THE FIGHT FOR SELF-REGULATION

The Fight for Self-Regulation

Discussions about the development of a profession are sometimes referred to as a professionalization trajectory. A professionalization trajectory, simply stated, is the path a profession takes from the status of an unregulated trade to a recognized and regulated profession with a high level of autonomy. In fact, it has been stated that this autonomy is a distinguishing characteristic of modern professions (Freidson, 1970). Therefore, the struggle to become autonomous becomes a central part of the process of professionalization.

It has been suggested that this trajectory begins with a voluntary association of like-minded practitioners who are interested in enhancing the credibility and status of their profession. Through a gradual process of development and maturation, this body creates standards of practice, codes of conduct, professional ethics, educational standards for entrance to practice, an ethos of public service, a profession-specific language, and a solid knowledge base. Eventually, the profession reaches the point on the professionalization trajectory where, in order to enhance credibility and develop autonomy, a form of regulation and self-governance are sought.

Although massage therapy had been regulated in Ontario under the Drugless Practitioners Act since 1919, changes in government policy in regard to the regulated health professions in the early 1980s propelled the professionalization trajectory of massage therapy in new directions.

The Changing State of the Regulation of the Health Professions

In the early 1980s, the framework under which health professions were regulated in Ontario was under scrutiny. At that time, massage therapy in Ontario was regulated under the Drugless Practitioners Act, overseen by the Board of Masseurs (who would end up becoming the Council of the College of Massage Therapists). There was no omnibus legislation that set out regulations for all health professionals and there was no transparent interrelationship between the governing documents.

The provincial government at the time had concerns about rapidly escalating health care costs and about the number, complexity and inconsistencies in the legislation that governed the regulated health professions. It was determined that an overall review of the health professions legislation needed to take place to closely look at which practitioners were currently considered to be regulated health professionals, and to determine who should and shouldn’t be included. At the same time, the question as to whether it was possible to create one overarching legislative act inclusive of all regulated health professionals was investigated.

A government committee was created to review the regulated health professions and provide recommendations to the Minister (this group would eventually become the Health Professions Regulatory Advisory Council [HPRAC] with the introduction of the Regulated Health Professions Act, 1991). The group requested that health professions seeking to be regulated under the proposed new legislation submit applications. The application would need to address certain criteria such as identifying the profession’s scope of practice and potential risk of harm to the public.

The Massage Therapy Perspective on Regulation

The request for health professions to submit applications was received with mixed feelings by the massage therapy profession. There were those who believed that massage therapy did not need to be included in the new legislation and in fact should not be regulated at all. Some members of the profession at the time advocated an independent, anti-regulation agenda, and a sharp debate regarding whether or not massage therapy should pursue regulation rose in various professional circles. Simultaneously, there was a need for massage therapy to find ways to further distinguish itself in the eyes of the public from the growing number of “body rub parlours.”

On one side of the debate were individuals who preferred to be unregulated rather than having increased education and reporting requirements, registration fees and increased rules regarding record keeping. Today some of these arguments are still heard. The other side saw massage therapy as a developing profession in which the potential as a health care practice had only begun to blossom. For this group, the pursuit of regulation under the new legislation and the concurrent development of increased standards and accountability were seen as fundamental to the growth of the profession. At the same time (in the mid-’80s), a few massage therapy schools were actively developing the first clinical placements for supervised students to work in hospitals, with increasingly complex patients. These schools supported the pro-legislation agenda, including increased hours of education and higher levels of professional standards of practice.

For those who agreed that regulation should be pursued by the massage therapy profession, it was not, at the time, easy to make a compelling case for massage therapy as a regulated health profession. In the early days of the Health Professions Legislative Review (HPLR), both the Board of Masseurs and the Registered Massage Therapists' Association of Ontario(RMTAO) had been asked to submit answers to the same questions. Neither group saw each other’s work prior to submission. As time went on and the review process continued, it became increasingly clear that to be successful both organizations would need to set aside perceived and actual historical conflicts and differences and work together to strengthen the quality of submissions and to position the profession to speak to the government with one voice, in a consistent and compelling way.

Developing a Case for Massage Therapy Regulation

Having decided to present one unified case for massage therapy to be a regulated health care profession, both the Board of Masseurs and the RMTAO acknowledged that the evidence and claims to be included in all government-requested documents would need to be as rigorous as possible if massage was going to stand a chance of being recognized.

A review of the literature at the time revealed that there was very little evidence to support massage as a health care intervention. There was very little written down about scope of practice, body of knowledge or risk of harm. At the time, there were four schools with no agreed upon curriculum and even the code of ethics was very basic. Despite having been regulated since 1919, the case for massage therapy to be regulated under the new umbrella of regulated health care professions was thin.

A core of determined massage therapists from both the Board of Masseurs and from the RMTAO learned to work together during the 1980s to develop the case for massage therapy. They also needed to work together to convince the massage therapists of Ontario that the profession would benefit from regulation. Massage therapists understood that with regulation would come increased standards. It was important to unite massage therapists and convince them of the importance of staying in control of the development of standards.

Over the years it took for the review of the health professions to be completed (1982–1991), the group representing the profession quickly learned how to interact effectively with the government. What began as naïve communication quickly turned to more savvy interaction with the help and guidance of the lawyer who was hired to move the agenda of massage therapy regulation forward. The case for massage therapy was based on the creation of good standards of practice, increasing the amount of required education, clearly defining the scope of practice and establishing risk of harm. The discussion of risk of harm was difficult, as it was mostly based on common sense and anecdotal evidence. However, with the ability to prove that the public was turning more and more to massage therapy—and by an aging public with increasingly complex health issues—the case could be made, even without the benefit of systematic research on the safety and effectiveness of massage therapy, that it was in the government’s best interest to ensure that the standards of care for massage therapy were high.

A Professional Revolution

Regulation of massage therapy under the Regulated Health Professions Act, 1991 was the catalyst for major changes in the profession. Ethics, therapeutic relationship, evidence-based approach, critical thinking, interdisciplinary care and business practices were all enhanced as a result of the new legislation.

Massage regulation drove the creation of a number of professional documents that were missing. Also, major changes to professional education and certification examinations were made. The model of education moved away from an apprenticeship model of education to a more competency-based model. The changes that were made within the profession as a result of regulation were undertaken in order to achieve credibility and recognition for the profession, to increase accountability to the public and quality of care. The changes that were made produced nothing short of a revolution.

Commitment to the Future of the Massage Therapy Profession

Undertaking the responsibility of seeking regulation for massage therapy was an incredibly important time in our history. It took many individuals committing volunteer time to move this forward. It also took vision and bravery to stand up and fight for what was best for the profession. To this day, the people who continue to drive professional growth and change are usually volunteers who are involved because they want the profession to continue to improve.

With the regulation of massage therapy, many aspects of the profession improved, but we need to recognize that we are a work in progress and there is more work to be done. Being regulated is part of our commitment to offer safe and effective treatment to the public through high standards of education and practice.

The future of regulated health professions is to continue to develop safer, more effective and cost efficient health care for all Canadians. One of the ways this will be accomplished is through the development of collaborative, patient-focused interprofessional teams. The potential for massage therapists to become increasingly valued and valuable contributing members of interprofessional health care teams is significant. However, in order to do that, the massage therapy profession must develop the necessary levels of research and standards of practice. We are not there yet. The opportunities are there but not for a profession that stands back and says, “There is nothing more I need to do here,” or “There is nothing more I need to learn.”

The health care that will be needed for our aging population, for our children as they age, has yet to be developed. As a profession, if we are not poised to learn and develop with the changing face of health care, we may miss out on these opportunities and we may not be able to grow in our ability to deliver safe, effective and cost-effective treatment. If we do not see ourselves as potential contributors to community-based interprofessional teams delivering health care that matters, then we are a service industry. If we don’t think massage therapists have an active role to play in the future of health care, then we shouldn’t be regulated.

The pioneers of our profession fought for massage therapy to be part of the RHPA so massage therapists could contribute to improving the health and quality of life for people with complex medical conditions. They fought so we can improve the quality of health care for Canadians. The best of how massage therapists will contribute to health care has yet to be determined.