Welcome to CAMEL

The California Massage Education League's goal is to advance a positive business environment for practicing and teaching massage within California. In furthering this goal, we straightforwardly answer many of the questions surrounding the practice and regulation of massage. "The CAMEL" believes in FATE — Forthrightness, Activism/Advocacy, Tenacity, and Endurance. Please see our about the CAMEL page and our Cover Letter (PDF file).

What do you mean by a positive business environment?

Massage is practiced as both a service of personal care and of health care by an estimated 28,000 practitioners within California. Current practitioners and practitioners just entering the profession have a reasonable expectation to practice with training requirements based on the actual content of training necessary to practice effectively. They also have a business expectation of individual and office licensing fee structures that are reasonable in relation to expected gross income, whether their anticipated practice is part-time or full-time. The 220 state-approved massage schools within California have similar expectations to be able to base their curricula on the actual needs of training designed to best benefit their students' ability to practice successfully.

CAMEL's interest is to provide input to cities, counties, and chambers of commerce furthering a business environment for massage that works for all of us. We see this as both an ongoing process and one of advocacy. Agencies tend to reevaluate policies when they feel the heat rather than when they see the light. We aim to provide such heat in a firm but ultimately cooperative manner.

Would you say more about massage being practiced both as personal care and as health care?

Massage provides generalized emotional and physiological benefits as well as being able to address specific injuries. We live in a culture with high stress and with too little time for friends to fulfil each other's needs for interpersonal connection. The costs to society are staggering.It's estimated that stress costs US business $300 billion a year. Also see Stress Costs and Costs Plenty and Stress at Work. The costs of stress show up in illness, lost productivity, increased violence and litigation, and decreased ability to enjoy family and community. In this context, regular massage is one way of caring for and maintaining oneself or, as a gift, a loved one. A recent meta-analysis of massage research concluded that massage can produce significant reductions in chronic anxiety and depression.

Massage also has clinical techniques that can facilitate sports performance and aid recovery from minor injuries. Research has also shown massage to be effective for low back pain, an ailment impacting the quality of life of many persons. Four out of five adults will experience significant low back pain sometime during their life. After the common cold, problems caused by the lower back are the most frequent cause of lost work days in adults under the age of 45. The 26 April 2004 cover story of Newsweek is on this very topic, including the use of massage to gain relief.

Are there legal problems with having massage practitioners treat injuries as you describe?

Until recently is was a gray area because anything that was preventative or a treatment and not otherwise licensed fell under the medical practices act. That changed with the passage of SB 577 in 2002. SB 577 explicitly recognized that there are unlicensed, noninvasive health care practices. The bill both set explicit limitations on invasive practices that can't be done and set consumer disclosure requirements on practitioner methods and training. Now, within the state Business and Professions Code (§ 2053.5, § 2053.6), there is an explicit recognition that practices such as massage have a health care status. SB 577 is also explicit that "The Legislature intends, by enactment of this act, to allow access by California residents to complementary and alternative health care practitioners who are not providing services that require medical training and credentials". SB 577 thus minimally sets a legislative expectation that massage done under its provisions will be regulated in accordance with other health care and may well constitute a legally preemptive definition of such massage as health care.

What are the legal implications of having the state define massage as unlicensed health care?

The more direct implication is that the state, by defining unlicensed health care practices, has now defined the category under which massage should be regulated given that the intent of a practitioner is to practice under SB 577 rules. For example, a local zoning ordinance that relegates massage to adult entertainment, even if a reasonable person could determine that the intent was health care, could be determined to be in conflict with the Business and Professions code (§ 2053.5, § 2053.6).

There is also a less direct effect of SB 577 related to giving massage practitioners the legal ability to apply techniques as health care treatment or prevention. With the legal ability to claim treatment comes the ability to be reimbursed by health insurance or health care reimbursement accounts (HCRAs). With that ability comes the need and responsibility to use office procedures that, by default, insure protection of health information under the Health Insurance Portability & Accountability Act (HIPAA). Local ordinances requiring access to client records in violation of HIPAA compatible procedures could be ruled to be in violation of federal law.

How should we evaluate what training is needed to enter practice?

Unfortunately, many answers have been given to this question with little objective basis in needs of training. Fortunately, a reasonable determination of entry level training needs has been done by the California Alliance of Massage and Bodywork Schools (CAMBS). The CAMBS hour analysis includes tiers of massage technician (100 hours), massage practitioner (180 hours), and massage therapist (250 hours) based on time needed to effectively field a marketable practitioner. CAMBS provides statistics on the relative hour distributions for types of program offered by their state-approved member schools. By far the majority of entry-level certificate programs (third histogram) are between 100 and 240 hours. In multi-group negotiations over last year's failed AB 1388 (state licensing act), both CAMBS and the Associated Bodyworkers & Massage Professionals (ABMP) actively opposed any bill with an entry level above 250 hours. In the same ballpark, San Francisco passed a new ordinance last December with 100 and 200 hour tiers.

Why are some answers to how many hours are needed higher?

Many times requirements have been promoted that are simply arbitrary entry hurdles. Such hurdles are costly to the student, to their families, and ultimately to their communities. Each 100 hours required can be expected to cost a student about $1200 in tuition alone. Particularly for those having other job and family responsibilities, the total costs include the loss of time to unneeded training. Ultimately, costs are to the consumer and to time students unnecessarily shift from family and community involvement. As a rule of thumb, a parent who can only spend two evenings a week taking class will require a year to complete 250 hours of training. Many current programs are oriented to serve exactly such adult learners.

Some parties and organizations have also pushed to make minimum requirements near those for obtaining federal financial aid. Currently programs must be a minimum of 600 hours to be eligible for federal loans and 720 hours to be eligible for Perkins grants. Eligibility also requires that a program be accredited by an agency approved by the Department of Education. As training hour requirements approach financial aid minimums, costs push students into greater dependency on such aid. The requirements that go along with such aid undercut the economic viability of smaller schools, reducing student options.

Financial aid comes with requirements for accreditation and for meeting minimums for student completion rates (60%) and full-time job placement rates (70%). The administrative overhead is large, necessitating larger schools that can support the class size and administrative staff required. This is why the apparent paradox of massage schools not supporting hour increases exists. Many current schools are small and many current students are adult learners with other responsibilities. Many current students are oriented toward part-time practice and many take classes on a pay-as-you-go basis. Faced with conflicting time commitments and a higher cost and debt burden, potential students can simply choose not to enter the profession. Massage currently shares an exemption with dance and performing arts in state school regulations as to meeting completion and job placement rates. This exemption would likely end if training requirements increase so that most students in California depend on financial aid. The bottom line of all of this is that the economic consequences of regulation are far reaching to both students and schools.

What's the likelihood of injuries from undertrained practitioners?

Two recent peer-reviewed papers (Grant, KE, 2003; Ernst E, 2003) have reviewed over forty years of indexed medical literature for injuries caused by massage. Both papers concluded that such injury is a true rarity. Professional liability insurance offered by major organizations adds only about $65 to annual dues, indicative of very low rates of injury occurrence and extent. A paper by Studdert et al. (1998) reports insurance data from 1993 through 1996 indicating only 0.79 paid claims per 1000 insured for the practice of massage. The average indemnity for paid claims was approximately $6000. The likelihood of injury for basic entry-level massage is, on mechanistic grounds, substantially lower than that for more invasive techniques. As noted in One Scope of Massage Practice (pdf file), commonly used levels of licensing do not address specific training for more technical levels of practice.

• Ernst E, 2003 The safety of massage therapy. Rheumatology, 42 (9), 1101–1106.
• Grant KE, 2003 Massage safety: injuries reported in Medline relating to the practice of therapeutic massage — 1965–2003. Journal of Bodywork and Movement Therapies, 7(4), 207-212.
• Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Brennan TA 1998 Medical malpractice implications of alternative medicine. The Journal of the American Medical Association 280: 1610-1615

Should massage schools be required to be accredited?

Definitely not! This is a misuse of accreditation for something beyond its original intent. The US Department of Education uses accreditation as one of several gatekeepers for distribution of financial aid. Part of the accreditation process is that a training program demonstrate its viability over a two-year period. The assumption is made that students will be able to attend new programs using a combination of self-financing, private financing, and state financial aid. Using accreditation as a prerequirement for practitioner licensing means that no new unaccredited programs can start. You can't run a viable school offering training that won't qualify a student for practice. Accreditation should be kept as a voluntary process used by longer training programs to gain access to federal financial aid.

What qualifications should be required of a massage school?

Schools used for entry-level massage training should be state approved. In California, there are 220 approved massage schools. The approval and monitoring of schools is a function of the Bureau for Private Postsecondary & Vocational Education (BPPVE), under the California Department of Consumer Affairs. The BPPVE is very stringent in auditing attendance records of students and verifying that missed hours are later completed. They also verify that school administrators and teachers have the needed experience. One can find such schools by searching for "massage" in the BPPVE directory. The California Alliance of Massage & Bodywork Schools (CAMBS), an association of state-approved schools, is another good source to contact for information on or discussion about massage schools.

I've heard of national certification. Should this be required of practitioners?

Requirement of national certification is very controversial within the massage profession. The white paper After a Closer View, Requiring the NCE Just Doesn't Look so Great! (pdf file) summarizes a number of the concerns. In multi-group negotiations over the 2003-2004 failed AB 1388 (state licensing act), both CAMBS and the ABMP actively opposed any bill with a mandatory requirement for national certification. Both organizations continue to oppose such a mandatory requirement in any future bill. Since a prerequisite for sitting the national certification exam (NCE) is 500 hours of training, this opposition is congruent with positions relative to required hours. As the white paper linked above notes, an online poll in October 2003 by Massage Today indicated only 7.5% of responders felt that the NCE was a reliable tool to evaluate practitioner skills and knowledge. Even allowing for nonresponse by those without a strong opinion, those having a negative view of the reliability of the NCE would be a supermajority. In the Dec 2003/Jan 2004 issue of Massage & Bodywork. ABMP president Bob Benson wrote an editorial strongly advocating that tests such as the NCE be limited to voluntary use. In the June/July 2004 issue, David Lauterstein further questions and rebukes the course chosen by the NCBTMB. Requiring certification is tantamount to requiring membership in a private organization. Requiring passage of a private exam may require the mandating agency to ensure that applicants have the option of opting out of paying fees used for political or idealogical expression. Both issues appear to have a substantial First Amendment basis for legal challenge.

Statistics recently compiled by ABMP for a state sunrise questionnaire response (pdf, 1MB) note the significant difference between state-approved school programs and NCE (national certification exam) requirements within California. ABMP has also noted that the national certification board is not accountable to the public and schools in recent unilateral changes to curriculum requirements prerequisite to taking the NCE. Looking at current school curricula nationally, ABMP concludes that only 15.7 percent of school curricula currently meet the new impending NCBTMB requirements.

In 2005, the need for more public accountability combined with the desire to promote better portability prompted the creation of a Federation of State Massage Therapy Boards (FSMTB). In December 2005, Atkinson & Atkinson, the legal counsel retained by the FSMTB, wrote a memo outlining the legal exposure stemming from delegation of authority to private agencies not operating under direct public control.

While feeling that private certification tests have their place as voluntary achievement marks, CAMEL joins ABMP and CAMBS in opposing the mandatory requirement of national certification.

How do you recommend that local agencies recognize legitimate practitioners?

The best way to do this is by using multiple criteria, similar to the way banks look at approving loans. The concept of a preponderance of the evidence is well-established as being a legally defensible basis. Graduation from a state-approved massage school is a good basic determination of entry-level training. Passing a background check is a reasonable precaution. Other useful measures are professional experience, filing of a business plan, and carrying of professional liability insurance.

There is ample precedent for the use of a preponderance of the evidence in other California regulation. San Bruno uses this criterion for licensing of gambling clubs and amusement facilities. The Bay Area Rapid Transit District (BART) uses the criterion of a preponderance of the evidence for denial and removal hearings. The State of California uses the criterion for day care center licensing. The California Department of Social Services uses the preponderance criterion in licensing actions. The California Respiratory Care Board uses the criterion for disciplinary actions. Preponderance of evidence is thus seen as a legally valid criterion, avoiding rigid requirements, by which local agencies can differentiate professional massage practitioners and businesses from those using massage as a front for adult entertainment and prostitution.

Some surrounding areas require professional membership. What about this?

Unfortunately, some local agencies have based their regulations on notably self-serving lobbying by members of a particularly political professional organization. There has been a lot of acrimony and divisiveness within the massage profession because of such tactics. There are a number of professional organizations serving the massage profession and having a number of different organizational structures. Some of these are service agencies with membership, such as the Associated Bodyworkers & Massage Professionals (ABMP), International Massage Association (IMA), and the Ancient Healing Arts Association (AHAA). The American Massage Therapy Association (AMTA) is a 501(c) membership entity. A number of the organizations offer several levels of membership, starting at 100 hours. All are providers of professional liability insurance and all have a code of ethics. In addition, Massage Magazine offers a professional liability insurance plan. The approximate distribution of organizational members in California are IMA (10,000), ABMP (8500), and AMTA (3200). Requiring membership in a private organization likely violates First Amendment guarantees of Freedom of Association, opening a regulation to legal challenge.

Given the diversity of professional massage organizations and membership types, ordinances framed to specifically select the AMTA on the basis of its 501(c) status and entry level are likely not defensible in court. It would be significantly better to look at liability insurance as a common factor among organizations recognized within the profession than to proceed down this acrimonious path.

Thank you for your attention!
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