Is Massage Therapy Industry in the USA in Danger ? 
By Yehuda J. Lev, MA, LMT, CEKGT. April.2008©, Updated May2008.

Foreword

The contents of this article are dedicated to all massage therapists in the USA.

It comes to shed light on the injustice, exploitation and often contempt with which Massage therapist are frequently dealt due to the socio-economical structure of this country.

The article was written based on 17 years of personal practice as massage therapist, and on documented data, not all of which I could include here without making it a book...
Read on, and do not take what I wrote  for granted. I challenge you to check the data, find  the truth and only then make a well calculated decision regarding your future.
 Whichever way you chose - whether to simply accept the present situation, or  fight for what you are truly worth - I wish you luck.

                                                             **********

Genesis and thereafter

Along with other forms of medicine Massage Therapy is thousands years old, yet until quite recently it was not considered (at least in the West) as “ real therapy” but rather as some obscure modality presumed mostly as related to indulging in luxury, and provided mostly to the rich, whether for relaxation, fun or as a prelude to sexual activity.
It took virtually ages to prove that massage and bodywork, in fact helps and speeds healing, reduces pain and stress, improves circulation, boosts the immune system and much more. The annual consumer survey conducted by CARAVAN® Opinion Research Corporation International in July 2007 and sponsored by AMTA (American Massage Therapy Association) points out that while the use of massage is growing, the reasons of people that chose to turn to massage are also in shift. More and more people (30%) recognize massage as an important tool to improve and restore their health .

Over the last decades massage practitioners developed new methods of massage and new bodywork techniques. While nobody reinvented the wheel, some of these techniques are applicable and effective more than others to specific conditions.
Massage and Bodywork is still in the process of overcoming decades of ignorance, suspicion and distrust by the medicinal community, looked upon as charlatans, “masseuses” etc., the title “therapist” was accepted not too long ago as proudly representing this profession.(it should be noted, for the sake of adequacy the "masseuse" or masseur" or in French  the normal terminology associated with massage therapy - not so in the US, where these terms usually  belittle it's practitioners).
And yet, although massage therapy is slowly yet steadily backed up by research pointing to it’s benefits , and even though research points out to massage therapists as often aiding patients more than the latest modern drugs, and doctors - massage therapy remains the underdog of the medical profession. Moreover, it may face a dramatic setback.

This continuous mistrust of this very real therapy, actually invites further abuse of Massage and Bodywork, and exposes those who engage in this profession to indiscriminate exploitation of the therapists .

Let us examine a few troubling facts :

With oncoming recession the US is facing a significant unemployment rate, and a desperate search for a source of income is present almost everywhere. In the 1800’s massage therapy was incorporated into standard medicinal treatments in Europe, and in 1856 arrived in USA, and was taught possibly for the first time on American soil, by Charles F. Taylor and George H. Taylor. In the last decades entrepreneurs understood that teaching massage therapy can  also constitute a great source of income – and they proved to be right. Every several months, with the accomplishment of about 500-650 study hours, (and at times - less very rarely -more) a new batch of hundreds of new massage therapists is certified, licensed and poured into the already frequently saturated massage therapy market.(in North Carolina alone there are some 30 massage schools).

Ever so often a new facility acquires the right to the title “massage school” and replicates the very same process, pocketing frequently over $12,000 in tuition from each massage student, after promising the new therapist a quick and easy high income.

Just like every respectable medicinal profession - Massage Therapy needs a “national organization” to assure the professional skills and the ethics of the therapists, as well as sponsor and carry on further studies of this profession, and continuously strive to elevate it’s professional status. Even in this niche there is room for the opportunists to make an extra buck.

Who controls the massage therapy industry?

It is completely justified to demand that the profession of massage therapy will be regulated just like any other medical profession. 

Massage therapy  is controlled and supervised in most states by four "levels" of institutions:

• The National Certification Board for Therapeutic Massage and Bodywork,(NCBTMB) states in it’s mission:” to foster high standards of ethical and professional practice in the delivery of services through a recognized credible certification program that strives to assure the competency and professionalism of practitioners of therapeutic massage and bodywork..”
  The NCBTMB has a single role : to provide a graduate of a massage therapy school with a nationally recognized test. The test is not necessarily more thorough than what a student goes through in a school, but even though the therapist is tested ONCE – he pays his dues to NCBTMB  constantly if he/she wants to remain nationally certified.

• There is little or no justification for the NCBTMB continuous fees (paid once every 4     years).
  The NCBTMB does not mention and does nothing to promote the status of this profession .

• COMTA, the Comission on Massage Therapy Accreditation , which aspires to be the premier accrediting body for Massage Therapy, claims to be a non-profit organization - but does it  collect fees from the schools it accredits? It does not collect money from students directly, however  indirectly it is from the students'  pockets integrated in their school/tuition fees. At least so far the US Department of Education recognizes COMTA as an authority advising massage schools and individuals interested in teaching  Massage therapy on matters of accreditation. And yet, only few of the massage schools are accredited by COMTA. In 2004 . Interestingly, some graduates of certain schools I spoke to, claimed that they were accredited by COMTA. It remains obscure whether such accreditation is passed on to the graduate by the school he attends, or is the accreditation given to the school alone.

• While the “nation wide” entities such as AMTA and COMTA,  Hands-On Trade Association and others,( the membership in which is almost a must to practice massage and carry a professional liability insurance), compete between themselves on the practitioners pocket – there is “naturally”  also a State Board of Massage and Bodywork therapy in most (34) states. While NCBTMB, AMTA and such, each charge the poor therapist a bundle be it  every year year,or every other, or fourth year-depending on the institution for membership.

          AMTA speaks highly about it’s mission as well as of it’s future years goals:
          Mission : To serve AMTA members while advancing the art, science and practice of

         massage therapy.

          AMTA's Core Values:

        * We are a diverse and nurturing community working with integrity, honesty and dignity. 
        *We are a nonprofit member-driven organization of ethical professionals. 
        * We embrace excellence in education, service, and leadership. 
        * We endorse professional standards and support fair regulation of massage therapy. 
        * We believe that massage benefits all.

• The State Boards are little more than parasites, that due to bureaucratic and political manipulation and with little real justification tax the massage therapists for enforcing their own code of ethics.They are supposedly created to "protect the public from the wrong doing of the Massage therapists", yet NEVER to protect the Massage Therapists against the wrong doings of  their clients ( assault, non-payment, insults etc).They  collect the proof provided by the therapists that they indeed took their required number of hours of Continued Education, and act as "almighty tribunals" that scrutinize the ethics of therapists and approve/supervise new and existing schools.Interestingly, the local boards  are also required, according to their rules and regulations to enforce the subject of hygiene  in clinics. Naturally, it is a difficult thing to do in the numerous private clinics, yet in the clinics of Franchised Massage therapy, like Massage Envy - it should not consist a real problem, employing "secret shoppers" and such. The reality with specific  vision of Massage Envy and other franchised clinics -  is that the blankets covering the clients are changed and washed rarely - maybe once in 2-3 days, thus same blanket being used for the average of at least 10 patients....and this is just a tip of the iceberg.

•  

• It is  important to understand  and reiterate that  massage therapists, just like nurses, doctors, etc. should be supervised in their professional and ethical realm. There is little doubt in my mind that amongst many compassionate,honest and good therapists there are some "rotten apples" just like in any other profession. I thus agree that  we need an executive local arm to deal with ethical, professional and at times criminal transgressions. And yet,  one must take into consideration how easy it is to point at a doctor or a therapist and call him a "name" - and how difficult it is to disprove the accusation. Moreover - if found innocent of charges - to restore the suspects' career is next to impossible. In my opinion it is also wrong to create an institution (state board) that by it's very own definition is created " to protect the public from the therapist" If the American public wishes to accept Massage as a legitimate medical modality, it should first  respect the therapist as it respects MDs and RNs. And the Massage related State institutions should promote the status of this profession at least as much as it supervises it for disciplinary and punitive purposes.

•  To the very best of my knowledge there is no entity that oversees the actions of the State Boards in their investigations of massage related complaints civil complaints.

The nature of the Massage Therapy organizations, and the Massage Industry

 Although most of these institutions call themselves “non-profit” -  it is my personal opinion that such a title is somewhat unrealistic.

It does not take  a "conspiracy theory" to understand that the National, Professional and State institutions, along with the massage schools and various  franchise massage employers form an interdependent circle, each feeding and ensuring the continuous existence and prosperity of the other. The schools , approved and supposedly controlled by the State Boards, and COMTA flood the massage market with new massage therapists insured (liability) by the likes of AMTA, and nationally certified by  NCBTMB - the booming franchise industry provides a lowest possible wage "solution" for the new,job-hungry  therapists.

The established massage therapists find it harder and harder to  find new clients and stick to the service prices that were accepted over the years. Since there is simply no comparison between the quality  and the therapeutic value offered by private Massage Therapists, and that offered by the franchised massage the result is  significant deterioration with the overall quality and  therapeutic value of Massage therapy.

It is unfortunate but true that the public knows little about the difference between professional and less professional massage. The public is often swayed by the  fancy looking facilities and supposedly cheaper services hoax created by the franchised businesses. 
It may be an interesting idea for the the proper Government authority to take a deeper look at the business of massage therapy. It’s not Emron but it "smells" nonetheless.

The profession of massage & bodywork therapy must be regulated and closely supervised,and just like any other medicinal profession follow a Code of Ethics. Thus it is questionable  – why each of the above mentioned national or state organizations has a different code of ethics, different and cumulative fees and demands. Yet none of these organizations truly regulate nor has any realistic impact on the number of new massage schools, nor on the number of new certified massage therapists poured into the market. God forbid mentioning any involvement in expressing opinion that would suggest a nationally accepted median fee for massage services.

AMTA's former President,Leena S.Guptha claims that such an act would constitute  interfering with the  American "free market" economy.

AMTA is indeed not empowered to impose a national pay scale, but  along with the US Department of Labor it can certainly suggest and advocate such scale.

To be a nationally certified and licensed massage therapist, and get the right to earn $10,000(or less) and in rare cases $31,000   per year through sweat, tears and frequent disrespect, by prospective employers -  massage therapists are “taxed” three times, and nobody truly cares about their real status within the medicinal profession.

The puzzle over why does a massage therapist has to pay so much to earn so little  has been addressed even  by the American Medical Association: “…So what is the justification for having massage therapists pay as much or more than other health professionals, such as physical therapy and chiropractic?….it simply seems be inevitable, like death and taxes .” 6

.
While certain institutions e.g. AMTA indeed offer their  members a professional liability insurance, the ability to purchase, at a reasonable price, some of the required Continued Education (CEU), and some other perks like free web listing etc, (which can be purchased privately at competitive prices) – they fail in truly caring for the massage therapist as an individual. They offer no competitive group health and disability insurance or retirement plan, and they could not care less if the massage therapist is shamelessly exploited by the employer, allowing the  practice of  massage and bodywork, in ways which may constitute health risk to the clients, and the therapists.

The growth rate of the massage market and the decline in massage  practice quality quality

According to NCBTMB there are over 87,000 massage therapists registered and certified on the national level, a certification which allows  the nationally certified therapist to practice almost anywhere within the US (in theory only since the State Boards mostly  want their "cut"). There are some 300,000 massage therapist certified on state level (the only difference between the two – an extra exam, and local certification). According to yet another source each year about 63,000 new massage therapists are certified . Indeed, many quit, yet there is an continuous, uncontrolled growth in the number of massage therapists, and it is a blatant lie that they can easily find enough clients to sustain their hard earned, and modest income.

 Licensed Massage therapists, due to their rapidly growing numbers  are losing their status within the medicinal professions and becoming  a cheap, exploited, unhappy labor .
 And yet, according to AMTA massage therapy is so popular that Americans visit massage therapists 114 million times a year, and spend 4-6 billion dollars for massage and bodywork services.
Since there is a growing number of massage therapists, consistently with the laws of supply and demand, the competition over clients is fierce and while the costs of living increases  massage therapists' wages and sometimes  their professional performance  take a plunge. Frequently  although not always, the therapeutic quality is affected by tired, worn out, disillusioned therapists, willing to settle for low wages because they need some source of  income, and because there are fresh out of school and just want get started in the massage business. 

Even the US Government statistics are missing the true picture. According to the US Department of Labor statistics “…Because of the nature of massage therapy, opportunities for advancement are limited. However, with increased experience and an expanding client base, there are opportunities for therapist to increase client fees, and therefore income…”7
The dream that attracted many into this profession: care and compassion to fellow human beings in need – is often shuttered by uncompromising financial reality.

Massage and Bodywork therapy is a very physically demanding medical profession. While a new and young person engaged in this profession, may work longer continuous  hours using his whole body in the process, within few years the attrition takes it’s toll; joint and other musculoskeletal problems develop along with often debilitating pain  and frequent disability. The overworked display symptoms of burnout and depression.Many simply quit.

A massage therapist has no disability insurance (unless he can pay privately find a reliable carrier and for it).The disability insurance offered by AMTA (for example) is not covering a massage therapist who is sixty and wants to join it.
In 99.9% of the cases he/she does not have an employee related retirement plan.
The massage therapist has nobody to voice his personal concerns.Massage therapist has nothing.

New downhill trends

This state of helplessness created a relatively new trend of exploiting the massage therapists even more.
For example: about 2-3 years ago,  an average, well skilled massage therapist was earning an average of $65-$75 per one hourly session, and had a reasonable number of clients to sustain  modest yearly earnings, still mostly  bellow the poverty line. Those working at SPAs and various sport clubs, were forced to split 60%-40%  (or even worse terms) with the institution’s owners. Moreover, some employers considered gratuity ( tips) as part of  therapist's wages, and saw it as a valid reason for a low wages offer.

In contrast to the above many private therapists and massage clinics decline gratuity.

It is my personal opinion that if Massage Therapy  would become an accepted medical modality there would be no room for "tipping" ( after all we don't tip our family physician or his nurse...).

For the mean time it  must be clear that Gratuity is a personal expression of the client's  satisfaction to his/her therapist for their work. It has nothing to do with the wages, and  clients are not obliged to give any gratuity, nor is the height of the gratuity standardized ( although it is a taxable income in the US, and the standard is 15% of the service's charge or more).

.
Today's therapists are often offered... $12 -$15 per hour (before tax) for the very same service, and requested to comply with preserving the highest standards of skills, ethics, and display of concern and compassion for the client...The $15 option is unfortunately a rising storm on the horizon of massage therapy. It is such a devastating reality, that if allowed to spread – it will most likely drive massage therapy decades backwards.

About Franchised Massage Therapy

In 2002 an Arizona businessman specializing in franchising named John Leonesio and his partner Shawn Haycock, (at that time the coach for the University of Utah Gymnastics team),  had  a vision :
Considering the fact that much of the population of the USA has very little knowledge about quality and the therapeutic aspects of massage therapy, and due to relative ignorance still often considers it either as “luxury”, or “a fun thing to do” – why not offer them a dream : In Mr. Leonesio’s company’s Massage Therapist Training manual it says : “….John Leonesio had a simple goal…He wanted more people to enjoy the therapeutic, stress relieving benefits of massage. John wanted to bring massaAbout Franchised Massage Therapyge therapy out of the elite and expensive circle and make it available to everyone by offering affordable, convenient, professional massage services…..”
Or has he really???
The truth is that Mr. Leonesio knew very well that indeed many people need and want massage, yet massage therapy has not yet been accepted by most of the insurance companies as medicinal modality, and the  fees charged by massage therapists for their services, however realistic, were often a deterrent. Leonesio’s mind certainly did not escape the fact that there are huge numbers of new, unemployed, disillusioned massage therapists willing to do just anything to make a few bucks. Why then not present the franchised massage therapy concept as a "much cheaper", and as professional and therapeutic as massage session in a private well established clinic.

Thus a franchise named Massage Envy was born.In  April 2005 Mr. Leonesio (who by then parted from Shawn Haycock ) invited Mrs.  Merry Beth Braun, an Indiana massage therapist and a prominent figure in AMTA to the yearly Massage Envy meeting. This AMTA  high ranking representative said that she hoped that Massage Envy will succeed, since "it would help AMTA's push to make massage therapy a part of everyone's routine healthcare - "as long as they (Massage Envy) don't lose the personal touch". Possible a good intention that failed to see through the true business intentions.  Massage Envy and AMTA  walk "hand in hand" ever since, and AMTA could not care less about the conditions in which massage therapists work. In 2005 Mr. Leonasio predicted that by 2009/10 there will be about 1000 franchise units sold across the US. He certainly keeps his word. The latest data points out that to date Massage Envy has opened up to date approximately 1000 (this figure was given to me by the owner of one of the Massage Envy Clinics ) well equipped yet soulless, impersonal, clinics nationwide , each employing some 10 - 30+ massage therapists, offering the client his first, 50 minute massage (valued $65) for…. $39. Sounds terrific doesn’t it?. Entering a Massage Envy clinic and using such facility for the first time, may look like a  bargain to a novice client. However the sad truth is that what the Complementary and Alternative Medicine (CAM)  has been teaching massage students and offering for years to it’s patients : compassion, attentive ear, true interest in helping one’s well being , the very things CAM accuses Western Medicine of lacking, are even more lost in franchised massage clinics .

Aside from a smile and courtesy, the client is just another “body” the clinic owners hope will return, or still better – sign up as a “member” for a whole year.

Out of each 60 minutes Massage Envy promises a 50 minutes "head-to-toe" “professional, therapeutic” massage, and 10 minutes in which the therapist has to wash his hands,(which he/she sometimes fails to do due to the shortage in time, and thus possibly contributing to the transmission of some  diseases), use the bathroom, change the linens between clients, and then intently listen, write notes and register in his/her tired brain  the client’s description of his/her aches and pains.

As a result of this shortage in time often important information about the client's health and mental condition, the medications he takes etc, are not discussed nor listed .

In April 2008 I heard about a case in which the client suffered a heart attack during a massage  session.I do not know where it happened, but I wonder - Are Franchised massage clinics prepared  for emergencies. I know that only few massage therapist went through CPR instruction, and I doubt (but  don't know) if any of the clinics is equipped with a defibrillator...

Another issue that bothers me is the fact that most clinics are equipped with the proper fire-fighting equipment - but I have yet to hear of one that had a fire evacuation drill...

After the session is over – the therapist is expected to  await the leaving client with a paper cup of cold water in hand (in my personal opinion a degrading and humiliating to the therapist), while the client gets dressed and the clock is ticking away….and finally escort the client to the front desk. 

Make no mistake ; after massage, every respectable private therapist offers bottled water or unlimited access to a cooler by the client himself/herself.
Is offering a full, sealed bottle of purified drinking water (costing less than 10 cents !)
too expensive? If 1000 clients = at least $39,000 (gross income) – can’t the management invest less than $100 in water?
Indeed  a “highly professional and therapeutic" approach….

And the therapists ? The therapist is paid…$12-$15 per hour (before tax) , and if he/she is capable to work full time, after several months of slaving through endless clients, he/she may purchase certain health insurance benefits and other less significant perks .

 
From a strictly professional and health related point of view, a realistic quota of single- hour massage sessions  per therapist should not accede five clients a day (to avoid injury and disablement as well as be able to offer the attention the client deserves) with at least a 20-30 minutes rest between each session. While in certain franchised massage  clinics therapist may sit unoccupied (and unpaid for this idle time) for several hours – he may then be requested to perform 4 or even 8 consecutive session without a break….(a method nicknamed “ back-to-back”).
The above described time table is so hard that few therapist can work full time for an extended period – thus for the majority, even the previously mentioned “health benefits” are not within realistic reach..
By the way, should a client not show for his scheduled appointment, or if a therapist showed up to work as expected – but there were no clients to treat – he is not paid for his time….

Another “hoax” behind franchising massage therapy is it’s “cheap, affordable to all price". This can be calculated very simply:
As a first time guest of  most franchised massage  clinic( e.g. Massage Envy) you pay $39 for a 50 minutes of supposedly “top quality, head to toe massage”, you are naturally expected, just like in a restaurant, to pay at least 15% gratuity for this service. However since the real value of the service is not $39 but $65-$70, if the client does not want to devastate the truly hard working therapist he/she will leave  a tip of at least $10-$15. Simple math using even the one time discounted rate as an example: $39(discounted session) +$15-$20 average tip =$60 (approx) or more. So – is the franchised -setting massage really significantly more affordable as promised ???

Moreover, this calculation looks even poorer the next time you come to this clinic. This time, unless you joined as a member - you pay $49 +tip, and thus approximately $70+...

In many privately owned clinics there is no “gratuity” (tipping). And you pay $65-$75 per full, relaxed hour, with no pressure to rush in or out, during which the therapist can truly listen  and understand your concerns and address them accordingly, sometimes extending your session for a short client rest, at no extra cost .
The therapists employed by a Franchised Massage Therapy clinic are not to blame for the rush, and for the fact that they want you out of the room after  the 50 minutes of massage.
If they do not comply with these rules they are harshly reprimanded.

Massage Envy is not all alone. Since 2002 we witness a growing number of competing massage franchise endeavors: Massage Heights, Fitness Together Franchise Corporation, Elements Therapeutic Massage Corporation, Hand and Stone Massage Center – to mention a few. Massage Envy and the likes of it has a never stopping “conveyer-supply" producing constantly new batches of dreamers. New massage therapists. A great “gun feeder” to his industry.
Obviously there is no shortage of buyers to this franchise, after all the moral standards of the average person who is willing to make money no matter what, are hardly the highest.
It hurts though, at times, when an owner of such franchised massage  clinic is an ex massage therapist…
Can  we blame the owners of Franchised Massage clinics of being greedy?
I believe that the $75,000-$100,00 per year as a median income of an owner of such clinic is earned through hard work on the part of the owner, but greed is always there as part of our culture.
It is the Massage therapist who is the victim as long as he choses to agree being a victim.
After all nobody coerces any therapist into joining the franchised system.
But does it mean that it is the second nature of the rich to exploit the week and the poor - definitely yes. Why not change it then?

One might expect the NCBMT, AMTA,COMTA and the like institutions as well as the State Massage Boards along with the US Department of Labor, and the US Department of Education do something proactive in the area of legislation or suggestion regarding “reasonable” charges for massage session, regulate the saturation of the massage therapy market, enforce mandatory breaks between massage sessions and much more.

Will any of the above supervisory entities I mentioned above do something to stop this trend that will bring massage therapy to its knees? – I doubt that they are truly concerned with what happens to massage therapists as long as they pay their dues, and they just “keep coming”.

Massage and Bodywork Therapists, nation wide,the fresh and the veterans should realize, as soon as possible their true value  and stop selling their hard-earned talent  short.

All massage therapist should stand up for themselves, possibly unite, possibly form a union that will consider all the issues addressed here and more. There is no reason for the further heartless exploitation of this hard working health professionals.

This is not a dream. It can be done.

                                                       ++++++