Key Points

• One of the challenges facing the profession today is how to appropriately credential practitioners for each of these two categories: personal-care service and health-care service.

• Advanced credentialing for health-care service could be implemented in one of three ways: tiered licensure, college degrees, or alternative credentialing.

• Voluntary national certification seems to have the fewest logistical hurdles, and there is already a program in place to meet the credentialing requirement.

The massage therapy profession is leaps and bounds ahead of where it was in its infancy in the 1960s. The field continues to develop and still has some growing pains as it faces contemporary challenges. The profession has diversified as it has matured and realized its true potential. Today, there are a host of specialty applications in massage. These applications range from spa-focused relaxation forms to specialized health-care and medically oriented treatments. There is now, literally, something for everybody in massage care.

These specialties have been a real boon to the practicing therapist, helping them expand their careers and increase their treatment success for a wide range of clients. This article explores the state of massage credentialing today, presents some of the big questions around credentialing that face the profession, and then examines three options for addressing these credential challenges.

The Current State of Licensure and Credentialing

A credential is an external indicator that someone has mastered a pre-determined set of knowledge, skills, and abilities (KSAs) in a designated content area. Upon graduation from school, a massage therapy student receives a diploma or completion certificate from a school. Next, if the state requires it, they pass a state licensure test. Presently, 44 states require a license to practice massage therapy.

Licensure is the main recognized credential for massage therapists at this time. Its primary purpose is to protect the public. However, massage therapy licensing has not solved some of our biggest challenges around questions of credentialing. The profession has dozens of specialties, but these can mostly be placed into two broad massage categories. The first includes those whose work is primarily general relaxation, often called “personal-care service.” We can all agree that this type of work has health benefits, so please do not assume I am suggesting this first model is not beneficial for enhancing health and well-being.

The second category specifically focuses on using massage to address compromised health conditions; this will be referred to as massage as a “health-care service.” This model could involve treating pain or injury conditions, massage provided in a hospital with cancer patients, care of geriatric patients, or any number of other practice environments. The key distinguishing factor for this second category is that a greater understanding of working with compromised health conditions is necessary for effective and safe practice.

One of the challenges facing the profession today is how to appropriately credential practitioners for each of these two categories. Initial licensure does a pretty good job of covering the primary KSAs when massage is used as a personal-care service. However, the scope of KSAs required to address compromised health conditions is far more complex.

Practitioners work with much more complex client cases when using massage specifically as a health-care approach. As a result, there is a greater potential for adverse outcomes. One of the more critical lessons learned over the decades is that massage is not benign—it has profound physiological effects. It is important to verify that practitioners are adequately trained to work with clients needing specialized care.

Some argue that for massage to be taken seriously by other health-care professionals, additional credentialing above and beyond entry-level licensure is necessary. Practitioners, educators, and other stakeholders, such as insurance companies, have recognized it would be helpful if there were some type of advanced credential for this second category of massage as a health-care practice.

Three Models of Credentialing

Advanced credentialing is implemented in several ways. However, three models attract the most attention: tiered licensure, college degrees, and alternative credentialing. Admittedly, a move toward advanced credentialing will be an incremental process taking years to unfold fully. Let’s look at each of these models and some of the pros and cons of each.

Tiered Licensure

There is only one level of licensure in states that regulate massage. In a tiered licensure model, there would be an advanced license level administered by each state in addition to the basic license. Practitioners who want to work with clients seeking massage to treat compromised health conditions would need to acquire additional licensure. Let’s take a look at some of the benefits first. 

Tiered Licensure: Pros 

A tiered licensure program would provide a clearly designated credential above the entry-level license. This distinction would make it easier for stakeholders (like an insurance company or physician) to identify individuals who have completed additional training for working in the health-care model.

A separate license designation might make acceptance by other health-care providers and external stakeholders more likely.

A tiered licensure program might help create better portability of advanced training credentials between states. However, this would only be likely if there were standardized agreements among states for the curriculum of an upper-level license.

Tiered Licensure: Cons

It has been difficult to get states to agree on consistent licensure requirements at the entry level. Trying to get them to agree on requirements for an advanced level of training is likely to be even more complicated.

There is likely to be confusion and significant debate about what kind of massage requires what kind of license. This debate could end up being very divisive for the profession.

Individual state boards establish guidelines for state licensure. There may be a big enough pool of practitioners to staff a state board for entry-level training. However, there may not be enough practitioners with advanced skills and knowledge to help create separate advanced licensure in each state.

Additional licensure levels may pressure schools to train students for both potential career tracks. This pressure could further inflate required hours in training programs, significantly increasing their cost.

States are unlikely to take on more significant expenses for further regulating the massage profession, mainly because one level of public protection already exists.

Currently, the Federation of State Massage Therapy Boards provides a national exam (Massage & Bodywork Licensing Examination) used by most states for entry-level licensure. Creating a new advanced national licensing exam would be a monumental task.  

Convincing the public and legislators there is a need for a second type of licensure will be a massive public relations effort, and it’s not clear who would fund that effort.

College Degrees

One of the most common discussions around credentialing in our field is whether massage should eventually become a degree-required profession. In one model, massage could stay as a vocational field for those operating as a personal-care service. The current state licensure would remain for basic massage practice.

Those who wanted to work as health-care practitioners would complete a specific degree program. These degrees might start as an associate’s degree and eventually go to a full bachelor’s degree program. A program like this could begin with voluntary degree programs with no specific statewide requirement for degrees. Still, employers, clients, and other stakeholders could ask for practitioners who have completed the degree program. There are currently a few associate degrees in massage, some offering more advanced training.

College Degree: Pros

A college degree is a recognized credential. Other health professions have college degree requirements; these degrees would put the massage profession in line with the development tracks of other professions.

A college degree may increase the perceived credibility of the massage profession and lead to greater interest from researchers and others in the clinical science communities.

Degree programs do not put additional financial burdens on states to create and manage statewide credentialing programs as tiered licensure would. If degree programs become a requirement, massage education could become more academically oriented.

Advanced training through a degree program might be more accessible to some students through financial aid programs offered by the colleges.

College Degree: Cons

The return on investment (ROI) for college degrees is becoming a serious issue in our country. The cost of a college degree has significantly outpaced inflation and has risen nearly 25 percent in the last 10 years alone.¹ Students may question whether the cost of a full degree program could be recouped by a career in the massage profession, especially with the high attrition rate in the first few years of practice.

Colleges are facing financial and business-model pressures right now.² While the high-ticket schools like Harvard, Yale, and Stanford will likely weather this storm, other lower-tier schools are more susceptible. It seems unlikely that many of these schools would want to start degree programs in a field like massage therapy where there is a high attrition rate, declining enrollments, and the potential earning for graduates is not that high.

A degree program may be more about adding general studies to the curriculum and not more about advanced massage therapy applications. If so, is a degree program the preferred means of advanced credentialing? These additional areas of study may help round out an individual’s education, but there isn’t clear evidence they better prepare a massage therapist to be a health-care provider. It is likely to cost students more on coursework that may not be as helpful for their career goals.

Many people enter the massage profession after careers in other professions. They often already have degrees in other fields. If there is a requirement for a degree in massage therapy to work in the health-care arena, would they have to go back to school to get a specific degree in massage therapy?

Until there is a standardization of massage laws in all 50 states, it may be difficult to get degree programs to be transferable between states with widely divergent licensing requirements. It is already very difficult to get schools to recognize the programs from other schools for equivalency.

Chiropractic is a field that created its own degree and requirements. However, that model has kept chiropractic training out of most colleges and limited it to specific chiropractic schools. Massage is unlikely to have independent free-standing degree-granting institutions like chiropractic does. The money required to do this doesn’t seem to be there.

Alternative Credentialing

Alternative credentialing is the third model, and it is a broad category encompassing a diversity of providers, models, and options for how credentials may be earned and validated. In recent years, private companies, organizations, and other entities have recognized the need for validating specialized training. These educational providers have created specialized training programs that are significantly shorter than complete college degree programs. Some even offer credentials that measure prior learning and experience.

Alternative credentialing programs are rapidly expanding for several reasons. Many have developed in response to the changes and pressures facing colleges mentioned above. A recent piece on InsideHigherEd.com mentioned five key indicators of why alternative credentialing programs will continue to gain popularity.³ Two of these motivating factors are:

 (1) New content producers and distributors will continue to enter the marketplace, driving up competition and consumer choice while driving down prices. They will emphasize digital technologies, reject time-and-place-based education, create low-cost degrees, offer competency- or outcome-based education, and award nontraditional credentials. 

 (2) The dominance of time-bound degrees and “just-in-case” education will diminish. Meanwhile, non-degree certifications and “just-in-time” education will increase in status and value. We will see a reset between the value placed on degrees, once highly prized for indicating a level of skill and knowledge to be ready for the future, and “just-in-time” education, which is present-oriented and more immediate.

 There are too many alternative credentialing models to explore in detail in this article. However, some of the most common types include digital badges, verified certificates, and micro-credentials. These all show mastery and proficiency in the particular knowledge or skill taught. These credentials are offered through a private organization, an academic institution, or independent learning platforms such as Coursera, Udemy, or LinkedIn Learning.

The most common alternative credentialing programs in the massage therapy field are certificates and certification. There is a crucial distinction between certificates and certification programs. A particular provider offers a certificate program, and that provider determines what qualifies for completion and awards the certificate. In some cases, attendance alone is sufficient to achieve the certificate. In other cases, the individual needs to show mastery in some form of learning assessment in addition to completing the program.

A certification program, by contrast, is developed by an external party and is designed to measure a core group of KSAs but is independent of where or when the learning took place. For example, two people could qualify and be awarded the same certification credential, even though their training is acquired from entirely different sources. The certification is designed to measure the acquisition of KSAs, not where, when, or how they are acquired. (Read about these key distinctions in the blog post “Certificate vs. Certification Programs Credentialing Terminology Matters.”)⁴ 

Most continuing education courses in our field that offer alternative credentials are certificate programs, even though many are listed as certifications. Our field’s one main certification program is the Board Certified in Therapeutic Massage & Bodywork (BCTMB) credential offered by the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB).

The BCTMB program is a likely model to be used for alternative credentialing, so the pro and con discussion of alternative credentialing uses this program as an example.

Alternative Credentialing: Pros

An independent third-party organization establishes a national standard. With a national standard, the challenges of differing requirements from state to state are eliminated.

The one national standard in the massage therapy profession (BCTMB) uses a single exam to evaluate achievement of the credential. Developing one quality exam is much easier and more sensible than developing numerous exams on a state-by-state basis.

This model avoids the legislative costs carried by the states for multiple levels of licensure.

Certification programs are training agnostic. That means it doesn’t matter where or when you got your training (or how many hours you sat in a class—described as “seat time”). What is essential is that the student demonstrates adequate mastery of core knowledge, skills, and abilities necessary to perform in that particular certification’s work environments.

The decreased emphasis on seat time for the training program and increased emphasis on outcomes is consistent with emerging best practices in learning science.

Even if massage eventually goes to a degree-granting profession, starting with a national certification program is a vital first step in that direction. This model has often been used in other fields.

The costs of acquiring an alternative credential are likely to be much less than those of degree programs or the tiered licensure structure. A national alternative credentialing program that is not dependent on a particular school’s training or degree removes geographic restraints that may limit who can achieve the credential.

The system for a national credential with one exam evaluating advanced practice is already in place with the NCBTMB. Improvements in the system would be necessary, but the basic structure already exists.

Alternative Credentialing: Cons

Getting subject matter experts (SMEs) to agree on content for a single certification program is a significant challenge. However, this is still far easier than getting SMEs to agree on content for multiple licensing exams or degree programs for each of the 50 states.

If some credential is established other than the BCTMB, finding SMEs, administrators, and funding to create a new certification credential would be daunting.

It has been challenging to define the specific types of work or clientele that require advanced certification. It is generally agreed upon that those treating complex health conditions could benefit from credentialing.

The existing national certification organization (NCBTMB) faced many of these challenges as it developed the BCTMB and improved it over the decades. They have faced personnel challenges, financial difficulties, and a lack of focus by getting involved with entry-level licensing for several years. The good news is that the organization seems to be moving in the right direction, returning to its original mission as a voluntary certification organization. This move can strengthen their program as a valid alternative credential.

A national certification program like the BCTMB still requires a large-scale public relations campaign to help clients, health-care providers, and other stakeholders understand the distinctions and purpose of the credentialing program. Creating an advanced credential has the potential to further a division in our profession and make some people feel they are “less than others” because they have not acquired the voluntary certification credential.

The Case for Voluntary National Certification

Many believe the massage profession sorely needs some type of national advanced credentialing. The options mentioned above are not the only paths to credentialing, but they are the ones that seem to get the most traction. I have spent a great deal of time analyzing these different options. They all have strengths and weaknesses.

After weighing all the pros and cons, I will admit a bias in thinking the strongest option for us at this stage of our profession’s development is with the third model—voluntary national certification. This option seems to have the fewest logistical hurdles, and there is already a program in place to meet the credentialing requirement. For that reason, I, along with a number of other highly talented experts in the profession, have been volunteering for the NCBTMB to further this goal.

The massage field is certainly experiencing growing pains as it continues to grow as a health-care profession. Many advances have been made in improving the training and education of those working with clients with complex health conditions. A national credential would offer the public and stakeholders a way to identify those clinicians who have chosen the health-care path. Massage therapists would greatly benefit from a credential that evidences all the work, training, and skill-building they have dedicated themselves to in order to help clients who need advanced therapeutic applications.  

Notes

1. Abigail Johnson Hess, CNBC.com, “The Cost of College Increased by More Than 25% in the Last 10 Years—Here’s Why,” updated December 13, 2019, www.cnbc.com/2019/12/13/cost-of-college-increased-by-more-than-25percent-in-the-last-10-years.html.

2. Michael B. Horn, Forbes.com, “Will Half of All Colleges Really Close in the Next Decade?,” December 13, 2018, www.forbes.com/sites/michaelhorn/2018/12/13/will-half-of-all-colleges-really-close-in-the-next-decade/?sh=68df7da852e5.

3. Arthur Levine and Scott Van Pelt, InsideHigherEd.com, “The Future of Higher Ed is Occurring at the Margins,” October 4, 2021, www.insidehighered.com/views/2021/10/04/higher-education-should-prepare-five-new-realities-opinion.

4. Whitney Lowe, AcademyOfClinicalMassage.com, “Certificate vs. Certification: Credentialing Terminology Matters,” January 9, 2018, www.academyofclinicalmassage.com/certificate-vs-certification-credentialing-terminology-matters.