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Research into body work based complementary and alternative therapies, such as osteopathy and chiropractic has highlighted barriers and benefits of professionalization for these professions. There has been no examination of the road massage therapy has taken towards legitimation and professionalization. This review article examines the drive by massage therapists for legitimation as health professionals within New Zealand. Massage therapy has an extensive and complex history. Within this history, massage therapy has gone from being part of orthodox medicine and acceptable, to being complementary and marginalized as an industry. In an effort to overcome this position, the massage therapy industry has attempted to gain legitimation by establishing professional associations, defining scopes of practice, lobbying government, and raising education standards. This article also discusses the historical journey of massage therapy, the evolution of massage therapy education in New Zealand, higher education as a means to occupational recognition and control, and the elements of professionalization that may support legitimation and occupational boundary protection for massage therapists.
Complementary and alternative medicine (CAM) is a broad domain encompassing a varied collection of therapies, practiced alongside or as an alternative to mainstream medicine(1), that incorporate holism(2) to treat illness and promote well-being(3,4). Practitioners of CAM therapies commonly do not accept biomedical dominance or their own marginality, and seek political–legal recognition in terms of public support, often through satisfied patients, and statutory registration(5). With the growth in the number of CAM therapists and the establishment of professional associations, many CAM groups are undertaking the process of professionalization to enhance their own legitimacy(6–8). However, the process of professionalization involves the aspirant profession and the state(8), and state recognition is not enjoyed by all CAM therapies. In Australia for example, chiropractic, osteopathy, naturopathy, and Chinese medicine have become highly professionalized and legitimized, whereas other healing systems remain marginal.
In New Zealand, massage therapy can be performed by a number of orthodox and CAM practitioners, as either an adjunct or stand-alone therapy(9). In this review the focus is on the practice of massage therapy by massage therapists. In common with most CAM therapies, the practice of massage therapy involves more than applying massage techniques. Their practice sits within the wellness paradigm and aims to support clients in balancing mental, emotional, and physical needs(10–12).
New Zealand massage therapists are engaged in the professionalization process to help create a sense of legitimacy or acceptance but, to date, the New Zealand government has not regulated the practice of massage therapy or the massage therapist. Little is known about the evolution of massage therapy in New Zealand or its journey towards legitimation. The aim of this review is to map out the pathway towards legitimation for massage therapy in New Zealand. First, the road from orthodox to complementary and alternative medicine is presented, followed by a review of the evolution of massage therapy in New Zealand. The influence of physiotherapy (physical therapy) is highlighted, as is the role of the CAM consumer movement. Issues of regulation and educational standards, and strategies for professionalization of massage therapists are explored, and the implementation of degree-based education for massage therapists is advocated as a useful strategy towards occupational recognition and control. Legitimation is a road worth exploring if massage therapy as a professional entity is to move forward and establish itself as a serious health care profession.
The use of the hands for treatment as a remedy for pain is believed to be as old as humankind, reflected in the instinctive human response to pain. Massage therapy in its most basic form can be the expression of human touch(13), and instinctive touching and rubbing ‘where it hurts’ serves as validation that massage is intertwined with human history.
Calvert(14) offers an extensive look at the history of massage therapy through the ages where its inclusion in the daily lives of indigenous cultures is documented. There is evidence within the history of massage that it was part of the medical orthodox community and was accepted as traditional and mainstream and approved by the establishments of the time. However, in 1894, the respectability of massage therapy in Britain was questioned over scandals where the practices of massage establishments were implicated as a front for brothels (houses of prostitution). Young uneducated women were enticed into the massage profession by the promise of an education and a respectable occupation. Many were bonded to massage schools, but were often unable to meet the high cost of this education. They were forced into prostitution in order to pay their bond. In response to these massage scandals, the Society of Trained Masseuses (STM) was formed.
Recognizing the need for standards, the founders of STM modeled massage standards on the medical profession and registered massage therapists, forming what would eventually be the beginning of Physiotherapy in the United Kingdom(15,16). Thus, massage as a profession regained recognition by “skilful association with medical practitioners”(17) and by tolerating a prescribed subsidiary role to orthodox medicine, practitioners of massage avoided the stigma and antipathy directed towards ‘quackery’ by the established medical profession(17). After both World Wars, massage therapy was employed as a restorative treatment in the rehabilitation of soldiers and was widely valued by the medical community(15,18,19). By this stage, massage therapy was considered part of the practice of physiotherapy within many parts of the world, including New Zealand. In the 1980s, to enhance legitimacy with the biomedical model, physiotherapists aligned with the ‘biomechanical discourse’, viewing “the body as a machine rather than a sensual being”(16) and ‘shed’ the mantle of massage therapy—despite the fact that it’s raison d’être was to gain legitimacy for the therapeutic practice of Swedish Massage. Consequently, the practice of massage therapy within orthodox medicine in New Zealand was further diminished. Massage therapy as a stand-alone practice not only had lost its professional boundary, but was also repositioned from being an integral part of orthodox medicine to a complementary approach to rehabilitation, as the biomechanical model of health care gained momentum.
CAM and orthodox medicine have a fluid and changing boundary, based on cultural and political attitudes(20,21). The term ‘complementary’ can be seen as symbolizing the move by the medical profession to subdue therapies, such as massage, to a more subsidiary role to primary medical care(22). However, monopolization by orthodox medicine is currently being challenged by the global expansion and increase in popularity of CAM(1). CAM therapies are being used to treat and/or prevent musculoskeletal conditions or chronic or recurring pain,(1) and with massage therapy as a specific CAM health service being one of the fastest growing CAM services in the United States of America(23), occupational and political boundaries within massage therapy may once again change.
Massage (mirimiri) was highly developed amongst the Māori people prior to colonization(24). Māori healers (Tohunga) used mirimiri as a means of healing injuries, releasing old tensions, and balancing bodily function, and it was considered a multidimensional therapy used in conjunction with other healing approaches( 25). Mirimiri is still practiced today; however, at the turn of the 20th century a number of factors began to influence its practice. In 1907 the “Tohunga Suppression Act” was passed as a “direct challenge to Māori healing practices by the scientific medical establishment”(24). This Act prohibited Tohunga from claiming to possess any supernatural powers in the treatment or cure of any disease. As a result, Tohunga were driven underground and with them the practice of mirimiri(24).
Soon afterwards in 1913, the University of Otago Medical School established the School of Massage, offering an 18-month Certificate in Massage; this School is now the current University of Otago School of Physiotherapy. The “Masseurs Registration Act” was implemented in 1921 as a means to “setting up a Masseurs Registration Board, the registration of approved persons, penalties for offences and employment of registered masseurs only in public hospitals”( 26). Most masseurs who registered under this Act wanted to cooperate with the medical profession and accepted the situation of only treating patients under the recommendation and supervision of an attending doctor. This was the beginning of Physiotherapy within New Zealand. Later this Act was superseded by the “Physiotherapy Act” of 1949 which effectively claimed jurisdiction over therapeutic massage; with it came the illegalization of the use of therapeutic massage by anyone who was not a trained Physiotherapist, with some minor exceptions(27). The practice of therapeutic massage by nonphysiotherapists at this point in history is unknown. The “Physiotherapy Act” (1949) formed a legally enforced boundary and therapeutic massage by massage therapists was illegal; a situation that remained until the Act was repealed in 2004(27).
In the 1980s massage therapists became more visible. Therapeutic massage by massage therapists was still illegal, but this was not strongly enforced. However, the credibility of massage therapy was influenced by the association of the term ‘massage’ with ‘massage parlours/brothels’. Massage therapists were struggling “to be seen as providers of treatment” as opposed to workers in massage parlours(27). This unfortunate association of massage with the prostitution industry still lingers today(9).
To improve the image of massage therapists, professional bodies were formed. The first documented political push by massage therapists was when Jim Sandford and five other massage therapists formed the New Zealand Association of Therapeutic Massage Practitioners (NZATMP). This Association had a focus on education, professionalism, and recognition of therapeutic massage(28). A second professional association, the Massage Institute of New Zealand Incorporated (MINZI), also provided representation for massage therapists. Over the coming years, the NZATMP transformed itself and later combined with MINZI in 2001 to form the contemporary Massage New Zealand (MNZ), which has the same focus as the original NZATMP, but includes relaxation massage therapists, as well as therapeutic massage therapists. Today, MNZ is the only voluntary national association specifically for massage therapists. MNZ is self-regulating and members are bound by a code of ethics, a scope of practice, a complaints procedure, and have continuing professional development requirements. These professional bodies raised the standard of education and profile for massage therapists in New Zealand(9).
For the last twenty years of the 20th century, physiotherapists were using a ‘body-as-machine’ approach( 29). Massage therapists have commonly differentiated themselves from physiotherapists by focusing on the whole person and large areas of the body for treatment, and at times have incorporated other CAM therapies (e.g., aromatherapy or Reiki)(27). In 2003, the “Health Practitioners Competency Act” (HPCA) resulted in the repeal of the 1949 “Physiotherapy Act” and, as a consequence, the provision of therapeutic massage by massage therapists is no longer illegal in New Zealand. However, massage therapists are not included in the HPCA, and are not an established part of the public health care system(9). Instead, the practice of massage therapy for health and wellness has become more evident and is considered part of the manipulative and body-based CAM therapies(30). Massage therapy is among the many growing CAM modalities within New Zealand. The 2006/07 Health Survey indicated that 9.1% of adults had seen a massage therapist(31), and there had been a 54% growth since 2001 and a 451% growth since 1996 in the number people employed as massage therapists(32). Nowadays, New Zealand massage therapists commonly treat musculoskeletal problems, such as back and neck pain, using therapeutic massage, as well as provide relaxation massage, in a range of practice settings, and receive referrals from a broad range of CAM and other orthodox healthcare providers(33).
As seen above, since the 1900s there have been a number of barriers to the establishment, development, and expansion of the practice of massage therapy. These barriers have included: legal disparities, a lack of health funding, ideological differences, negative connotations, and interprofessional boundaries. However, different professional ideologies, in particular the alignment of massage therapy with a clientcentered approach, along with the growth of CAM and consumer demand, may have not only assisted the survival of massage therapy, but strengthened its practice as a chosen form of health treatment. The professional identity of the massage therapist from within and outside the profession is still tenuous; occupational boundary maintenance needs to be sustained and strengthened. Challenges to the credibility of massage therapy as a health service remain.
Self-regulation by a particular occupational group is often an endeavor to improve its own legitimacy and occupational closure(3,7,8). In doing so, groups undertake a process of professionalization. The process of professionalization is often problematic, with numerous barriers, but ultimately the outcome is the acquisition of a monopoly in the area of expertise and professional autonomy(7). Recognition through professionalization generally involves the steps of: unification of the group; codification of knowledge, social closure, alignment with the scientific paradigm, support from other powerful groups; and recognition by the larger community and continuing professional requirements through a credentialing system(7,34,35). Of particular note in this process is the method of social closure, which attempts to maximize rewards and establish and maintain status for its members. Social closure utilizes higher entry training programs, limiting the number of practitioners and providing a method to discredit practitioners who practice outside the professional parameters(7).
Many CAM professions often emulate biomedicine by pursuing some form of registration(6). For example, homeopaths, chiropractors, and osteopaths in the United Kingdom(7), and osteopaths in Australasia( 5) have engaged with professionalization, but not without discontent within their ranks. For instance, some are concerned that professional status brings “disadvantage [to] members whose academic qualifications were not adequate”(8). Moreover, there are costs for registration, a loss of autonomy as the state takes control, competing professions, and expectations of the benefits and privileges usually assumed by a professionalized group not being met(8). Regulation of massage therapy has also been discussed in Canada(36).
Massage therapists in New Zealand have shown some evidence of taking steps towards professionalization such as forming a professional association with continuing professional development requirements, some alignment with the scientific paradigm, generating support from some politicians, and recognition by the consumer. However, massage therapists are still not regulated by the government and are only recognized under common law. Part of this exclusion is due to massage practice not being viewed as injurious to the public; evidence of public harm is required for regulation under the HPCA(37), and evidence of serious harm following a massage intervention is rare(38). However, a systematic review on adverse events from a massage therapy intervention reported that massage therapy was “not entirely risk free”, and that adverse events may be under reported(39). Nonetheless, in 2008, at the Hamilton Annual General Meeting of MNZ, the idea of regulation and registration for massage therapists was discussed. Steps were made to table submissions to the Health and Disability Commission to be included in the HPCA review(40). This direction has been unsuccessful to date.
The drive toward regulation of massage therapy practice in New Zealand by MNZ and other stakeholders has diminished over the past four years, perhaps due to unenthusiastic members and low membership numbers of the voluntary professional body. Questions still remain for New Zealand massage therapists regarding the road to professionalization. Is there a need to seek professional status through regulation, or are massage therapists better served by raising educational standards and building a sound collective knowledge base?
Paralleling the growth in interest and use of massage therapy in health care has been the evolution of massage therapy education for massage therapists. Early educational practices were informal and revolved around the weekend workshop. In 1992, the first ‘formal’ massage diploma (to meet the educational standards advocated by NZATMP) was delivered by a private training establishment in Auckland. There have been significant developments in massage therapy education over the past fifteen years, and the advent of NZQA unit standards in 1999/2001 provided a National Certificate and National Diploma in Massage Therapy(41,42). The New Zealand Qualifications Authority (NZQA) acts on behalf of the New Zealand government to accredit all educational qualifications within New Zealand. A unit standard is a collection of learning outcomes and unit standards collectively create a standardized competency-based curriculum. This was a significant move away from the cottage industry style of massage education delivery. Private Training Establishments (PTE) (i.e., privately owned tertiary schools) and Polytechnics (state-owned tertiary schools) seized this opportunity and an increase in education providers ensued. Today, a massage therapist’s education could involve a six-month certificate in relaxation massage, a one to two-year diploma in therapeutic massage, or a three-year bachelor’s degree. The evolution in training options has resulted in an increase in the duration of training, as well as the addition of research literacy and higher level thinking, aspects commonly found in bachelor degree level education(43).
Higher education is one means to recognition and professional expertise(44) and this belief was one of the motivating factors behind the establishment of bachelor degree-level education for massage therapists in New Zealand. Degree-based education for massage therapists was first established in 2002 at the Southern Institute of Technology (SIT), with a subsequent degree being introduced by the New Zealand College of Massage, a PTE, in 2006. The developers of the Bachelor of Therapeutic and Sports Massage (BTSM) at SIT wanted to create a course that developed a reflective, research-literate, independent, health practitioner expert in soft-tissue therapy, who was recognized as an equal by other health care professionals. Graduates would also develop the ability to re-educate themselves throughout their lives(45). This profile is in harmony with the general view of higher education, where students increase their capacity to learn and gain skills to deal with new information, while developing as professionals(46,47).
Another intention of the BTSM development was to move away from the NZQA unit standards, competency-based curriculum that was in operation at SIT and that was taking hold as the standard for massage therapy training in New Zealand. The primary developer of the BTSM did not believe that this mode of operational competency, which tended to develop technicians, was conducive to the development of a reflective practitioner, nor useful in developing critical thinking(48). In addition, competency-based courses are less effective in preparing future academics and researchers(49), and would limit the future standing of massage therapy as a profession. The following quote from the primary developer clearly identifies a range of motivations and strategies related to the use of higher education for professionalization and legitimation:
“As an educator I have been active in attempting to gain profession status for massage therapy in order that it be perceived, by society and purse holders, as equal in knowledge and skills to other health professions such as physiotherapy or medicine. My primary purpose behind the move to degree-based education was to gain power to provide opportunity for increased autonomy, to promote the benefits of massage therapy and subsequently cement a place for massage therapy as a legitimate and viable health service(50).”
Degree-based education for massage therapists had forced a change within the New Zealand industry. Knowledge in a curriculum is not a universal truth, but is constructed by social groups who have power to put forward their version of knowledge(51). The gold standard of diploma education for massage therapists and the power base of guru practitioners were challenged by the degree development; the massage industry did not greet this change with support(50). Degree level qualifications within the membership levels of the professional body at the time were absent—a situation that remained unchanged until 2009.
Utilization of higher education has been central in the development of many CAM occupations. For example, British chiropractors “have had the most success in the educational field, gaining degree status in 1988”(7). The education of chiropractors in New Zealand requires them to undertake five years higher education and ongoing postgraduate professional development. To further support and gain legitimacy, chiropractors have adopted a model of education that has been used in medical schools and have infused their curriculum with medical science(52). As noted by Baer(34), H. Wilensky suggested that occupations align with universities to develop academic degrees and research programs to expand the base of knowledge; nowadays osteopathic education occurs in universities in the UK and Australia(5,6). Similarly, within Australia, acupuncture and naturopathy degree conversion courses have been developed in response to changing professional and educational requirements(53). Although some CAM therapies (for example, acupuncture) are taught in the university sector to other health professionals, the university sector is not aligned with the education of any CAM profession in New Zealand.
Higher education also fosters professionally mature practitioners who have acquired appropriate knowledge, attitudes, and behaviors(54), and develops skills in “learning how to think”, becoming lifelong learners(55). Furthermore, the content of higher degree-based education increases a student’s research literacy and capacity. With research literacy, research capacity, and the attributes established from receiving a higher education, comes a responsibility to help shape the industry in which therapists work, therefore creating not only a competent practitioner, but also an interactive professional(47). Until recently, it was not common to teach research utilization and research literacy in US-based CAM academic programs(56), and a study(57) suggested that Canadian massage therapists do not consistently apply research in practice as a result of a lack of research education and skills. Perhaps in response to these insights, massage therapy education in the US has begun to recognize the need for research literacy to be integrated into curricula for massage therapists(58). This is especially important given the rapid increase in massage therapy research(59) that has occurred during the past 20 years (1988 to 2008). Kreitzer and colleagues(56) identified nine competencies of a research literate CAM practitioner, all of which are commonly incorporated into a New Zealand bachelor’s degree curriculum and the BTSM. Of note is the ability to participate in the culture of research and the need to up-skill educators(56), a benefit proposed by the developers of the BTSM, which is now evident with the establishment of the New Zealand Massage Therapy Research Centre:
“As well as providing quality massage therapy education, the BTSM has been nurturing research literate students who are able to participate in entry-level research in their 3rd year of study. Through valuing research and research-informed education, the BTSM has provided an avenue for publicly demonstrating the role and value of research for the massage therapy profession. The BTSM has also provided a vehicle for change, and is now leading the way in fostering a community of research practice as a result; the New Zealand Massage Therapy Research Centre (NZMTRC) at SIT was established in 2009(60).”
On the face of it, it appears that massage therapy education is advancing and there is potential for adding credibility to massage therapy practice through education. However, there is no legislated title or educational requirements for massage therapists; a ‘therapist’ can today set up shop with little or no training. MNZ sets a certificate or a diploma in massage therapy as the minimum qualification level requirements for its members, and with the removal of massage unit standards from the NZQA framework in 2012, there is no standardized national curriculum. There is some consensus amongst massage education providers as to the content, but less agreement on the level of training necessary for practice as a therapeutic massage therapist. In addition, it appears that there is some resistance to higher education, which may result in massage therapists, individually and collectively, not gaining the broader benefits obtained from gaining a higher education. This could place the growth, stability, and advancement of massage therapy practice as a health care service in New Zealand at risk(61).
As massage therapy provided by massage therapists is a self-funded service, it could be argued that massage therapy as a health and wellness modality is already recognized, well-used, and seen as credible and legitimate by the most important group, the consumer. It is foreseeable that massage therapists forego professional status and continue to operate independently as market-driven practitioners, outside of the formal health system and the rules it requires(62). However, legitimacy remains a concern for some New Zealand massage practitioners(33,61); some therapists seek recognition and credibility from the public and other ‘orthodox’ health care providers. Given the evolutionary path that massage therapy as a stand-alone practice has taken since the beginning of time (i.e., from orthodox to CAM) from being accepted to marginalized and (at times) tainted by its association with prostitution, and from a strong professional identity to being subsumed by physiotherapy, this yearning for massage therapist recognition and credibility is understandable.
The last 30 years of massage therapy evolution clearly shows evidence of the process of professionalization for massage therapists. However, the small numbers of massage therapists joining their professional association(9) and the part-time nature of the job(33) may slow down this process of professionalization. In addition, the practice of massage therapy commonly expresses a duality (i.e., being an enjoyable luxury (a treat)) and/or a treatment directed at an identified health need(63,64)—a duality that at times clouds its professional identity and may contribute to the internal industry agitation. A clear and strong professional identity can guide a profession during times of external change(65). Therapist disagreement and discontent, along with current New Zealand health policies, suggests that legitimacy through legal state-controlled regulation is unlikely, and may not bring the recognition and strong occupational boundary that massage therapists seek. Massage therapy techniques are still used within physiotherapy(66,67) and other occupations, and there remains a risk of intellectual colonization of massage therapy from academia, and co-opting and gate-keeping from other more dominant health discourses(62). If patch protection (i.e., occupational boundary maintenance), especially in the treatment of musculoskeletal problems, rather than regulation is the current crisis affecting the New Zealand massage therapy industry, then the strategy of degree-level education with its inherent scientific research and theory development and role in social closure, may be better suited to shape and guide the next 30 years.
Rationality and the scientific method became the dominant forces in the theory of knowledge during 1920–1960(68); through their dominance they redefined what was legitimate and relevant(69). These forces affected the development and legitimacy of massage therapy within and outside of physiotherapy. However, broader societal changes have allowed CAM to seek its own power(22). In addition, a growing body of knowledge supports massage therapy as being an evidence-based therapeutic modality for a range of conditions and symptoms(70,71). Massage therapists need to understand, critique, and keep up with these advancements for continuous improvement of professional competencies and for a higher level of expertise for their clients.
Benner(72) suggested engagement was the bridge from competence to expertise in nursing education. Perhaps the challenge for the massage therapy industry is to engage all stakeholders in creating a vision and taking the next steps towards clarifying and building the future professional identity of massage therapists—an identity that integrates the practices, culture, and values of the massage industry. The “construction of practitioners’ identities is a collective enterprise and is only partly a matter of an individual’s sense of self”(73). A shared identity expresses the composition of a community through the actions of its practitioners(73) and by pursuing a shared interest and actions, a Community of Practice will contribute to the development of its members and the evolution of the industry as a whole. After all, “personal and collective efforts are required to foster the progressions towards expertise”(44). Barriers to participation for both the Community of Practice and higher education, along with resistance to degree-level education will need to be addressed and overcome. Challenges of integration with and acceptance by other established health professions will also need to be addressed. Canadian research indicates that stakeholders (orthodox health professions) are not only reluctant to endorse the professionalization of CAM, but also oppose funding of CAM education, research, and access to the health system dollar(62).
Knowledge is an exercise of power and, as a result, local initiatives such as the BTSM can continually challenge and/or exploit the global culture(74). The challenge for degree-based education within New Zealand is its ability to market itself as a viable option for future massage therapists and gain recognition by the massage therapy industry as a valid educational option. Today in 2012, 11 years after the establishment of degree-level education for massage therapists, it remains to be seen whether the benefits of higher education (i.e., legitimation, patch protection, and best practice) will encourage the adoption of this curriculum innovation, or whether resistance and barriers will prevail.
Massage therapists in New Zealand continue to create their own complex history in an attempt to become valued once again, not only by consumers but by society as a whole. It could be argued that massage therapy as a health service, as practiced by massage therapists, has not moved forward due to inconsistent educational practices, no legal registration, little recognition from other health professionals, low industry standards, a feeble collective professional identity, and a weak industry voice. If massage therapists want professional status, then educational standards that support best practice, evidence-based practice, and research capability are required. Degree-based education for massage therapists is one means to gaining acceptance as a serious health care option and recognition from other health professionals, and it may help to recover ground lost through historical and contemporary challenges.
There is resistance to higher education for massage therapists for many reasons; however, there is also a growing trend toward engagement in degree-based education, evidenced by continuing student enrolments into massage therapy degrees within New Zealand. Research into the perceptions of degree-based education for massage therapists is needed to gain insight into the factors that contribute to resistance and engagement in degree-based education.
Engagement of all stakeholders is needed to clarify the future professional identity of massage therapists. The massage therapy industry within New Zealand could once again move towards a stronger professional identity, occupational boundary, and legitimation as a viable health care provider by accessing the benefits of higher educational standards and practice.
CONFLICT OF INTEREST NOTIFICATION
Two researchers (DS and JS) are massage therapist educators teaching on the Bachelor of Therapeutic and Sports Massage.
Published under the CreativeCommons Attribution-NonCommercial-NoDerivs 3.0 License.