MTBOK: Missed Opportunity?

by | May 15, 2012 | Bodywork, Politics, Touch

Reading the impressive 58-page paper entitled Massage Therapy Body of Knowledge (MTBOK) was both exhilarating and disappointing. Developed by a coalition of six national massage organizations, Version 1 of this effort was published in 2010 and is a landmark document for massage therapy and a must-read for everyone in the profession.

MTBOK: Missed OpportunityThe purpose of the MTBOK Project is to define the scope of practice for massage professionals and the entry-level knowledge, skills and abilities (KSA) necessary to responsibly perform massage therapy. It is intended to be a living document that is constantly modified and updated as information, understanding and perspectives change.

Unfortunately, the MTBOK effort, while commendable, is fundamentally flawed as, once again, the mainstream massage industry conflates “massage” with “massage therapy.” This is a 30-year old problem that continues to hold back our industry by presuming that all massage is massage therapy. You can read the history of how this came about and why it has been a disaster for the industry in the related articles How Massage Became Therapy and Moving from Acceptability to Accessibility.

In this article I want to use the MTBOK report to help identify the difference between “massage” and “massage therapy” and lay the groundwork for future discussion.

First, let’s start with the report’s definition of “Bodywork” on page 39. It notes, correctly I believe, that bodywork includes all forms of massage therapy. Indeed, bodywork is the umbrella term for all forms of skilled touch some of which are massage, and others of which are clearly not (e.g. Reiki, Therapeutic Touch).

Where the report fails is that it doesn’t make clear that the subset of bodywork that includes massage can be further subdivided, only one category of which is massage therapy. That is to say, while all massage therapy is massage, not all massage is massage therapy [See The Realms of Massage].

What part of massage is not massage therapy? That’s easy—personal care massage.

The MTBOK paper, like the industry as a whole, defines massage therapy (meaning all massage) exclusively as “a healthcare and wellness profession” and goes on to say, “The practice of [massage] involves a client/patient-centered session, intended to support therapeutic goals.” Really? That is not the massage I have been doing for 30 years.

I don’t serve “clients” or “patients,” I serve customers. The personal care service I perform has more in common with cosmetologists (“If you feel good, you look good”), tour guides (“Let me show you your body from the inside out”) and aerobics instructors (“Let’s get fit”) than with physical therapists or athletic trainers. Indeed, the Bureau of Labor Statistics places the largest concentration of massage professionals, by far, in the personal care service industry, not the health care industry.

So, clearly, there is personal care massage and there is health care massage therapy. Is the body of knowledge required for safe, effective practice the same for both occupations?  Obviously not, but inadvertently here is where the MTBOK paper has done us a great service. Since all massage therapy is a subset of all massage then, if they did their work well, within the body of knowledge of massage therapy must be the core knowledge, skills and abilities to perform all massage, including the subset of personal care massage.

It’s all about touch

Let’s start with one of their definitions on page 6: “Massage therapy at its essence is human touch with clear intention, focused attention and the attitudes of compassion and non-judgment.” I would maintain that this is also a perfectly serviceable definition for personal care massage so let’s take the word “therapy” out of the sentence and we can all agree that the primary KSAs of all massage should revolve around touch.

So, what does it take to be a professional touch provider? Clearly far less than is required to become a massage therapist. In fact, separating personal care massage from massage therapy will finally allow massage therapy to have the growth path it so justifiably deserves—that of becoming medical massage, a health care specialty—while allowing basic massage training to focus on the simple but profound benefits of touch.

The MTBOK sections on Boundaries, Ethics and the Therapeutic Relationship along with Body Mechanics, Self Care and Massage Techniques contain a wealth of relevant suggestions about learning to be a good skilled touch provider. The in-depth knowledge outlined in Anatomy, Physiology, Pathology, Kinesiology, Assessment, Treatment Planning, Documentation, Research and Information Literacy however, are far more suited for a massage therapist.

Massage therapy training has always been too much and too little. If you read through the MTBOK recommendations, you can come to no other conclusion than that 500 hours is a woefully inadequate number of hours for training a qualified massage therapist. The 2,100-hour standard in Ontario province or the 3,000-hour standard in British Columbia are much closer to the mark.

However, 500 hours is far more than is necessary for me to train a world-class chair massage practitioner doing personal care massage. I could accomplish it in 300 hours and half of that would be supervised practice.

At this point there is ample evidence that the effort to attract the marketplace to high-priced massage therapy has failed. The only significant growth markets for the industry are the chair massage provided by the current wave of Chinese immigrants in malls and low cost suburban table massage offered by Massage Envy and its clones. Neither of those approaches, by and large, requires the full training and skill set outlined in the MTBOK. Each of those avenues could rightly be called “entry level” for both the practitioners and the consumers. I would suggest there is little point in training thousands of massage therapists for jobs that don’t exist. Better to train personal care service massage practitioners for jobs that do.

Let’s first teach all our massage students to do one thing really well—skilled touch. If they later want to specialize in massage therapy in all of its many, varied and glorious forms, great, but that is advanced training for a clearly limited market.

An Outsider Analyzes Massage

by | Feb 27, 2012 | Bodywork, Business

David Palmer

The shy David Palmer

I was a mama’s boy. The youngest of four males born to my parents within five years, I was the baby of the family and spoiled rotten. There are a number of family stories dramatizing that fact, my favorite of which is how I bravely got on the school bus for my first day in kindergarten only to run screaming down the aisle for my mother the moment the doors closed. I did get chauffeured to school that day but still the teacher had to peel me off my mother’s leg while firmly assuring Mom that I would be all right.

And, eventually, I was. The next day, and every subsequent day, I couldn’t wait to get on the bus. However, I remained a sometimes painfully shy kid until I graduated from high school and was living on my own making my own way in the world. I managed my shy nature with loving support and (mostly) outgrew it with self-sufficiency and self-awareness.

Today shy kids are diagnosed with “social anxiety disorder” and given Paxil or other medication. Our contemporary culture has a well-documented tendency to turn every cursory personal quirk into a disease that needs treatment. While I am certain that there are a few shy folk, overweight people, fidgety kids and existentially troubled adults who could benefit from a prescription, I harbor the sneaking suspicion that: a) these are symptoms of a cultural disorder, not a personal one, and b) that it only benefits the pharmaceutical companies to encourage us to believe that the reverse is true.

Virginia PostrelI was thinking of this tendency to pathologize life as I was re-reading an article by Virginia Postrel analyzing the massage industry. Ms. Postrel is a journalist who focuses on the intersection of culture and commerce. She has been a reporter for Inc. and The Wall Street Journal as well as a columnist for The New York Times and The Atlantic Monthly. She has also authored two books, The Future and Its Enemies and The Substance of Style about how cultural trends become commercial enterprises.

One of her columns from The Atlantic Monthly contained an insightful outsider’s critique of the massage industry tracing its history from the strip club to the strip mall. Below is a lengthy excerpt from the original piece published in The Atlantic.

As a business, massage has two basic problems. The first is that prostitution is generally illegal. A brothel can’t openly advertise its services: no “Madame Julia’s House of Great Sex.” Instead, Madame Julia pretends she runs a “massage parlor,” which creates confusion, and sometimes legal obstacles, for people who want to buy and sell back rubs.

The second problem is that most potential customers consider massage a luxury—an optional indulgence, if not a slightly shameful extravagance. So they’re acutely sensitive to price. A massage business can’t pass high labor costs along to consumers without suffering a rapid drop in sales.

One way to attack these problems is to declare massage a medical service. Hence in 1983 the American Massage & Therapy Association dropped its ampersand to create a new profession: “massage therapy.” Customers and legal authorities can be pretty sure—though not 100 percent certain—that a massage therapist isn’t selling sex. A therapist not only will keep the client discreetly draped with a sheet but also will take a reassuringly clinical approach to kneading naked flesh. A masseuse, on the other hand, may well be a hooker in a skimpy disguise.

Calling massage a “therapy” also suggests that it’s good for you, which means you don’t have to feel guilty about spending money on it. You might even be able to pass the bill on to your insurance company (only rarely, so far). Massage therapists understandably want their clients to think of massage as a necessity. “At one point in my career I had to defend massage against the ‘prostitution attitude,’” says Brenda L. Griffith, a massage therapist in Richmond, Virginia, who has been practicing since 1988. “Now I have to defend massage against the ‘pampering attitude.’” Many of her clients do, in fact, have chronic ailments for which massage offers some relief.

But relentlessly touting the healing power of touch makes too many massage therapists sound like quacks. The medical strategy also treats clients as patients, eliminating potential customers who feel healthy. It attracts clients by turning everyday life into a disease. Who, after all, doesn’t suffer from stress? Like graphic and industrial designers who refuse to talk about aesthetics, massage therapists seem embarrassed to say they make people feel good.

As something of a massage addict, I don’t buy the medical line, and I don’t think it’s necessary. Assuming it’s not too vigorous, a massage not only feels good but also helps me think. It’s relaxing, but not so relaxing that I fall asleep. Like a nice glass of wine with dinner or an all-white Heavenly Bed in a hotel room, a massage break adds a little pleasure to everyday life. Even if the massage does nothing for my health, I consider the money well spent.

Humans are sensory beings. Massage doesn’t need to justify pleasing our muscles and skin any more than music has to justify pleasing our ears. Chefs don’t have to call themselves “nutritional therapists.” Hairstylists don’t have to pretend that gray hair is a disease. Enjoyment is a perfectly fine reason to get a massage.

I love that last line. Why is it that people feel they are not allowed to get a massage unless something is wrong? In our quest to distance ourselves from a shady past have we turned massage into purely a medical treatment? Have we trained the public to see massage as being required only when we have something amiss in our soul, psyche or somatic self?

When I ran a retail chair massage studio, I noticed that virtually all new customers felt obligated to justify their visit with a medical complaint such as a crick in their neck, a headache or a sore back or shoulders. At the end of their visit, either their problem is resolved, or not, so regardless of the outcome, there is little motivation for them to return unless we take the time to reeducate them away from the point of view that there has to be something wrong before they can get a massage.

Interestingly, at the time the article was published in 2006 it provoked a harsh reaction from the American Massage Therapy Association.  The president at the time, Mary Beth Braun, wrote a letter of complaint to the magazine accusing Postrel both of connecting massage to prostitution and implying that massage is only to make people feel good.

Setting aside the fact that both charges are a gross misreading of the article, what exactly is the problem with “feeling good” being the foundation of massage? Wouldn’t it be a major contribution to society if the primary focus of massage was to make people feel good? It just might even be a non-pharmaceutical solution to “social anxiety disorder.” [And, for more on why a strong mother-son bond is crucial, check out this great article.]

Do you think “feeling good” is a legitimate goal for massage? Have we overemphasized the need to define massage as “therapy?” Your comments below are welcome.

 

Moving Massage from Acceptability to Accessibility

by | Jan 9, 2012 | Bodywork, Politics

Acceptability-to-Accessibility ImageFor as long as people have been paying for therapeutic massage services, practitioners have feared being mistaken for prostitutes. That fear was the primary driving force that, in 1983, led the American Massage Therapy Association to re-brand “massage” into “massage therapy” in an attempt to define it as the health care profession. [Related article] I call this quest for professional legitimacy the “acceptability” strategy.

Within a decade this strategy was almost universally embraced by massage schools, educators, associations, regulators and vendors serving the industry. It seemed like an obvious strategy and the perfect solution. In point of fact, it was remarkably successful at validating therapeutic massage in the public mindset.

Unlike 20 years ago, nowadays no one blinks twice when a young woman announces her desire to attend massage school–no snickers, no raised eyebrows. The public generally perceives that there is a clear distinction between adult entertainment massage and therapeutic massage. The battle for acceptability has, for the most part, been won.

But now there is another front that needs our attention. What I call the “accessibility” problem.

While we have steadily increased the numbers of people who want a massage, the number of people who actually can get a regular massage has barely budged from less than 5% of the US adult population [see related article]. The reason is painfully simple. Massage therapy is  too expensive.

Since I am writing to a primarily professional audience, let me do a quick reality check. How many readers pay full price for at least one massage every two months? How many of your friends do? If you are at all like the typical massage practitioner in my continuing education classes, you can’t afford to pay $65 for a regular table massage, and neither can your friends. The primary reason people don’t get a massage is because they can’t afford it.

The only two significantly expanding models for massage services are the pay-by-the-month model pioneered by Massage Envy and chair massage in malls delivered by Chinese immigrants. What they both have in common is that they are lowering the price of massage.

Those of you who have experimented with online coupons also know what I am talking about. Discount massage shoppers rarely turn into full price regular customers. The only people who pay full price for regular table massage are the very wealthy, the very fanatical, and the very desperate people in pain.

While turning “massage” into “massage therapy” made our services more acceptable, it did little to make them more accessible. In fact, there is a case to be made that the effort to make massage into a health care profession has actually limited its growth.

Massage as health care

When you define massage as massage therapy in a health care context you are defining it as a treatment. The problem is that most massage is not performed as a health care treatment. Most massage, according to consumer surveys, is done for health promotion and relaxation. That has resulted in a huge disconnect between what massage practitioners think they are selling and the general public is looking to buy.

Massage schools graduates are encouraged to believe that they are training to become a health care professional–sort of junior physical therapist. [Indeed, I just searched “Physical Therapy Training” in Google and one of the three sponsored ads at the top was for a massage school.] But the reality is that the vast majority of graduates, if they are lucky enough to be working at all, will be doing massage, not massage therapy. While it may increase school enrollment to have them think otherwise, it does nothing for their level of frustration when the inner image of practitioners does not jive with their outer experience.

For massage customers, particularly new ones, defining massage as therapy often leads them to believe they have to have something wrong in order to get a massage. Every day that I work in a chair massage studio new customers invariably feel obligated to have a physical problem before they step through the front door.  “I woke up with a pain in my neck/back/shoulder,” being the most common statement.

Massage as personal care or fitness

If we want to make massage truly accessible, we need to recognize the difference between massage as a health care service and massage as a personal care service.

Defining massage as a health care profession only makes sense for that small, highly trained and experienced segment of practitioners that actually performs massage as treatment and for that small fraction of the public that actually needs and wants to pay for that service. Massage therapy should be defined for what it actually is–medical massage–and we should require far more than the standard 500 hours of training. Something closer to 2,300 or 3,000 hours of the Ontario and British Columbia models would be appropriate.

I admit that I am very conservative on the issue of training but, in my experience, 500 or 600 hours of training to become a massage therapist is totally inadequate, does nothing for creating credibility as a health care profession and sets totally unrealistic expectations for massage school graduates, the vast majority of whom will never make even a part-time living doing massage.

“Massage therapy” should never have been defined as entry-level into the profession. It is not. Plain old circulation/relaxation/prevention-oriented “massage” is entry-level. Let students focus on learning how to touch and be touched [Related article].

Massage has always rested comfortably in the personal care services arena along with spas, hair salons and nail studios. Over the past twenty-five years, massage has also grown up with the wellness and fitness industries. These two economic sandboxes are where the majority of massage practitioners should be playing and it is the kind of massage that massage schools should be selling and teaching.

Radically reinventing an industry

Knowing what we now know, if I was creating the U.S. massage industry from scratch, here is how it would be structured:

  • Entry-level into the field should be a 200-hour course in chair massage.
  • Table massage would be a second, optional level of training. Add on another 300-hours to make the current 500-hour standard and have the focus be on training practitioners to be wellness educators as well as table practitioners.
  • Massage Therapy would be true medical massage and require at least a masters level program.

There are some strong arguments for making chair massage entry-level. For the industry, chair massage provides a strong foundation:

  1. Chair massage is what the general public can afford and, because there is no disrobing or private rooms required, is more likely to try.
  2. Because it is affordable, people will get massaged more regularly.
  3. People who have had a chair massage are more likely to consider having a table massage or massage therapy.
  4. The net result will be far more work, more jobs, more successful students, and more sales for chair and table manufacturers.

For the budding massage practitioner, starting with chair massage will eliminate a lot of needless heartache and financial burden:

  1. Since there is really no way of knowing whether you will like doing massage professionally until you get into massage school, a 200-hour tuition mistake is a lot less painful than a 500-hour mistake.
  2. More students will be able to afford to go to massage school without going deep into debt and actually make a living doing upon graduation.
  3. After they are making a living doing chair massage, chair practitioners can save up money to pay for table massage school without taking out loans.
  4. It is easier for entrepreneurs to open chair massage businesses than table massage establishments resulting in more jobs.

The bottom line

Can my ideal industry model become real? Realistically, I doubt it. The massage schools, associations and regulatory agencies are far too entrenched to consider reforming the profession so radically. The quest for acceptability as a health care profession continues to be seen as the primary goal. Too bad. A lot of people just need to feel better through touch.

Quality Control Through Katas

by | Aug 1, 2011 | Bodywork, Business, Chair Massage, Education

When I first began developing chair massage sequences in 1982, one of my students was also a student of Haruyoshi Ito, who had introduced a Japanese movement form called Shintaido to the United States and Europe during the mid 1970s.

One day this practitioner came to me to say that he had given his teacher one of our chair massages and Mr. Ito’s response was to say, “That’s a good Kata.”

“A good what?” I asked. “What is a Kata?”

Thus began my introduction to a concept that is fundamental to Japanese society.

While there is no exact translation of the word, the basic concept of Kata has to do with the form or correct way by which something is accomplished. In the West the word is most often encountered in a martial arts context. Students practice Katas, or sequences of defensive and offensive movements, over and over again until they become automatic.

Katas are studied in all of the Japanese arts­—brush painting, theater, flower arranging, the tea ceremony, as well as the martial arts. But the word has a much broader meaning in Japanese culture, which places a great emphasis on the correct way to do anything, from how low to bow in greeting to brushing your teeth.

To begin thinking of teaching and learning massage as a Kata prompted a major shift in my understanding of our work.

For one thing, it was a way of honoring the vast history of Japanese massage that had come before us. The path we travel is well worn; only the scenery has changed over the years.

Practicing a Kata also relieves us of the burden of having to know everything about what we are doing. We now understand that the master of massage is not the practitioner, but the Kata itself. We adopt the point of view that the only way you can truly learn about massage is by doing massage. The Kata gives us the opportunity to practice (in the learning sense of the word) with confidence. We teach a Kata and it is the Kata that teaches us massage.

The Kata is like a very wise elder who has the wisdom of the centuries behind her. The Kata has a long lineage that extends from teacher to teacher and is based on a theoretical foundation and philosophical world view that transcends our individual understanding.

If you trust the Kata and develop an honest relationship with it, you will be rewarded with unlimited insights about the nature of touch, massage, service, relationships, yourself, and your place in the grand scheme of the universe.

Another advantage of practicing a Kata is that it becomes a discipline in the spiritual sense of the word. One of the hallmarks of every spiritual discipline is the practice of repetitive rituals that become automatic and allow for openings into higher states of consciousness. Praying the Catholic rosary, Buddhist meditation, yogic breathing, and Sufi dancing­ all fall into this category.

When you practice a ­­­massage Kata it eventually becomes something like a beautiful dance or a piece of classical music. Highly structured and cho­­­­­­reographed, it is the same each time it is performed and yet, each time, it is also different.

On a practical level, performing massage as a Kata allows for quality control to enter into the massage business equation. When you have a private practice doing table massage, you can basically do whatever you want. Your clients will either like it, or not. However, when you are doing 15-minute chair massages for someone else’s business in a convention hall alongside nine other practitioners, exactly what you are doing becomes crucial to providing a high quality, consistent service.

Finally, the Kata is eminently researchable. One of the reasons broad-based research has been so hard to do in our field is because everyone does something different. It’s nearly impossible to control for the differences in practitioners. The Kata solves a great many of these problems because it provides the consistency needed for good data collection.

In touch,
David