I've always been interested in massage as a form of health—as opposed to disease—care. I was going to nursing school when I decided to go to massage school instead. After completing my training in 1982, I was living in Charlottesville, Va., where I was only one of three therapists—the other two were Betty Siegner Mooney and Ruth Turner.

When I told people that I was starting my private practice in massage therapy, many of them asked me, in all innocence,  if I was going to have my own parlor—as in massage parlor. And in actual fact, there was a massage parlor, right across the street from a steakhouse, called the Holiday Health Spa. It had a big, red neon sign out front that said, "All Girl Staff" and when Betty Siegner called them to ask what qualifications were necessary to apply for a job there, the woman managing the place said, "Honey, you don't need no qualifications—just put on some red nail polish and come on down!"

A Regulated Profession

Massage therapy has come a long way since then. Massage therapists can work in many settings—health care, private practice, fitness and wellness—and with many different focuses—oncology and hospital based massage, special populations, seated massage in the workplace, even massage for animals.

And now we have massage as a regulated profession in almost every state. Massage has become recognized as one of the five licensed complementary and integrative health care disciplines in the U.S., and it's also becoming a regulated health care profession in Canada—4 of 7 provinces. That's a lot for any discipline to have accomplished in a relatively short time, and we should all be proud of that.

But in spite of all these things that we've accomplished, I think we're facing some serious challenges as a profession. It's so easy to be focused on our individual situations, the challenges of running our own businesses, or making ends meet, just dealing with the day-to-day, that we forget to look around at what is happening in the larger community, in the U.S., and in the world.

The larger community of health care in the U.S., the community of integrative health care disciplines more widely is changing dramatically. And it's changing rapidly. In this new landscape, I think massage therapy is in danger of becoming irrelevant. I think it's a critical time for all of us to become more engaged in the larger communities in which we live and in which we work.

The U.S. Health Care System, a Failure?

I think several things are all happening together over the last ten years or so—have heard of the Institute of Medicine's 2013 report on current state of U.S. health care? It's called "Shorter Lives/ Poorer Health" and that really sums it up. Even though the U.S. as a nation spends more money than any other developed nation on health care, it's not doing us any good. We don't live any longer. Not only do we die sooner, we're less healthy while we're alive. More people are living with chronic health conditions, like diabetes. And obesity rates are rising, which also is a contributing factor to developing chronic illnesses and premature death. So in spite of the millions and billions of dollars the U.S. spends on health care, it's not working very well.

Our health care system is broken. Part of the problem is that it's based on a fee-for-service model, where everyone makes more money based on ordering or performing more procedures. And I think one of the best examples of how that doesn't work very well is at the end of life. Instead of dying peacefully at home surrounded by loved ones, which is what I think most of us would want, an awful lot of us end our lives in hospitals—after undergoing invasive and costly procedures in a futile effort to prolong life.

A Different Model

Has anyone heard of the Triple Aim? ACOs, accountable care organizations? The triple aim is three ambitious goals—improve population health, increase patient satisfaction, and at the same time lower health care costs.

Accountable care organizations are a strategy that is attempting to move away from the fee for service model and instead pay health care organizations and providers based on how good a job they do meeting these three aims. Basically, it's the radical concept of paying doctors for keeping people well. While the concept of the Triple Aim was first introduced in 2008—it's only recently that it's being implemented in the form of ACOs.

So how does massage therapy fit into all this? Massage therapy could be playing an important role in helping people with chronic health conditions manage their symptoms, improve their quality of life, maybe even encourage healthier lifestyle behaviors.

Maybe we could be helping primary care providers in screening programs—we see lots of people's skin, right? We get to know our regular clients, so maybe we might notice if they consistently seem a little down for more than a few weeks? Do you think all these kinds of things might help improve population health, lower health care costs, and improve patient satisfaction?

Research & Education

So why aren't family practices hiring us? Why aren't more hospitals hiring us? Why aren't integrative medical clinics hiring us in droves? Even though doctors like Adam Perlman at Duke, who teaches a program on successful business models for integrative clinics, calls incorporating massage therapists a "no-brainer."

Maybe we need more research? Well, we can always use more good research, now that everything in health care needs to have evidence to support its application. But I think over 8,000 studies is a pretty good start, even if all of them aren't randomized controlled trials or systematic reviews. So there is more than enough research to support the use of massage as part of health care.

I think one of the biggest reasons is our relative lack of entry-level professional education, compared to other providers, and an even bigger reason is how inconsistent that education is. Massage therapy has become widely accepted, and wildly popular. In a sense we've become victims of our own success. Massage therapy, and now even massage education have become commodities.

Almost all of the independent, private schools that were started by practitioners have been bought by corporations. While some dedicated teachers have remained, the corporations don't particularly care about improving the quality of massage education—they care more about improving their profits. The results is that a few schools are great, some schools are terrible, and a lot are just so-so. And I'll tell you why I think that is.

My Findings

In 2010, the Commission on Massage Therapy Accreditation (COMTA) hired me to conduct an evaluation of the quality of massage education in the U.S. I wanted to look at both some hard numbers on educational outcomes, and also to talk with educators inside the massage therapy profession and with other integrative health care educators, who are also often practitioners themselves, about their perceptions of the quality of massage education. What I found was that everyone knows that the quality of basic massage education varies—a lot.

And when I talked with educators, I found out some interesting things as well. I conducted a lot of individual and group interviews, and used the information I gathered to develop a survey. I sent the survey, which asked about perceptions of quality, what competencies they considered necessary to consider a massage therapist as a colleague or to be their own personal therapist, and what criteria they used to choose a therapist.

The survey went out online to three groups of massage educators, and two groups of other integrative health educators. When I asked about quality, overwhelming the majority of respondents found it inconsistent—and a lot of massage educators found it poor.

Most also agreed that the quality needed to improve if MTs were going to be considered as allied health care providers, and there were different opinions about what was needed. Most of the competencies were similar between groups. But here's something important—when I asked what criteria they used to choose a provider, it was overwhelmingly personal experience or word of mouth. Because people don't trust the consistency of the professional training we get to prepare us to be their colleagues or their own therapists. As a group, we are not perceived as educated enough. And it's holding us back as a profession.

The Value of Massage

Inconsistent quality undermines the integrity and perceived value of massage therapy education, and consequently, the integrity and value of massage therapy as a profession. If the educational process that produces massage practitioners is unreliable, then the reputation of all practitioners is damaged by those who complete an educational program, pass a qualifying examination and become credentialed to practice, and yet cannot perform a massage to the satisfaction of the consumer.

The current changes that are rapidly happening in the larger health care landscape hold tremendous opportunities for massage therapy as a discipline. At the same time, unless educational and regulatory standards can evolve to keep pace, massage therapists who wish to practice as integrative health care providers are being (and will continue to be) shut out of those opportunities.

Here's what I think we, as individuals, can do about this situation—

• Keep learning—knowledge changes, and what you learned in school can change too. Read about research on massage therapy. There are a lot of resources that summarize recent or important studies—Massage Today, MTJ, and Massage Magazine all carry stories about massage research studies. The IJTMB, which published my COMTA study, is a free, open access, peer-reviewed journal. Become research literate if you want to work in a health care setting—you have to speak the language, just like medical terminology. Use your common sense as you read research, and be prepared to talk about why a study influenced how you practice or why you find it flawed.
• Be visible in your community of practice and draw the circle bigger—network with non-massage health care professionals. Get involved with other health care provider organizations in your community. If you work a lot with people who have chronic pain, then get to know other health care providers that work with pain too. Join a professional group or at least introduce yourself to other providers. Talk to patient educators and nurse navigators at public events, like walkathons. Be a good ambassador for the profession.
• Stay informed about what's happening with integrative health locally and nationally.
• Value what you do and what you offer. Massage therapy is an incredibly valuable service, and quality is not cheap. We have something unique to offer. So my advice, from a purely business perspective is this—stop giving yourself away. Lose the Groupons. Most of those folks are looking for cheap, and are not going to become regular clients at your normal rate. If you are going to give away your services, be strategic. Don't be the only professional on a team that isn't getting paid. Put boundaries on how long you'll do it and call it a trial period or demonstration project. Then send an invoice with the rate you should have been charging and show a 100 percent discount. And measure outcomes to document the benefit you've provided, so you can use data to make your case about why they should hire you.

Massage therapy has some major challenges ahead. We have to adapt if we want to continue to be as successful in the future as we have in the past. We can take a lesson from our own history—massage was very popular at the turn of the 20th century, practiced by doctors, and then became so wildly popular—and lucrative—that everyone and their uncle hung out a shingle and started claiming it was a cure-all for everything. Massage as a therapeutic intervention lost all credibility, and it practically disappeared for the next 50 years. So, let's not let that happen again.