The previous column [Fall 1999] in this series defined the term "Scope of Practice" (SOP) and introduced four key factors that shape and change it: the law, educational training, competency, and personal accountability. It explained how local laws determine the legal parameters of what massage therapists can and cannot do, and suggested steps that can be taken to influence and change the laws that govern you as a massage therapist. The intention of Part II is to personalize SOP by examining the influences of educational training and competency. It also introduces the need for self-accountability, which will be featured in Part III.

Educational Training

One definition of the term "Scope of Practice" is "the knowledge base and practice parameters of a profession."¹ Use of the term "practice parameters" insinuates that there is a collective SOP for a profession. However, defining practice parameters is not so simple in the massage therapy profession. The phrase "knowledge base" suggests that there is a common framework of fundamental information provided by the educational training process in a particular field. Again, not so in massage therapy.

Training in massage is unlike training in such other professions as nursing, dental hygiene, and physical therapy. In these more standardized professions, basic training programs throughout the country are fairly consistent in what they teach the students to know and do. Educational offerings in massage training programs, however, are as diverse and inconstant as the local laws that govern them. It is, therefore, difficult to determine a comprehensive, consistent common knowledge base among massage therapists.

Massage, A Career at Your Fingertips, features information on approximately five hundred sixty schools in the United States.² The length of the school programs range from 100 hours to 1,000 hours in basic training for massage therapists-a dramatic variation in how long massage therapists are trained. Moreover, the course content and focus of all training programs also vary, for they traverse a wide range of modalities, philosophies, and approaches. Even if 500 hours is considered to be the average requirement for state or local licensing, a broad range of subjects and modalities are taught in these 500-hour programs. It is, then, also difficult to surmise a clear and definitive list of what a massage therapist is trained to know and do. Although some common skills and information are taught, in both course length and content, there is no "typical" training in massage. So, each massage professional, empowered by his or her basic and advanced training, has a unique base of information and knowledge, or SOP.

Consider procedures such as lymphatic-drainage massage, pregnancy massage, colon hydrotherapy, applied kinesiology, myofascial release, aromatherapy, trigger point therapy, Shiatsu, energy healing, and reflexology. While some of these modalities are taught in some massage training programs, they are not taught in all of them. Is it within your personal SOP to perform them or not? Part I in this series [Fall 1999] showed that, ultimately, if local licensing laws exist where you practice, they govern your SOP and determine what you can and cannot do. Even if laws do exist, however, many of them are very general and make no mention of these modalities. So, while laws serve as a guide, two therapists governed by the same laws may have significant differences in their scopes, or parameters, of practice based on their education and unique knowledge base. Beyond the law's watchful eye, educational training individualizes SOP and it becomes a personal issue rather than a collective one.

Competency

Taking the educational and training considerations one step further, the issue of competency arises. As surely as educational training and the laws which govern a therapist influences personal SOP, so does ability and adeptness. This brings forth several questions. What determines competency? Who is the ultimate judge of competency? In many localities, the law states that competency is presumed once the required number of hours of formal education is complete. Growing numbers of city and state laws require the passing of a written test to be a more convincing measure of competency, yet written exams vary in degree of difficulty.

Twenty-six states have legislatures to regulate massage; sixteen of them use the National Certification Exam for Therapeutic Massage and Bodyworkers (NCETMB) to assess competency before issuing licensure.³ The remaining ten, apparently, have their own licensing exam. Regarding the evaluation of hands-on skills, only five states have laws that require a practical evaluation in the licensing process.⁴ So, to satisfy most licensure laws, if you graduate from an acceptable training program and pass a written test, you are deemed competent.

This does not, however, take into account that competency could change if the testing is done only upon initial licensure. In Rhode Island, for instance, a massage therapist must pass the NCETMB in order to obtain a license, but the maintenance of NCTMB certification is never followed up. A Rhode Island licensed massage therapist could conceivably never practice, never take continuing education (unless she wanted to maintain AMTA membership), never stay current in the field, and still renew her license. In this scenario, the therapist is licensed but never practices massage. In your opinion, would she be considered a competent massage therapist? This is not such an unusual situation; a significant number of people graduate from massage schools, maintain licensure, and do not practice massage. Upholding high standards to promote professional expertise, then, requires methods to assure quality and competence.

Beyond basic training, offerings for advanced studies in the massage therapy field abound. Once again, the concern of competency brings more questions. Does a therapist need credentials from a week-long certification course, or does it suffice to attend a 2-hour seminar to become proficient in new methods? Is it sufficient to watch a video on the subject, or read a book that teaches about it in order to be properly trained and competent? How much and what type of training is adequate?

Patricia J. Benjamin, former AMTA national director of education, warns against paper tiger credentials, or "credentials, titles or certifications which may sound impressive but which lack teeth." She goes on to say that, "A disturbing number of practitioners are claiming credentials in various disciplines or specialties only after an introductory workshop or a few class hours on the subject. Likewise, there are school approvals available upon request with nothing required but a sign-up application. If a credential is to mean something of value it must represent meeting a certain standard of quality or the significant mastery of a particular area, and not just a passing familiarity."⁵

There is no checks and balance system, nor is there an effective system to monitor paper-tiger credentials. The challenge is to find methods that ensure competency, assure quality, and maintain standards of expertise throughout the profession. The answers lies in this approach: Individuals must have unshakable personal ethics and a high capacity for self-accountability. Look for these topics in Part III of this series.

Personal SOP

Governing laws, individual acquired knowledge base, and a capacity to apply and practice responsibly and well, are what personalize the SOP. These steps can help clarify and establish a SOP:

1. Update your résumé. This is a very effective way to help a therapist realize and remind them of the breadth and width of this acquired knowledge base. List education, training, and work experience, including what you did before you became a massage therapist. Everything you know and have done contributes to who you are as a person. In some cases, the work may actually enrich your SOP as a massage therapist. For example, a practitioner who was a physical therapist before becoming a massage therapist would have knowledge and experience that might make her personal SOP different from a psychotherapist who becomes a massage therapist. They would most likely have very different approaches to working with a client who sees them for disability from low-back pain.

2. Reread your local licensing laws. Become familiar with what is permitted and prohibited by your laws, and stay current with legislative changes that affect you. Then, function honestly within your legal limits. See Part I of this series [Fall 1999] on how the law has a continuing, powerful influence on personal SOP.

3. Define your personal strengths. List techniques, procedures, and modalities that you do regularly and feel competent in. Identify what you do that makes you unique and different from other bodyworkers. Perhaps your preferred area of interest is injury rehabilitation massage, or maybe you consider Swedish relaxation treatments to be your specialty. Or, it may not be a technique at all that is your forté. Maybe it is the quality of presence you bring to the table. Be nonjudgmental about your talents, preferences, and true interests. You will have greater career satisfaction and you may likely be more competent when you do the things you enjoy most.

4. List the techniques and modalities that you were trained in but seldom do. As in all things, "Practice makes perfect," and if "You don't use it, you lose it." If, for example, you have not performed foot reflexology since your course in massage school 3 years ago, serve the client who requests a reflexology treatment by referring him to a colleague who does it regularly. And, do not list reflexology on your business card. If your list reminds you of aspirations you had long forgotten about, decide if you want to pursue them at this time.

5. Network with other professionals. This includes other massage therapists and bodyworkers, as well as other healthcare professionals. Talk with them about their SOPs and see how yours is different from theirs. For example, the next time you attend a conference or workshop, chat with a massage therapist who went to another school and compare notes. The contrast can help you better identify your own parameters, strengths, and limitations. Also, knowing what they do and specialize in offers you referral options when you encounter clients whose needs exceed your ability. When a client wants or needs a modality that you seldom practice, even if you were trained in it, referring the client to another more qualified and experienced massage therapist in that area may better meet their needs.

6. Represent yourself honestly. Be realistic about what you were officially and properly trained in, versus information you acquired "in your travels." Being self-taught can be a valuable attribute, but there are substantial differences between working in a field or researching for years and watching one or two videos on a subject. Would a parent be in more competent hands learning infant massage from a former nursery nurse who has become a massage therapist, or from a massage therapist who watched a video on how to massage infants?

7. Be attentive to "high-risk areas." These situations tempt you to go beyond your qualifications. I have had the experience of clients who expect me to diagnose their problems, or clients who ask me to do spinal adjustments. Clients also often ask about strengthening exercises and nutritional advice. I am not officially trained in, nor am I qualified to function in these areas, even though I may be well informed due to my own personal interests. Have a prepared response in situations such as these, such as, "That is not within my scope of practice, but I can refer you to ______ for that."

The final column in this series will deal with self-accountability. Our capacity for self-accountability is what keeps us functioning ethically and responsibly within our personal SOP.

. . .

Dianne Polseno, former chair of the National Ethics subcommittee, is a practicing massage therapist, practical nurse, author and publisher of Comprehensive Review Manual for Massage Therapists. A teacher at Bancroft School of Massage Therapy, she receives mail at dipol@aol.com or 1 Raymond St., North Smithfield, RI 20896-8215.

Resources

1. Grosenbach, James M.; Fritz, Sandy; Paholsky, Kathy. Ethics and Professionalism. Lapeer, Michigan: Health Enrichment Center, Inc., 1997: p. 1.

2. Ashley, Martin. Massage A Career at your Fingertips. Blair, Nebraska: Enterprise Publishing, 1998: pp. 219-314.

3. "U.S. Laws and Legislation," Massage Magazine, 81: p. 141, September-October 1999.

4. Ibid.

5. Benjamin, Patricia J., "Paper Tiger Credentials," MTJ, 29 (3): p. 9, Summer 1990.