MLN Vol.8.No.4

Massage Law Newsletter

Vol. 8, No.4                                      ISSN 1073-5461                                       April 1999   



Albert Schatz and Mary Brewster

Part 1: Our examination of the National Certification Examination (NCE)

Part 2: Unanswered questions about NCE direct attention to broader issues

Part 3: Additional relevant information

Ye shall know the truth and the truth will make you free. - Daniel 8:15

You have been weighed and found wanting. Daniel 5:27



Why the National Certification

 Examination (NCE) should be examined

NCE obtains all its information from the num-ber of questions that individuals answer correctly in a multiple-choice written test. People are then evaluated solely on the basis of their test scores.

It is important to examine NCE because there are serious questions about it since it is a written test. Can a written test objectively measure the competence involved in hands-on work.? Can a written test differentiate that competence from knowledge? Can a written test differentiate the act of doing hands-on work from the quality of the hands-on work that is done.

Our protocol   

Our research defines and analyzes NCE's objectives, evaluates what NCE does to achieve its objectives, and questions whether NCE achieves its objectives.

Our examination of NCE

reveals a structural contradiction

We began our research by asking, "What does NCE say it can and cannot do?" We considered this question historically because NCE was conceived in controversy. This approach uncovered the following contradiction.

In 1991, we were told that a written exam could not test hands-on work for national certification. If a written exam could not test for  hands-on work, it obviously could not test for the competence involved in that hands-on work.

In 1998, we were told that NCE's written exam did test for job performance and for the competence involved in job performance.

In both years, the terms hands-on work and job performance refer to the same thing.

The contradiction in what we were told, in 1991 and 1998, raised the following questions:

1. How could the written NCE measure competence for job performance in 1998, when we were told that a written exam could not test  hands-on work for national certification  in 1991?

2. If NCE presently does have the ability  to measure competence for hands-on work, how and when did it acquire that ability?

To answer these questions, it is necessary to know what happened in 1991 and 1998.

What happened in 1991?

To answer this question, we have to go back to 1988, when "the AMTA National Board of Directors unanimously approved a plan to develop a National Certification Examination in massage therapy."  But national certification quickly became controversial, and encountered opposition.

The AMTA therefore distributed a brochure which contained "A message  from" Robert King,  "President of the American Massage Therapy Association." The message, entitled "The truth about certification," stated, among other things:

"We seek to close the information gap and help separate rumor from reality," and "avoid misunderstanding and misrepresentation." This brochure was distributed before "The first administration of the new certifying examination" [was] "projected to take place in the Fall of 1991."

Three years later, in 1991, the opposition to national certification had increased to such an extent that it motivated the Public Information Committee of the Council for the National Certification Program for Massage Therapists to respond to a major controversial issue which it defined, in question form, as follows:

"How can a written examination be valid as a basis for National Certification since it cannot test for essential things like hands-on work and the more intuitive aspects of massage therapy?"

The Committee's question required no answer because the question answered itself. The answer is  obvious. "A written examination" is not "valid as a basis for National Certification" precisely because "it cannot test for essential things like hands-on work and the more intuitive aspects of massage therapy."

The important question is not whether "a written exam," with such serious limitations, is "a valid basis for National Certification." Of course, it isn't. How can it be? The important question is, "Can any written test reliably evaluate competence in terms of on-the-job performance? Some aspects of this issue has  already been discussed in detail. (Massage Law Newsletter. 5(4):1-5. 1998)

What happened in 1998?

The August, 1998, National Certification Examination Candidate Handbook (which is currently used) provides the following information which contradicts what we were told in 1991.

1. "The exam designed to measure your competence."

2. "The National Certification Board for  Therapeutic Massage and  Bodywork, NCBTMB", was
"formed to set high standards ... through a ...certification program that evaluates the competence of its practitioners."

3. 'The National Certification Exam is a valid tool for measuring ...the competency of entry-level massage and bodywork professionals."

4. "The exam is designed to reflect the knowledge that is required to perform the job of massage therapists and bodyworkers."

It is important to understand that:

1. The Handbook neither provides nor refers to  well-documented evidence that NCE is a "valid tool" for the measuring "competency."

2. NCE allegedly measures competence quantitatively by determining how many questions an individual answers correctly in a written test.

3. The Handbook differentiates between  competency  and knowledge, but does not define competency. We therefore do not know whether that competency refers to the simple act of doing hands-on work, or to the quality of the hands-on work which is done.

For these reasons, the Handbook raises a plethora of questions.


If a written exam cannot test hands-on work, how can it test the competence of the hands-on worker?

If a written test cannot test the competence of the hands-on worker, how can it be "a valid tool for measuring" the worker's "competency" to "perform the job"?

What knowledge does the exam measure other than how much and what kinds of factual information people have memorized?

What well-documented evidence tells us that a passing score is really needed to do competent hands-on work without causing harm?

What does "perform the job" mean? Does this phrase refer to the simple act of doing massage? Or, does it refer to  the quality of the job that is done; that is, the quality of the massage?

How can one and the same written test measure three such qualitatively different things as  WHAT knowledge is required to "perform the job,  HOW one "performs the job," and HOW well one "performs the job"?

The core problem of NCE

The problem of using one written test  to measure both knowledge and competence is complicated by the qualitative difference between the two. Knowledge can be tested by an appropriate written test.

Competence is how well one performs a physical activity. How can a written test, which gives quantitative information  (i.e., how many questions are answered correctly) also provide  qualitative information about how well one performs the physical activity involved in massage therapy?

What reality tell us

The following information reveals that a written test for one's knowledge about massage does not necessarily provide reliable information about one's competence as a massage therapist.

Many massage therapists, in states which do not regulate massage, could not pass NCE without considerable preparation. Nevertheless, they have had many satisfied clients for many years, without harming  anybody. Their clients are obviously satisfied with their knowledge and competence.

On the other hand, some people could pass NCE even though they have not massaged anyone or received a massage. They may also never have seen a massage given. Such people are certainly knowledgeable about massage. However, they are obviously not competent to do the actual hands-on work of giving a massage. But they could pass the written test.


How can NCE be a "valid tool" to measure  competence in hands-on work if some massage therapists, who are competent in hands-on work, cannot pass this written test; while others, who are incompetent in hands-on work, can pass the same written test?

If NCE cannot identify these two groups on the basis of test scores, how can it measure the "competency" of the hands-on work which massage therapists do?

If NCE cannot measure the "competency" of  hands-on work, how can it be a "valid tool for measuring ... the competency of entry-level massage and bodywork professionals?

What else does NCE do?

The Handbook tells us that The Certification Program:

"Promotes the status and credibility of the profession.

"Safeguards the public by upholding a Code of Ethics.

"Develops and sustains an examination that covers a core of knowledge shared by practition- ers.

"Advances more uniform standards of practice and ethical conduct.

"Lets those who are certified carry their certification with them when they move within the United States. That's because it's a national program, not just local or statewide.

"Helps clients and employers select practitioners though the referral system.

"Promotes continuing professional development.

"Has the recertification program so you can renew your credentials.

"Lets practitioners meet other professionals within the industry."

"Gives updates about the profession through a quarterly newsletter, called, NCB Connection."

Why does this statement refer, in one place, to the massage profession as "the industry." We have pointed out elsewhere that massage therapists are not assembly lines, and their massages are not assembly line products designed to be identical in order to meet industrial  standards of quality control.

Does NCE "safeguard"

the public?

The Certification Program tells us that NCE "safeguards the public by upholding a Code of Ethics."

There's no well-documented evidence that massage therapists who have passed NCE sexually molest fewer clients than massage therapists who have not taken or have failed NCE.

There's no well-documented evidence that massage therapists (regardless of their training, knowledge, and competence; and regardless of whether they have taken, passed, or failed NCE) have caused significant physical harm to people with and without contraindications.

NCE does not consider the issue of harm important because it allocates only a small percent of its content to contraindications. We shall publish our research on this in a subsequent report.

Intuition is an "essential"

component of massage therapy

The qualitative aspect of competence is determined by knowledge, hands-on work, and intuition. The Committee (already mentioned) told us, in 1991, that: "The more intuitive aspects of massage therapy" are "essential." but cannot be measured by a written test.

If intuitive aspects were an essential component of massage therapy in 1991, we assume they are an essential component of massage therapy today.

If a written test could not measure the intuitive aspects of massage in 1991, we assume NCE cannot test the same intuitive aspects today.

NCE cannot test for


Because NCE tests only knowledge, but not hands-on work and the intuitive aspects of massage, it tests only one of the three components that determine competence.

How can NCE measure the competence of massage therapists if it tests only one of the three major components that make up competence?

Many massage therapists, with little or no formal (school) training, have had many satisfied clients for many years without harming people.

Their satisfied clients believe these massage therapists have the necessary knowledge, competence, and intuition to be good massage therapists even though they do not have the training which state regulation requires, and have not taken and  passed NCE.

These same massage therapists could not pass NCE, which tests for knowledge, without considerable preparation that may be costly in time and money. Why should they be required to do that?



Who needs state regulatory requirements, NCE, and school accreditation, and why?

What well-documented evidence reveals that massage therapists are more competent in states which regulate massage than in states which do not?

How necessary is formal (massage school) training?

Why are massage therapists, who have graduated from accredited schools, required to pass a written test to determine whether they have sufficient knowledge to do massage?

If accredited schools graduate massage therapists with insufficient knowledge to pass NCE, why are those schools accredited?

Why do some state regulatory

requirements include NCE?

There's no well-documented evidence that NCE assures competence of massage therapists.

There's no well-documented evidence that NCE protects the public from harm because there's no well-documented evidence that massage therapists, who have not taken or passed NCE, have actually harmed people with and without contraindications.

In what ways is NCE


NCE and other written tests are an integral  part of the regulatory requirements of 24 states and Washington, D.C. Twenty-three states and D.C. require written tests. In nine states, NCE is the written test. Utah requires graduation from an approved training program or NCE.

We are concerned about the following two ways in which these written tests may adversely affect many people.

The right to earn a living.  Whether massage therapists pass or fail a written test may determine whether they are permitted to earn a living by doing massage; even though there is well-documented evidence that massage therapists (regardless of their training) have not caused sufficient harm to justify the alleged need for state regulation to protect the public from harm.

The money it costs to take NCE. Since NCE began in 1992, we estimate about 34,000 people have paid to take it. The fee was originally $150, Now it is $195. This is an increase of 30%.

NCE's total income, since 1992, may be approximately $5,500,000. With this income, why has the fee increased 30%?

In addition to the fee, people  pay the cost of travel to take NCE. They also pay for books, and workshops to prepare for the test, and have other expenses directly and indirectly involved.

The $5,500,000 highlights the need for research on the macroeconomics of massage. This would reveal the total amount of money state regulation requires massage therapists to pay, and other expenses they have to pay annually in order to conduct their business.

Is NCE a component of

monopoly control?

It seems that proponents of licensing are hopeful that a state license would mean more money, status, and power. - Jerry A. Green, Attorney  for the California Coalition on Somatic Practices.

 I think the move toward licensure is regrettable. I believe licensing creates state-sanctioned monopolies ... with the explicit goal of  'protecting the public,' but with the real effect of protecting those who hold the monopolies' respective entitlements, reducing information to the public, and restricting competition. - Don Schwartz.

Is NCE legally valid?

The issue of NCE's legality  was raised in 1993, a year after NCE was established.

So many massage therapists with so many kinds of training in so many states (which do not regulate massage) have been massaging so many people with so many contraindications, so many times for so many years, with so many well-documented reports of so many benefits, but with so few if any well-documented reports of harm.

Therefore, since massage therapists - regardless of their training - cause so little if any harm, is it legal to prohibit them from earning a living by doing massage simply because they have not passed a written test that does not measure their competence in the hands-on work which is needed to "perform the job" they do?

What legal  decisions, concerning written examinations, might apply to NCE?



We consider the following information important for understanding the importance of the issues we have raised about the validity of NCE.

What is massage therapy?

There are two general categories of massage therapy. One provides stress reduction. The other is symptom-directed, medically-oriented treatment. Some view the former as preventive massage and the latter as interventive massage.

Why does NCE require all massage therapists to have the same body of knowledge, regardless of whether they do massage for stress reduction or symptom-directed, medically-oriented massage?

For massage therapists who provide stress reduction, Mr. Justice Braidwood (in  the Supreme Court of British Columbia) concluded that people who provide "relaxation or comfort massage" need little if any instruction. He considered that four hours or less training might well be adequate for that purpose.

Foot massage (foot reflexology) can be learned from books. Kevin and Barbara Kunz' book The Complete Guide to Foot Reflexology (Prentice-Hall. NY. 1982) "is intended as a tool for those wishing to apply reflexology either to their own or someone else's feet." The book "is the complete guide to foot reflexology" and is "written for both the layperson and the practicing reflexologist."

Judy Dobbs, President of the Pennsylvania Reflexology Association, offered an 8-hour workshop in foot reflexology. Why then did Pennsylvania Senate Bill 1171 require a 200-hour training for foot reflexology?

What is competence?

We define competence of massage therapists as the quality of their on-job performance (i.e., their hands-on work) which satisfies those who pay for their service.

This is how we customarily evaluate the competence of people who provide us with  many other kinds of services, which involve hands-on work, for our house, lawns, and cars, for which we pay.

The quality of the hands-on work, which determines client satisfaction is influenced by the massage therapist's knowledge of how and when to do the hands-on work, and by her intuition. Our definition of competence precludes harm because people are not satisfied with massage therapists who harm them.

Many massage therapists with little or no massage school training have had many satisfied clients for many years. They have become competent by practice. They have acquired their knowledge largely on their own. And they have developed their intuition. But they cannot pass  NCE without considerable preparation that my be costly in time and money.

Come dance with us.

Massage is a performing art

Massage therapists are artists, each of  whom intuitively develops her own unique choreography. Their massages are not comparable to "paint-by-number pictures." Nor are they assembly line products designed to be identical in order to meet industrial standards of quality control.

"Massage, like mucic, is what Aldus Huxley called 'a psycho-physical skill' ... Did Bach know how his muscles worked? No. But he played the organ very well and was a magnificent teacher. If proficiency in any psycho-physical skill depended on correct knowledge of physiology, there would have been no good singers, dancers, pianists, runners, and so forth, until the middle of the twentieth century."

Competence is how well one performs a psycho-physical activity like playing a musical instrument, ballroom dancing, and massaging.

It would be ridiculous to require artists, to pass a written test to determine whether they have sufficient knowledge to be considered competent artists.

A pianist is not required to pass a written test on music theory to determine whether he has sufficient knowledge to be a member of a band or a concert pianist. Some musicians, who are considered remarkably competent, "play by ear." They have had no formal training.

A vocalist is not required to pass a written test on the anatomy of the musculoskeletal system, that is involved in singing, to determine whether she has sufficient knowledge to be an opera singer.

Figure skaters are not required to pass a written test on anatomy and physiology to determine whether they have sufficient knowledge to qualify for the Olympic games?

Why are some massage therapists, who have been doing massage professionally for several years, without harming anybody,  required to pass a written test to determine whether they have sufficient knowledge to do what they have been doing for several years?

Competitive sports in which

players are harmed 

Professional football and hockey players, who not infrequently violate the rules of the game (which is why they are penalized) and harm one another, are not required to pass a written test to determine whether they have sufficient knowledge of anatomy, physiology, contraindications for their sport, and the rules of their games.

Why then are some massage therapists, who have been doing massage for several years without harming anybody, required to pass a written test to determine whether they have sufficient knowledge to do what they have been doing for several years?


The history of progress is in large part the history of controversy. We believe it is important to have friendly, constructive dialogue on controversial issues. We therefore welcome Letters to the Editor from those who agree and disagree with us.

Where all men think alike, no man thinks very much. - Walter Lippmann

Those who cannot remember the past are condemned to repeat it. - George Santayana

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