and the National Certification Examination be abolished?

Two alternatives to state regulation, the Commission on Massage

Therapy Accreditation, and the National Certification

Examination avoid monopoly control

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.

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?

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

We' d like to hear from you.

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."

 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"?

Does COMTA

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?

 Questions about

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

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

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.

The following vignette of massage history  motivated us to question whether there is well-documented evidence that the present National Certification Examination measures competence.

"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."

Questions

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.

Conclusions

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

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.

Conclusion

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?

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/>. 

Another alternative to state regulation, which also avoids monopoly control, is Barbara York's proposal for what she calls a permit system. Barbara is a Jin Shin Jyutsu practitioner, in Minneapolis, who  has been in touch therapy since 1983. She is president of the Minnesota Touch Movement Network. This professional state- wide organization was originally formed  in 1981 as the Minnesota Therapeutic Massage Network.

Her permit system would include massage therapists, bodyworkers, touch therapists, and somatic educators. It incorporates many concerns of the (now defunct) Coalition of Touch Therapists and Somatic Educators. This group existed for several years, working on options instead of licensure.

Her permit system is the least restrictive form of regulation, with no state requirements for education, experience, or standards of practice. It would require only professional ("malpractice') liability insurance.

There is no need for state regulation, COMTA, and NCE because:

The insurance companies already determine education, experience and other requirements, and screen and weed out applicants with prior and pending criminal activity, whether there is a conviction or not. The insurance companies would be responsible to the State Department of Commerce.

No grandparenting would be involved because anyone could obtain a permit at any time  if  he obtains professional liability insurance. The state would maintain a list of therapists holding permits and respond only to complaints.

This permit system would allow prac-titioners to obtain a statewide permit which is especially useful if bodyworkers are dealing with licenses in multiple municipalities.

The permit would include all modalities of education. So, for example, a reflexologist could obtain a permit without having to train as a massage therapist in order to meet a municipal requirement. The goal of the bill is inclusivity instead of exclusivity at a high price.

State regulation of massage does not prevent harm, does not protect the massage therapist in a personal injury claim, and does not pay the injured client any compensation. Insurance therefore provides more protection for all concerned than state regulation does.

Because massage is safe, the cost of professional liability insurance for massage therapists has decreased significantly, while the cost of medical malpractice insurance has significantly increased.

The most likely explanation for the significant drop in the cost of professional liability insurance is that insurance companies recognize that massage is not harmful.

The fee was originally $150, then $165, and finally $195. If we assume an  average fee of $170 (because the number of people taking the exam has increased annually) the gross income for the seven year period is about $5,780,000.

Table 1 provides information about how many people passed NCE for five years.

Table 1  

  ___________________________________

     Year            No. who                Passed

                         took NCE           No.          % 

    1992                  897               848          98

    1993               1,289             1,264         98

    1996               5,497             5,295         96

    1997               6,986             6,786         97 

    1998               8,588             7,902         92                    

        Total       19,983           21,071        

An average of 96% passed and 4% (1,360 out of 34, 000) failed. This means that an average of 26 failed in each state for the seven year period, and 3.7  failed annually in each state.

The average total fees paid annually, during the seven year period are $826,000. This means that it cost $22,300 to detect each one of the average number of 3.7 people who failed the exam annually in each state.

What do we know

1. We know they failed the exam. But what does this mean?

2. We know there is no well-documented evidence that they are less competent than those who passed the exam because we know that a written test cannot measure competence in hands-on performance. Therefore, no one knows  that those who pass are more competent than those who fail.

3. We know they are not more likely to harm people than those who pass the exam because we know that no harm has actually occurred.

4. We know that Georgia legislators, who did their own research, concluded, "There is no documented evidence of actual harm to the public... The potential for harm to the public appears to be remote and would not be alleviated by licensing."

5. We  know that NCE, which some state regulatory requirements include, does not  protect the pubic from harm because there is no well-documented evidence that state regulation, with or without NCE, protects the public from harm.

Questions

 Does having the information - that an average of 3.7 people (who are competent and do not  cause harm) failed the exam in each state annually - justify the $5,780,000 fees that 34,000 people paid?