I recently presented at the Canadian Massage Conference in Richmond Hill, ON. Scott Dartnall of ONE Concept and a co-organizer of the conference asked me to provide a perspective on “the state of the profession.” He implicated the breadth and depth of the problems facing massage therapists in Ontario and abroad. The following is a transcript from my presentation.
I’ve lectured to thousands of massage therapists across this nation, and have personally spoken with hundreds over my 31 years in the field. Many have expressed a particular pain point that can be summarized as this: the massage therapy profession has tremendous potential for contributing to society…why haven’t we hit our stride?
Consider this: it required a quarter century to regulate just five provinces; the profession is largely research illiterate, with little support for our highly educated RMTs to advance; we endure tenuous relations with government, insurers, gatekeeper health disciplines and media – all essential to the health of the profession; resources to regulate the profession far outpace resources to represent our collective interests; advocacy efforts on all fronts remain largely uncoordinated; we suffer irregular engagement or consultation with the decision-makers of our profession. Thus, our collective potential is squandered.
Today I ask you to petition with me for leadership reform – a reform that fully engages, advocates for and develops massage therapists (RMTs) in serving and educating patients at the front-lines of care. What’s the state of the profession? Why are we stuck? Today I provide a prescription for the profession, and argue for the need to L.E.A.D.
Residing in Ontario, naturally my items for your consideration will be Ontario-centric. However, I encourage you to review what I’ve provided, and consider examples in your own locale.
Before we answer Scott’s question re: the state of the profession, let’s frame the historic context, examining the socio-economic influences that cultivated fertile ground for your massage therapy practice and mine as they exist today. In a post-war economy, manufacturing sectors in North America switched from producing the machines of war to consumer goods – automobiles, washing machines, house and road construction.
Consumer demand drove economic growth, leading to job surplus and great demand for skilled workers. Employers offered high wages and employee health benefits to retain these workers, while trade unions negotiated better working conditions to provide workers discretionary money and leisure time.
These economic circumstances led to demand for massage therapy[i] in at least five areas:
Rehabilitation – initially in the treatment of war wounds and the physical consequences of conditions like polio, massage therapy is now applied to rehabilitation of work-related and automobile crash injuries.
Athletics and fitness – With surplus time and an increased appreciation for health and vitality, people began exercising. These new fitness-enthusiasts required massage for their acquired aches and pains. High-level athletes see massage as a must-have to ensure athletic performance.
Hedonism and well-being – With more time and money on their hands, North Americans swarmed the European-style spas as refuge from demanding work schedules, and to enjoy their status.[ii] The European spa offered a mecca to nurture one’s body beyond the objectives of injury resolution or pain relief. Massage is a primary application in spas and includes various forms of hydrotherapies to enhance relaxation and wellness.
Human potential movement – with post-war reflections on human values, self-cultivation and liberalism, the concept of purposeful life and self-actualization appealed to many North Americans. People who were well-educated with discretionary income invested in psychotherapies, philosophical and religious studies and various forms of bodywork[iii] – all in aspiration for a richer human experience.[iv]
Worker performance and productivity – Employers want to maximize worker productivity and job satisfaction, while lowering absenteeism and employee turnover, in an increasingly competitive marketplace. Progressive companies offer workplace wellness programs on-site – including massage services – to counter-act chronic postural stresses and strains from specialized workstations.
Economic growth supported massage therapy and other wellness-focused industries to thrive. As a result, investment in education, regulation and representation has flourished. Currently, massage therapists across Canada invest millions every year to finance education, regulation and representation. Think about that…a whole industry developed to support the infrastructure of our profession. Let’s evaluate how our investments in this industry are performing.
Education – Education has become more sophisticated over time. Initial course offerings included massage theory, technique, myology/osteology, eventually adding neurology, assessment (ortho-neuro and musculoskeletal), regulatory standards, communications, ethics, and basic commerce. The education of massage therapists originated in sole-program private vocational colleges, and now includes multi-program private colleges and public community colleges.
In 2009 regulators met to begin the construction of entry-to-practice inter-jurisdictional competencies and performance indicators. They eventually established a mandate for accrediting MT training colleges. Accreditation includes an extensive audit of existing operations, and auditors determine if these align with desired quality of education and training.
In 2015, the Canadian Massage Therapy Council for Accreditation (CMTCA)[v] begin it’s process of accrediting massage therapy training colleges across Canada. Fast forward to Autumn 2022, only 4 of the 56 campuses in Ontario is accredited, with 16 campuses granted preliminary accreditation.
In recent years, some schools have closed or amalgamated. In the USA there has been a significant reduction in the number of campuses providing massage training, year over year[vi], and we should search for similar problems in Canada. It appears in Ontario anecdotally (our decision-makers don’t appear to be tracking this) demand for RMTs significantly outpaces supply, and solicitation of prospective RMTs is left entirely to the marketing budgets of independent campuses.
I’ve spoken with many RMTs who broker practice opportunities for other RMTs, and by doing so assume larger commercial leases and operating costs. These “practice brokers” are very concerned the wellspring of new graduates is not keeping pace with demand in the marketplace. The pandemic and recent scandal regarding the certification exams[vii] only worsens this problem.
Let’s talk about knowledge transfer and apprenticeship.
When I consider my conversations with RMTs, and the social media chatter I peruse, I conclude there are large gaps in knowledge transfer and apprenticeship in our profession. Gaps include understanding the efficacy of massage therapy and accessing the available research[viii]; business acumen in operations, marketing and administration[ix]; an understanding of contracts and working agreements[x]; proper body mechanics and delivery of care design that preserves the practitioner’s body[xi]; the history and scope of our profession; communication, setting boundaries and managing confrontive or predatory behaviour[xii] in clients.
I regularly perceive RMTs in social media asking questions that should be tacit knowledge, included in their initial education and training. Our profession requires constructive ways to assist massage therapists in properly acquiring and understanding the available knowledge within the profession and mentoring them in the maturation of their practical and operational skills. With only 4% of RMTs in the total Ontario population in the cohort of 25 years of practice or more, RMTs also require support in building longevity into practice[xiii]. We can float all boats with the same tide, and raise the excellence in practice for all RMTs, if applied properly.
Regulation – Before the Regulated Health Professions Act (RHPA) of 1991, massage therapy was regulated under the Drugless Practitioner’s Act of 1935.[xiv] Following the RHPA was the Massage Therapy Act (1994), Health Care Consent Act, Personal Health Information Protection Act (PHIPA), and other regulations and Standards RMTs must abide by. Regulation serves to protect the public by holding RMTs accountable, demanding a high level of ethical fortitude.
Yet despite favourable support, regulation has been slow to progress across the country. Ontario led regulation with the Massage Therapy Act in 1994, and British Columbia followed in 1995. It took another 8 years to regulate Newfoundland/Labrador, and another 11 years after that for New Brunswick. Prince Edward Island (PEI) became regulated in 2019, so all in all our profession has taken 25 years – a ¼ century! – to regulate just 5 provinces.
This despite the formation of the Federation of Massage Therapy Regulatory Authorities of Canada (FoMTRAC) in 2003, and pre-existing regulation in Ontario and British Columbia. Some would argue regulatory authorities don’t pass regulation…governments do. While this is certainly true, I can’t help wondering why almost 20 years after the formation of FoMTRAC that regulation across Canada is not farther along.
The recent announcement by the regulator in Ontario to increase registration fees for active registrants by $100 (and $248.50 for inactive registrants), was met with great agitation by many RMTs. If the number of registrants remains the same as 2021, the regulator will gain an additional $1.7 million revenues on top of $11.6 million it currently expects. The regulator conducted a survey and received almost 2400 responses, with 95% of respondents saying “no” to the increase for active registrants.
The regulator then held a Special Meeting of Council[xv] to announce their decision. Registrants, or “members” as they are referred to, were invited to attend but observe only. Any participation was muted, in spite of the Registered Massage Therapists Association of Ontario (RMTAO) Executive Director assuring us the RMTAO was “monitoring the situation closely.” The motion to increase fees passed without objection. Is this proper consideration for people the regulator regards as “members”?
The cost of self-regulation appears to be a runaway juggernaut. Referencing 2021 annual reports of both the College of Massage Therapists of Ontario (CMTO) and our representative RMTAO, resources (revenues in) paid to regulate massage therapists in Ontario outpaced professional representation by over eleven times[xvi] Consider this: would the convenience of owning of an automobile remain worthwhile if the fuel, maintenance and insurance for the automobile outpaced its utility by a factor of 11?
While the self-regulation model has benefits, it may prove unmanageable for RMTs in the long run.[xvii] Regulation normally benefits a profession by increasing credibility and public perception, government funding and positioning in community health care…funding and positioning have not materialized, and credibility has suffered in the media.[xviii] Perhaps RMTs might consider less expensive forms of regulation, such as an amalgamated regulator being considered in British Columbia.[xix]
Representation – Massage therapists rely on proper representation from their association to bring their collective interests to government, insurers, gatekeeper health care practitioners (HCPs) and the public media. Such representation requires large amounts of pooled resources and representatives with skills and experience – a workload impossible for individual RMTs to undertake alone. In addition, associations can scale the costs of client education materials, offer protection from exploiters and profiteers, form strategic alliances[xx], accumulate essential data for practitioners to use in decision-making, and a menu of competitively priced services, such as professional liability insurance. This is what an effective representative looks like.
RMTs also require the interaction of a community of their peers, and the opportunity to engage. Platforms facilitating respectful dialogue and debate, local hubs to gather, symposia to share knowledge and perspective, town hall meetings to address pertinent problems and existential issues – all nurture the theory and practice of massage therapy.
Now there’s a cost to such services. Across this country, massage therapists pay millions of dollars each year for executive director salaries, financing Board of Director meetings and association operations. It’s fair to account for how the money’s being spent.
In mid-2020, the RMTAO suspended the members’ social media page on Facebook, when pandemic strife turned some online conversations into rageful, vitriolic arguments. Fast forward to Autumn 2022, the page has not been restored. RMTAO members have restricted opportunity for constructive dialogue and debate with their cohort to advance the theory and philosophy of practice.
Regrettably, the 2020 COVID-19 lockdown and suspension of every RMT practice for three months was the perfect opportunity for our representative to sit down with us – virtually – to listen, to learn, to strategize, to plan, and eventually address the jugular issues facing the profession. The RMTAO did not capitalize on this.
The RMTAO is missing out in every conceivable way to engage its members – town hall meetings to engender robust discussions, symposia to share knowledge, perspective and evidence, round-table discussions with subject-matter-experts that can lead to strategic planning, and surveys to accumulate data and perspective essential to decision-making.
Local hubs, “Community-Based Networks” can act as a forum for dialogue, debate and support for RMTs in their geographic area. Yet these hubs receive scarce training, support or interaction from the parent association. If “association” is in the title, why aren’t they associating more with their members, or facilitating regular engagement between members?
And what’s taking HST exemption so long? The GST was applied to massage therapy services in 1991 – the same year the RHPA was enacted. In 2014, smaller and arguably more “alternative” professions providing naturopathic and acupuncture services achieved HST exemption[xxi]. How? These groups identified their target, focused their efforts, hired lobbyists, advanced regulation in more provinces, and eventually applied for HST exemption. And they did it over eight years ago. What’s taking our profession – larger and more centrist in philosophy – so long to achieve the same measure?
Per 2021 figures, less than 44% of RMTs registered as active with the regulator are active members of the RMTAO. What’s the reason for this lack of confidence in our representative association?
I remain particularly critical of the RMTAO’s failure to build closer relationships with Greenshield Canada after it’s “Elephant in the Room” campaign[xxii], designed to undermine claimant confidence in MT care. As well, we can begroan the banal responses offered by our representative to serious national media inquiries[xxiii] in the last 2 years regarding the profession’s position on insurance fraud[xxiv], association with the sex trade, and the prioritization of RMTs to access COVID vaccines.
Massage therapists require information to make important decisions in their practice: business expansion, serve new markets, seek cost efficiencies, invest in more training. Yet there’s a paucity of information. The last RMTAO earnings survey was conducted 10 years ago, and the last comprehensive survey by the regulatory body is almost 20 years old. If you’re considering a major professional decision like expansion or launching a new practice location, or are prospectively looking at massage therapy as a career, you’ve got nothing but antiquated and incomplete data to go on.
In the RMTAO’s 2022 Membership satisfaction survey, respondents clearly identified the need for RMTAO to offer better client education materials, detailed advocacy updates particular to HST exemption campaign, access to research database, inclusion in government healthcare initiatives, workshops offering practical massage therapy techniques, and increasing the public profile of RMTs to the general public. Hello RMTAO…are you listening?
There are other issues facing the profession. Managing a complex professional identity[xxv], how to establish credibility, regular reports of sexual misconduct[xxvi], irregular collaboration between stakeholders, forging strategic alliances with other health disciplines[xxvii], determining fair remuneration for massage therapists[xxviii], addressing the cult-like ideology manifested in the wellness industry[xxix]…all require deep, rich conversations to resolve. And all require much better leadership than our decision-makers have demonstrated thus far, and far more engagement of each and every practitioner.
Examples of Good Leadership
Despite the apparent failures in education, regulation and representation I’ve accounted for, I also wish to account for work well done. Some of the problems I’ve cited are systemic problems affecting an inchoate professional culture still growing and developing. Many individuals in the three areas of industry mentioned have worked hard and produced considerable gains for the collective. Many are good people, trying to do a good job, in challenging circumstances. Let me cite here just a few examples of good leadership demonstrated in our profession.
Massage Therapy Association of Manitoba (MTAM) funded a series of simple, impactful ads carried on the side of city buses in Winnipeg. These ads cleverly and cogently put the topic of massage therapy squarely in front of the right audience.
Registered Massage Therapists Association of British Columbia (RMTBC) launched a number of short videos[xxx] to educate the public. You can view these effective videos on their website.
The former RMTAO administration – when Kristen Bokalo was Chair and Andrew Lewarne Executive Director – did marvelous things. They conducted Town Halls across the province with members, addressed big issues like the Greenshield “Elephant in the Room” campaign, performed two earnings surveys over a 4-year span so we’d have relevant, reliable information. And, coordinated by their proficient operations staff, the RMTAO sent 42 delegates in 2018 to meet Members of Provincial Parliament (MPP) and senior policy analysts at Queen’s Park to request inclusion in discussions on chronic pain and palliative care. This was a time of a highly functioning and effective representative.
Here’s another example. ONE Concept began over 15 years ago when Scott Dartnall and Monica Pasinato-Forchielli jumped in to save the annual conference held by Massage Therapy Canada magazine. The owner/publisher at that time became ill and was unable to orchestrate the final 6 weeks. This was also a time when the RMTAO took a long break from holding conferences, so there was really no other avenue for RMTs to gather, dialogue and enjoy rich interaction with colleagues. Scott, Monica and other partners eventually developed the Canadian Massage Conference (CMC) to include more workshops, a larger exhibit hall, international speakers and now, virtual streaming during the in-person conference. Massage Therapists need to gather, to engage, to dialogue and debate. The CMC remains the most consistent and comprehensive venue to do just that.
I began my presentation by petitioning you to consider leadership reform – a move away from the top-down, autocratic structure to a framework that fully engages you, advocates your interests, and assists you in transforming patient education at the front-lines of care. The current model is authoritarian, places power of decision-making in a small number of hands, fails to broadly consult the RMT population as to their circumstances and needs, and fails to make use of our rich human capital via incorporating every massage therapist in the planning and execution of decisions that affect us all.
L.E.A.D. is an acronym for Leadership – Engagement – Advocacy – Development. I propose we adopt these four variables as our measuring stick. Just as our patients look to us for positive outcomes, let’s measure the progress of our decision makers by the quality of these outcomes.
Here’s what our profession could function like if we all stood up, spoke up, and leaned in:
Leadership – Your leaders would be among the people, not above them. Your leaders would meet with you regularly, ask straight questions about your experiences, make plans and centre priorities along outcomes meaningful to your interests. Your leaders would keep one eye to the future while managing day-to-day operations. They would collaborate with strategic partners within the profession, in community health care and integrated medicine to better position massage therapy in society. Your leaders would engage you in complex problems – such as how to better serve under-served populations. Your leaders would collaborate with their contemporaries in other representative associations, combine resources and nurture effective government, insurer, gatekeeper HCP and media relations campaigns. Your leaders would be in the business of serving your collective interests effectively.
Engagement – Your leaders would engage you through surveys, town halls, local hub gatherings, and social media. They would solicit your ideas and perspectives, and listen intently to what matters to you. These decision-makers would put you in touch with others facing the same pressing practice problems, and support us collectively towards resolving the sticking points in practice. You would be recruited at every step of the process, using your boots-on-the-ground expertise to tackle the systemic problems facing the profession. You would be granted regular opportunity and support to share, dialogue and debate with your colleagues. Evolution of the theory and practice of massage therapy would be – literally – in your hands.
Advocacy – Your leaders would advocate confidently to powerful extrinsic authorities – government, insurers, gatekeeper health disciplines and the media – with the resources you’ve provided them from your membership fees. And they would generate constructive results! Through shared resources, your leaders would design national public and media education campaigns, and provide you graphics, animations, informational pieces so you could contribute every day in your practice to positive public perception. Together, every day, we would transform how government, insurers, gatekeeper health disciplines and the public/media view the profession…for the better.
Now, the “A” in advocacy has a corollary. Our educators, representatives and regulators are only partially responsible for the outcomes of our profession. Each of us has a role to play. “A” alternatively stands for Agency…our agency. I regret we’ve learned to fear the regulator, to entrust our representative without regular scrutiny, and it’s left us all passive and frustrated.
We exercise agency when we inform ourselves on the collective problems we face, when we engage colleagues in dialogue and debate, to work through our theories and philosophies of care, when we address our representatives, directly, and advocate for our needs and preferences. For our decision-makers to be fully functional, they require our involvement in making the decisions that affect each and every one of us. So, attend gatherings with your colleagues, talk things out, it’s OK if you disagree…it forces you to strengthen your arguments or alter your position based on new information. This is how the profession matures.
Development – Your leaders would develop you as 1) a practitioner – critical thinking[xxxi], research literacy, business acumen, technical proficiency – and as 2) an agent of the profession – skills in public and media relations[xxxii], patient education, integration with complementary health disciplines. These leaders would regularly monitor and collect critical data from the profession to observe trends, sharing their analyses with you so you can make informed day-to-day decisions in practice. Your leaders would recognize and acknowledge exceptional members, “train the trainers” and make succession plans for training the next generation of leaders.
You are the key element, the missing link in the machinery that’s required for essential change. Exercise your agency – knock on the doors of your decision-makers and demand competent Leadership, broad Engagement, effectual Advocacy and rich Development. The society of Massage Therapists, if properly applied, can contribute immensely to challenges faced by community health, productive workforces, and underserved populations. The stakes are high for all of us, and particularly if you’re closer to the entry-level stage of your practice. Go ahead, knock on that door…and do not leave until you have been listened to.
For those with interest of richer context, I’ve provided 32 references below. These references are largely mine, and admittedly fail to properly reflect a cadre of opinions. Despite the cost and the consequences to one’s practice and livelihood, few seem interested in comprehending the history, culture and context of the MT profession. Many I suppose channel interest in learning one more novel technique instead – as if that will fix everything else. I entreat you to review the references that interest you. You might just form a perspective previously unknown, and awake within you eagerness to learn more on this essential subject.