When American therapists debate regulation of massage, inevitably Canada’s example comes up, either as a path to follow or a terrible warning of how demanding regulation can be. Canada has the highest standards in the world, but that’s really only in three provinces—Newfoundland and Labrador, Ontario, and British Columbia. Most provinces aren’t ruled by a regulatory college put in place by government legislation.

Looking deeper, it’s a long and complex road to similar regulation in the remaining seven provinces and three territories, and success is not guaranteed. For instance, a 1999 report by the Office of the Professions of Quebec states, “The Ministry for Education considers that massage does not represent any danger to the public.” Though there are lobbying efforts from within Quebec to establish a government-sanctioned regulatory body, it’s clear the government isn’t leaning that way since public protection is job one for legislators. Not all legislators are convinced provincial regulation is necessary.

The Educational Number

“We’re looking to have a national standard,” says Damon Marchand, president of the Canadian Massage Therapy Alliance (CMTA). The CMTA is made up of provincial associations in favor of a minimum twenty-two hundred-hour massage education for unregulated provinces, the establishment of regulatory colleges, and mandatory continuing education. In nonregulated provinces, CMTA associations set a common code of conduct and in many ways mirror the goals and language of the regulatory colleges. Adherence to those standards is enforced only by membership, not by governmental constraints.

In the absence of regulatory colleges, the rules can be a patchwork very like the situation in the United States where individual municipalities set the guidelines for how much education is required to practice massage therapy. For instance, Sherwood Park, Alberta, only requires a business development permit, while just down the road, the city of Edmonton requires a criminal record check and two hundred fifty hours of training from a recognized school.

In British Columbia, the educational standard is three thousand hours. Though “functionally” we talk about three thousand hours, “we prefer to talk in terms of competencies,” says Doug Fairweather, president of the College of Massage Therapists of British Columbia (CMTBC.) “The three thousand-hour standard is the minimum time it takes to learn those competencies.” In Ontario, it takes two to three years to learn the competencies necessary to write the provincial registration examinations to become a massage therapist. Ontario used to have a twenty-two hundred-hour time-based standard, but changed to a competency-based system in 1993.

Regulated or not, it’s clear massage therapy is growing in numbers of therapists and improving in how it is perceived by the public. A study published by the Fraser Institute found that nationally, massage leads the complementary therapies with 19 percent usage. The research states: “On a provincial basis, Alberta saw the largest increase in the use of alternative therapies in the year previous to the 2006 survey (68 percent compared to 54 percent in 1997), followed by Ontario (55 percent compared to 50 percent in 1997), and British Columbia (64 percent from 60 percent in 1997). Quebec and Saskatchewan/Manitoba both experienced a 1 percent increase, moving from 44 to 45 and from 58 to 59 percent respectively, while Atlantic Canada experienced a decrease in the use of alternative therapies, falling to 39 percent in 2006 from 45 percent in 1997.”¹

According to Doug Alexander, editor of the online magazine Massagetherapypractice.com and a teacher at Algonquin College in Ottawa, newly-trained physicians are much more open to what we do. After twenty-two years of practice, he’s seen a lot of changes in the perception of the profession. “Massage therapy started off very alternative [catering to] people who tended to live outside the norm,” he says. It’s commonly acknowledged that thoughts and feelings can affect physical health and now alternative is mainstream. “We were ahead of the wave.”

Advantages of Regulation

The common impulse to regulate the profession is to protect the public. “I can easily get into resenting regulation though I am a proponent of regulation,” Alexander says. “[Regulation] helps accessibility and I do want massage therapy to be part of the world. Massage therapy is a very safe intervention.” But, Alexander says, regulation is a good thing because it provides oversight when therapists violate the relationship of trust with clients. Alexander points to deep vein thrombosis as an example of a health threat for which therapists must have higher levels of training to recognize.

Though harm can be hard to prove, when working with patient groups that have pathologies, you could do things that could do harm, Fairweather says. Beyond the safety of the public, regulation to such high standards also creates a clear identity and a level of assurance of quality of what the public will receive, he says, as well as enhancing the confidence of third-party insurers and health professions who refer to massage therapists.

Another spur to regulation is tax exemption. If a total of five provinces become regulated by colleges, the Federal Ministry of Finance has said they will exempt massage therapists from paying the Goods and Services Tax—currently 5 percent of their fee.

Without the establishment of a regulatory college, “There is no solid way for someone to have recourse if hurt by a therapist,” says Chandra Kastern, president of the Massage Therapist Association of Alberta. “There’s no one body to come down with a hammer on MTs.” She points out that some instances of impropriety don’t lend themselves to civil or criminal action. For instance, a massage therapist could ask a client invasive questions. “That crosses the line ethically; in a civil court it means nothing.” Kastern says peers would see ethical faults differently from the way a court might see the situation.

“There’s a whole lot of fear about regulation,” Kastern says. However, she predicts that when regulation goes through, politicians will not only have public protection in mind, but also the well-being of people in the profession. “You can’t suddenly axe people from their jobs. Legislators are not going to regulate in an exclusive manner. It doesn’t happen like that and it won’t happen for massage therapy in Canada.” She suggests a grandfathering process would protect therapists who haven’t attained a twenty-two hundred-hour competency, allowing them to continue to work and upgrade to the new standard.

Competing Visions of Regulation

Until a consensus among lobby groups is achieved, regulation of more provinces might be stymied. The opposing models of massage regulation hinge on whether regulation would embrace a one-category or multi-category model. The CMTA advocates a single category model in which massage therapists attain a minimum twenty-two hundred-hour level of competency to qualify to practice the profession.

Countering that is the multi-category model proposed by the Association of Massage Therapists and Wholistic Practitioners (AMTWP).² They favor regulation that would include three categories of practice: the general intent therapist, the basic remedial therapist, and the advanced remedial therapist. The general intent therapist practices relaxation massage for clients with no pathological processes. The remedial therapist would be capable of working with issues like tennis elbow, and the advanced remedial therapist is capable of dealing with complex conditions requiring a higher degree of assessment skills.

 “We are the largest national massage therapy organization in Canada,” says Colleen MacDougall, the AMTWP executive director. “Representing the majority of the MTs in Canada, we certainly feel research has to be done … to look at it [regulation and the profession] from a broader perspective.” That’s how the multi-category model evolved, she adds. Still, she is concerned about what form regulation may take. “Regulation is not based upon the [desire] of the profession to be more credible. It’s based upon more elements than that.” Access and choice, for example, are factors that she feels the single-category approach will limit.

Proponents see the multi-category model as a way to include the full spectrum of massage as it is practiced in Canada. “Right now there are massage therapists and nonregulated bodyworkers practicing massage. Why not bring them into the fold?” MacDougall asks. “[Bodyworkers] might have a different education and focus, but capture them and create a place for them to exist so they’re accountable for what they are doing. If they encounter a condition outside their scope of practice, they’d refer on. You ensure that there’s training in place to recognize [contraindications].”

MacDougall often feels the efforts of her association are misconstrued. For instance, despite the inclusion of holistic practitioners in her association’s title and membership, people who practice reiki alone would not be included in the proposed multi-category model because they aren’t massage therapists.

“The future is positive for massage as a whole if our focus is to ensure that [we] recognize the competency of the various levels of massage therapy within a defined scope of practice. The more people we have within the regulation fold the stronger we will be in protecting the public interest. I think massage therapy can go upward, but it’s the industry coming together that’s going to make that happen,” MacDougall says.

Single-category proponents disagree. “Multi-tiering training doesn’t work,” says Marchand of the CMTA. “We view it as lowering of competency standards. Minimum standards and training [of the one category model] need to be set … to provide safe and effective treatment. If practiced incompetently, you can harm somebody.” Marchand says interaction with clients requires assessment skills, knowing when not to treat, knowing what to do, and knowing when not to do it. 

Registered massage therapists (RMTs) are not simply service providers in Ontario, says Andrew Parr, executive director for the Ontario Massage Therapist Association (OMTA). RMTs are an access point to the health system, he says. The higher standards of training required ensure public safety in that RMTs can recognize contraindications and refer out. “I’m not sure the AMTWP’s model will allow an individual to fill that role,” he says.

MacDougall is confident all massage therapists can be trained to recognize contraindications and refer out, no matter their therapeutic intent and focus. “A multi-category model is not new to healthcare. It exists already. Paramedics have a multi-category system, for instance.”

Disadvantages of Regulation

If or when regulation goes through, many people agree that start-up can be expensive. Ongoing operating costs aren’t inconsiderable either; the annual budget for the College of Massage Therapists of Ontario for 2006 was more than $4 million.

When asked about the disadvantages of regulation, Parr is frank, “Your costs are a little higher. There are always cost issues when you regulate a group of individuals and … this tends to drive consumer costs up somewhat.” Higher educational standards mean it takes longer to enter practice so there will be fewer people able to provide the service, he adds. However, Parr emphasizes that the benefits outweigh the costs and there are safeguards in place so standards don’t change so fast as to be prohibitive. The phenomenon of “creeping credentialism” in which higher and higher standards are fobbed on therapists too fast is prohibited by the governmental oversight process, Parr says.    

“You have to follow the law and work within the regulations … which means you are not a free agent in the world,” says Deborah Worrad, registrar for the College of Massage Therapists of Ontario. “You have professional obligations and responsibilities. And you have financial obligations. I don’t necessarily see that as the downside, but it is a reality.” There’s a cost involved to balance out the benefits, she says. “Some people like to be freer and of course anyone has the option to be an unregulated bodyworker; they don’t have to belong to the profession.”

Marchand provides a personal example of how regulation restricts his practice. “As an MT in British Columbia … we are not allowed to use any sort of medical electricity [like] TENS machines, ultrasound, or cold laser. The general public can go buy a TENS machine and use it on themselves … and yet I’m not allowed to take training and use that because it’s outside my scope of practice as a healthcare professional. That’s a challenge.”

The Road Ahead

There are many broader challenges ahead as letters are written, governments are lobbied, and the paper piles up. Proponents of single-category and multi-category systems all desire regulation, yet the obstacles are laid down not just by provincial governments but by the competition itself.

Marchand makes no predictions when more provinces will be regulated, though he says a lobby group like the AMTWP slows the march to regulation of massage therapy. “One of the difficulties we’ve heard from the provinces [is that] if there’s more than one association, governments have told them, ‘We want to deal with one association,’” he says.

“If there were some compromise toward adopting the multi-category model, many of the obstacles on the road to regulation would be cleared,” MacDougall says. However, as it stands “We have no identification yet as to when [regulation] would occur. Some of the provinces have said no, outright. They’re not going to move forward with regulation. Quebec, in 1999, declined. Saskatchewan is no. Manitoba said all the profession needs to come together to see what it would look like and even then they weren’t sure it needs to be regulated. Nova Scotia is no. They [the provincial governments] haven’t been convinced there’s significant risk of harm. I know it’s purported that they’re on the brink of regulation, but that’s factually incorrect,” MacDougall says.

An official for Nova Scotia’s Health Ministry said his office was flooded with letters that opposed regulation outright or expressed concern about the form of proposed regulation so the legislation didn’t go through. A source at the Massage Therapy Association of Nova Scotia who preferred not to be identified said the board intends to take it back to the membership to see if they will take another run at establishing a regulatory college.

“New Brunswick has some legislation in front of them, but we spoke in opposition to it,” MacDougall says. “It’s not multi-category based nor were we consulted on development of that regulation. The last two years all I’ve heard is that [provinces are] going to be regulated. I hear, ‘It’s coming soon! It’s coming soon!’ If they were going to be regulated, why aren’t they already regulated?”

  Robert Chute is a writer and massage therapist in Ontario.

NoteS

1.    Quoted with permission from The Fraser Institute, Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitudes, 1997-2006, published May 2007.

2.                                At press time, the AMTWP changed its name to the Natural Health Practitioners of Canada.