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Hands On

Massage therapy is a huge industry--and a regulation nightmare

By Kimberly Arnold

The slight Swedish lilt in Terry Jay's voice adds charm to this feisty, rugged wrangler. At age 52, and at a petite 5'3", she spends her days working with horses, routinely picking up 120-pound bales of hay. It takes a lot to set her back.

Then one day it happened. The young colt Jay was riding spooked. He bucked and bolted, causing Jay to twist her back: "I felt a sharp pain. I expected it to go away in a few days." Two weeks of soaking in the hot tub and high levels of ibuprofen didn't do any good.

True to Jay's grit-yer-teeth-and-bear-it nature, she had no plans to seek help. Out of concern, a good friend introduced her to Bev Emery, a massage therapist. "She's a miracle worker," Jay says with unequivocal enthusiasm. "Bev said the muscle was practically torn and severed in places. It hurt like hell. She was pushing and pressing on the injury." Jay went back for a second session. "This time the pain was gone. I mean gone, and I have never felt it since."

Emery specializes in treating severe muscle injury. "I use a more clinical approach, not like most foo-foo massage, when you go for an hour to a spa," says Emery. Most people who come to Emery come for a torn muscle, an injured shoulder, or damaged tissue. A lot of her patients are referred to her through the physical therapy department at Kaiser Permanente. These people are seeking a cure rather than momentary relief.

The chasm between healing and curing is but one of the issues that is up for debate among massage therapists. For years practitioners have argued for and against state licensure for certified massage therapists. California currently does not have a standard that massage therapists are required to meet in order to obtain their certificates, and as a result, training varies widely.

Certification is available through various nongovernment venues (such as one of California's many institutes or vocational programs), but licenses are issued only from a government agency. There are 30 states that require practicing massage therapists to have a license. California is not one of them.

Bureaucratic Headaches

Over the past years, massage therapists, health spas, and massage shops have propagated across the country. According to a recent article in L.A. Vocational, massage therapy is one of the fastest growing healthcare fields in the country today.

There are presently 170 individual and group massage therapists and practices listed in the 2002 Sonoma County yellow pages, and that doesn't include practitioners working for health spas, clubs, supervised medical institutes, and doctor or chiropractic offices. According to the records of the City of Santa Rosa Revenue and Collection Department, nearly 50 new massage therapists applied for business licenses in the last 15 months alone.

Individual schools, teachers, or workshop facilitators issue certificates; states issue licenses. Certificates are voluntary; essentially, certificates can be issued by anyone who decides to offer one. As a result, a certified massage therapist, or CMT, could be someone who has completed an 8-hour class or someone who has completed 1,000 hours of course work.

A certificate from a vocational school is no guarantee that the CMT has completed the minimum standard of 500 hours of training required for most state licenses. Proponents for licensing in California feel concerned by the lack of uniformity in the profession and the disparity in certification requirements from state to state.

Each state determines for itself whether or not it will require massage therapists to be licensed and the regulations for licensure. There is also an optional national certificate--the NCTMB--that individual practitioners from either licensed or nonlicensed states can obtain.

According to Dorothy Schwartzberg, NCTMB, the current president of the Redwood Empire unit of the California chapter of the American Massage Therapy Association, "There is no real title in California; there is no CMT. People put it there for legitimacy, but there isn't a certifying agency. [People] are certified by the school they attended. But there are no set hours required by a governing body."

To gain credibility, a school will seek the stamp of approval from a professional organization such as the AMTA or the International Massage Association to establish that they meet that organization's particular requirements. A state license would guarantee that a CMT has completed a minimum of 500 hours of approved course work and passed a state exam.

Man against Machine

A growing organization with a powerful influence politically as well as professionally, the AMTA is the largest massage therapy professional association in the country, with over 18,000 members representing all 50 states, the District of Columbia, and the Virgin Islands. Without its backing, it is much harder to establish a practice or run a school. For the past decade, the AMTA has actively lobbied for state legislation, and if it gets its way, every state in the nation will require licensing.

The AMTA is an affiliate of the Commission on Massage Therapy Accreditation, which accredits schools in both licensed and unlicensed states. Accreditation is voluntary, although without the commission's accreditation a school can't provide courses that qualify for the NCTMB. According to the AMTA, "The National Certification Exam has become the standard for licensure used by most of the 30 states that regulate massage, to measure a competent and qualified practitioner."

Hands-on Training

If California were to require a license for massage therapists, the level of required training would also come under scrutiny. If the state required a license, someone practicing stress-relief massage would be held to the same educational requirements as a muscle specialist like Emery. Her training in Britain included anatomy, physiology, aromatherapy, reflexology, deep tissue massage, lymphatic drainage, nutrition, iridology, kinesiology, and even psychotherapy. Most European students complete 1,000 hours of training for certification.

"Indian head massage is part of the basic training, but it is not used in the U.S.," says Emery. "Here, everybody learns Swedish massage, and that's about it." In the end, Emery believes, "training does make a difference in quality."

Not everyone agrees. "The truth of it is, there is absolutely no regulation about what goes into those hours," says Schwartzberg. "There is no equality in the level of training [in the United States]."

Dionne Nelsen, CMT, is a graduate with 500 hours from the Western Institute of Science and Health in Rohnert Park. She chose the school because she felt they had one of the more comprehensive programs, with high standards for its students. Much of the curriculum is comparable to the course work in Europe.

Nelsen is a strong proponent for state licensing. She feels that it would improve the legitimacy of the profession, as well as assure a set standard that clients can count on. "I want to give the best care I can to my clients, and I can't do that if I don't have a basic understanding of anatomy and how the body works. You might get a really nice massage from someone with minimal hours, but they may miss some important health issues for each client," says Nelsen. "It takes experience and training to know what to look for."

But quality training isn't necessary for the client's sake alone, Nelsen argues; it is also important for the therapists'. "There is a high burnout rate in the profession, with practitioners staying an average of two and half years. One of the things I was taught . . . was how to take really good care of myself," Nelsen explains. "How can I tell other people how to take care of themselves if I don't practice that myself?"

Nelsen is careful to schedule time between clients to release any tension. She centers herself with meditation, getting a drink, and resting her body. During each treatment she is careful to use appropriate posture, leg support, and arm-stroke techniques to prevent injury to herself.

Emery is also vigilant about taking care of herself. "I never work on more than three people a day. I'm very careful and don't want to damage myself. I have a massage every other week through trading with a friend who is also a massage therapist. I have seen therapists who have damaged shoulders or arms and can't work any more.

"It happens a lot here [in the United States], more than in Britain," Emery continues. "I know people who have worked for the past 15 years and are still going strong."

Schwartzberg has been a practitioner for 22 years and considers herself to be a Swedish eclectic massage therapist. She has also taught infant massage at the Sebastopol Community Center for 10 years. "I have probably had just as much training as someone who is into remedial massage treatments. Doing a good healing, relaxing massage takes as much training as the other kind," she says. "I am more into the healing aspect rather than curing. Why would that be less valuable?"

Measuring value based on training gets into a sticky area. Schwartzberg has her own set of questions and concerns, "How do you train to touch someone with healing energy? . . . You have to know when someone needs more and to be able to refer."

While lack of training may cause problems for the practitioners themselves, there appears to be little data to support the idea that lack of training can cause any real damage to clients. Even if the quality of the massage may be less, there is no documentation of a client sustaining any long-term physical discomfort, let alone injury, from a poorly administered massage.

"It is difficult to injure somebody," says Emery. "It isn't like chiropractics where you are manipulating the spine and can cause damage. You may not help them if you are not getting it right, but I don't know of any occasions where somebody has been damaged by massage."

Patricia Oberg, MsT, director of the Sebastopol Massage Center and member of the International Massage Association, has trained hundreds of massage therapists in Sonoma County since 1985. She asserts that someone who has completed only 50 hours may give a better massage than someone who has done thousands of hours of massage. "A license doesn't necessarily guarantee that the therapist will be sensitive to a client's particular needs," Oberg says.

Nelsen agrees, acknowledging that "even experienced therapists may lack a certain bedside manner or neglect to inquire into a client's medical history."

Clients are more likely to suffer from practitioner abuses of healer-client trust than from physical manipulations. Requiring further training could be a little like requiring lawyers to study elocution in order to make them better lawyers. It might help their style, but it will do nothing to stop unethical behavior.

Concern for client welfare is admirable but unfounded, according to Keith Eric Grant, Ph.D., NCTMB. Grant believes that those in favor of further regulations are doing so out of a noble desire to protect clients. But what is really at issue has more to do with professional ethics than with the qualifications and experience level of a particular practitioner.

According to Grant, licensing will do nothing to stop therapists who abuse the trust and vulnerability of the clients under their care. He compares the effectiveness of state occupational regulations to that imposed on physicians. A June 16, 1998, ABC News report stated that "40 percent of physicians punished for sex offenses continue to practice."

If consumer protection is the goal, suggests Grant, then following up on complaints and enforcing disciplinary actions would do far more good than regulating training.

The Oldest Profession

Nelsen argues that state licensing will also help to elevate the reputation of massage therapists. Professional massage therapists still combat the public's impression that they are simply providing a professional front for a business that is actually of less reputable nature. Many do not believe licensing itself will solve this problem.

The purpose of licensing from a local police perspective has to do with controlling prostitution. Schwartzberg considers what it would mean if state licensing were actually carried out. "Will they come and investigate me? See if I'm clean? Have the right shots? . . . A TB test, am wearing certain clothes, STD testing? People have really struggled with this."

While the police involvement worries her, Schwartzberg says she "would like to have regulations so that we know what we can do and what we can't do. How much should we charge for this or that?" Despite Schwartzberg's heavy involvement with the AMTA, she has a few doubts about the desirability of state licensing. "I slightly lean towards regulation, only because I think it would clean up something that has been messy for a long time."

Emery also has mixed feelings about regulation. "It is a difficult issue. For years people have looked at it as a sexual venue," she says. "I've known girls--massage therapists--on cruise lines who have been propositioned. There will always be that kind of image to it until the public has been educated. I don't know that licensing will change that."

Paying the Price

At the conference in Roseville for owners of massage therapy schools last April, most of the school owners did not want to see state regulated licensing for individual massage therapists. Many feel there is already enough red tape in order to get a license from the local municipality and from the state for a business license to operate a school. The added expense for practitioners will undoubtedly be passed on to the consumer and there is little guarantee that the state will regulate the rates.

Some of the state's resistance may have to do with the cost of administering the program. As Schwartzberg points out, "The fees might not cover the cost of overseeing it."

Part of the rise in the popularity of massage as an alternative form of healthcare is due to the relative affordability of a session. Currently the cost for liability insurance, certification, and a business license is minimal.

According to Toni Knott, director of the organizational behavior program at the California School of Professional Psychology at Alliant International University in Fresno, "Annually, $26 billion [is] paid out in disability claims related to stress." Massage is currently a quick, effective, and relatively low-cost way to reduce stress. Those supporting increased regulation insist that licensing is essential for consumer protection. It is this very argument that ironically may be the best reason not to regulate.

"Many clients on disability couldn't afford to come to me as often as they do if I had my fees up," says Emery, who only charges $50 a session. Further regulations will certainly increase costs and in so doing discourage the availability of massage.

No one is arguing for less training. "I'm very much for people learning as much as possible," says Emery. "At the end of the day, you've got somebody's health in your hands. It's about making somebody better."

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From the October 3-9, 2002 issue of the North Bay Bohemian.

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