Kelle Walsh, Managing Editor
the 1990s the number of states that regulated massage therapy more
than doubled, from 14 states in 1989 to 29 states plus the District
of Columbia just 10 years later. Since then, four more states have
passed regulatory laws - Mississippi, Illinois, Kentucky and Arizona.
Industry experts speculate that in time most, if not all, states
will regulate massage.
of regulation see it as a way of: untangling massage therapy from
a net of city and county regulations aimed at curbing prostitution;
standardizing a wide range of education levels among therapists
and ensuring a baseline of knowledge and skill; and earning professional
credibility as health-care practitioners.
of state regulatory laws say that the laws: limit the range of massage-therapy
practices by requiring what they believe are arbitrary education
standards; legislate an agenda promoted by one group; and most of
all, that there has no been no proof that state laws are needed
to protect the public.
shift away from a relaxation model of massage and toward a standardized,
regulated version has come at a cost. Legislative efforts have sparked
the most divisive debates to ever face the profession.
seven years, Danny Holland evaded the law. The self-taught massage
therapist worked on both male and female clients in Charlestown,
South Carolina, despite restrictions in the state’s massage-parlor
statute that made it illegal to perform cross-gender massage. Holland,
like many of his peers, tried to stay below the legal radar in order
to do the work he loved and that his clients needed.
"We just ignored
[the law] and hoped it would go away," Holland says.
During the 1980s and early
1990s, while massage therapy’s acceptance grew throughout
the country, therapists in South Carolina were still bound by the
Massage Parlor Act of 1976, which was created to curtail prostitution.
In addition to restrictions on cross-gender massage, the law also
required that practitioners undergo testing for sexually transmitted
diseases (STD) each month. According to Holland, no therapist he
knew agreed with the law, but most didn’t think they could
Yet when Holland heard
about an effort to establish state licensure just for massage therapists,
instead of feeling relieved, he was afraid.
The proposed law required
that therapists have 500 hours of education and pass the National
Certification Exam for Therapeutic Massage and Bodywork (NCETMB)
- qualifications that self-taught and apprenticed massage practitioners
like Holland didn’t have.
"It scared us to
death because we didn’t have the formal education," Holland
says. "I thought I was going to have to go back to construction
The author of South Carolina’s
massage law, Carolyn Talley Porter, recalls getting little support
for the effort from the state’s massage community. "I
couldn’t get any massage therapists to help me," she
says. "Everybody was negative. I had some people say, ‘Just
leave it alone.’ I did a lot of these town meetings and I
thought people were going to hang me."
But Talley Porter was
determined. "I told people, ‘I won’t work under
that prostitution law. You might work under it, but I won’t.
And if you want to stop me, you can show up before the [legislative]
committee when the bill would be introduced," she said.
She struck a nerve. Instead
of fighting the effort, after about a year, therapists began joining
Talley Porter on her weekly pilgrimages to the state capitol to
educate legislators about massage therapy.
One of those therapists
was Danny Holland. Holland explains that when he learned that the
proposed law included a provision to grandfather-in massage therapists
who didn’t have the 500 hours of education but who could prove
that they had been practicing massage for more than a year, he decided
not to sit on the sidelines any longer. "What really kept me
in was knowing that I wouldn’t have to go to school. When
I found that out I got involved," he says.
The South Carolina Massage
Practice Act passed unanimously in 1996, successfully replacing
the state’s massage-parlor law. Talley Porter says that one-time
opponents of the licensing law became its biggest fans, and saw
their businesses grow.
"Once the therapists
could say, ‘I’m a licensed massage therapist,’
it brought more credibility to the picture," she says.
Holland agrees. "I’ve
had some folks ask, when they first call, ‘Are you state licensed?’
[People] are checking you out," he says. "Saying that
I have a state license has changed a lot of people’s minds
South Carolina’s success in wiping out an oppressive, inappropriate
massage law came relatively easy. One person’s unwavering
conviction that the law could be changed was enough to motivate
others to fight for their dignity. But the battle is rarely so swift
- nor the issues so clear.
In the past 10 years,
state regulation of massage therapy has fueled the industry’s
most heated debate. Differences abound about the value of state
regulation, with supporters and opponents offering equally passionate
arguments for their beliefs.
The "pro" camp
cites the following motivations for state regulation: unequal and
oppressive local regulation; greater professional respect and visibility;
to ensure a baseline level of education and skill; a desire to work
with the medical community or to bill insurance; and perhaps the
most controversial argument, the need to protect the public from
less-educated massage practitioners who could cause physical harm.
For their part, opponents
say that state oversight of massage therapy is not the way to go.
Regulation, they say, squashes the creative art and intuitive spirit
of massage; limits the diversity of styles and personalities in
the field; and imposes an "arbitrary" designation of 500
hours education as the standard for competency. But the biggest
argument against state licensure, they say, is that its supporters
have failed to show proof of harm caused by massage therapists who
do not meet their criteria.
In most states, ordinances that regulate massage therapists were
designed to stop prostitution. For example, prior to the state massage-licensure
law that passed in 1998, practitioners in Kansas City, Missouri,
were required to have 1,000 hours of training that included an apprenticeship,
and passage of annual physicals and AIDS tests. Licenses were issued
by the same office that issued licenses to cab drivers and exotic
dancers. Meanwhile, many of the surrounding communities required
just 70 education hours, or the equivalent "of a basic Swedish
massage class," says Kansas City massage therapist Jennifer
Thorton. "Some cities didn’t require any education hours."
The nearby city of Liberty also required an annual physical, but
from a physician within the city’s health department. "You
couldn’t even go to your own doctor," Thorton says.
In California, where the
regulation debate is in full swing thanks to a massage-therapy law
poised on the docket of the state legislature, the picture is much
the same. Massage ordinances range from requiring as few as 75 hours
of education in Danville, to 1,000 hours to practice as a "holistic
health practitioner," which recognizes advanced levels of massage
and other somatic therapies, in San Diego. Some cities require that
the therapists take annual STD tests and pay fees that can run upwards
of $2,000. Since permitting requirements vary from city to city,
massage therapists who serve clients in more than one community
often must pay for multiple permits to practice.
Regulation advocates argue
that state licensure is the most effective way to quickly override
these unequal and often disparaging local laws. Of course, cities
and towns maintain the right to regulate massage-therapy businesses,
including where they can open, what kinds of equipment (windows
on doors or multiple sinks for example) must be on hand, and their
hours of operation.
But in states where massage
therapy is designated a health-care profession, municipalities can
only impose the same zoning restrictions as they do on other health-care
businesses. "[State regulation] helps on a local level, certainly,"
says Betsy Krizenesky, a certified massage therapist in Wisconsin,
where massage therapists are designated as health-care providers.
"You can’t tell other health-care professionals how many
sinks they should have."
In the mid 1990s a shift occurred in the regulation arena. While
the AMTA, whose members are often on the front lines of the regulatory
movement, does not have an official policy advocating state regulation,
according to Denise Logsden, former government-relations chair of
the AMTA, it does state that it "strives for a fair regulatory
climate." This could mean working to change laws on a local
level, a state level or choosing "no regulation if it’s
working [in that community]," she says.
But the association also
maintains the position, according to Logsden, "that state-governing
regulation of massage therapy is a desirable means of meeting the
needs of the public and the profession."
In the 1990s, therapists
in non-regulated states worked to change local laws one community
at a time, and used tools like the AMTA model ordinance and the
guidance of Associated Massage and Bodywork Professionals’
(ABMP) Legislative Services Department.
But as more states passed
laws that rescinded local regulations, the focus seemed to change
to trying to affect change on the state level. "This was true
in Virginia, and I think most people [trying to change local regulations]
think this," said Logsden, who as a resident of Virginia, helped
to implement, in 1996, that state’s law to certify massage
therapists. "Since it’s going to have to be done city
by city, and it’s more efficient, why not take care of it
on a state level?"
"In North Carolina
it was a matter of it being time consuming [to try to change every
local ordinance]," says MK Knollmeyer, the former chair of
the steering committee of the North Carolina Law and Legislative
Task Force, which helped pass that state’s massage and bodywork
law in 1998.
Knollmeyer also says that
changing local laws does not guarantee uniformity in regulation
from one city to the next - a problem for both massage therapists
who travel and consumers. "[For] the consumer, there is not
necessarily the same level of education or credentialing" of
massage therapists working under local regulations in different
communities, she says.
Beverly May, government
relations chair for the California chapter of the AMTA, described
her decision to work for a state law in an April 2003, posting to
an online forum for massage therapists and bodyworkers:
"After 15 years of
working on reform of local regulations with so little progress,
and in some cases laws getting worse, I finally reached my limit.
The progress we have made is that, unlike 10 years ago, now local
police, sheriffs and counsel members do acknowledge the legitimate
practice of massage. However, they still feel that if there is a
problem with prostitution under the guise of massage, that enforcement
of the state vice laws is not enough. As a result, they pass, or
revise ordinances that still subject massage therapists to onerous
regulations and fees, in some cases making it difficult or impossible
to work openly. This is not acceptable to me and many of us."
In California, which has
a number of charter cities that can decide their municipal affairs
by the state constitution instead of the state laws, there has been
speculation that even if state licensing passes, massage therapists
may still have to abide by local regulations in those cities.
have ruled in regards to professional licensing that, while the
state has the right to set eligibility requirements, that local
agencies retain a considerable latitude to set conditions of use
and to assess fees," says Keith Eric Grant, a California massage-therapy
educator, writer and political commentator.
"Such considerations can have profound effects on the ‘trickle
down’ of state regulations to the local level that act to
separate reality from theory."
Bob Benson, president
of ABMP, counters that the "home rule" fear of charter
cities choosing to override state massage-therapy licensing laws
is unlikely. "The professional advice we have received is that
pre-emption could only fail to apply if a city’s home rule
charter contains specific language reserving for the city the right
to regulate and license massage therapists or health-care professions
generally. Though it’s possible some may exist, I’ve
yet to see a city charter explicitly mention licensing of massage
therapists or other health-care professionals."
Benson continues. "We
get queries about local massage regulations with some frequency
from members practicing in states lacking statewide massage-licensing
regulations, but none of us can think of a single instance in which
a member voiced a problem about local massage-licensing regulation
after statewide regulations became effective," he says. "In
other words, pre-emption of local laws by state massage licensing
regulation seems to be working."
Perhaps the most controversial argument for state licensure is that
only massage therapists with a modicum of training, 500 hours being
the industry standard, are competent to touch clients safely and
effectively. The "public protection" criterion is often
required by states in order to establish licensure for a profession.
"Anyone can hurt
anybody, you have to know the appropriate ways to touch, when not
to do massage, when to refer, the type of pressure that you need,
the type of therapy that you can do on that person," says Mary
Donker, a former nurse and a current L.M.T. in Louisiana, and the
owner of the Center for Pain Relief in Metairie.
But to this argument regulatory
opponents say, "show us the proof."
Donald Schiff, a licensed
massage therapist in New Mexico, sat on the committee that drafted
his state’s licensing bill, enacted in 1991. "I thought
people were being injured by incompetent therapists," Schiff
says. "It turns out I was wrong. Actual physical harm from
massage is extremely rare. Unfortunately, the reality of licensing
didn’t match our starry-eyed expectations, and I have since
become convinced that licensing is unnecessary and onerous."
Early this year, a review
of West Virginia’s massage-therapy licensure board seemed
to back up the "no-proof-of-harm" argument. "The
review has found no compelling evidence to support continued licensure
of this profession because there is low risk of physical harm if
the profession were unregulated," the report states.
Similar findings have
been reported in Georgia and Kentucky (although the latter state
just passed a state licensing law this year).
Even some regulation advocates
say that the risk of physical harm from massage is small, although
they do advocate that more education is always better than less.
"As a majority I
don’t think that massage therapists hurt people, but I think
there are unique cases [that they need to be aware of] like don’t
push hard behind the knee because you can put strain on the arteries,
and that sort of thing," says Karen Lewis, owner of the Blue
Sky School of Professional Massage and Therapeutic Bodywork, with
three campuses in Wisconsin.
"Some people need
the deep-tissue work, some need the light touch, or craniosacral
therapy, or the reiki or polarity," she continues. "But
[massage therapists] need to have the knowledge to work with each
In California, regulation
proponents have opted to try and broaden the definition of harm.
"I’m not building
a case on physical harm,? AMTA-CA’s Beverly May told MASSAGE
Magazine. "I am taking the approach that in much of the state
massage is already regulated, and that if that must be, uniform
state regulation is preferable to hundreds of adult entertainment
ordinances, which are ineffective and costly to local governments
to enforce, and take public funds from more needed uses. Public
harm occurs when clients unwittingly enter a sex business [and]
the fact that afterwards, they are unlikely to ever go for a massage,
or to only go to the high-end spas, causes economic harm, [and that]
lack of access to home appointments, in most cases at all, in others
where prescription is required, is harm."
Meanwhile some regulation
advocates say that proof of harm is available, even if is not documented
in a study. "You have to advertise [to find it]," says
Logsden says that when
massage therapists were preparing Virginia’s state law, they
put ads in local newspapers seeking clients who had been hurt in
a massage session. There were ample responses.
"I saw one [client]
who had burns on her from hot packs administered by a therapist
from a 200-hour program [who was] not properly trained to use them,"
In another instance, an
enthusiastic graduate of a 200-hour massage-therapy program set
up a massage chair in a local gym. A man who had just finished a
vigorous workout sat down and the therapist began vigorously working
the area around on the man’s vagus nerve. "He had not
been taught about the vasovagal response [and] worked so hard on
the guy that he passed out and fell off the chair," says Logsden.
"Somebody who had more [training] in physiology would not do
vigorous friction massage on someone’s neck like that."
also argue that today, with massage therapy used for an increasing
array of physical and medical conditions, therapists need to have
more knowledge about anatomy and pathology than they once did.
"[When I started]
I thought I was as good as anyone out there, I thought I knew more
than I did," say’s South Carolina’s Danny Holland.
"Because of the workshops I’ve been attending, by having
to do the CEUs, it’s improved my business and my ability."
But opponents like Schiff believe outlawing the practice of massage
therapy unless you have met the education and testing requirements
and earned a license, is a disservice to those who want to explore
the field. Indeed, many of the therapists interviewed for this story
started out with a hodge-podge of training, including weekend workshops,
book learning, apprenticeships and self-teaching.
new practitioners had the opportunity to take a few classes and
try out their skills to see whether the massage/bodywork profession
really fit their inclinations and skills before investing in an
expensive private vocational education," Schiff says. "Now
they have to spend several thousands of dollars before finding out
whether they have what it takes."
"If I had to have
had 500 hours [of education] to start out, I probably wouldn’t
have gotten into massage," says Craig Denega, president and
founder of the Ancient Healing Arts Association (AHAA), which formed
earlier this year to oppose national regulatory efforts. "You
are not allowed to [do apprenticeships] anymore. And [the laws]
break everything down to standardization and legislated mediocrity."
But can the "learn-as-you-go"
style of massage therapy work in today’s regulatory climate?
Delaware massage therapists
work under a tiered regulatory system where they are designated
as either licensed massage therapists or certified massage technicians.
Licensed practitioners, who graduate from a 500-hour massage program,
pass the NCETMB and take 24 hours of continuing education every
two years, are allowed to treat people with medically diagnosed
conditions. Certification, which requires, as of July 2004, 200
hours of education, up from 100 hours, allows technicians to work
on anyone other than those people with medically diagnosed conditions.
Rob Eppes, L.M.T., is
heading an effort raise the minimum education requirement for technicians
to 500 hours, although they would not have to sit for the NCETMB
nor take CEUs.
"I think that is
just the right thing for the profession as a whole," he says.
"The difference between 100 and 500 hours is so disparate,
you can’t make any logical assumption that a person with 100
hours [of education] would have the entry-level skills to practice
in the profession."
Eppes says that this discrepancy
is apparent in the continuing-education classes offered through
his business, The Massage Center in Wilmington. "I have had
multiple complaints from instructors of the course we offer that
some students do not have the rudimentary knowledge required to
take [the] classes," he says.
Massage therapist and
school owner Deb Jedlicka was one of the people who sought a state
law in Delaware. The tiered law, she says, came about from a desire
to accommodate all massage therapists and not limit anyone’s
right to practice. She now regrets this action.
"I’m just so
sorry that there were so many practitioners who were disillusioned
about massage education, and who thought just a little bit was enough,"
she says. "It wasn’t."
Jedlicka says that in
her school, the Deep Muscle Therapy School and Center, there is
a difference in the breadth of knowledge of graduates from the 200-hour
program and the 600-hour program.
"The [600-hour program
graduates] are more well-rounded as individuals with some kind of
medical backing," she says.
She also says that the
demand for the more highly educated graduates far surpasses that
for the 200-hour program graduates.
"We are finding with
our 200-hour graduates, it’s very hard to place them,"
she says. "There are not a lot of employers, and the ones there
are want graduates with 500 hours [of education] at least; they
want the licensed individuals."
The school has recently
decided to increase its programs to 500 and 850 hours. Jedlicka
disagrees with speculation among some critics that increased education-hour
requirements benefit the schools more than they do students, or
"Even our accrediting
agency is saying that [the 200-hour program] is not a viable program
anymore," Jedlicka says. "Over the last five years we
really evaluated [this]. First it was 100 hours, then 150 and then
200. It’s just not enough to get in what the student needs
"For us it’s
not about making more money, it’s about helping students applying
to viable programs that give them jobs," she adds. "It’s
about quality education."
out what your state regulations
with Part Two: Exploring
the different levels of regulation and look at how state licensing
efforts have impacted non-massage bodyworkers.