State regulation, the Commission for Massage Therapy Accreditation (CMTA) , and the National Certification Examination (NCE) are justified only if they are needed for the welfare, health, and safety of the public.
Each of these three agencies should therefore be evaluated to determine whether there is well-documented evidence that the agency
1. assures competence; and, if so, how and how effectively does it do that.
2. protects the public from harm; and if so, how effectively does it provide that protection; i.e., how much harm and what kinds of harm occurred before and after each agency was established.
3. achieves its stated objectives; and, if so, to what extent does it do that for each objective. If either COMTA or NCE achieves its stated objectives, why does the other exist? If neither achieves its stated objectives, why do they both exist?
Those who do the evaluation should clearly define such terms as competence, harm, and risk of harm so that everybody will have a clear understanding of what they are talking about.
Each agency should provide whatever well-documented information the evaluation requires.
IS STATE REGUALATION NEEDED
AND IS IT LEGAL?
State regulation does not assure competence and does not protect the public from harm by requiring massage therapists to graduate from accredited schools and pass the National Certification Examination.
Therefore, does state regulation violate Constitutional law and U.S. Supreme Court decisions which
1. protect freedom of speech and freedom of the press, including commercial speech and use of the generic term massage?
2. prohibit discrimination and arbitrary governmental interference in lawful business?
3. prohibit restraint of trade, monopolies, and unfair trade practices?
Does state regulation also violate the "right to work" provision in the United Nations' International Bill of Human Rights?
IS STATE REGULATION OF
MASSAGE A HOUSE OF CARDS
BUILT ON SAND?
A comprehensive and in-depth evaluation of the entire regulatory structure for massage therapy, including its state and private components, is long overdue because:
1. The need for state regulation is not supported by well-documented evidence. It rests on a paradigm of allegations. This raises the question, "Is state regulation of massage a house of cards built on sand?"
2. There is no well-documented evidence that state regulation assures competence and protects the public from harm.
3. There is no well-documented evidence that state regulation could protect the public from harm if that protection were needed.
4. There is no well-documented evidence that allegedly inadequately trained massage therapists have caused sufficient harm to justify the alleged need for state regulation to protect the public from that harm.
5. Because there is no general agreement on what an adequate training for massage therapy is, state regulatory requirements differ widely and wildly. Therefore, geography determines whether an individual is or is not legally qualified to do massage!
6. State regulation itself causes harm. It prohibits practitioners, who do not meet unjustified requirements, from continuing to earn a living by doing massage, despite the fact that many of them have had many satisfied clients for many years without having harmed anybody.
The talk about the need for national uniform requirements, throughout the United States, will not solve the problem of unnecessary state regulation. Since there's no need for state regulation, there's no need for national regulation. National standards will only nationalize unnecessary and unjustified state regulatory requirements
The issue of harm
One of the main arguments to support the alleged need for state regulation is that it is needed to protect the public from harm. This argument is based on the fact that contraindications are potentially harmful, But those who promote state regulation do not provide legislators with well-documented evidence about how much harm has actually occurred.
If contraindications were associated with a significant amount of serious harm which has actually occurred, one would expect NCE to devote a significant amount of its content to contraindications. In fact, NCE devotes only about 1% of its content to contraindications. Obviously, contraindications are not very important in the practice of massage. The most logical reason why contraindications are not very important in the practice of massage is that they have so seldom been associated with serious harm.
COMTA requires that contraindications be included in the instructional program. But we are not aware of any published information that COMTA-accredited and approved programs do a better job of teaching about contraindications than schools which have not met COMTA's standards.
How and by whom should
state regulation be evaluated?
We have pointed out elsewhere why the state regulatory apparatus should be evaluated by the guidelines in the Pew Health Profession's Report of the Taskforce on Health Care Workforce Regulation, That report is entitled, Reforming Health Care Workforce Regulation. Policy Considerations for the 21st Century (December,
The basic issue with which an evaluation should directly focus is what well-documented evidence justifies the need for state regulation and for the private agencies which are components of state regulation. In other words, do they achieve their stated objectives: and, if so to what extent?
If there is no such well-documented evidence, that's the end of the evaluation. There is nothing more to do but write a brief report that state regulation and the private agencies associated with state regulation, COMTA, and NCE are not needed.
Some states are considering deregulating occupations, for which there have been few if any complaints during the past several years. This highlights the need for definitive information about how many complaints and what kinds of complaints have been filed against massage therapists during the past several years in states which regulate massage.
This information should then be objectively evaluated to determine whether other means are available to handle complaints from the points of view of the state, the public, and the massage therapists and clients who are involved. Those who allege that state regulation is the most advantageous way to handle such complaints should be required to provide well-documented evidence that it is.
The evaluation of regulation should not be done by components of what Steve Eabry calls the massage industry, which benefit economically from state regulation, but by an independent body with no vested interest in the issue one way or another.
Steve Eabry has differentiated the massage industry from the massage profession. "The work and the worker are the bodywork profession. The industry is not part of the profession. The industry includes the organizations, media, table and product manufactures, regulators, and schools."
The Commission for Massage Therapy Accre-ditation (COMTA) and the National Certification Examination (NCE) are part of the massage industry.
Our research has revealed no well-documented evidence that state regulation (a) assures that massage therapists are competent, (b) protects the public from harm allegedly caused by practitioners who are allegedly inadequately trained and therefore allegedly incompetent, and (c) reduces prostitution.
One therefore wonders whether COMTA and NCE can assure competence and do protect the public from harm. The simplest way to begin researching this issue is to examine well-documented evidence which reveals whether NCE and COMTA in fact achieve their stated objectives; and, if so, how and to what extent.
Those who administer such agencies have an obligation to provide this information because those who are affected by these agencies are entitled to have this information.
Therefore, ... I say unto you, Ask and it shall be given to you; seek, and ye shall find; knock, and it shall be opened unto you. For every one that asketh receiveth; and he that seeketh findeth; and to him who knocketh it shall be opened. Luke 11:9-10
IS COMTA NEEDED?
I was pleased to see the following notice in the Fall, 1998, issue of the COMTA NEWS newsletter. Thank you for this invitation.
We' d like to hear from you.
Please write and tell us what's
on your mind.
What is on my mind is, 'What well-document-ed evidence does COMTA have that it achieves its stated objectives?"
My questions about COMTA are motivated by the following phrases in COMTA's 'Mission Statement and Purpose (Document 1-1. Adopted October 1997).
1. COMTA's "mission ... is to maintain and improve quality assurance."
2. "focusing on programmatic content and quality."
3. "students receive quality education and training."
4, "the public receives quality services."
5. "the public ... is assured a certain standard of quality."
6. "standards developed and monitored by the Commission."
7. "a universally accepted yardstick of standards."
8. "the industry receives competently trained practitioners."
Why is COMTA called the Commission on Massage Therapy Accreditation? COMTA accredits programs of study. Programs of study are not massage therapy. How can COMTA accredit massage therapy?
Are COMTA's standards
Why are COMTA's standards described in the Mission Statement as "universally accepted"? COMTA's standards are not accepted by all 700 or more schools that teach massage and other kinds of bodywork.
As of 10/19/98, only 27 schools in the United States and one in Canada had COMTA's accredited programs. Only 17 schools in the U.S. and one in Canada had COMTA's approved programs. This gives a total of only 46 schools.
Therefore, only about 6.5% of the 700 or more schools have COMTA's accredited and approved programs. If we take into account all schools in Canada and other countries, the figure would probably be considerably less than 1%.
How does 6.5% and less than 1% equate to "universally accepted"?
What well-documented evidence does COMTA have that graduates from COMTA's accredited and approved programs are more com-petent than graduates from programs which do not meet COMTA's standards?
How does COMTA define and objectively (quantitatively) measure the competence of practitioners and the quality of their hands-on work?
If COMTA cannot objectively measure the above-mentioned competence and quality, how does COMTA know that COMTA's accredited and approved programs produce more competent massage therapists than programs which have not met COMTA's standards?
The Purpose in the Mission Statement tells us: "The benefit of program accreditation lies in the fact that the public to whom the profession is rendering a service is assured of a certain standard of quality from the graduates of accredited programs."
If the quality of hands-on work cannot be objectively (quantitatively) measured, how can there be an objective standard of quality?
If COMTA does not have an objective standard of quality, what kind of standard does COMTA have?
What well-documented evidence does COMTA have that massage therapists, from programs that have met COMTA's standards, provide services of better quality than massage therapists from programs which have not met COMTA's standards?
How has COMTA affected
the public's image?
What well-documented evidence does COMTA have that COMTA's accredited and approved programs have raised "the profession in the eyes of the public" and have increased "the public's confidence."?
What well-documented evidence does COMTA have that graduates of COMTA's accredited and approved programs are more highly regarded by the public than graduates of programs which have not met COMTA's standards?
What well-documented evidence does COMTA have that the public has more confidence in massage therapists who graduate from COMTA's accredited and approved programs than in massage therapists who graduate from programs which have not met COMTA's standards?
COMTA and the
National Certification Examination
What percent of graduates from COMTA's approved and accredited programs, and from programs that have not met COMTA's standards have passed and failed the National Certification Examination?
What percentage of practitioners who have passed and failed the National Certification Examination are graduates form COMTA's approved and accredited programs and from programs that have not met COMTA's standards?
Does COMTA protect the
public from harm?
What well-documented evidence does COMTA have that bodyworkers from COMTA's accredited and approved programs have caused significantly less harm in people, with and without contraindications, than graduates of programs which have not met COMTA's standards?
If there is no such well-documented harm, is it not appropriate to assume that COMTA's accredited and approved programs are not needed to protect the public from harm?
Is massage an industry?
Why does COMTA's Mission Statement refer to massage therapy as an "industry"?
Should massage be included with the pharma-ceutical industry, the petroleum industry, the steel industry, the optical industry, the automobile industry, the clothing industry, the entertainment industry, the home appliances industry, the entertainment industry, etc.?
Massage therapy is a personal service in which a skilled practitioner works directly on an individual's body, without using tools, to enable an individual to regain and/or maintain her well-being.
Massage is not a trade. The term trade applies to skilled work done with tools. Electrical work, plumbing, carpentry, masonry, auto mechanics, and stone cutting are examples of trades. Tradesmen serve people by working on their property, and things such as refrigerators and TVs.
IS NATIONAL CERTIFICATION
Those who cannot remember the past are condemned to repeat it. - George Santayana
The following vignette of massage history motivated us to question whether there is well-documented evidence that the present National Certification Examination measures competence.
In 1988, "The AMTA National Board of Directors unanimously approved a plan to develop a National Certification Examination in massage therapy." But national certification became controversial, and engendered 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 misunder-standing and misrepresentation."
This brochure was to be distributed before "The first administration of the new certifying examination [was] projected to take place in the Fall of 1991."
By 1991, the growing opposition to national certification motivated the Public Information Committee of the Council for the National Certification Program for Massage Therapists to respond to the 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?"
So, in 1991, this Committee, which supported national certification, unequivocally admitted that "a written examination ... cannot test for ... "hands-on work, which it considered "essential" for massage therapy.
If a written exam could not test for hands-on work in 1991, how can the present written National Certification Examination measure competence in 1999?
n October 10, 1997, a news release from the National Certification Board for Therapeutic Massage & Bodywork, was entitled NCBTMB Content Outline Aligns Exam with Profession's Task.
This news release states, A "blueprint for determining the content of the exam ... is used for construction of a state of the art written exam- nation that assesses the current knowledge and competencies required to practice therapeutic massage and bodywork."
These competencies, which are allegedly assessed by a state of the art written exam, are the ones required to practice (i.e., do) massage and bodywork. This means the written test allegedly "assesses" (i.e., measures) an individual's competence to do hands-on work.
The August, 1998, National Certification Examination Candidate Handbook, which is currently used, provides the following information:
1. "The exam ... is 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."
If a written exam could not test hands-on work in 1991, how can the present written NCE test hands-on work?
If the present written NCE cannot test hand-on work, how can it test the competence of the hands-on worker?
If the present written NCE cannot test hands-on work and cannot test the competence of the hands-on worker, a test score on the written NCE does not tell us anything about the competence of the individual who got that test score.
We define competence in massage therapy and other kinds of bodywork as the practitioner's ability to provide a hands-on service which has the quality that satisfies her clients.
There's no well-documented evidence that a written exam can test hands-on competence today, than it could in 1991.
Consequently, there's no well-documented evidence which justifies the allegation that the present NCE measures the competence of massage therapists and other bodyworkers.
There's also no well-documented evidence that massage therapists who have passed NCE have caused less harm in people, with and without contraindications, than massage therapists who have failed NCE?
If there is no such well-documented harm, isn't it appropriate to assume that NCE is not needed to protect the public from harm?
Test scores take us to Alice in
National Certification Land
What NCE tells us is how many questions an individual has answered correctly by knowing the answers or guessing correctly from the selection of answers offered. NCE assumes that a test score measures competence to do hands-on work. But this assumption raises serious questions.
1. If competence in the performance of hands-on work can be directly and objectively measured, why have a written test?
2. What well-documented research tells us that a written test (regardless of what questions it includes) can measure competence in the performance of hands-on work ?
3. Do all who get the same score on the same written test have the same amount of knowledge that is required to do the same kind of hands-on work competently?
Even if some people all have the same amount of knowledge, they don't all have the same kind of knowledge.
They would not all have the same kind of knowledge even if they had all answered the same (multiple choice) questions correctly and the same questions incorrectly, and had the same score.
People's knowledge differs qualitatively, and this qualitative difference in knowledge may influence their competence in terms of the quality of their hands-on work.
This is the Alice in National Certification Land in which we find ourselves if we try to figure our how NCE can measure competence in the performance of hands-on work.
But we don't have to do this. Those who allege that NCE measures competence have an obligation to provide well-documented evidence that it does.
Many people make a living by doing massage. They have had many clients, for many years, who have been satisfied with their hand-on work. And they have not harmed anybody.
Is it lawful for state regulation to suddenly tell the prople, mentioned above,that they are not qualified to continue earning a living by doing massage unless they pass the written NCE which does not measure their competence to do massage and does not protect their clients from harm?
SOME PERSONAL COMMENTS
By your words you will be justified, and by your words you will be condemned. (Matthew 12:37) This applies to me and to those who disagree with me.
To my opponents, I say, "If you can justify what you say, have no fear that, I will condemn you out of your own mouth." (Luke 19:22) In like manner, I must also justify what I say, lest I be condemned.
I have no vested economic interest in the issues which I research. No patron or grant compensates me for the research I do and the reports I publish. "I pay my own way."
I am neither prosecutor, judge, or jury. I am a retired professor for whom investigative reporting on certain aspects of massage has become a second career. History will judge me and those who oppose me.
I am also a research scientist who has been applying, to controversial issues in massage, the modus operandi that I have used for more than half a century.
I taught Swedish Massge for several years.
I emphasize the importance of relying on well-documented evidence rather than unsubstantiated allegations because the latter cannot resolve controversial issues. On the contrary, unsub- stantiated allegations create and prolong controversy.
I believe those whom I question (and others) have the right to question me, and that we all have an obligation to answer questions addressed to us.
For me, the important issue is not whether I am right or wrong, but what is best for massage therapists and for the public. I prefer to be right; but I want to know when, where, why, and how I may be wrong. This is one way we learn.
If I have been wrong, I shall publish that because I have an obligation to do so. Those who disagree with me have that same obligation.
Our other reports on state regulation and related subjects are on the internet <http://www.tiac.net/users/maryella/>.
The editors of the Massage Law Newsletter believe that a large part of the history of progress is the history of controversy. They therefore welcome constructive dialogue with those who have different views on state regulation and will publish their comments, letters, and articles in this newsletter.