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Expanding Our Scope, Protecting Our Future

There have been numerous attempts to come up with a good working definition of  massage therapy. While I certainly appreciate the effort that has gone into them, in my opinion, most have fallen short in one way or another. Part of the problem is that massage therapists are independent-minded and are harder to organize than a bunch of cats. If you look at the 44 state massage laws that currently exist, you’ll find 44 different versions of what is called a scope of practice definition. Add to that the newest definitions found in the MTBOK and the ELAP, and we’ve got a murky mess that makes it nearly impossible to achieve portability of licensure. In fairness to the creators of both of those documents, which were collaborative efforts with support from all of the professional massage organizations, they were put out for public comment, which really didn’t amount to a ripple in the general scheme of things. My attitude is, if you didn’t take time to comment, then don’t gripe about the results.

We arrived here because there was no common template that was used during the rush to get state massage license laws passed over the past 15 years. Licensure standards are much more consistent in other healthcare professions because each one has been working from something called a Model Practice Act (MPA). I’m wondering… where can we get one of those?

Well, after nearly a decade after it came onto the landscape, the Federation of State Massage Therapy Boards has finally come up with their own MPA. They’re wrapping up the open comment period on the first public draft of this document, which has been posted to the their website. Much of it is run-of-the-mill legislative kind of language, but some sections really need further work. I’ve sent them my comments, and I hope you have too.

What I’m most concerned about in the FSMTB Model Practice Act is the scope of practice definition. As presented, it could restrict what massage therapists are allowed to do in their practices in the future. That’s a giant problem. If we define ourselves in a narrow way, other healthcare providers and business interests will ensure that we stay in our own little box.

Fortunately, I just heard from my North Carolina colleague Rick Rosen on this subject. He has developed what I think is a much more appropriate definition that strengthens and clarifies the diverse range of massage therapy practice in a way that expands possibilities, rather than shrinks them. By the way, Rosen was one of the co-founders of FSMTB, and was also the founding chairman of our state licensing board in NC, where he contributed to the writing of its laws and rules. Here’s what he said in his comments to the MPA Task Force:

“I am concerned that the definition set forth in Section 103 of the MPA is potentially limiting, as it characterizes the work performed by licensees as only that which relates to the manual application of techniques to the soft tissues of the body. Massage therapists are much more than pressure-delivery technicians. For example, they interact with clients in varied ways and provide assessment, treatment planning, and make recommendations for changes in a client’s ergonomic usage and movement patterns that can reduce chronic muscle tension. In addition, massage therapists can work with body awareness to assist clients in reducing stress and developing a healthier sense of self.”

“During the start-up phase of FSMTB in 2005, we looked carefully at the structure of board federations in other health care professions. I remembered from that research that most health care professions had robust and extensive scope definitions, as compared with the relatively one-dimensional definitions found in state massage practice acts.
With that in mind, I accessed the current model practice acts from the fields of nursing, physical therapy and occupational therapy. Using these templates as a guide, I developed a new definition that is broadly inclusive of the range of treatment models in our field, and establishes an expanded scope that more accurately represents the major areas of application in clinical practice.”

With that said, I’m sharing the full text of Rosen’s proposal for a new scope of practice definition:

PRACTICE OF MASSAGE THERAPY. A healthcare service of the healing arts provided to clients by a person who is licensed pursuant to this Act.

(1) The practice includes:

(a) Assessment of the functional and structural characteristics of the myofascial network and related systems of the body through tactile, visual and verbal methods;

(b) Treatment of the myofascial network and related systems of the body using manual methods, or by mechanical or electrical devices or tools that emulate or enhance the action of human hands;

(c) Active or passive movement of the body within the normal anatomical range of movement;

(d) Application of lubricants and other topical agents to the skin;

(e) Use of hydrotherapy and other adjunctive methods to produce therapeutic effects;

(f) Client education to facilitate body awareness and self-care;

(g) Treatment planning, communicating or collaborating with massage therapists and other licensed healthcare providers, and engaging in research, teaching and administration.

(2) Primary areas of application for massage therapy include:

(a) Wellness/Stress Reduction: treatment that supports the general health and well-being of the client, facilitates the relaxation response, addresses patterns of chronic tension related to stress, reduces pain and discomfort, promotes a more positive sense of self;

(b) Corrective/Rehabilitative: treatment that addresses specific symptoms or conditions, provides rehabilitation from the effects of injury, trauma or surgery

(c) Performance Optimization: treatment that improves the performance of specific activities or occupations, facilitates postural alignment and more efficient ergonomic patterns of use;

(d) Palliative: treatment for clients in recovery from illness or in the end stage of life that focuses on providing psychosocial support and relief from discomfort;

(e) Integrative: treatment that promotes awareness of the connections within the physical, cognitive and emotional aspects of the client, as well as treatment in conjunction with other licensed medical or mental health providers in a coordinated plan of care.

(3) The practice does not include:

(a) The diagnosis of illness or disease;

(b) Medical procedures, high-velocity low-amplitude chiropractic adjustive procedures, or prescription of medicines.

(d) The use of modalities for which a license to practice medicine, chiropractic, nursing, physical therapy, occupational therapy, acupuncture or podiatry is required by law; or

(d) Sexual activity of any kind.

I think Rosen has nailed it here. Without going beyond what we should do, this is more inclusive and a much more accurate description of what we do actually do. This more inclusive definition could save us headaches down the road if we are challenged by other professions for infringing on their scope of practice.

Today, June 15, is the last day for public comment on the MPA. Please pass this around… this should be the start of some interesting and important discussion. There’s nothing less than the future of the massage therapy profession at stake, so we have to get this piece right! Don’t sit on your hands. Take the time to comment, and if you don’t, then you are giving up any right to complain about it after the fact.

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It’s All About Me

It’s all about me, so here’s my wishlist for the profession. It’s difficult to place these in order of importance, because some of them depend on each other, and in my little corner of massage, they’re all important. It’s election time–aren’t we all just about sick of hearing about it–candidates mudslinging and making campaign promises? If I was the President of Massage Land, here’s what I’d do:

The Federation of State Massage Therapy Boards would sit down at the table with the National Certification Boardand hammer out an agreement to a) help ease the NCBTMB out of the entry-level test market, b) contract with them to collaboratively administer continuing education instead of trying to take it over and c) forget their MOCC-ERY plan.

The NCBTMB would a) graciously accept that it’s time for them to get out of the entry-level test market, b) focus on cleaning up the CE approval program, and c) get it together with their new plan of raising standards of certification.

Both of these entities would cease and desist in sending out Job Task Analysis Surveys that are flawed from the get-go….they both supposedly pay psychometricians to help them out with these things, and still they are falling way short of the mark in ascertaining what they really need to ascertain. Stop worrying about how many times a week we give a massage, and stop ignoring the relaxation benefits of massage as if they don’t exist.

There will continue to be Leadership Summits. They will stick to the agreed-upon agenda at their meetings and not allow major surprises  to slide in from any of the organizations, and they will practice complete transparency and stop sending out press releases that contain no more information than an invitation to a baby shower.

Every one who is involved in massage therapy education will join the Alliance for Massage Therapy Education.

The profession will come to a consensus on what constitutes required core competencies for entry-level education, while still giving school owners the autonomy and individuality to rise over and above that.

All unregulated states will get state-wide regulation and all localities will honor those and not place ridiculous additional burdens on licensed therapists.

All massage schools will be required to teach research literacy to their students, and will only hire instructors who are capable of doing so.

The NCBTMB will stop approving woo-woo courses for CE credit, and all entry-level massage schools will stop teaching it. I don’t care if you study Interplanetary Voodoo with the Archangels, but you don’t deserve any credit for doing that.

Our professional associations will conduct annual surveys that have NOTHING to do with a Job Task Analysis–the sole purpose of it will be “Tell us what you think we are doing wrong and give us your suggestions for how we could do it better.”

The Alliance for Massage Therapy Education will develop a program to offer instructor training to the masses that will be accessible and affordable–perhaps online.

Board members of all representing organizations will recognize their responsibility to not blindly follow the leader; to avoid not only conflicts of interest, but the appearance of conflicts of interest; will not put up with any cover-your-ass type behavior within their organizations; will hold their hired leadership accountable, and will have enough gumption to get rid of them if and when such behavior occurs.

All massage schools would seek COMTAapproval. If your school can’t afford that or doesn’t qualify because of not meeting the hour requirement, may I say that their standards are on their website for all the world to see for free, and you could still go about the self-study process and getting things up to snuff, even if you don’t formally seek the accreditation.

All school owners would be bound to have their school bonded, so that no school goes bankrupt and leaves students in the lurch in the middle of their program.

All schools would be required to post their pass rates on the licensing and certification exams on their websites and in their catalogs.

No school owner will be allowed to say to a potential student “Don’t worry, your criminal record won’t keep you from getting a license.” It should be mandatory for it to be disclosed that they may not receive a license. The state of Texas has a non-binding review, where for $50 a person seeking a career in any licensed profession can submit their criminal record for review prior to spending their time and money on pursuing education. Every state should do the same.

There should be a national exam for instructors to prove they are competent in teaching methodology and a subject matter expert in whatever area they intend to teach.

Each state should require a jurisprudence exam. Your licensees can’t adhere to the law unless they know what it is, and the percentage of applicants who actually read your practice act in its entirety is probably less than 5%–I’m basing that on asking that question in all the classes I teach. Hardly anyone reads them, but if they had to pass a test on it, they would.

The Massage Therapy Body of Knowledge would be about massage.If you want to have an energy work body of knowledge, create that.

Everyone involved in the profession would give financial support to the Massage Therapy Foundation. Give $100. Give $5. Give $1. Give whatever you can afford to give, just do it.

 

I could probably go on for days, but I have other chores to get to today. I invite my readers to add what they will. What’s on YOUR wishlist? What’s on mine that you object to, and why?

 

 

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The ELAP Flap Continues

Earlier this week I received the ELAP (Entry-Level Analysis Project) Description from ABMP. I’ve been blogging about this for several weeks, first because I was upset that it was shrouded in secrecy; then last week because I finally got word of who is serving on this work group. While that information didn’t exactly smooth my ruffled feathers, I was gratified to see that I know some of the people working on it and know that they do the best job they can at whatever tasks they take on. And the document has changed quite a bit from the first proposal I saw, which I had numerous objections to (see previous blogs under this one). That being said, I’m still not thrilled with it.

I feel that there are some big pieces missing here, and that the profession would be better served by pointing resources in a different direction. To begin with, the document makes the point that how regulatory agencies arrived at the 500-hour minimum that has been a benchmark of entry-level education is unknown…that’s true, but it’s also unknown of how states with more hours arrived at those requirements. One thing that’s mentioned is the influence of federal financial aid, which presumably has led some schools  to offer more hours (or states to require them). As is the case with a lot of things, following the money trail often gives insight into real motivation.

Personally, I don’t think financial aid, or the lack of it, should be influencing this project at all. As a former school administrator, I’ve been involved in the financial aid process first-hand in the past. Whenever a recession and massive job layoffs happen, as they have here in my home state for the past three years or so, there’s a phenomenon that occurs. There’s an influx of displaced workers into the community college system, where financial aid is a given, and I’ve been told by students who had never even considered massage as a career that “the job counselor said I could get my schooling paid for if I would study massage.” That’s just not the reason I want to see people coming into the profession.

I feel there are some other tasks that need to be completed before anything like this is undertaken. The ELAP description states only two goals, one of which is to assess how many program hours are needed to attain this KSA (knowledge, skills, and abilities) goal, assuming capable instruction.

That’s a major issue, in my opinion—because you can’t and shouldn’t assume capable instruction. The Alliance for Massage Therapy Education is working on a National Teacher Education Standards Project to define the KSAs needed by teachers, both entry-level and more experienced/advanced. There is also a line-by-line review of the MTBOK going on. To charge headlong into the ELAP before these two initiatives are complete seems like putting the cart before the horse.  In all fairness, I am glad to see our organizations collaborating instead of refusing to play nice, but I would prefer to see them applying their resources to the National Teacher Education Standards project. The ELAP claims to be addressing what it takes to make a therapist able to practice competently. The fact is if the teachers aren’t competent in a 500-hour program, they’re not going to be any more competent in a 750-hour program until they are educated. We need educators who are competent enough to teach competencies, not just stand in front of a classroom for a longer number of hours.

Part of the rationale for this entire undertaking is the perceived  lack of competence of entry-level therapists. While the FSMTB is about to launch a new Job Task Analysis Survey, and the NCBTMB recently did the same, we ought to bear in mind what it is that a JTA shows. They tend to be snapshots of a day in the life of a massage therapist: see the clients, do the laundry, keep up the paperwork. If the perception is that therapists are not doing what they need to do in order to keep the public safe and practice competently, is asking them what they do all day really effective for this purpose? I don’t think it is. As one of the comments on last week’s blog said, “They don’t know what they don’t know.” There will be also be an accompanying survey within the JTA survey, intended to eliminate the “experience bias” present in these types of surveys, but I think that’s a tricky proposition. The return rate on these surveys tend to be very small–and usually answered by the minority of us who actually give a rip about the state of things. JTA surveys tend to be long and somewhat boring and it’s a very small percentage of people who will even fill them out to begin with.

Reportedly, the ELAP project was conceived to help address the problem of portability of massage between the states. One of the statements reads in part “we need to identify the key KSAs required to pass a national licensing exam and provide competent, safe massage in an early massage career.”

Right there is another problem. While the FSMTB would like to see every state exclusively using the MBLEx, it hasn’t yet happened. Since the NCBTMB is increasing the requirements for National Certification, leaving them with only the NESL options for entry-level exams in the states that accept those, the MBLEx will undoubtedly become exclusive in some places, but New York is not going to throw over their exam for the MBLEx, in my opinion. There is no such thing as national licensing, and there is never going to be. National licensing doesn’t exist in any profession I am aware of. If you’re a doctor, you still have to get licensed in each state in which you want to practice. While portability is a pain in the butt for massage therapists, it has never been shown to be harmful to the public or to the profession on the whole. Inconvenient, yes; but harmful, no.

The FSMTB is also working on the Model Practice Act, as mentioned in the ELAP description. While I wouldn’t go so far as to say it’s a waste of time, I don’t expect any influx of the regulated states lining up to change their existing practice acts to whatever the FSMTB comes up with. I’m sure it will be a helpful guideline for the unregulated states if and when they decide to join the fold, but it will be interesting to see how that document ends up harmonizing with the ELAP. Since the MBLEx has been an exam that uses the 500-hour threshold (and in fact, you can take that exam at any point during your education, prior to graduation), if this project somehow demonstrates that more hours are needed, is the FSMTB going to jack up the requirement to sit for the MBLEx? The Model Practice Act project was also undertaken prior to the ELAP project starting up, and while I haven’t seen a draft and don’t know what it includes, my prior knowledge of state practice acts demonstrates that those generally spell out required education and the breakdown of those hours, so presumably the ELAP would affect the Model Practice Act project as well.

Another part of the hoped-for result of this project is to cut down on the number of lawsuits and ethics complaints against entry-level massage therapists. Personally, I believe someone who is going to act unethically is going to do it regardless of how much education they have. When it comes right down to it, the injuries resulting from massage are a tiny fraction of what they are in other health-care related fields. I’m not saying there aren’t any, but on the whole it’s relatively insignificant when compared to the number of practitioners.

Lest anyone think I am against raising the standards of the profession on general principles, that’s not so. I don’t own a school, and I’m already licensed, so it’s not like this is going to inconvenience me personally. In fact, a few years ago when I was on the North Carolina Board of Massage & Bodywork Therapy, we looked at raising the hour requirement here (currently it’s 500 hours). Like any good organizational beaurocracy, the result of that was to appoint a committee to study the situation. The research they conducted was to ascertain whether or not students from schools with higher number of hours had a better pass rate on the exams than students from 500-hour schools. The answer to that was a big fat “no.”

I’m not sure how much money is being spent on this project; the first proposal I saw mentioned between $60-70,000 to be shared as an expense between the organizations. I urge, or rather, challenge, all of these organizations to pour an equal amount of money into the AFMTE Teacher Standards project. Improving the KSAs of entry-level educators—many of whom tend to be last year’s star students, who may be talented at massage but without a whit of experience and training in teaching methodology—will improve the KSAs of the students, the entry-level practitioners. That should be the important first step—the key word there being first. Don’t try to build a house without a good foundation. It’s a waste of time and money, and ultimately, it doesn’t work.