (Ziegenfus & Bentley, 2003, p. 232). “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 “ (Juhan, 2007, p. 1-2).
In summary, research is intended to bestow legitimacy to the profession, and solidify the right of massage therapists to practice their trade. This aspect intersects with scope of practice, and is further addressed in regulatory activities. But it might have unintended and possibly uncontrollable consequences. “The result of more uniform licensure and credentialing may be excessive standardization and a decrease in individualization of services. Thus, increased standardization of credentialing for CAM practitioners may alter CAM practice substantially.” (Eisenberg, 2002) In this professionalization process, the character of massage therapy could be permanently altered. “What we could lose is the very basis of open-ended inquiry and exploration that have made us “alternatives” in the first place” (Juhan, 2007, p. 7).
ABMP: the Counterweight
ABMP often appears as a contributor and supporter to research projects (Health News, 2007) and alliances to establish industry standards (MTBOK, 2009). A personal interview with ABMP Executive Director, L. Sweeney (2008) provided further insight on ABMP’s view of the market and movement, which contrasts with the views held by AMTA.
Sweeney is “not sure” about AMTA’s push for professionalization (Sweeney, 2008). Pursuit of massage therapy as adjunct health care has “not turned out to be as viable a path as some expected” (Sweeney). He predicts a “third party pay backlash” that will make insurance reimbursement a stumbling block for massage therapists already stressed financially. Sweeney further suggests that accreditation is not necessarily the “panacea”, as massage providers compete for increasingly limited disposable income. Instead, marketing is the key, which must be supported by consistent and reliable practices in massage education. Sweeney thinks that ABMP’s commitment to supply members improved marketing tools, supporting a broader array of massage opportunities, is one of their cornerstones.
From the metaphor of recognizing the political aspects of association interaction, Sweeney states “ABMP and AMTA have differences in constituencies, but still have more in common than not” (2008). From a practical standpoint, Sweeney suggests that the professional gestalt will be enhanced by medical community acceptance and that even spa-based massage could benefit from research. However, “not every school needs to embrace research and research literacy” (Sweeney, 2008). According to Sweeney, the massage therapist “wants to be defended against the skeptics” (Sweeney), and personal experience is the critical factor. But there is room for evidence informed awareness in the variety of massage settings: even spas appreciate research (Sweeney). Whether ABMP’s partnership in some efforts is motivated by collaboration or strategic self-defense, their presence will influence the ultimate direction of professionalization developments.
Massage therapist perspective
Survey data that claims to represent how massage therapists view their work appears self-referential. The AMTA and the ABMP quote each other’s proprietary data, and furthermore claim that other data sources, including the U.S. Department of Labor have questionable data (Sweeney, 2008). Both associations agree that there is not, to their knowledge, any studies that investigate how massage therapists experience their work, how they decide to work on any given client, or how their choices are influenced by their work setting (Lucas, 2008; Sweeney, 2008).
In February 2009, at a small assembly of local AMTA massage therapists, I asked for metaphors for how they viewed their work with clients (Appendix 2). They suggested a breadth of possibilities, from their role as a “provider of safe touch” to that of a “re-embodier”, or one who “put(s) body together, put(s) body with mind and spirit” (Appendix 2). One metaphoric role was that of “body mechanic” (Appendix 2). They were further asked, based on their familiarity with the current movement towards evidence-based practice, how their insights related. All agreed that the move to evidence-based practice only recognized the “body mechanic” function.
Medicalization of massage could adversely affect massage therapists’ freedom to integrate various techniques and modalities. “Legitimate practice of massage therapy…can help people relax, relieve aching muscles, and temporarily lift a person’s mood. However, many therapists make claims that go far beyond what massage can accomplish” (Barrett, 2006). Barrett (2006) goes on to name various techniques that are not medically based as “quackery”, and warns consumers and regulators that such practices should be abolished. “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” (Juhan, 2007, p. 7).
Discussion
The move to professionalize massage has both risen from changes in the environment and constructed its own environmental changes. Positions of the stakeholders can be examined from separate metaphorical perspectives of how organizations and entire industries operate. Although more conventional paradigms of organizational theory, based on the analogy of a machine (Morgan, 1997), are not considered here, one summarizing comment from a former COMTA commissioner invokes a mechanistic perspective.
“Massage is a sort of free-wheeling occupation. A lot of them did not like what they were seeing in the AMTA in terms of moving toward more standardization, that sort of thing. They thought it would be imposed on them against their will. And that’s happened in some ways” (Thomas, 2006, p. 4).
Organizational Theory: Organization As Organism
The metaphor of the organization as an organism relies on the organic nature of human groupings, especially in context of their environment (Morgan, 1997, p. 34). This perspective tends to focus on how interactive forces shape development. A set of constructs called Population Ecology (Morgan, 1997, p. 61-64) is grounded in Darwinian principles. Survival depends on an organization’s ability to control adequate resource supplies (Morgan, p. 61) as the population progresses through phases of variation, selection, retention, and modification. From this perspective, the organization is a discrete entity interacting with the environment (Morgan, p. 64) in an ongoing, open-ended process. The organization is highly opportunistic, and monitors environmental conditions.
This paradigm particularly reflects how the ABMP sees the evolving massage industry, as well as its own role (Sweeney, 2006). One aspect of this view, developmental openness, allows increased options for innovation (Morgan, 1997, p. 65-66). ABMP’s advanced marketing efforts seek to exploit such opportunities. But the perspective also allows for reciprocal change, since not just single entities but whole eco-systems evolve (Morgan, 1997, p. 64). Assumption of scarcity indicates that evolution will occur competitively. But if the assumption becomes that resources can be self-generating, entities can collaborate (Morgan, p. 65), e.g., as ABMP’s position on alliances for accreditation and research. ABMP acts as an “agent operating with others” (Morgan, p. 69) both in its interaction with and its construction of the massage industry. Neglected aspects of the population ecology, such as consumers who still need to be introduced to massage, can be cultivated. Thus, ABMP supports the national chain, Massage Envy, in spite of a lack of commitment to higher standards. Potentially, new patterns of inter-organizational and inter-environmental relations can shape future development in a proactive way. Organizational theorists argue “social and economic resources, especially in a knowledge economy, are inherently self-generating” (Morgan, p. 63-64). Through environmental interaction, innovators can create value niches that did not previously exist (Morgan, p. 63).
Another example illuminated by the organic viewpoint concerns the language of massage therapy. As a byproduct to create evidence for practice, standardized definitions of massage terms (Thompson, 2006) are evolving out of necessity. Terms that were individual and personalized are channeled into organizational missions and process. Various outlets, such as accreditation procedures, examination protocols, and research parameters, spread the usage and application of uniform definitions. Eventually, these become homogenous and universal.
Understanding evolution in the massage industry solely through organismic perspective has limitations. Organizations are not materialistic entities (Morgan, 1997, p. 64) but rather social constructions of their members (Morgan, p. 69). The potential for self-directed organizational transformation (Morgan, 1997, p. 63) is better appreciated through another metaphor, that of organizations as agents of flux and transformation (Morgan, 1997, p. 251-300).
Organizational Theory: Organization As Agents of Flux and Transformation
Some organizations encounter problems by failing to recognize how they interact with their environment (Morgan, 1997, p. 258). Characteristic of so-called “egocentric organizations” is a self-centered perspective dominated by a narrow domain (p. 260). Subsequently, they advance the agenda of the minority, mistaking it for a force of critical mass. In the massage industry, different perspectives can claim that the proponents of professionalization are either leading the pack or being chased by it.
An alternative is for organizations to see themselves as agents of change. Astute organizations appreciate that they do not exist separately from their environments (Morgan, 1997, p. 298). Instead, they continually influence the processes that construct the atmosphere and are furthermore inseparable from it. The AMTA, along with its offshoots, explicitly embraces this metaphor. Advancing along this line of thought, they can engage the change process mindfully through collective and individual self-reflection and behavior. “The way we see and manage change is ultimately a product of how we see and think about ourselves” (Morgan, p. 298).
Change agency carries inherent risks, especially if generative efforts operate in a closed system of relations. In such cases, entities misguidedly strive to clone their goals in various incarnations, as “their own organization and identity is the most important product” (Morgan, 197, p. 253). They do this by engaging in “circular patterns of interaction that are self-referential” (p. 253). Under these criteria, the AMTA cornerstone model is vulnerable to inbreeding.
Successful change management tends to allow for value consideration, reflection, synthesis, and process integration (Hatch, 2006, p. 319-320) at all levels of ownership and influence. Open-ended collection and transfer of information can strengthen mutual learning, and help avoid common pitfalls of growth. One potential pitfall, labeled the “competency trap” (Hatch, 2006, p. 320) is when organizations fail to recognize that directed changes result in little or no competitive advantage. In this application, the change refers to the reorientation of the industry towards the medical model. If successful, this could result in bifurcation of massage therapy into either medical practice or spa setting. Where the non-medical, non-spa massage would then reside is questionable. The benefits of such an outcome are unclear.
Organizational Theory: Chaos Theory
Examining the organizations and their principals surfaced multiple incidences of inconsistencies and mis-matches. For instance, revisiting the challenge of incongruent language that MTF’s Thompson raises (2008) it is critical to note that many in the healthcare community do not equate “therapeutic” with “medical” (Juhan, 2006, p. 5). Some constructs in massage practices are clearly outside of evidence-based practice. But in defense of some “quackery” techniques (Barrett, 2006), “energy medicine”, as it is known in other circles, is practiced by many (ABMP, 2009) and purports to be foundationally supported by theoretical advancements in physics. “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” (Juhan, p. 7). Some argue that forces towards professionalism, especially evidence-based practice, could be edging us toward a “trip switch that could have major unintended consequences” (Juhan, 2006, p. 5).
Invoking precepts from Chaos Theory (Morgan, 1997, p. 299), organizations and their environments are part of an “attractor pattern” (p. 265) that holds together until pushed to the edge of chaos, and then flip into new patterns that are always coherent. Allowing for the butterfly effect, the challenge is to introduce small, manageable changes that can morph into major impacts (Morgan, p. 299). In the process, insight can be gained by examining “paradoxes and tensions that are created whenever elements of a system try to push in a particular direction” (Morgan, p. 299).
Final Thoughts from Organizational Theory
Organizational theory suggests that best the chances of transforming along with the environment is through “open-ended” evolution (Morgan, 1997, p. 261). Empirical science makes many claims, but open-endedness is not one of them. In its goals, the AMTA states two points: “Massage therapy practice will be evidence-based” and, that “People recognize the power of touch to affect the mind/body/spirit continuum” (AMTA, n.d.). Yet, AMTA offers no tactic to reconcile the incongruity between pursuing evidence situated in empirical medical science and the mind/body/spirit continuum. MTF further recognizes the value of finding another model to apply to wellness questions (Thompson, 2006). For MTF’s upcoming conference to revise its research agenda, it plans to convene a group of massage therapy experts “put them in a room and close the door” to create strategies (Thompson, 2008). Applicable organization theory suggests that they will be most effective if they remember to take practice realities into the room with them.
Conclusions
“I don’t know. But it’s different, and whenever the world changes, you wonder how it’s going to be. Clearly the world is changing. (Freeman, 2006, p. 9)
Organizational theorists (Morgan, 1997, p. 63) claim that entities become extinct as a result of change that results in a less effective environmental fit. As the association stakeholders continue to respond to, as well as construct industry change, extinction could apply to any of the associations, the cornerstones, or even the craft of massage therapy as it was once practiced.
Massage therapy industry stakeholders should be mindful of the idea that change has a mind of its own. Like other developmental phenomenon, it is an “emergent phenomenon” (Morgan, 1997, p. 299) that eludes predetermination and evades control. Attempts to elevate professional standards will be effective as they match the needs and desires of the massage consumer and practitioners. But attempts to manipulate the culture in pursuit of vision that lacks consensus is ladened with unpredictability. Stakeholders can benefit from systematic reflection and planning directly related to industry developments. Unfortunately, “order becomes apparent only with hindsight” (Morgan, 1997, p. 300). In the case of evidence-based practice, this could be an idea that is generative. Or it could be a residue from a prior paradigm, based in empirical medical science and practice, whose potential application has already diminished.
Acknowledgements
The author wishes to acknowledge the cooperation, candidness, and assistance of Diane Thompson, Director of MTF, Glenn Hymel, Editior of Journal of Bodywork and Movement Therapies, Liz Lucas, Executive Director of the AMTA, John Gosse, Interim Director of COMTA, Les Sweeney, Director of the ABMP, and members of the D.C. Chapter of the AMTA for providing personal, individual interviews and sharing non-proprietary industry and association information.
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Embodied Living: by Luann Fortune, PhD, LMT 