The Impact of State Regulation
By Kelle Walsh, Managing Editor for MASSAGE Magazine
What are your state regulations?

Read Part One: How massage therapists have fared in states that have passed regulatory laws.

At the time it seemed like a good idea. A two-tiered massage regulation system would make everyone happy: massage therapists who believed that 500 or more hours provided greater technical skill and knowledge; and therapists who felt they only needed 100 hours of education to perform safe, effective relaxation massage. But the real impetus for the Delaware law, and its greatest benefit, for all massage therapists, would be freedom from mandatory registration under the state’s anti-prostitution statute, a law that many practitioners nervously ignored.

In that sense, the massage law worked. "All massage therapists were released from the adult-entertainment law," says Deb Jedlicka, a Delaware massage-school owner who sat on the committee that drafted the massage-and-bodywork regulation, which went into effect in 1992. "We finally felt relieved that we were state-approved and that we [didn’t] have to be worried that [the police enforcing the registration law were] going to come after us."

Massage and bodywork therapists with at least 500 hours of education became licensed, while those with 100 hours of education became certified massage and bodywork technicians. There was just one problem, says Jedlicka: The law didn’t differentiate between the two tiers, other than education hours. So, the law was refined in 1996 to include practice requirements allowing licensed therapists to treat medically diagnosed conditions, and certified technicians to work on any other but medically diagnosed conditions.

In 2000 the number of continuing education unit hours (CEUs) required to maintain state licensure increased from 12 to 24. Certificate holders need 12 CEUs.

In June 2003, legislation was introduced again, this time to increase the number of education hours required for certification to 200. But some massage therapists are hoping to raise that even further, to 500 hours. If passed, the amended legislation will require that certificate holders have the same education hours as licensees, but will not be required to sit for the National Certification Exam for Therapeutic Massage and Bodywork (NCETMB) and will still need just half the CEUs. Yet they still won’t be able to treat medical conditions.

Delaware therapists pushing for the change say they want to level the playing field so all massage practitioners will start out with the same skills and knowledge, and that consumers will be better served. "Now [all therapists] will have the education to know when a non-diagnosed medical condition may exist," says Rob Eppes, member at large of the Delaware chapter of the American Massage Therapy Association (AMTA).

But the perceived need for yet another change, a decade after the first celebrated legislation was enacted, begs the question that hangs over every state regulatory effort: What type of massage regulation will best serve the needs of the massage community and the public?

That question, and its myriad scenarios, is being played out on the West Coast, where a controversial massage law has gripped the state’s massage community. AB1388 now seeks two tiers of regulation: one for licensed massage or bodywork therapists, who have 500 hours of education from a state-approved school, hold a license or certificate from another state with similar requirements, or have 750 hours of experience; and another for licensed massage or bodywork practitioners, who need just 250 hours of education. As of press time, the bill didn’t further distinguish differences between the two tiers.

According to the bill’s supporters, the tier system developed out of a compromise by the California chapter of the AMTA, to quell opposition from a consortium of massage schools and other therapists to the original 500-hour education requirement. "This was complaint driven, for people who said ‘Why not 250 hours or 150 hours?’" explains Beverly May, law and legislative chair of the chapter. "Well, yeah, but some of us want the recognition of our peers and want portability [to move among states]."

"Our goal is to just get out from under local ordinances," she adds.

Licenses, certificates, registration
Par for the course of regulatory efforts is the decision of whether to try for licensure, the highest level of regulation that restricts anyone without a license from practicing massage therapy or from calling themselves by a protected title; certification, a lesser form of regulation which allows only those who meet certain education criteria to use a protected title; or the less-common registration, which simply provides a listing of therapists who apply and meet an education requirement. CEUs are often required to maintain the professional designation under all three.

(In some states these definitions vary. In Mississippi, for example, one cannot practice massage without being registered, which requires 700 hours of education and passage the NCETMB or equivalent examination. The state board of massage maintains the right to seek prosecution of offenders.)

As in Delaware, combinations of the above are sometimes believed to be the best way to meet the needs and demands of all involved parties. In these cases, therapists with more education are granted greater privileges, such as the ability to work in health-care settings or, sometimes, to transfer their credential to other states with similar regulation. Those with less education typically are only allowed to practice relaxation massage in their state.

Each level has its pluses and minuses. Licensure is considered the most desirable regulation because of its practice and title protection, and the police power of the state to enforce the regulation, yet is also presents the greatest challenge to state legislatures wary of trade restrictions and of creating more government bureaucracy. Without proof that massage may cause harm to the public, many states won’t consider a licensure law.

Certification is often viewed as a fair compromise when licensure isn’t possible. It verifies that those using the protected title (typically "certified massage therapist" or some derivative) have met education requirements and standards, but does not bar entry into the profession by those who do not use the title. And without the practice protection provided by licensure, it does not ensure that only those with a certain level of training are practicing massage - a key issue for therapists who believe that a 500-hour minimum education is necessary to practice massage safely and effectively.

Registration is the most innocuous of all regulatory measures. A registrar maintains a list of applicants who prove they have met a certain education requirement, and who may use a designated title such as "registered massage therapist." This kind of regulation, while providing general guidance to the public as to one’s education level, does not protect the title or the practice of massage therapy. Like certification, registration doesn’t have the enforcement mechanism of a licensure law.

But sometimes therapists seeking regulation have little say over what level they will be granted.

In Wisconsin, a 1999 massage-registration act was the first step into the regulatory arena. "That first time we wanted to go for licensure but were told by the legislature, ‘No way.’ It’s seen as limiting a profession and employment," says Betsy Krizenesky, president of the Wisconsin chapter of the AMTA and its law and legislative chair.

"When we came before the legislature, the argument thrown at us was, ‘Show us proof of harm.’ There was very little," she adds.

There was, however, a patchwork of local laws under which massage therapists were treated as prostitutes, Krizenesky says, with fingerprinting and mug-shot requirements and restrictions that had little to do with massage therapy.

When therapists tried for licensure again, in 2002, they were told that they could get certification instead. Now to hold the title of "certified massage or bodywork therapist," one has to have 600 hours of education from an approved school, and pass the NCETMB or the exam developed by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM).

"The initial problems have been addressed, we have relief from being harassed on the local level. And we are designated as health-care providers in the statute; that helps on a local level, certainly," says Krizenesky.

But she admits that the law does not ensure that only those therapists who meet the requirements are practicing massage. Wisconsin, like other states with certification laws, does not have a massage board with the power to enforce the law. Instead it has an advisory council, made up of governor appointees, that reports to the health division of the state’s Department of Regulation and Licensing. "There are people who are not getting the credential who are using the title of certified massage therapist, which is protected; or using a different title, like massage practitioner, which is misleading but technically not infringing [on the law]," says Krizenesky.

This problem is common in states with certification laws.

"There’s lots of ways for people to skirt title protection" provided by certification law, says Virginia massage therapist Lee Holtman. "They can do massage as long as they don’t call themselves [certified] massage therapists. It’s very difficult to enforce."

Susan Walsh, a certified massage therapist in Annandale, Virginia, agrees. Although the state law has eased restrictions in her town, which at one time outlawed home-based massage practices, the problem of prostitution businesses posing as legitimate massage practices abounds. And the illicit-business owners are getting savvy. Capitalizing on the public acceptance and growing popularity of massage therapy, they often use misleading titles such as "therapeutic massage establishment."

But if the business does not advertise "certified massage therapy" it is not infringing upon the state’s massage-certification law. Furthermore, the statute states that the board of nursing, under which massage therapy is regulated, "has the authority to deny, revoke or suspend a certificate issued, or to otherwise discipline a certificate holder upon proof that the practitioner has violated any of the provisions of [the law]." Yet disciplinary measures are not defined for people who are not certificate holders.

"I think licensure would be a better option for us," Walsh told MASSAGE Magazine. "It would give us more credibility and make it easier to shut down these massage parlors."

"It’s halfway to the goal of what we want it to be," says Holtman.

Getting it right, finally
Martin Chamberlain, a Maryland massage therapist, describes the long road to regulatory language that seems to finally meet the needs of his state: "When our bill was first passed, in 1996, it was a title protection act. We thought we had it nailed down, but didn’t. As long as someone did not call himself or herself a ‘certified massage therapist’ they could do anything they wanted. Our law would not touch them. We went back to the legislators and had the language changed to become a practice act. Our practice act put other modalities in jeopardy. Then we came back to the legislature, and changed the bill once more, allowing space for those other modalities to exist. We have all worked hard to get it right. And it seems to be working now. There are still some issues, but things are getting better."

Maryland’s nearly 10-year journey through the legislative process serves as an example of what can happen if all of the pertinent issues are not addressed prior to the submission of a licensure bill. Spurred by threats from physical therapists on one side and dealing with onerous anti-prostitution laws on the other, members of the state AMTA chapter (AMTA-MD) sought a controversial licensure law to protect their practices.

After a long battle with the state’s physical therapists, and conflicts with some people from within the massage profession, Maryland now regulates practitioners under the titles of "certified massage therapist" (CMT) or "registered massage practitioner" (RMP). CMTs have 500 hours of education, have passed either the NCBTMB or NCCAOM, and have at least 60 college credits in any subject. The latter provision was added at the insistence of legislators who felt that health-care professionals should have a two-year college education, according to Kenneth Adler, Ph.D., former AMTA-MD president.

As health-care practitioners overseen by the nursing board, CMTs may work in health-care settings and also give and take referrals from other health-care practitioners.

Registered massage practitioners also have 500 hours of education and must pass a national exam, but do not require college credit. They may not practice in a health-care setting.

Is this law ideal? Maryland massage therapists acknowledge that the law may have hurt some practitioners, particularly those who didn’t have access to 500-hour massage programs, or who fail to pass NCETMB. But for the 2,500 CMT/RMPs working in the state, the main objectives have been met.

"The public can now clearly distinguish legitimate massage therapists from others who are not. This has contributed to a healthy expansion of the massage-therapy profession and opportunities for massage therapists in Maryland," says Justin Frank, a former member of the AMTA-MD law and legislation committee. "Massage therapy is recognized as a health-care profession in Maryland, which has pretty much stopped threats by other professions, such as physical therapists, against the right to practice massage therapy. Professional standing as a health-care profession has also led to greater collaboration with other health-care professions, which has raised the status of massage therapists in the state."

In search of a perfect law
Few massage therapists who support state regulation claim that there is any one perfect state law. Some therapists in states with laws that don’t protect the practice of massage therapy say they long for more stringent regulation. Others, particularly practitioners of non-massage bodywork therapies, say they feel bulldozed by laws that don’t recognize their unique educational or practice standards. But leaders in the massage industry say that important lessons have been learned along the way - of what works, and what doesn’t - when it comes to state laws. The result has been smoother legislative efforts, which, hopefully, will avoid the need for returning to the legislature later on. "Some of that comes with experience," says AMTA Immediate Past President Brenda Griffith.

Griffith, and others, point to Kentucky’s massage-licensure law as a model of good legislation drafted out of experience. They say it meets the needs of massage therapists, protects the practice and title of massage therapy, grandfathers in those with less experience, and is perceived to be fair to other bodywork practitioners. The law passed swiftly through the state legislature in 2003, and requires that massage therapists have 500 hours of education (to increase to 600 hours in 2005), and pass a national exam. "It’s an example of one of the most successful," says Griffith. "There was a really successful coalition, [the law included] language in such a way that other groups weren’t impacted, so far it seems to have accommodated everyone."

A new landscape
The past 15 years has seen tremendous change for the massage-therapy profession: The public has embraced massage for self-care; a growing body of research has proven its health benefits; and professional opportunities abound, from working in spas or on cruise ships, to taking referrals from doctors in hospitals and collaborating with other health-care professionals in wellness centers.

Concurrent to these changes is the perceived need for increased levels of education and accountability, and a desire among many massage therapists for recognition of their work as a profession - not as something to be regulated through local police departments or that can be mastered in a weekend workshop. Controversial as it has been, in this era of recognition of massage and all the good it does, massage regulation has come of age, demanding that today's therapists are up for the task of this new professional status.

Find out what your state regulations are.