Mindfulness for a VUCA Healthcare World

I am cautiously optimistic and also skeptical about the McMindfulness movement (Hyland, 2017; Purser & Loy, 2013).  Critics of proliferating mindfulness training in organizations point to challenges to the ethics (Wolverman, Schwartz, & Schoenberg, 2018) and over-capitalization of the movement (Hyland, 2017).  Plus, the tips provided by popular organizational gurus (e.g., Hougaard & Carter, 2018) sometimes strike me as simplistic, e.g. offer healthy food and drinks, control digital distractions, encourage boundary setting.  Perhaps each small change is meant to be a pebble in the pond towards shifting organizational culture.  Yet none of these tactics are novel, making me wonder why they have not worked up to this point to stem the volatile, uncertain, complex and ambiguous (VUCA) tide.

I teach a course in Reflective Leadership in Mindful Leadership in Healthcare at Saybrook University.  This course is experiential in that we are all doing the Mindful Leader app (Hougaard & Carter, 2018), practicing mindfulness meditation each day in addition to textbook readings and assessing original research.  As an educator and advocate of integrative healthcare, I am committed to integrative healthcare and envision myself as a “pebble in the pond”, creating large changes with small actions (Perlman, Horrigan, Goldblatt, Maizes, & Kligler, 2014). While our Mindful Leadership curriculum focuses on integrative healthcare and mind-body medicine, we have to do this in a VUCA world, where instability is the norm in fields and settings beyond healthcare.  Perlman et al.’s (2014) called for unique leadership to lead integrative healthcare systems, where mindfulness can serve as the connector between self-awareness, self-regulation, and the educated decision making needed to succeed.  They are not alone in suggesting that mindfulness is the answer, as evidenced by the volumes of readings, conferences, and apps readily available.

I admit to a slight mistrust of the panacea of mindful leadership tactics to reform VUCA environments. Turns out that my distrust is at least organic, a reflection of typical norms in the U.S.

Globalization of Trust

According to the Organisation for Economic Co-operation and Development (OECD, n.d.), the U.S. is lower than all but one of the European countries in the survey on trust and on a downward slide.  Generalized trust has declined steadily in the U.S. from 1972 to 2014.  More strikingly, trust in U.S government institutions declined from a rating near 80% trust in 1964 to <20% respondents expressing trust in 2015 (OECD, 2017). Based on this data, the U.S. is a global leader in the diminishment of trust in our institutions.

So, what is going on in the U.S.?  Deteriorating healthcare aside, was not the late 20th century a time of great solidarity, prosperity, and innovation lead by the U.S.?   I suspect a shadow side, the metaphor of the allegory of Plato’s Cave, and possible psychodynamics at play. “Human beings have a knack for getting trapped in webs of their own creation” (Morgan, 2006, p. 207).

Psychodynamics of Organizations and Mindfulness

We remember the Socratic teaching moment drawn in an ancient cave with three prisoners. They were shackled and tied so they could only see the outside world represented in shadows cast by firelight on a wall before them (Plato, VII, 514 a, 2 to 517 a, 7).  They never saw the world outside.  When one prisoner escaped and saw the other side of the cave wall, he was at first shocked but eventually realized that his former reality was false.  He returned to the cave and told his fellow prisoners.  But when he tried to set them free, they threatened to kill him.  Some philosophers argue this allegory shows the dangers of believing empirical evidence ensures knowledge, others claim it shows that people are afraid of higher truths, and others that we are psycho-dynamically predisposed to keeping ourselves trapped (Morgan, 2006).

Mindfulness consultants Hougaard and Carter (2018) admitted that organizational change is not easy and that influencing culture “goes deeper than articulating a set of values and posting them on the wall” (p. 163).  There are multiple practical and observable obstacles to implementing wide-spread change in any organization.  In addition, even in apparently well-functioning organizations, members experience normal psychological injuries, expected and normal hurts that people feel when collaborating with others to reach organizational goals in uncertain environments (Hirschhorn, 1999).

Hirschhorn is a global leader in training organizational consultants in psychodynamic structures (CFAR, n.d.).  I consulted Hirschhorn about his opinions on the current mindfulness movement and its potential to reach to the shadows of organizational prisons.  He positioned mindfulness as a useful tool, a “framework for knowing yourself and for being attuned to the tacit dimensions of organizational life around you.  A kind of tuning in to what is below the surface in yourself and in your setting” (L. Hirschhorn, personal communication, November 12, 2019).  Hirschhorn also pointed me to his blog site and a recent psychodynamic assessment of President Trump (Hirschhorn, 2019). In his post that examines psychological traits for larger organizational manifestations, one point involves the importance of considering how the role one occupies in an organization will describe potential contributions as well as the ability to successfully influence organizational change.  So, in affecting change, we need to remember our place.  In addition, Hirschhorn highlighted the importance of an effective leader marrying basic ideas to the entourage of organizational membership.  In a reframing of this consideration, I return to the challenge of shifting values and a recent personal experience (Donaldson-Feilder, Lewis, & Yarker, 2019).

Saga of an Orthopedic Surgeon: What Can and Cannot be Changed

I recently witnessed an illustration of the personal costs of unresponsive, unmindful leadership in a healthcare organization.  I share this story with the endorsement of the physician involved.  On Thanksgiving Day, I was visiting a hospitalized friend.  Overall, in her many weeks there, I observed the hospital operation was not entirely responsive, and I knew they had no competition in this community for the level of trauma care provided.  But I had several opportunities to observe the surgeon and his staff in this setting.  I was impressed by the level of patient-centered, compassionate care they provided my friend, and her level of trust in them.  On that morning, her surgeon visited her and delivered very unfortunate news.  This news was not about her condition, which improved steadily with his expert and abundant care. Rather, he came to tell her he had quit the hospital system, no longer able to work with inconsistent, unreliable, and inexpert support.

During the next minutes, he calmly explained to us the multiple issues with the organization, and the myriad issues tied to quality patient care that he repeatedly reported to administrators.  He explained he was hampered by so many incompetent systems and unresponsive management that he could not be the effective surgeon and healer he aspired to be.  He repeatedly said he was not burned out, at least not yet, but suffered on a moral level.  I suggested to him, “moral injury” and he concurred:  that was it.  Very soon, he would be returning to his place of residency, a nationally recognized leader in integrative healthcare, to pursue his surgery practice in a more compassionate, like-minded, supportive environment.  He hoped he could someday come back, when the climate of the organization had shifted to a more patient-centered and practitioner-supporting organization and system.

But he was not optimistic about changing the embedded mindset that was generating toxicity in this large, unmalleable organization.  This demonstrates the embeddedness of resistant thinking:  replacing a physician entails hundreds of thousands of dollars cost to an organization, plus loss of quality of care, safety, and patient satisfaction.  Yet this physician was aware of the larger risks of not leaving:  costs associated with burnout are escalating each day, physician suicide incidence is over three times the national average, and the associated costs are deep due to loss of skills, care quality, and sustainability (West, Dyrbye, & Shanafelt, 2018).

I propose that one possible strategy is decentralize, to diminish the size and power of the mega-organizations to smaller, collaborative entities.  Shifting the operations off the mothership onto smaller, innovative operations could be grounded in mindful-selfless-compassionate (MSC) principles, practices, and values.  By de-centralizing control, change makers can introduce the practices touted by Hougaard and Carter (2018) and cultivate MSC cultures.  Further, this could create a fertile ground for adopting integrative medicine models and components.

In an argument I never expected to make, for-profit healthcare does have advantages:  it could benefit from innovation if it leads to improved outcomes.  This approach should ultimately make for more satisfied customers, measurable outcomes, and provide competitive edge.  As I have seen in my association with IM4US (n.d.), we can also include the under-served.

According to Hirschhorn, there will always be psychodynamics to overcome:  These can be better overcome with awareness.  There will also be nay-sayers who prefer Plato’s Cave: leaving them behind requires decisive and hard actions.  At the heart of my proposed evacuate-and-rebuilt strategy are MSC-oriented leaders able to garner support and willing to take risks.  Even my sense of mistrust is optimistic.

Perlman et al. (2014) concluded in their argument for mindful, integrative leadership that each leader and each member should do what they can in the present moment and wait until the foundational support is stronger to do more.  In the meantime, we build up each other, which we can do with MSC practices. Donaldson-Feilder, Lewis, and Yarker (2019) found that mindfulness practices enhanced the leader’s well-being, resilience, leadership capabilities, and possibly their innovation.  The analysis failed to identify which type of mindfulness practice was most effective.  Also, the researchers found little evidence of benefits to the leaders’ direct reports.  Hence, the evidence indicates the leaders should first attend to self, in whatever mode best builds individual self-efficacy.  If we are each attending to self, we need to be less worried about bringing along the other:  they will bring along themselves and also become empowered in the process.

In conclusion, I argue for continuing our individual practices and sharing with members of our organizations and communities and the people we serve.  By cultivating our awareness and also our fortitude, we are preparing for the opportunity of each moment, as it unfolds.  MSC practices are endeavors that remind us we are solitary and concurrently interconnected.  We simultaneously operate at the systems level, joined by our underlying intention to transform healthcare based on shared values.  By taking an MSC approach, we have added tools to achieve sustainable transformation, and in the process, transform ourselves.

I welcome your comments here as we all continue with this important work.


CFAR. (n.d.). Dynamics of Consulting.  Retrieved from https://www.dynamicsofconsulting.net

Donaldson-Feilder, E., Lewis, R., & Yarker, J. (2019). What outcomes have mindfulness and meditation interventions for managers and leaders achieved? A systematic review. European Journal of Work and Organizational Psychology28(1), 11-29.

IM4US. (n.d.).  Mission and philosophy.  Retrieved from https://im4us.org/about/mission-philosophy/

Hirschhorn, L. (1999). The workplace within: Psychodynamics of organizational life (Vol. 8). Cambridge, MA: MIT Press.

Hirschhorn, L. (2019, July 22).  Trump’s style of executive functioning. Learning from experience: Larry Hirschhorn.  Retrieved from http://learningfromexperiencelarryhirschhorn.blogspot.com

Hougaard, R., & Carter, J. (2018). The mind of the leader: How to lead yourself, your people, and your organization for extraordinary results. Boston, MA: Harvard Business Review Press.

Hyland, T. (2017). McDonaldizing spirituality: Mindfulness, education, and consumerism. Journal of Transformative Education15(4), 334-356.

Morgan, G. (2006). Exploring Plato’s Cave: Organizations as psychic prisons. In Images of organzations (pp. 207-240). Thousand Oaks, CA:  Sage.

OECD. (2019) About. Retrieved from https://www.oecd.org/about/

OECD. (2017).  Guidelines on measuring trust. Paris: OECD Publishing. http://dx.doi.org/10.1787/9789264278219-en

Perlman, A., Horrigan, B., Goldblatt, E., Maizes, V., & Kligler, B. (2014). The pebble in the pond: How integrative leadership can bring about transformation. EXPLORE: The Journal of Science and Healing10(5), S1-S14.

Plato. Allegory of the cave.  Republic, VII, 514 a, 2 to 517 a, 7. (T. Sheehan, Trans.).  Retrieved from https://web.stanford.edu/class/ihum40/cave.pdf

Purser, R., & Loy, D. (2013). Beyond mcmindfulness. Huffington post1(7), 13.

West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: contributors, consequences and solutions. Journal of internal medicine, 283(6), 516-529.

Wolever, R. Q., Schwartz, E. R., & Schoenberg, P. L. (2018). Mindfulness in corporate America: Is the Trojan Horse ethical?  The Journal of Alternative and Complementary Medicine,  24(5), 403-406.






Leave a comment

Filed under Integrative Healthcare, Scholar-practitioner, Uncategorized

Self-Care & Mind-Body Medicine: Structure, Function, and a Thoughts of a Tattoo

Tattoo Self-care conversations are expanding as we seek strategies for advancing better wellness and transforming healthcare.  We live in increasingly challenging, divisive times and healthcare costs continue to escalate.  Drawing nurturing attention inward helps us connect daily with our humanity and corporeal presence.  It seems like almost anything can qualify as self-care.  My practice experience has taught me that each individual must find their own path to well-being.  My advocacy work has exposed me to the music of collective steps that can remodel entire systems.  Self-care energy could be animating a rhythm of hope for a better way of being human on this planet.

In theory, integrative medicine loves self-care.  This multi-disciplinary genre of healing has earned a place in our lives as well as at the Academy.  At my day job at Saybrook University, I get to teach and research a growing collection of practices that inspire and enhance self-care, from guided imagery to mindfulness.  Various techniques and therapies, captured under the umbrella of complementary and integrative healthcare, including mind-body medicine, are increasingly supported by evidence and availability.

Ever ready to share the good news of integrative medicine and self-care, I recently gave a TV interview where I was asked to summarize my views in 5 minutes or less.  Much to my surprise, I found myself stuck on the simple question, “what exactly is mind-body medicine?”.  Even though I teach and champion this subject every day, I failed to deliver a cogent message.  In order to enlighten and advocate, I needed to first define: What exactly is mind-body medicine?  (And what does a tattoo have to do with it?)


Faced with higher costs and reduced satisfaction, patients increasingly seek solutions through what was initially termed alternative medicine (Moss, 2003).  In 2015, NIH revised the lexicon and complementary-alternative medicine (CAM) became complementary and integrative health reflecting its improved acceptance into conventional healthcare systems (NCCIH, 2018).  Beginning in the 1990s and continuing to today, surveys reported use of complementary therapies and practices in majority of populations and in increasing numbers (Eisenberg et al., 1993; Eisenberg et al., 2016).  One assortment of complementary practices is labeled mind-body medicine.

Reflecting a sort of medical science colonialism, mind-body medicine is defined by its position in the prevailing healthcare delivery system, situated offsides in the realm of complementary therapies and practices.  According to NIH, mind-body interventions remain “a large and diverse group of procedures or techniques” that are administered or taught by qualified practitioners (NIH, 2018).  By logical extension, the individual can then continue to practice what they learn independently, thus perpetuating prevalence (McGrady & Moss, 2018).  But the debate over what constitutes a mind-body therapy and where it sits in healthcare’s hierarchy remains under-developed.


Even in the imprecise language defining complementary therapies and practices, mind-body medicine definitions are vague.  Mind-body services and procedures are described by what they are not:  they are not typically found in primary care physicians’ medicine bag.  Researchers and clinicians, striving for a standard taxonomy, lumped together as mind-body a wide variety of interventions not otherwise connected in foundational tenets or practice conventions.  Initially, these included psychotherapy, hypnosis, biofeedback, dance and movement therapies, massage and body work, mediation and prayer, biofield therapies, and homeopathic remedies (Lake, 2003; NIH, 2018).  It seems like almost anything could qualify as mind-body medicine.

Gradually, some of these became elevated to sub-disciplines, such as psychotherapy, now a mostly reimbursable mental health treatment.  This raises the issue of legitimacy through economic valuation or demonstrated return-on-investment.  I will save this consideration for another discussion.

Mind-body medicine remedies share a common function: they initiate a change in one realm to affect a positive change in equilibrium of the whole.  Thus, our mental states can affect our physiology and susceptibility to illness.  Mind-body therapies and practices encompass a full spectrum of activities and all promote healing and well-being through the mechanisms of the psycho-neuro-immunological system (PNI) (Litrell, 2008).  Initially understood as how the mind influenced biological functions, the PNI is now seen as a complex, bi-directional system where mind and body physiology mutually influence the whole (Yan, 2016).

Changes attributed to mind-body interactions can be viewed from every crevice of physiology, behavior, and attitude.  Research now well establishes that environmentally-based perceptions are linked to illness as well as well-being.  For instance, stress impacts quality of life and is also a primary factor in cardiac conditions, the foremost global disease (Kivimäki & Steptoe, 2018).  Further, bodily generated effects influence the mind, e.g. research on the gut-brain axis links digestive microbes to mental states such as depression (Rieder, Wisniewski, Alderman, & Campbell, 2017).  Evidence abounds demonstrating positive effects of mind-body approaches (Russo & Fortune, 2016), including mitigation of pain and addiction (Hart, 2016).

Yet aside from how mind-body interventions function in healing, and plentiful examples supported by evidence, we lack a concise definition of what exactly is mind-body medicine.

Thoughts on a Tattoo

I asked a colleague who practices as a primary care physician how he defines mind-body medicine.  He referenced the PNI interactions and provided some anecdotes on related illness triggers he has witnessed.  Pressed to define mind-body medicine based on mutual interconnectivity of states and systems, we agreed that mind-body practices can refer to just about anything that one undertakes on behalf of improving their well-being.  For instance, I suggested that reading a good novel could trigger a positive PNI reaction.  He agreed and shared his own unexpected story.

By accident, he discovered that receiving a tattoo initiated for him a state of deep relaxation, with a subsequent ripple effect of improved well-being.  Recent studies have linked the practice of tattooing with non-suicidal self-injury (NSSI) behavior (Solís-Bravo et al., 2019).   Findings indicate that NSSI activities relieve tension and induce positive feelings. He was aware of research linking tattoo-ing with risk of self-injury and assured me that he did not present with such indications.  However, he was equally certain that the process of receiving a tattoo induced a deeply healing state on a physical and possibly a spiritual level:  Tattoo Medicine.

Theoretically, the experience of tattoo medicine could be a mind-body intervention.  In the anecdote provided, it sits in the structure of non-conventional approaches.  Functionally, it appears to have invoked the relaxation response and triggered PNI reactions.  In addition, the exact symbol used in the tattoo could have influenced the experience if it conveyed emotional or spiritual meaning.  Clearly, more research is indicated about the prevalence of this phenomenon and its place in the collection of mind-body medicine practices.


 When considering the possibility that tattoo practice is a mind-body intervention, perhaps defining mind-body medicine is ultimately all about intentions.  Alternatively, the mismatched components and practices now termed “mind-body” might simply be in a taxonomy holding-space, awaiting more informed and sophisticated knowledge systems to define, examine, and apply more precise terms.  If practices as apparently unconnected as tattoos and meditation can be grouped together for the greater good, what indeed is in a name.  Certainly, healthcare and well-being can use an incentive to empower uncommitted individuals to step into their own self-care path.

Based on popularity and the potential to infuse self-care with creative options, the practice and research of mind-body medicine is timely.  Proponents need to be articulate and clear about applications and relevance, even if that includes acknowledging that the definitions are still under construction.  Under any name, better tools for health and wellness are needed now.

So, scholars and practitioners can roll up our sleeves and get to work on this.  In the meantime, consider a recent statement from the World Health Organization calling for quality self-care: adopting evidence-based practices that the individual undertakes with or without the support of a healthcare professional.  Consider also how NIH recently defined mind-body medicine as large collection of procedures and techniques that are administered or taught by qualified practitioners to affect healing (NIH, 2018).   Self-care and mind-body medicine seem like a perfect match, even minus the tattoo.


Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., & Delbanco, T. L. (1993). Unconventional medicine in the United States: Prevalence, costs, and patterns of use. New England Journal of Medicine328(4), 246-252.

Eisenberg, D. M., Kaptchuk, T., Post, D. E., Hrbek, A. L., O’Connor, B. B., Osypiuk, K., … & Levy, D. B. (2016). Establishing an integrative medicine program within an academic health center: Essential considerations. Academic Medicine: Journal of the Association of American Medical Colleges91(9), 1223-1230.

Hart, J. (2016). Chronic pain, addiction and complementary therapies. Alternative and Complementary Therapies, 22(3), 117-119. https://doi.org/10.1089/act.2016.29058.jha

Kivimäki, M., & Steptoe, A. (2018). Effects of stress on the development and progression of cardiovascular disease. Nature Reviews Cardiology15(4), 215.

Littrell, J. (2008). The mind-body connection: not just a theory anymore. Social Work in Health Care46(4), 17-37.

Lake, J. (2003). Complementary, alternative, and integrative medicine. In D. Moss, A. McGrady, T. Davies, & I. Wickramasekera (Eds.), Handbook of mind-body medicine for primary care, (pp. 57-68). Thousand Oaks, CA: Sage.

McGrady, A., & Moss, D. (2018). Integrative pathways: Navigating chronic illness with a mind-body-spirit approach. Cham, SZ: Springer.

Moss, D. (2003).  Mind-body medicine, evidence-based medicine, clinical psychophysiology, and integrative medicine.  In D. Moss, A. McGrady, T. Davies, & I. Wickramasekera (Eds.), Handbook of mind-body medicine for primary care, (pp. 3-18). Thousand Oaks, CA: Sage.

National Center for Complementary and Integrative Health (NCCIH). (2018, July).  Complementary, alternative, or integrative health: What’s in a name? Retrieved from https://nccih.nih.gov/health/integrative-health

Rieder, R., Wisniewski, P. J., Alderman, B. L., & Campbell, S. C. (2017). Microbes and mental health: a review. Brain, behavior, and immunity66, 9-17.

Russo, R., & Fortune, L. D. (2016). Six evidence-based integrative health practices to manage eight common chronic conditions and promote self-care: A review with findings inspired by a workplace wellness case study. SM J Community Med2(2), 1018.

Solís-Bravo, M. A., Flores-Rodríguez, Y., Tapia-Guillen, L. G., Gatica-Hernández, A., Guzmán-Reséndiz, M., Salinas-Torres, L. A., … & Albores-Gallo, L. (2019). Are tattoos an indicator of severity of non-suicidal self-injury behavior in adolescents?. Psychiatry investigation16(7), 504.

World Health Organization (WHO) (2019, April 2).  Self-care can be an effective part of national health systems. Retrieved from https://www.who.int/reproductivehealth/self-care-national-health-systems/en/

Yan, Q. (2016). The translation of psychoneuroimmunology into mind–body medicine. In Psychoneuroimmunology:  Systems biology approaches to mind-body medicine (pp. 121-129). Cham, SZ: Springer.

Leave a comment

Filed under Integrative Healthcare, Self-care

Self-Care: Pursuing the Ultimate Path to Optimal Well-Being

September 8, 2019

The past months I have been engaged in a lot of conversations about self-care.  I sense a self-care zeitgeist arising in communities and healthcare settings.  A spirit is gaining momentum to educate and empower individuals, strengthen communities, and also stem the tide of escalating healthcare costs.  More so, from the humanistic perspective, self-care offers each individual a path to improve their life-quality and become the best they can be.

Self-care topics beckon researchers to reframe medical science and healthcare studies. I am inspired by excellent work done by my students and colleagues along with a wider proliferation of wellness scholarship.  Translating evidence to practice demands inter-professional collaboration and interdisciplinary worldviews, appropriate to an increasing number of scholar-practitioners.  My own self-care workshops and presentations have received enthusiastic responses from healthcare professionals as well as people simply wanting more from everyday living. I see this as a further shift, moving healthcare consciousness from providing cures to promoting optimal well-being.

There is no shortage of information.  One can hardly log onto the internet without encountering news and products to improve wellness.  Myriad educational and commercial offerings flooding inboxes can lead to information overload.  Now is a good time to reflect on how the self-care movement is authentic and meaningful both personally and professionally.

Why Self-Care

Self-care is the collection of actions and attitudes intentionally taken to promote and maintain health, prevent disease, and cope with illness and disability when it occurs.  It functions at several levels: for each individual, as family, and within community.   Self-care practices can be undertaking with or without the support of a healthcare professional.  As well, I see opportunities for healthcare settings to engage in quality education.

To borrow from the World Health Organization (2019), “Just as high quality healthcare is important, high quality self-care is too.”  Quality self-care is particularly important when healthcare access is limited and, in some cases, not available.  Self-care can also be a preferred option in some situations, allowing autonomy and agency, particularly for vulnerable populations.  Self-care is equally important for healthcare providers who are experiencing burnout and lack of well-being at unprecedented rates (Kuhn & Flanagan, 2017).

Key ingredient:  An Appropriate Framework

As a practical matter, adopting a self-care model or framework is key (WHO, 2019).  Plentiful sources are ripe with self-help ideas, possibilities, and solutions, from community programs to self-help articles, from workplace wellness to wellness tourism.  The self-care explorer can easily become inundated by the latest research or practice recommendations.  From a cognitive as well as an idiosyncratic level, it makes sense to first adopt a framework that considers readiness to change, provides integration of various practices, and is rewarding (Prochaska, Redding, & Evers, 2015).  A framework that matches with individual beliefs, preferences, and understanding provides a skeletal structure to support exploring, adopting, and developing practices.

A model is a framework, based on theories and principles, that provides structure.  It allows sense-making, in terms of which practices to adopt and when.  There are various scholarly-based, thoughtful models available.  The best self-care models reach beyond monitoring exercise frequency and whole food eating. Individualization can allow for flexibility according to each individual’s biochemistry, life-style, and preferences.

Here are two models that I find helpful for practice translation as well as suggesting avenues for further research.

The 7 Sources of Health (7SOH)(SoHL7x. com) is an original framework to teach and develop self-care skills and support community health systems.  Drawing from seven sources (Life Purpose, Body, Mind, Emotions, Creativity, Community, and Environment), the model’s education component offers evidence-based practices that individuals can adopt based on their needs and preferences (Russo, & Fortune, 2016).

The Pathwaysmodel is a behavioral medicine approach that directs individuals to improve self-care through three levels of engagement: self-care and skills acquisition, use of community resources, and with professionally administered treatments.  This model is particularly compatible with complementary-integrative practices and mind-body skills, such as mindfulness, guided imagery, self-hypnosis, and biofeedback (e.g., heart rate variability training) (McGrady & Moss, 2018).

Call for Action

In addition to supporting individual self-actualization, quality self-care is a sustainability issue.  Self-care is a need for those who live in communities, who fuel organizations and businesses, and also for the professionals who address healthcare needs.  While the path to better well-being is individual, there is a broader opportunity for collaboration.  Consider becoming a self-care advocate:  because self-care adopted on a community systems level has implications for shifting the future of healthcare.


Kuhn, C. M., & Flanagan, E. M. (2017). Self-care as a professional imperative: physician burnout, depression, and suicide. Canadian Journal of Anesthesia/Journal canadien d’anesthésie64(2), 158-168.

McGrady, A., & Moss, D. (2018). Integrative pathways: Navigating chronic illness with a mind-body-spirit approach. Cham, SZ: Springer.

Moss, D. (2019, August 30). Self care in palliative care — Pathways model.  Retrieved from https://www.youtube.com/watch?v=MrYpTUk61_A&list=PLUakTEuPjbFDg-IbovVkI_dRwSCFCSZ3s&index=13&t=0s

Prochaska, J. O., Redding, C. A., & Evers, K. E. (2015). The transtheoretical model and stages of change. Health Behavior: Theory, Research, and Practice, 125-148. Retrieved from https://www.researchgate.net/profile/Daniel_Montano2/publication/233894824_Theory_of_reasoned_action_theory_of_planned_behavior_and_the_integrated_behavior_model/links/0a85e53b67d742bc29000000.pdf#page=135

Russo, R., & Fortune, L. D. (2016). Six evidence-based integrative health practices to manage eight common chronic conditions and promote self-care: A review with findings inspired by a workplace wellness case study. SM J Community Med2(2), 1018.

World Health Organization (WHO) (2019, April 2). Self-care can be an effective part of national health systems.  Retrieved from https://www.who.int/reproductivehealth/self-care-national-health-systems/en/


Leave a comment

Filed under Integrative Healthcare, Self-care, Uncategorized

Five Dissertation Tips from Game of Thrones

I am a latecomer to explore elements of popular culture.  So not surprisingly, I took on viewing the Game of Thrones in its entirety only a few weeks ago, weeks after the final episode aired.  The national conversations had mostly died off when I called up Season 1 and started at the beginning.  Initially enticed by the filming and acting, I also could converse with many who openly shared with me the plot twists and even the surprise endings far in advance.  No matter I knew the endings:  I was hooked on the quality of the productions and soon made my way through all 73 hours of fantasy, relationships, power brokering, military engagements, and heart break.

I know from social media that I was not alone in falling down this tunnel after the proverbial train had left the station.  Why so many others binged along with me is another developmental question.  In the end, I was not compelled to find deeper meanings in the plot line finishes, even where I was disappointed.  But I was haunted by naming meanings to the Game of Thrones storytelling experience and process.  Like any other carpenter who sees the need for a hammer and nail in every situation, I found lessons for my academic work in the unfolding and ending of Game of Thrones. Hence, I see lessons for my dissertation students as they forage toward their final chapter and the blessed typing of the word REFERENCES.

My Five Dissertation Tips from Game of Thrones

  1.  Avoid rush and compress at the end. If you think you can finish the last chapter off in a weekend, remember how it felt to have 10 episodes cramped into seven in the stage that was supposed to explain and make meaning of it all.  When writing and delivering your Discussion Chapter, there is no substitute for space, time, and well chosen words.
  2.  Remember your context. Do not ignore important information and questions you raised in your introductory chapters (chapters 1 and 2). Like abandoning the direwolves or the people of Meereen without explanation, it is very unsatisfying.  Likewise, you cannot discount or kill off a point or perspective you brought into the story earlier only to have it show up and save the day in the end.  It is like the Dothraki storming Kings Landing after they were all killed off earlier at Winterfell.
  3.  Hold sight of your question. You started this enormous quest with a question and a purpose. If you argue deeply for some idea and create many platitudes to elevate it, you should not kill it off without fighting just as hard to reframe it or clearly showing you had no alternative. It sinks your credibility even if you allow the fallen hypothesis to be flown off in the talons of a dragon.
  4.  Select your final comrades strategically. Choose carefully from the experts and theories that have come before as you assemble who will support you at the end. These stars should be your best and brightest, not simply the ones who had not been killed off or broken contract.  They will determine whether you even get a chance at a sequel.
  5.  No proselytizing.Above all, do not justify your ending by emotional pandering in the final statements.  You must find a better conclusion than that it was all about storytelling for the sake of the stories.

Leave a comment

Filed under Uncategorized

Contemplative Social Research

Luann’s Chapter, Retracing the Labyrinth describes her application of actual labyrinth walking to support indepth analysis in phenomenological research.  Newly released, this edited scholarly work includes chapters on infusing research and scholarship with embodied, including Luann Fortune’s chapter, 

 Bentz, V. M. & Giorgino, V. (2016)  Contemplative social research. Santa Barbara, CA: Fielding Press.


To view an interview with some of the authors, see:

Leave a comment

Filed under Uncategorized

Directed Body Scan

Directed Body Scan © Luann D. Fortune, January 5, 2009



Shift or adjust your body so you are comfortable and supported. Take a deep breath in. As you exhale, allow your eyes to close (Pause.) Take several more deep breaths. Allow yourself to put away thoughts and distractions from daily life, and give yourself permission to focus on yourself in this moment.

Notice your breath as you draw air from outside your body to inside your lungs. Notice your exhalation sends air from inside you to the space outside you. Continue to breathe, focusing on the in-flow and out-flow of air. Notice that your breath connects the external world to your internal self. Notice how this feels.

As you exhale, shift your focus to your internal physical body. Follow your breath as it enters your lungs, filling your chest, expanding your abdomen. (Pause). Notice your sensations inside your torso.  Expand your awareness to your whole body (Pause).  Notice where your attention next moves. Notice any feelings of pressure, movement, pain, temperature, or other sensations that you experience. Note any words that describe your internal experience in this area of your body.

Allow your attention to move through your body from the inside. Notice which body parts you can feel easily. Notice which body parts express little or no sensation. Continue moving your focus through the inside of your body. Note any words that describe your internal experience as you allow your attention to flow through your body.

Slowly, bring your attention back to your chest. Notice any sensations in this area. Now, shift your focus back to your breath. Inhale slowly. As you exhale, notice any feelings of pressure, movement, pain, temperature, or other sensations. Take several more slow, deep breaths, paying attention to your inhalations and exhalations (pause). Notice your exhalation sends air from inside you to the space outside you.

Gradually, bring your attention to the external world, the space outside your body. When you are ready, open your eyes.

Leave a comment

Filed under Uncategorized

Managing the Pain Above the Neck: Self-help for headache and migraine sufferers

Managing the Pain Above the Neck:  Self-help for headache and migraine sufferers

Offered at Circle Yoga, Sept 23, 2012-2 hr workshop

According to some estimates, migraine occurs in about 15% of the general population.  The incidence of non-migraine headaches is much higher.  Associated pain is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option.

This experiential workshop introduces a collection of self-help tools and techniques for the headache and migraine sufferer.  As with other health related concerns, headache sufferers are increasingly turning to complementary and alternative medicine practices to combat the pain and disability of migraines, tension headaches, and related symptoms.  Incorporating recent scientific evidence, this workshop offers hands-on techniques and tools that can help mitigate, reverse, and prevent the unpleasant symptoms from head pain.

I am delighted to be joined in offering this workshop with my colleagues in body-mind instruction and practice:

Joanne Checchi, LMT:  Joanne has been practicing and teaching massage in DC for over 20 years, and is in private practice in Cleveland Park.  One of her specialties is the proper use of body mechanics.

Luann Fortune, LMT, MA, PhD:  Luann holds a PhD in Human Development, and is part-time faculty at the graduate College of Mind-Body Medicine for Saybrook University.  She has been practicing and teaching massage in DC for over 20 years, and is in private practice in Chevy Chase, DC.   Her massage work incorporates western techniques, including NMT, deep connective tissue, and passive/active stretching, into various non-structural approaches, such as aromatherapy and energy modalities.

 Annie Mahon, MA, LMT: Annie is the founder and director of Circle Yoga Cooperative bringing mindfulness yoga to people of all ages.  Annie studies, practices, and teaches yoga in a mixed Anusara-mindfulness style, and teaches mindfulness in the tradition of her primary teacher Thich Nhat Hanh. Annie has a strong interest in using mindfulness, yoga, NVC, and touch to help support reduce suffering in herself and others.

This workshop is next scheduled for September 23 from 1 to 3pm at Circle Yoga in Washington, D.C.  To sign up, contact Circle Yoga at 202 686-1104.

Leave a comment

Filed under Uncategorized

Embodied medical care

My dear late friend Alan said pay “attention to the coincidences.”

I recently had surgery for a structural problem that was not responding to less invasive approaches.   This event and the supporting moments could make for a great protocol on what to expect, how to support diagnosis and treatment, and how to heal  but today the more interesting frontier for me is the critical role that my surgeons somatic awareness played in the success of this venture.  This broader phenomenon— awareness,communication, and empathetic somatic resonance in the surgeon with his patient—and more vitally his team—is an important arena for mind-body exploration and education.   I think this would make for an excellent phenomenology project.

Leave a comment

Filed under Uncategorized

Professionalizing Massage

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.


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.









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.


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).


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).



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).


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.



“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.




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.

American Bodywork and Massage Practitioners (ABMP) (2008). Massage therapy fast facts. Accessed March 2, 2009 from the ABMP website. http://www.massagetherapy.com/_content/images/Media/Factsheet1.pdf.

American Bodywork and Massage Practitioners (ABMP) (2009). About Associated Bodywork and Massage Professionals. Accessed March 9, 2009 from the ABMP websitehttp://www.abmp.com/about/index.php

American Bodywork and Massage Practitioners (ABMP) (2009a). Professional membership patterns. Accessed March 9, 2009 from the ABMP http://www.massagetherapy.com/media/metricscharacteristics.php

American Massage Therapy Association (AMTA) (n.d.). Envisioned Future – What the profession will look like in 10 – 30 years. Accessed on the AMTA website March 14, 2009 http://www.amtamassage.org/about/envisionedfuture.html

American Massage Therapy Association (AMTA) (n.d.a). AMTAs future directions. Accessed on the AMTA website March 14, 2009 http://www.amtamassage.org/about/futuredirections.html

American Massage Therapy Association (AMTA) (2006). Demographic study of AMTA members. Downloaded March 14, 2009 from http://www.amtamassage.org/news/03memberdemographics.html

American Massage Therapy Association (AMTA) (2007). Massage therapy industry fact sheet. (Electronic version). Accessed March 2, 2009 from http://www.amtamassage.org/news/MTindustryfacesheet.html

American Massage Therapy Association (AMTA) (2009). Michigan Governor signs massage therapy licensing act. Accessed March 2, 2009 from the AMTA website at http://www.amtamassage.org/news/011209Michigan.html.

American Massage Therapy Association (AMTA) (2009a). Advancing the Massage Therapy Profession for 60 Years. From The American Massage Therapy Association website. Accessed March 4, 2009 http://www.amtamassage.org/about/history.html.

American Massage Therapy Association (AMTA) (2009b). 2009 massage therapy industry fact sheet. Downloaded March 14, 2009 from http://www.amtamassage.org/news/03memberdemographics.html

American Massage Therapy Association (AMTA) (2009c). Foundation News: Teaching research literacy: A teacher’s in-service event. Hands on (newsletter), Jan/Feb 2009. Evanston, IL: AMTA.

Barnes, P., Powell-Griner, E., McFann, K., & Nahin, R. (2004). Complementary and alternative medicine use among adults: National health expenditure projections 2004-2014.  CDC Advance Data Report #343. Atlanta: Centers for Medicare & Medicaid Services. May 27, 2004.

Barnes, P., Bloom, B., Nahin, R. L. (2008). Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. Hyattsville, MD: U. S. Department of Health and Human Services. Accessed online http://nccam.nih.gov/news/2008/nhsr12.pdf.

Barrett, S. (2006). Massage Therapy: Riddled with Quackery. Quackwatch. Retrieved March 2, 2009 from http://www.quackwatch.com/01QuackeryRelatedTopics/massage.html.

Bentz, V. M. & Shapiro, J. J. (1998). Mindful inquiry in social research.  Thousand Oaks: SAGE.

Bondurant, C. (2007). ABMP Launches Education Initiative. Massage Today, 7(10). Accessed online March 9, 2009 http://www.massagetoday.com/mpacms/mt/article.php?id=13689.

Bondurant, C. (2008). Why massage therapy guidelines? Massage Today. 8(10), 1-3, 11.

Briggs, J. P. & Turman, R. J. (2008). Fiscal Year 2009 Budget Request. Witness appearing before the House Subcommittee on Labor-HHS-Education Appropriations (March 5.) Bethesda, MD, NCCAM.

Bureau of Labor Statistics. (2007). Occupational Outlook Handbook: 2008-2009. Washington, DC: U.S. Department of Labor.

Carlson, F.  M. (2006). Essential touch: Meeting the needs of young children. Washington, DC: National Association for the Education of Young Children.

Cassidy, C.M. (1998/1999). Methodological issues in investigations of massage/bodywork therapy. Paper prepared for the AMTA Foundation’s Massage Research Agenda Workgroup, Paradigms Found Consulting, Bethesda, MD.

Cherkin, D. (1998). Spa treatments: panacea or placebo? Medical Care. 36(9), 1303-1305.

Cherkin, D. C., Deyo, R. A., Sherman, K. J., Hart, L. G. , Street, J. H., Hrbek, A., Cramer, E., Milliman, B., Booker, J. ,Mootz, R., Barassi, J. ,Kahn, J. R., Kaptchuk, T. J. and Eisenberg, D. M. (2002). Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. The Journal of the American Board of Family Practice, 15(5), 378-390.

Cohen, M. H., Hrbek, A.,Davis, R. B., Schachter, S. C. & Eisenberg, D. M. (2005). Emerging Credentialing Practices, Malpractice Liability Policies, and Guidelines Governing Complementary and Alternative Medical Practices and Dietary Supplement Recommendations: A Descriptive Study of 19 Integrative Health Care Centers in the United States. Archives of Internal Medicine, 165(3), 289 – 295. http://archinte.ama-assn.org/cgi/content/full/165/3/289

“Commission on Massage Therapy Accreditation (COMTA).” (nd) Accessed from the Online Education Database on March 9, 2009 http://oedb.org/accreditation-agencies/comta

Commission on Massage Therapy Accreditation (COMTA) (2008).  Four new members, three incumbents elected COMTA commissioners. Press release Sept 2008. Washington, DC: COMTA.

COMTA (n.d.). “About COMTA”. Accessed from COMTA’s website on March 9, 2009http://www.comta.org/about.php

Crownfield, P. W.,Beychok, T., Bondurant, C. (2008). Winds of change in North Carolina & Pennsylvania. Massage Today, 8(12), 1-3.

Editorial Staff  (2005). AMTA and ABMP: Two Associations Compared. Massage Today, 5(9). Accessed online March 9, 2009 http://www.massagetoday.com/mpacms/mt/article.php?id=13274.

Eisenberg, D. M., Kessler, R. C., Foster, C.,Norlock, F. E., Calkins, D. R., Delbanco, T. L. (1993). Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use. The New England Journal of Medicine, 328 (4), 246-252.

Eisenberg, D. M., Cohen, M. H., Hrbek, A., Grayzel, J., Van Rompay, M. & Cooper, V. (2002). Credentialing Complementary and Alternative Medical Providers. Annals of Internal Medicine, 137(12), 965-973.

England, A. (2007). Massage organizations review: ABMP. Suite 101.com. Accessed online March 6, 2009 at http://massagetherapy.suite101.com/article.cfm/massage_organization_review_abmp

Field, T. (2001). Touch. Cambridge, MA: MIT Press.

Federation of State Massage Therapy Boards (FSMTB) (n.d.). About FSMTB. Accessed March 9, 2009 from the website http://www.fsmtb.org/about.html.

Freeman, I. (2006). From interviews for the 10th anniversary of the seating of the first Commission on Massage Therapy Accreditation. Report transcribed from recording done July 28, 2006. Evanston, IL: COMTA.

Gosse, J. (2008, September 25). Executive Director, Commission on Massage Therapy Accreditation (COMTA). Interview. Washington, DC.

Greene, E. (1997). “Maryland Massage Therapy Bill Passes after 10 Years.” The Journal of Alternative and Complementary Medicine, 3(1), 87-90.

Hatch, M. J, & Cunliffe, A. (2006). Organization theory (2nd edition). Oxford: Oxford University Press.

Health News. ABMP Commits To Help Raise Massage Therapy Status As Low-Back Pain Treatment. Medical News Today, April 4, 2007. Accessed March 9, 2009 http://www.medicalnewstoday.com/articles/67122.php.

Hymel, G. (2003). Advancing massage therapy research competencies: dimensions for thought and action. Journal of Bodywork and Movement Therapy, 7(3), 194-199.

Hymel, G. (2005). Integrating research competencies in massage therapy education. Journal of Bodywork and Movement Therapies, 9(1), 43-51.

Hymel, G. (2008, September 29). Editor, International Journal of Therapeutic Massage & Bodywork (IJTMB). Telephone interview.

International Massage Association (IMA) (n.d.) How it began. Accessed March 15, 2009 from the IMA website http://www.imagroup.com/home/index.php?site_config_id=73&page_selection=1248&s_page=

Johari, H. (1996). Ayurvedic massage: traditional Indian techniques for balancing body and mind. Rochester, VT: Healing Arts Press.

Juhan, D. (2007). Medical massage: A marriage or a monster. Massage and Bodywork, Feb/Mar. downloaded July 7, 2008 from http://www.massageandbodywork.com/Articles/FebMar2007/medicalmassage.html

Kahn, J. (2002). Massage Therapy research agenda. Evanston, IL: Massage Therapy Foundation.

Kahn, J. (2002a). Forward. In G. J. Rich (ed.), The evidence for practice (xv-xvii). Edinburgh: Mosby.

Kent, D. (2008). Year in Review: keeping it simple. Massage Today. 8(12), 16-18.

Lucas, L. (October, 2006). Welcome. Speech presented at the 2006 AMTA National Convention, Atlanta, GA. Accessed online March 9, 2009 http://www.amtamassage.org/member/liz06speech.html.

Lucas, L. (2008, October 20). Executive Director, American Massage Therapy Association. Telephone interview.

Manheimer, E. & Berman, B. (2004).  NCCAM support for the Cochrane Collaboration CAM Field. Complementary Therapies in Medicine, 11(4), 268-271.

“Massage therapy and medical malpractice: medical malpractice.” (nd). Wrong Diagnosis website, Accessed March 9, 2009 at http://www.wrongdiagnosis.com/medical-malpractice/massage_therapy_and_medical_malpractice.htm

Massage Therapy Body of Knowledge (MTBOK) Stewards: Under the direction of representatives from American Massage Therapy Association (AMTA), AMTA-Council of Schools, Associated Bodywork & Massage Professionals (ABMP), Federation of State Massage Therapy Boards (FSMTB), Massage Therapy Foundation (MTF), and National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). (2009). Massage Therapy Body of Knowledge (MTBOK). <http://www.mtbok.org/index.html&gt;.

Massage Therapy Foundation (MTB) (2007). Shape the future: Massage Therapy Foundation Annual Report. Downloaded March 9, 2009 http://www.massagetherapyfoundation.org/pdf/2007%20MTF%20Annual%20Report%20FINAL.pdf

McGinn, D. & Sterling, T. G.  (2008). Massage, Please!  Newsweek, Dec. 15, 2008.  Retrieved online March 2, 2009 at http://www.newsweek.com/id/171906?tid=relatedcl

Morgan, G. (1997). Images of organization, (2nd).  Thousand Oaks, CA: Sage.

Moyer, C. A., Rounds, J., Hannum, J. (2004). A Meta-analysis of massage therapy research. Psychological Bulletin, 130(1), 3-18.

National Center for Complimentary and Alternative Medicine (NCCAM) (2008). “Funding Strategy: Fiscal Year 2008.” From http://nccam.nih.gov/grants/strategy/2008.htm.

National Center for Complimentary and Alternative Medicine (NCCAM) (2009) Massage Therapy as CAM. PubMed, (8). Accessed online March 15, 2009

National Center for Complimentary and Alternative Medicine (NCCAM) (2009a). “National Center for Complementary and Alternative Medicine.” The NIH Almanac. Accessed March 9, 2009 from http://www.nih.gov/about/almanac/organization/NCCAM.htm.

National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) (2007). About NCBTMB. Accessed from NCBTMB website March 9, 2009. http://www.ncbtmb.org/about.php.

National Certification Board of Therapeutic Massage and Bodywork (NCBTMB) (2007a). Bylaws of the National Certification Board of Therapeutic Massage and Bodywork, Inc. Downloaded from http://www.ncbtmb.org/news_bylaws.php.

National Certification Board of Therapeutic Massage and Bodywork (NCBTMB) (2007b). Independent Governance Panel Report. Reported in NCBTMB’s Newsletters and reports, August 21, 2007. Accessed online March 9, 2009 http://www.ncbtmb.org/news_independent_report.php.

National Certification Board of Therapeutic Massage and Bodywork (NCBTMB). (2008). NCBTMB’s national certification: Pledge of safety (wall chart). Oakbrook Terrace, IL: NCBTMB.

Ostendorf, C. (2006). From interviews for the 10th anniversary of the seating of the first commission on massage therapy accreditation. Report transcribed from recording done August 1, 2006. Evanston, IL: COMTA.

Razzo, R. (2005). Winds of Change Blowing at NCBTMB. Massage Today, 5(4).  Accessed online March 9, 2009 http://www.massagetoday.com/mpacms/mt/article.php?id=13188.

Schwartz, J. (2006). From interviews for the 10th anniversary of the seating of the first commission on massage therapy accreditation. Report transcribed from recording done August 4, 2006. Evanston, IL: COMTA.

Spuller, M. (2008). About the American Organization for Bodywork Therapies of Asia (AOBTA).  Accessed March 9, 2009 from the AOBTA website http://www.aobta.org/about-aobta.html

Sweeney, L. (2008, October 23). Executive Director, American Bodywork and Massage Practitioners (ABMP) Telephone interview.

Thomas, J. (2006). From interviews for the 10th anniversary of the seating of the first commission on massage therapy accreditation. Report transcribed from recording done July 31, 2006. Evanston, IL: COMTA.

Thompson, D. (2008, September 20). President, Massage Therapy Foundation (MTF). Interview. Phoenix, AZ.

Trieste, D. (2006). From interviews for the 10th anniversary of the seating of the first commission on massage therapy accreditation. Report transcribed from recording done August 11, 2006. Evanston, IL: COMTA.

World Massage Forum (2007). Interview with Diane Thompson. Massage Therapy in USA. Accessed online http://worldmassageforum.com/index.php?option=com_content&task=view&id=1008&Itemid=65

Ziegenfus, J. & Bentley, J. M. (2003). Implementing cost control in health care.  In J. Ziegenfuss and J. Sassani (eds), Portable health administration (231-251). St. Louis, MO: Elsevier Academic Press.

Leave a comment

Filed under Uncategorized

Research for Massage Therapy

On Sunday, November 6, I will be presenting to the D.C. Chapter of the American Massage Therapy Association (AMTA) on the importance of research for MT practitioners, and how MTs can contribute to the growing body of research.  It will take place at Potomac Massage Training Institute, D.C. at 4pm.  The synopsis is below.

What Massage Therapy Research Means to You:And what you can do about it

With Luann Fortune, LMT, NCTMB, MA, Doctoral Candidate
An interactive workshop and discussion

For AMTA DC Chapter
November 6, 2011
In the past decade, medical science has taken an increased interest in massage therapy.  Seems like we read about a new clinical study or finding about every week in the popular press.  But other than serve as a useful marketing tool to generate new business, what application does this research have for the seasoned massage therapist?
In this hour presentation, Luann Fortune will describe how the growing body of scientific research is already impacting your everyday practice.  Find out how it is likely to continue to have an impact, how you can stay on top of the latest findings (before your clients tell you about it), and what you can do to be part of the movement to research (or not to research).
Luann has been practicing and teaching massage therapy in D.C. for over 20 years.  She has published numerous papers and articles, including a study on the impact of licensing on massage therapists (see http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091437/).  She is currently completing her doctoral dissertation in Human Development at Fielding Graduate University; her research examines how massage therapists conduct their work.  Luann can be contacted at lfortune@email.fielding.edu.

Leave a comment

Filed under Uncategorized