MASSAGE
THERAPIST
PRACTICE
START • SUSTAIN • SUCCEED
• Improve Your Lot in
Practice
• Past, Present and Prophecy
for the Massage Profession
• RMT Working
Relationships . . .
. . . Make Them Work!
• Secondary Sources of
Income - Low Labour,
High Return
• Prepare Your Massage
Therapy Business for Sale
• Advice for Entry-Level
Practice
Guest articles by:
Cherie Sohnen-Moe, Business Mastery
Dale Willerton, The Lease Coach
Meagan Holub, The Magic Touch
Jim Smyth, Find and Keep Great Associates
Plus: Interviews with successful practitioners
and employers in the ﬁeld
“Don Dillon is a leader and visionary - a person who
is helping to create the future of our profession (and)
holding massage therapy to a higher standard.”
by Donald
Q. Dillon RMT
From the author of
Charting Skills for Massage Therapists and
Better Business Agreements: Guide for Massage Therapists
REVIEWS
Of Better Business Agreements | 1st Edition
(published in 2006 and predecessor to this book)
“This book fills a void that has troubled both clinic owners and massage
therapists for years. Whether you are owner or therapist, the book will give
you a thorough understanding and appreciation of both sides of the coin, and
show you that workable solutions are possible. Mr. Dillon offers us hope that
Massage Therapy can be professional and successful, just like mainstream
health practices. Look forward to an informative and good read.”
- Jim Smyth, RMT
“Don describes some of the most common pitfalls that massage therapists fall
into - particularly when building practices or establishing clinical practices. A
useful guide for recently graduated therapists, new clinic owners and teachers
of MT business practices.”
- Pam Fitch, RMT
“Your book is very informative, easy to read, clear and concisely written.
You’ve found a way to enlighten both the clinic owner/manager and the
associate to see exactly what is important to both parties - therefore
establishing a mutual understanding before negotiations begin. It really is
a straightforward approach to doing business in a field full of non-businessminded individuals. I hope you can take some gratification in knowing that
you’ve probably saved some peoples’ businesses (lives) with this book.”
- Mike Awde, RMT
“Better Business Agreements: a Guide for Massage Therapists by Don Dillon,
RMT is essential reading for all massage therapists who contract their services
or operate clinics. Massage therapy schools across Canada should adopt this
book as a central component of their business curriculum. Thank you Don
for your continued commitment to the success of massage therapists and the
strengthening of our profession.”
- Scott Dartnall, RMT
“I wish I had had this information almost twenty years ago when I started my
first practice. This should be a mandatory reading for anyone in our profession.
It could have saved me thousands of dollars and a lot of wasted time both
emotionally and physically. I have no doubt this will be a best seller and go
international. Don’t hesitate. Get this book and build better agreements.”
- Barry Jenings, CEO Jenings Seminar Group
Massage Therapist Practice • Start • Sustain • Succeed©
3
No part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means, electronic, mechanical, recording or
otherwise, without the prior written permission of the author.
Published by MTCoach
19 Durham Drive, St. Catharines, ON L2M 1C1
www.MTCoach.com email: [email protected]
Library and Archives Canada Cataloguing in Publication
Dillon, Donald Quinn, 1965Massage Therapist Practice: Start. Sustain. Succeed.
First edition
Donald Quinn Dillon, author
Paper format
ISBN 978-0-9781193-4-8
1. Massage therapy. 2. Business and Economics, General
Disclaimer: Although the author and publisher have made every effort to ensure
the accuracy and completeness of information contained in this book, they
assume no responsibility for errors, inaccuracies, omissions or any inconsistency
herein.
Layout and Design: Pauline Johnson Graphic Design
4
Massage Therapist Practice • Start • Sustain • Succeed©
CONTENTS
Pick Your Urgency
(or How to Read This Book)
IntroductionImprove Your Lot in Practice...AND in Life!�� 7
Read this section to determine if this book is for you.
Chapter I
Past, Present and Prophecy................................................ 15
Examine the massage profession’s historical context in light
of current opportunities and threats, and the implications for
massage therapist practice.
Chapter II
Practitioner Working Relationships ................................ 29
If you employ or contract practitioners, plan to, or are
considering associating in an established practice yourself, this
chapter illuminates common practices that doom practitioner
working relationships and advises what you can do to mend
them. Contributing authors enhance the value in this chapter.
Chapter IIIGenerating Other Sources of Income ............................... 87
If you’re interested in creating other sources of income beyond
exclusively hands-on work, this chapter examines 12 ways to
generate income which is industry-related but surprisingly not
labour-intensive.
Chapter IV
Sell your Massage Therapy Business................................ 95
Will you work hard for years only to close shop at retirement
with nothing to show for it? Your investment of time, labour
and money represents residual value to an existing associate
or budding practitioner. Read real-life stories from massage
practitioners who have sold businesses in exchange for equity.
Chapter V
Thoughts on Entry-Level Practice .................................. 103
A collection of essays to guide entry-level practice and to help
massage business owners train associates to shorten practice
learning curves and fast track success.
Massage Therapist Practice • Start • Sustain • Succeed©
5
Dedication
To those massage practitioners who cornered me after a lecture,
who e-mailed me personally, who privately shared their
grief, frustration and fear in attempting to make a
reasonable living while doing what they love,
this book is especially for you.
6
Massage Therapist Practice • Start • Sustain • Succeed©
Introduction
Improve Your Lot In Practice . . . AND In Life!
Massage Therapist Practice • Start • Sustain • Succeed©
7
Improve Your Lot In Practice
. . . AND In Life!
“It had long since come to
my attention that people
of accomplishment
rarely sat back and let
things happen to them.
They went out and
happened to things
”
~ Elinor Smith
I
remember clearly the moment I decided I must succeed if I was to continue
practicing bodywork. I had struggled for more than a year in a new city trying
to build a practice. My initial tenure with a business-savvy chiropractor
provided the opportunity I needed to jumpstart my practice and quickly get
me busy. I left that chiropractor’s business within a year, because I believed I
could do better running my own business. I didn’t. I soon realized the high rent
I had paid the chiropractor was for the referrals, successful business model and
essential practice management skills I did not have.
My wife found a job in a city 40 km north and we relocated. I then struggled to
build a practice in another chiropractor’s office until he severed our agreement
for better prospects. He favoured as a tenant an ambitious and established
massage therapist promising growth much faster than I could. With my wife
pregnant with our first child and our family relying on my income alone, I faced
a daunting realization...sink or swim.
I set up an alternate location in a fitness club and dove into business books. I
found great advice and support particularly in Cherie Sohnen-Moe’s Business
Mastery and David Palmer’s The Bodywork Entrepreneur. I eventually read
other masters – David Chilton, The Wealthy Barber, Seth Godin (Permission
Marketing and Purple Cow), Michael Gerber (The E Myth), Robert Kiyosaki
(Cashflow Quadrant and Rich Dad Poor Dad), Jerrold Mundis (Get Out of Debt,
Stay Out of Debt and Live Prosperously and Earn What You Deserve) and a
host of other authors. I applied concepts presented in these books, learned and
developed others and today my income is happily more than six times that of my
initial year in practice.
Massage therapists, and collectively Complementary and Alternative Medicine
(CAM) practitioners, are in the business of healing. Practitioners invest thousands
of hours and tens of thousands of dollars in acquiring academic knowledge and
technical proficiency to provide the best care possible. Their common goal: To
eradicate suffering and symptoms, to harness the inherent and apparently
miraculous healing capacity of the body coupled with careful and marginally
invasive methods. In effect, to help the body heal itself as it was designed to do.
As valuable a service to humankind as this might appear, practitioners
commonly struggle in practice. They do not associate the concepts of “business”
and “healing” and, in fact, practitioners might strongly suggest these concepts
are mutually exclusive. They believe financial compensation would compromise
the sacred value of the healing act. Consequently, without the means to sustain
a business, the healer soon runs out of resources to meet business and personal
expenses and is forced to leave her/his profession to gain employment elsewhere.
8
Massage Therapist Practice • Start • Sustain • Succeed©
This book is for the practitioner who is eager to improve her or his lot in
practice, .to go beyond limited income and marginal success as a self-employed
massage practitioner. If you have been in practice for two years or more, have
acquired contacts, are well versed in promotion and communication, employ
INTRODUCTION
Improve Your Lot in
Practice . . . AND in Life!
solid hands-on skills and are discontent with your income, you will find this book
invaluable. If you’re a student or entry-level practitioner, this book provides
essential perspective and unique ideas to propel you toward the next level when
you are ready, and chapter V is written especially for you.
If you’ve been working for some time now, you realize your income is limited
by your work capacity i.e. how much service you can provide in a week at a
pace that can be comfortably sustained. You’ve learned that bodywork is timeand labour-intensive, and if you’re going to earn more than a basic income you
need to approach things differently. Understand that you and the business are
inseparable...you ARE the business. But in time you must learn to cultivate the
business beyond and separate from yourself - much like parenting a child who
will someday become self-reliant. If you do not do this, you will arrive at your
retirement without a valuable, saleable asset to show for all your hard work.
In addition to the talent, experience, staffing, equipment and capital you
bring to your venture, you must be aware of factors beyond your control that
affect your business. These include health of the economy and its impact on
employment, discretionary income and health benefit plans; government policy
and taxation; relations and influence with the insurance industry; positioning
with other health care providers…especially gatekeeper disciplines; public and
media opinion; competitors and profiteers, and the politico-culture within the
profession…all of which directly influence the operation and success of your
practice.
This book sounds an urgent call to practitioners, associations, training
institutions, suppliers and publication editors to examine our profession’s
historical context, current challenges and potential opportunities for massage
therapists in practice.
The most common way to increase work capacity and generate higher income
is to employ/contract associate practitioners in your business while adopting
the dual role of practitioner and manager. This requires investment of capital,
managing escalated business risk (but also profit potential) and providing work
opportunity for entry-level, less business-savvy practitioners. As contractors /
employees, these practitioners will share your hard-won location and reputation.
A large section of this book is dedicated specifically to address the often tense
and ruinous squabbles that ultimately develop in many massage business owner
and employee (contractor) relationships. As we’ll see, despite the challenges
for both owner and practitioner there are many benefits to joining forces in a
massage therapy business.
Practitioners frequently require secondary incomes because the time and
“Nurture your mind with
great thoughts, for you
will never go any higher
than you think.
”
~ Benjamin Disraeli
labour intensiveness of practice limits work capacity to largely a part-time
vocation (15-20 hours/week).1 The practitioner, in effect, must leverage a second
1
Yes, there are workhorses providing 30 - 40 hours/week of massage. However income surveys indicate
most practitioners maintain comfortably 16 - 19 hours/week hands-on care
Massage Therapist Practice • Start • Sustain • Succeed©
9
INTRODUCTION
Improve Your Lot in
Practice . . . AND in Life!
part-time occupation – manager, retailer, instructor, or even working outside the
profession – while maintaining her/his primary vocation as a massage therapist.
There are many ways to increase your income as a massage practitioner and
we’ll examine 12 in this book. All are industry-related but none are as labour
intensive as hands-on care.
Interestingly, the contractor/employee practitioner frequently blames her/
his insufficient income on the business owner, saying the owner is charging too
much rent. We will show the problem often lies in the business model applied –
time/labour-intensive work @ insufficient fees = limited income.
In the fourth section, we’ll explore the buying and selling of a massage therapy
business. To work for years and not project the value of your business asset into
your retirement is like building a house only to never live in it. Carefully planned,
your business can be a great source of employment, enjoyment and opportunity
for generations of practitioners to come, continued care for the patients / clients
you’ve served during your career, and a nest egg, for your next adventures.
The final section of this book contains selected, revised and updated essays
I’ve written for massage therapy publications directed towards the entry-level
practitioner. They will also serve the practitioner manager hoping to illuminate
the way for budding associates.
Let’s begin.
10
Massage Therapist Practice • Start • Sustain • Succeed©
Guest Article: Meagan Holub, LMT
INTRODUCTION
Face Your Fears
And Do It Anyway
A
Improve Your Lot in
Practice . . . AND in Life!
ll of us, in whatever stage of business we’re in, have a common problem –
we must take action despite our fears. Anyone striving to be successful
hits a wall of fear at some point in their development. In order to raise
our massage therapy practice to the next level we must learn not only to embrace
fear, but to walk through it.
For the first seven years of my massage therapy career, I was bound by fear.
Some of these fears were not even my own but had been handed down through
well-intentioned but misguided family members, friends, massage instructors
and social norms. I was encouraged to think it was wrong to make a good wage as
a massage therapist, and that healers were bound to a life of poverty to remain
“pure.” I resisted change at nearly every level. I was frightened of embracing a
“salesperson” attitude or behaving like a “business person.”
I carried this “money-monkey” mindset on my back until I couldn’t carry the
weight any further. I was exhausted, financially broke, burned out and sick and
tired of being sick and tired. I took a long, hard look at all that I had accomplished
for other people, working within their companies. I noticed how my reputation
had time and time again built a large clientele base for major corporations
whose only concern was their bottom line. I acknowledged the brutal reality – I
performed as a top level professional and business leader to their benefit, but
was unwilling to do so for myself. I was the top requested massage therapist,
salesperson and earner for every company I was employed by. It was time to
realize my anti-sales, anti-business beliefs were really a way to stop myself from
reaching my potential. I had a list of reasons why I “couldn’t” or “shouldn’t” - my
fears were masterful at coming up with excuses. But there was an even deeper
list of reasons that I kept to myself. At the top of that list was a paralyzing fear
of failure.
During these years I would often complain to other graduates from my class
about my woes. They understood my pain well. One by one, each of them had
given up trying to make a living as a massage therapist over the years. None
attempted to build their own business, preferring instead the safety of the
receptionist or waitress jobs they worked prior to entering massage school.
During these commiseration sessions, one graduate was consistently brought
up in conversation. In massage training this student, no matter how hard he
tried, simply didn’t have “it”. He didn’t have the touch. Because of his lack of
hands-on ability he was frequently last to be paired with a partner. No one
“A person’s success
in life can usually
be measured by the
number of uncomfortable
conversations he or she is
willing to have.
”
~ Timothy Ferriss
wanted to be on the receiving end of a massage with the poor fellow.
Rather then letting this get him down, he recited the same speech day after day,
week after week, how he was going to make $60,000 a year when he graduated
from massage school. We all rolled our eyes (this was after all, the early nineties
and $60K was A LOT of money then). A fellow student used to say “Meagan, if
he makes more money then you when we get out of here, with your ability, I will
Massage Therapist Practice • Start • Sustain • Succeed©
11
INTRODUCTION
Improve Your Lot in
Practice . . . AND in Life!
never forgive the God that let’s that happen.” Can you guess what happened
to this man? He went on to earn $60,000 a year, as an independent contractor,
almost immediately after graduation. Meanwhile I wallowed in poverty despite
my jam-packed schedule at each and every place I was employed.
I convinced myself each time I’d quit and start at a new place of employment
that THIS time would be different, but the result was always the same. I was
still broke and overworked. It never occurred to me that I could achieve anything
better. Deep (very deep) down I knew I had what it took, but it wasn’t worth the
risk of proving that nagging, negative voice in the back of my mind correct that
I was in fact, a “complete and utter failure.”
What is it that the $60K graduate, the new and improved “me” and every other
successful business-person have in common? We take action. By moving through
our fears, starting with the little ones and moving up to the big ones, we gradually
learn to assess each fear risk-to-payoff ratio. To weigh one’s fears against a worst
case scenario (to determine whether the potential benefit outweighs the risk) is
a valuable skill.
Often the benefit does outweigh the risk, and with practice we begin to see that
fears are commonly based on nothing at all. With practice, anyone can learn the
difference between the old, deceptive fear tapes running through one’s head, and
a truly dangerous scenario. Surprisingly, there are not many of the latter.
Developing this skill starts with taking action on the little stuff. The ability to
take action against our fears is a muscle within us that is always in a certain
level of atrophy. But with a small effort of moving through a fear each day
that muscle soon will be in all-star shape. Many people assume that business
owners like myself are born fearless...it’s not true. With each level of business
that a person reaches, they are forced to try new things; to be vulnerable while
becoming an “expert” at that next level.
This is why mentors can be such a powerful force in a business person’s life.
They “hold your hand” and help you move quickly through the stuff that might
otherwise bog you down. They have “been there and done that” and learned
from their mistakes, so you don’t have to. Once you start breaking through old
fear habits, and discovering new ways of being in your life and business, you
won’t stop. Once you are able to break through your fear of speaking in front of
large crowds, or of asking a professional medical provider to refer their clients
to you, or putting your words out for all the public to see… or stepping into
the role of business owner and leaving behind your currently unsatisfying role
as an employee, whatever your particular fear is… every other fear becomes
comparably easy to break through.
Once you unlock your ability to take action you become more confident in other
areas of your life. You see possibilities emerge where once you only saw obstacles.
You begin to think like a creator in this world, not someone just going along for
the ride. There is no way to describe this new way of being. It’s like your life has
all of the sudden been put in HD and Technicolour. All of a sudden you remember
the things you wanted to do and be when you were a kid and it becomes crazy
NOT to do those things. Suddenly, fears become a game. Fears act as a bridge
that must be crossed in order for you to reach your purpose in life, and it starts
with one little step through a small fear.
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Massage Therapist Practice • Start • Sustain • Succeed©
Pick any fearful thing. Maybe you want to ask that barista at your local coffee
shop for a date. Do it! Despite the outcome, you will find that you live another
day. To do something that scares you everyday is not a cliché, it is a way of life.
Adopt this way of life and you will find yourself surrounded by other people who
live by the same philosophy. And these are often people who have reached a
higher level of success, to say the least.
INTRODUCTION
Improve Your Lot in
Practice . . . AND in Life!
Our fears are masters at keeping us “safe” and often manipulate us to get what
they want. I’ve seen massage therapists sabotage themselves in many ways.
Some have been duped into believing if they become successful at this career it
will limit them from other dreams. Others can see the end result clearly in their
mind - a nationwide chain of wellness centres, for example. Their fears hide
behind a belief that this dream is already theirs and only need be manifested,
yet the basic steps that must be taken to build any business are never taken.
Fears keep these practitioners locked behind a grand vision - a vision that is all
too possible - except that the dreamer thinks they are exempt from taking all the
small steps required to get to the end goal. They tell themselves that they don’t
need to lay one brick at a time, that their success will come to them because it
is their destiny.
Still others alternate between these two fears. I know this from personal
experience. Talk about a rollercoaster ride on the way to “NoWheresVille”! When
we are that dreamer, we are not yet mature enough to handle the big dreams we
have for ourselves. Through the act of taking one step at a time we move through
all the scenarios (easy and challenging) that allow us to handle the ultimate
dream as our reality. We don’t win races without practice, and we are not handed
dreams without moving through our fears.
I have a client who is a business mentor to me - a billionaire. He grew up in a
shack, the son of parents caught up in a small-minded religious cult and living
on welfare. Imagine, he’s practically a poster boy for an unsuccessful life, having
been handed every reason to not follow his dreams. He has this to say about
success and reaching your dreams: “It matters not how attractive you are, how
smart you are, how much money you have, or who your family is. The only thing
that matters when it comes to reaching your goals is that you never give up.
Successful people come from all walks of life and have all kinds of abilities, but
the one thing they have in common is utter determination. Each and every one
of them refused to give up.”
If you don’t believe me, believe him. It is within your power to be as successful
as you want to be. It only takes moving through your fears, against all obstacles,
until one day you find you are that person you once dreamt of being. Just put one
foot in front of the other. Start today.
Meagan Holub is a Licensed Massage Therapist, in practice since 1995, and
a Celebrity Massage Therapist for the second half of her career. Meagan has
written two books on how to make $100,000 per year as a Massage Therapist,
The Magic Touch and More of the Magic Touch. She has mentored more than
100 massage therapists, written for and been featured in massage industry
magazines, and the world’s #1 selling fashion magazine. Meagan is a frequent
contributor to Women in Bodywork Business (WIBB) at www.massagetoday.
com. Meagan’s books can be purchased at any major online bookseller or through
www.HundredthousandDollarMassage.com.
Massage Therapist Practice • Start • Sustain • Succeed©
13
14
Massage Therapist Practice • Start • Sustain • Succeed©
Chapter I
Past, Present and Prophecy
Massage Therapist Practice • Start • Sustain • Succeed©
15
Past: Rise in Popularity
of Massage Therapy
I
t’s not enough to have talent, location and reputation, contacts and capital.
Your practice viability is inextricably entwined with economic vitality and
workplace benefit plans, government health, business and taxation policy,
access to insurance funding for injury claims, working relations with other health
“
care providers, public and media perception and anything you bring personally
Before you attempt to set
things right, make sure
you see things right
”
~ Blaine N. Lee
or professionally to the table. Context provides the big picture for the massage
therapy profession. This section attempts to answer “Where are we?” “How did
we get here?” and “Where are we going?”
Since the distinct separation from the physiotherapy and nursing professions,
massage therapists have been largely self employed, working from a home
base or corporate on-site location, or contracting work from a spa, chiropractor,
physiotherapist or another massage therapist.
In the period following the Second World War, massage therapists benefited from
a strong North American economy. Industrial manufacturing led to industrial
illnesses such as workplace-related musculoskeletal disorders (repetitive strain
injuries) and job-related stress syndromes. The information/computer technology
age ushered in further musculoskeletal and nervous/mental conditions requiring
remedy. During this boom period, workers had access to generous employee
benefit plans, enjoyed higher discretionary income, comprehensive health care,
and worker’s compensation plans or auto insurance funding for rehabilitation.
Massage therapy also sprouts roots from the European spa, which employs
a wellness approach rather than a rehabilitative focus. In North America, spa
therapy is often associated with luxury and hedonistic indulgence, attracting
a different market than the rehab sector. During the 1960s, the time of
experimentation, self-actualization and human potential, bodywork evolved
through the influence of Ida Rolf, Moshe Feldenkrais, F.M. Alexander and
others.2 Today, athletes pursue massage to enhance their human performance,
The corporate world embraces massage in workplace wellness programs to offset
skyrocketing costs of job-related stress and workplace-related injuries with an
eye to improve workplace performance. Practitioners provide chair-massage
on-site through clothing, without lubricants, conveniently and inexpensively.
Esoteric healing is practiced by some massage therapists, but this remains
at the fringes of a profession earnestly trying to prove itself in many respects
as a medical health service. So we see that massage, with its varying origins,
has developed at least four distinct identities or “brands” serving four different
sectors with differing needs, levels of skill and education required, different
lingo, funding, hierarchical relationships to referral sources and vastly different
working environments serving different types of customers.
2
Read Don Hanlon-Johnson’s Bone, Breath and Gestures and his other books on the subject.
http://www.donhanlonjohnson.com/publishing.html
16
Massage Therapist Practice • Start • Sustain • Succeed©
Registered Massage Therapists (RMTs) are not covered by government health
plans in North America, and so rely heavily on patients/clients with high
discretionary income, generous workplace benefit plans, third party coverage
Chapter I
Past, Present and Prophecy
from auto insurance/worker’s compensation claims and direct referrals from
“gatekeeper” health care providers.
Present: A New
Economy, a New Reality
B
oom has turned to economic bust in North America, imposing
change
in
the
employment
landscape
and
options
of
massage therapists:
• Workplace Benefits Claw Back – Disappearance or decline of
manufacturing and other sector jobs in economically-recessive North
America negatively impact employee benefit plans and worker
utilization of massage therapy.
• Disproportionate Taxation – Massage therapy is subject to the valueadded “Harmonized” Services Tax (HST) in several Canadian provinces
while competing services such as chiropractic and physiotherapy are
not. This creates a clearly competitive disadvantage.
• Barriers to Funding – Auto insurance and workers’ compensation
claims require gatekeeper health care disciplines to authorize massage
therapist plans. Massage practitioners are positioned as ancillary
health providers with controlled access to capped funding.
• Growing Competition – Health care provision is shifting from
physicians and nurses to lower cost and more readily-available
services of physiotherapists, pharmacists and nurse practitioners.
These professions employ assistants to deliver health care at lower
cost to a larger number of people. Physio/Occupational Therapy
assistants, kinesiologists and other assisting providers may usurp
massage therapist employment by providing “massage” in-house.
Gatekeepers earn profit keeping care in-house with assistants rather
than referring to an independent massage practitioner.
• Employment Upgrade – Large, business-savvy well-financed spas and
rehab facilities draw more practitioners to employment. Self-employed
small scale massage therapist practices find it tough to compete.
• Incredulity – Insurers and governments are sceptical of massage
therapist results without degree-level education and evidencebased practices…these are standard requirements for other health
disciplines. No credibility, no funding.
• Threat to Primary Funding – Insurance fraud, association with
prostitution and illegitimate business practices taint public and media
perception of massage therapy.
• Exploitation – Disorganization amongst the stakeholders of the
profession leave it vulnerable to commoditization and exploitation by
ignoble profiteers hoping to cash in on massage popularity.
Massage Therapist Practice • Start • Sustain • Succeed©
17
Professional-Cultural Entropy
Chapter I
Past, Present and Prophecy
The massage therapy profession is ill prepared to respond to the many
encroachments, in part because of problems inherent in its own culture. Some
are explored here:
Unsustainable Time and Labour-Intensive
Business Model
Given the physical labour of providing care, massage therapists are often
“You have to take your
values from your
customers, your designs
from nature, and your
discipline from the
marketplace.
”
~ Hunter Lovins
limited to 15-20 hours/week…a part-time work schedule. Yet they often require
full-time wages. Practitioners can charge exorbitant rates to earn sufficient
income, but only affluent patrons will bear these market prices. Rates are
capped in rehabilitative fee-for-service insurance-claims. It’s worth noting
rehabilitative origins of massage therapy in physiotherapy and nursing, where
massage application was only one of many interventions provided in a day’s
work. Nurses and physiotherapists didn’t provide massage therapy steadily all
day…it’s curious massage therapy practitioners haven’t critically examined this
convention.
Practitioners may increase their earnings i) applying spa or rehab modalities
to reduce hands-on care, thus increasing physical capacity and providing more
service per day, or ii) relegate providing massage to part-time hours and seek
secondary sources of income from other employment. Innovative practitioners
can design, field-test and implement better, viable models of providing care than
currently exist in the standard delivery model.
Strained, Dysfunctional Business Relationships
Incredibly, massage business owners assign 60 – 70% of service fees to the
contracting associate, despite fronting the capital investment in the practice
and shouldering much of the risk for failure. What sustainable business can
front capital and assume business risk, pay the operating expenses, give the
lion’s share to the worker and still make a profit? These ill-conceived terms
are financially foolish and potentially ruinous to the business owner.
It’s
this author’s contention that associating practitioners are precluded from
experiencing the error in their business model because their risk and actual
operating costs are shouldered and supplemented by empathically-generous but
accounting-ignorant massage business owners. The associate only learns the
true costs of business when they strike out on their own (as I experienced) or
apply to a commercial spa or rehab centre.
Many massage business owners realize their contract terms are unsustainable,
but feel trapped in a politico-culture that distrusts business owners and
disapproves of profit motives. A business MUST earn a profit for contingency,
expansion plans and as reward to the business owner for bearing the risk and
investing capital in the business. Tragically, many owners only experience
strife and financial ruin. Ironically the associate believing the grass is greener
elsewhere is financially better off staying put.
Contracting/employed practitioners are not trained in business and don’t
realize the true costs of operation (and apparently neither do the business
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Massage Therapist Practice • Start • Sustain • Succeed©
owners themselves). The associate may feel cheated if she/he pays the true
costs borne by the business owner. There are, of course, situations where the
associate really isn’t treated fairly but the root of the problem may well stem
Chapter I
Past, Present and Prophecy
from the miscalculation that one can work part-time hours and generate a fulltime income. It’s not that the business owner is charging too high a rent, but the
associating practitioner needs a more lucrative business model that provides a
full-time income.
Divisive Viewpoints
Massage therapists lag behind other health disciplines in evidence-based
practices, public relations strategy, school accreditation, regulation and
credibility. A particular point of tension is the polarity between spa- and rehabfocused massage therapists. We’re trying to squeeze two entirely different
identities (brands) into one, and mitigate the differences. The product (service),
pricing, distribution, promotion, funding, training, lingo and marketplace
needs are vastly different for these two identities, yet our professional culture
maintains an umbrella-like inclusion.
Is massage therapy a health care profession or personal service? Government
policy makers, insurance adjudicators, other health professions, the public and
media are trying to grasp our identity and are confused. Not surprisingly, an
overly broad and unfocused identity leads to marketplace confusion and impaired
credibility. The result is reluctant referrals and withheld funding dollars.
Another inherently divisive argument involves education and training. Some
practitioners oppose participating in degree-level programs and research
as onerous and expensive, yet feel entitled to the privileges enjoyed by those
health care providers who adhere to these standards. We cannot vie for status
and recognition as health care professionals if we avoid research literacy and
refuse to support evidence-based practice and higher educational requirements.
Some practitioners distrust professional associations and regulatory bodies and
oppose regulation. They view imposed policies and fees by government as an
intrusive cash grab. And while they advocate the interests of massage therapists
to government, the insurance industry, other health disciplines, the public and
media, massage therapist professional associations wrestle with insufficient
membership and therefore limited resources.
Many practitioners agree lay people should be restricted from applying massage,
yet they themselves won’t support the mechanism that lays the groundwork
for this restricted application. Credibility also comes into play here, for many
teaching institutions display wide variance in quality of education and training.
Most are non-accredited, so do not guarantee a certain standard of quality for
entry-level massage therapists. If you consider yourself a professional, you
should be supporting the efforts of your professional association and regulatory
body. “We have met the enemy, and he is us.” 3
3
Walt Kelly, Pogo comic strip. “The First Earth Day”
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19
Prophecy: An Era of Change
and Challenge
B
“A frequent goal of
prediction is to alter
the future - to warn of
impending danger so
that it can be avoided.
ased on the historical context, extrinsic threats and intrinsic politicocultural problems discussed, if the profession continues along its current
path I forecast:
•T
he recessive, debt-laden North American economy hacking away
at workplace health and dental benefits and wages while employers
”
~ Daniel Altman,
Outrageous Fortunes:
12 Surprising Trends that
will Shape the Global Economy
leverage surplus skilled workers. Surplus workers don’t inspire
companies to offer benefit plans…there’s less need to compete for
good workers. Massage therapist will suffer as will other health care
professions reliant on employees with workplace benefits and high
discretionary income.
•G
atekeeper professions and well-financed spas will take advantage of
massage popularity and aggressively control working conditions.
•S
pa franchises will become major employers of massage practitioners,
with self-employed practitioners unable to compete against these
well-run, highly-resourced businesses in high-traffic commercial sites.
A surplus of practitioners will drive wages down to $15 - 18/hour and
most will require secondary sources of income to make ends meet.
•G
atekeeper physiotherapists, nurse practitioners and physicians
in large rehab facilities will hire Physical/Occupational Therapist
assistants (PTA/OTA) to treat soft-tissue injuries.
Government
policies support entrenched conventional medicine’s hierarchical
structure to exert control over assistants, while massage therapists
will be pushed to the fringes of health care. Shut out, rehab-minded
massage practitioners will exit the profession and retrain as PTA/
OTAs, physiotherapists or perhaps sports medicine physicians…if
they have the resources to do so.
•P
ractitioners feel impotent in guiding the profession’s fate and exit
in large numbers, leaving massage professional associations, training
colleges, regulatory bodies, suppliers and publications to suffer heavy
losses.
•B
odywork is still sought by highly educated, higher income earners who
can afford health care expenditures out of pocket, or by corporations
willing to invest in workplace wellness programs. Practitioners in
this environment will need exceptional skill and marketing savvy to
properly position themselves and win favour with this sector.
•B
ioenergetic/esoteric health and wellness practices will continue
to exist, but with hard economic times there is less money for
experimentation.
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Despite the gloomy outlook, I don’t believe the profession’s fate is yet sealed.
There are real opportunities for a profession organized and focused in its
resources. Here are four such opportunities:
Chapter I
Past, Present and Prophecy
Improve Work Opportunities for Massage
Practitioners as Employees in Spa Franchises
and Rehab Facilities
If the professional associations focus on influencing fair work environments,
rehab centres and spa franchises will provide good working environments for
practitioners. In fact, working for these companies may resolve the common
practice problems facing self-employed, sole practitioners. Well-resourced
facilities
offer
highly-visible
commercial
locations,
rigorous
marketing
campaigns, high quality equipment with supplies and leasehold improvements
provided. The practitioner has the opportunity to work with a team while
enjoying time-tested operation and administration procedures, while delivering
a price-point and convenience to customers that is hard to beat.
Massage therapists regularly struggle to build and maintain a practice, many
failing due to insufficient business training, experience and capital. Some rely
heavily on referrals from feeder-gatekeeper professions. Many practitioners
prefer someone else to handle marketing, maintenance and business operations
to focus on what she/he loves best – providing care.
As employees, practitioners have access to workplace benefits such as pension
plans, employment insurance and maternity/paternity leave, workplace health
and dental plans and holiday/vacation pay. Companies can offer profit sharing
or the opportunity to buy into the business as a partner/investor. There is room
for organizational growth as a “lead therapist: moving up into management…an
option that reduces wear and tear on the body.
Practitioners may see clear advantages in being an employee/associate.
Franchises have a 75% success rate, compared to 20% success rate for new
business start-ups. Professional associations, regulatory bodies and schools can
play a major role in ensuring fair and equitable working conditions for massage
practitioners in spas and rehab centres.
Strengthen Massage Therapy’s Position as
Adjunctive Health Care
Though massage therapy has become mainstream in public perception, it
remains adjunctive or secondary health care in policy and funding. In Ontario,
massage therapy is one of 24 regulated health professions, yet with health care’s
existing hierarchy, practitioners face barriers to funding in provincial health
care, auto insurance and worker’s compensation. Apparent reasons are: i) lack
of degree-level education ii) insufficient research and hence evidence-based
practice and iii) lack of support for professional associations.
Associations
need ample funding to advocate for better government health care and taxation
policy, reasonable insurance funding for rehabilitative claims, favourable public
and media relations and to build bridges with other health care professions...
especially gatekeeper disciplines who authorize funding.
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21
Chapter I
Past, Present and Prophecy
Despite protestations against gatekeepers, this is unlikely to change. So “if you
can’t beat ‘em, join ‘em!”
I suggest we stop trying to change what is impossible to change and work
at strengthening our position as adjunctive health care. Recently the Ontario
government strengthened the breadth and scope of nurse practitioners,
pharmacists and physiotherapists, in part to fast-track the delivery of care
currently dependent on physician authority and availability. This policy change
offsets health care costs, for it’s cheaper to farm work to traditionally lower paid
providers rather than having physicians administer it.
These professions employ assistants, further enhancing the delivery of care
and driving costs down. There is opportunity here for massage practitioners
interested in rehabilitative care to retrain as Physiotherapy/Occupational
Therapy Assistants (PTA/OTA). It’s unlikely physiotherapists would continue
to hire or refer to off-site massage therapists because of the profit potential and
hierarchical structure existing in-house between the gatekeeper physiotherapist
and her/his assistants. This shift in health care hierarchy demands rethinking
how massage therapists are trained and educated.
Collaborate with Complementary and Alternative
Medicine (CAM) Professions
During the “Role of Massage Therapy in Public Health” round-table at the
Highlighting Massage Therapy in Complementary and Integrated Medicine
(CIM) Research conference 2010, panel moderator William Meeker asked the
essential question, “Why are we trying to do this by ourselves?” Meeker described
how CAM professions pursue similar goals of generating research and evidencebased practice, lobbying government for policy change and inclusion in health
care, negotiating claim service fees with the insurance industry, and raising the
standards of education and training of their practitioners. And yet, because each
profession pursues these objectives separately, they are limited by resources and
ultimately slow and ineffective. Meeker suggests these professions collaborate on
resources, share knowledge and coordinate lobbying and education initiatives.
The collaboration of CAM providers would benefit both providers and patients.
Progressive physicians and nurse practitioners eager to provide comprehensive
care may embrace Complementary and Integrated Medicine (CIM) practice that
is physician/nurse practitioner-led, offers both conventional and CAM therapies,
competitive in the marketplace and profitable for the gatekeeper disciplines and
investors.
There is also opportunity to align with fitness and wellness industries. Dr.
Jayne Alleyne, MD, in an article in Fitness Business Canada, wrote:
“Perhaps the time has come to connect the fitness and health care industry
together in a joint action plan of education, service delivery and preventative
medicine. I would like to see a Wellness Package that includes a monthly fee for
health services that would be used over the year for prevention, performance or
treatment. A wellness coordinator would meet with all clients and set out a plan
for achieving an improved state of health and wellness over the year. Services
such as massage therapy, dietary consultations, injury prevention assessments,
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Massage Therapist Practice • Start • Sustain • Succeed©
stress management strategies and ergonomic assessments are a few of the gems
that would be included in the package..a seamless transition from fitness to health
and back again.” 4
Chapter I
Past, Present and Prophecy
Human Potential and Workplace Wellness
Technology and generous discretionary income position Baby Boomers and their
kin to seek sophisticated, effective bodywork. Many are affluent, informationsavvy and looking far and wide for sophisticated solutions to their somatic
problems. Many Boomers suffer the effects of the industrial/manufacturing work
era while their Gen X and Y kin will seek care for extreme sport pursuits and
chronic stress syndromes from technology and culture-overload.
Progressive corporations will continue to invest in their employees, recognizing
investment in wellness outweighs the cost of managing workers’ compensation
claims, absenteeism and turnover. Employees work long hours and want
convenience and generosity. Daniel Altman explains “Changes in how people
work will lead them to change where they work as well; in the future, a growing
class of mobile professionals will populate a new set of economic hubs founded
on lifestyle choices rather than business imperatives.”5 Employers have
paid billions of dollars yearly to off-site, independent therapy clinics with no
substantive evidence that their employees are healthier or their workplace
benefit plans worth the investment. Progressive companies who establish an
on-site wellness clinic (with clear objectives and outcome measures), a fitness
facility, meditation/prayer rooms and incentives for healthy lifestyle choices will
flourish and generate real return on investment.
Like the human potential movement of the 1960s and 1970s, we’re heading for
a renaissance and in this technology-saturated world. Bodywork could play a
more important role than ever.
5
6
Alleyne, Dr. J: Welcome to Wellness. Fitness Business Canada July/August 2005, pg 70
Altman D: Outrageous Fortunes. Times Books, 2011. page 3
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23
Break-Out Session: Donald Q. Dillon, RMT
Let’s Collaborate for
“Integrated Medicine”
Join the discussion in Facebook, MTCoach Community
P
ublic health care is long overdue for a dose of the right medicine.
Citizens interested in holistic and preventative medicine broker their
own health care, making sense of what their physician and medical
specialists advise in conjunction (or opposition) with the remedies administered
by Complementary and Alternative (CAM) practitioners. Patients confide they
cannot disclose CAM applications to their physician for fear of reprisal, while
CAM practitioners work on the fringes of mainstream medicine with incomplete
information and limited collaboration. A growing number of physicians desire to
include CAM therapies in the larger circle of care. CAM practitioners, largely
sole providers, are riddled with business inefficiencies and barely-lucrative
business models and would benefit from partnership rather than competition
with conventional medicine.
Complementary and Integrated Medicine (CIM) comprises a physicianled community medical practice offering traditional medical applications pharmacy, dietician, social work/counseling, physiotherapy, public health,
specialty medicine – while embracing Complementary and Alternative Medicine
(CAM) - massage, chiropractic (osteopathic), homeopathy/naturopathy and
acupuncture / Traditional Chinese Medicine. A radical shift away from separate
health disciplines fighting for funding, supportive policy and positive public
relations towards an integrated, physician-led model has particular benefits for
CAM practitioners, physicians, government health care policy makers, insurance
compensators and a wellness-focused, information-savvy populace.
Interest has grown in CAM medicine. A study funded by Health Canada,
Complementary and Alternative Health Practices and Therapies -- A Canadian
Overview, states Canadians spent an estimated $3.8 billion on alternative
treatments in 1998.
“Many Canadians have already integrated complementary and alternative
health practices into their health care, and consumption is likely to grow. The
study shows it is time for us to move on from the mistrust that has characterized
the relationship between conventional medicine and alternative practitioners
in Canada, and start examining broader questions about alternative therapies,
their place in the health care system, and how efficacy is determined. This work
is sorely needed,”6 said Joan Gilmour, Associate Director of the Centre for Health
Studies at York University, Professor of Law at Osgoode Hall Law School and a
co-author of the study. 7
6
7
24
http://www.yorku.ca/mediar/releases_1996_2000/archive/112299.htm
ibid
Massage Therapist Practice • Start • Sustain • Succeed©
A more recent study by The Fraser Institute estimated 74% of Canadians had
used at least one CAM application sometime in their lives, and 35% of Canadians
had tried massage. Expenditures in 2006 were estimated at $5.6 billion out-of-
Chapter I
Past, Present and Prophecy
pocket for visits to CAM providers in Canada.8
The public appears somewhat dissatisfied with current administration of public
health care.9 With drug interactions, skyrocketing expenditures, unnecessarily
invasive, risky and costly procedures in lieu of lower cost, less invasive options,
long wait times, idiopathic diseases and burned-out health care providers…
there is increased interest in health care reform delivered with less risk and as
non-invasive as possible. Current medical practice need not be replaced...but
integrated and streamlined.
Many physicians are increasingly dissatisfied with linear, non-holistic
approaches for their patients,10
and are looking for partners in delivering
holistic care integrated with other providers. Dr. J.W. Diamond, MD, states
“The recent focus on health care reform has unfortunately been geared almost
entirely toward increasing access and decreasing costs. While these are laudable
goals, creating increased and affordable access to a failing medical system does
not address the actual causes of the high costs and poor outcomes—causes that
include a rapidly rising epidemic of chronic disease and a health care system
poorly designed to counteract or prevent it. It is the practice of medicine that
should be addressed first, with the greatest potential for effective change coming
from (combining conventional medicine and CAM).”11 Gatekeeper physicians
and registered nurse practitioners could recognize substantial marketplace
favor, secondary streams of income and cost offsets through collaboration, not to
mention better patient outcomes and reduced professional isolation.
Complementary and Alternative Medicine (CAM) providers are typically
directed into sole practice without the health care policy infrastructure that
physicians and nurses experience in the publicly-funded health care system.
With this lack of infrastructure come insufficient business models or management
experience required to successfully operate, promote and administer a business.
Unlike administration-led hospitals or large medical facilities, CAM providers
frequently work without administrative/support staff, public and media relations
experts or a board of directors (advisors). CAM is financed primarily out-ofpocket or by employee benefit/workplace plans which impact access to care and
treatment plan fulfillment. In collaborating with physician-led practices, CAM
practitioners could reap the benefits of business models employed by progressive
medical practices and hospitals, extend CAM scope in public health and disease
prevention, and avoid many of the pitfalls currently dogging CAM practices.
8Esmail, N: Complementary and Alternative Medicine in Canada: Trends in Use and Public
Attitudes 1997-2006. Public Policy Sources, The Fraser Institute. May 2007, p 4.
9Votova, KME: Complementary and Alternative Medicine Use Among Older Adults:
The Role of Health Beliefs. thesis BA University of Victoria, 1999,
Dip Gero, Simon Fraser University, 2000, pp 1 - 4
10Diamond, J: Allostatic Medicine, Part II: A New Model of Medical Practice.
Integrated Medicine Vol 9, No. 2. Apr/May 2010. Pp 40-45
11Allostatic Medicine, Part II: A New Model of Medical Practice,
Integrative Medicine, Vol 9, #2 Apr/May 2010
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25
Chapter I
Past, Present and Prophecy
CAM has traditionally been considered an alternative to conventional medicine,
and an unfortunate opposition has developed between the two ideologies. It’s
unlikely public/government funding will support CAM until its providers,
regulators, researchers and educators demonstrate efficacy, cost-savings and
willingness to work together with conventional medicine. CAM is typically seen
by insurers, government, media and the public as expensive and experimental.
Despite skepticism, public expenditures for CAM continue to rise annually.
Resource-rich Baby Boomers and their benefactor offspring are seeking and
financing more complementary and alternative medicine with workplace benefits
or out-of-pocket discretionary income. Government and insurance companies12
could become more interested in cost savings provided by Complementary and
Integrated Medicine (CIM), and serving the broader interests of informationsavvy health care users.13 Baby Boomers have made it clear they are willing to
finance a broader range of health care services for themselves and their families,
and they expect health care providers to work together towards best practices.
Government agencies and insurance companies want evidence-based practice,
cost savings and public safety. Working individually, independent CAM
professional associations are woefully inadequate in providing these assurances.
However physician/nurse practitioner-led complementary integrated medicine
would yield stronger lobbying efforts and influence on government policy, better
compensation in insurance plans, more resources towards research and evidencebased practice (hence greater public safety and cost-savings) and stronger public
confidence.
At the Highlighting Massage Therapy in CIM Research conference 2010,
William Meeker, DC, MPH, asks the salient question “Why are we trying to
do this by ourselves?” Moderating the panel Role of Massage Therapy in Public
Health, Meeker pointed out that all CAM professions are pursuing the same
goals: generating research and evidence-based practice, lobbying government
for policy change and inclusion in health care, negotiating with the insurance
industry for better service funding, and raising the standards of education and
training of their respective practitioners. Working separately, each profession
is limited by resources and is ultimately slow and ineffective. Meeker suggests
CAM professions collaborate on resources, share knowledge and coordinate
lobbying and education initiatives.
Some may complain physicians have the most authority in such a model
and could impair CAM application, affecting salaries or other benefits to
CAM practitioners. They may argue a loss of professional identity with such
collaboration. I argue that for the proper administration of health care we
need an “overseer,” a general practitioner who can direct the treatment plan,
especially in complex cases. Physicians and other gatekeepers can coordinate
care very well, especially in a collaborative effort under one roof.
12http://www.marketwatch.com/story/clear-one-health-plans-announces-new-natural-healthplan-first-oregon-health-insurance-plan-developed-with-specific-focus-on-holistic-care-2010-03-03?reflink=MW_news_stmp
13Bolles, S: Marketplace Dynamics: Implications for Integrative Providers. Integrative Medicine.
Vol 9, #5 Oct/Nov 2010 pp 20-25
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CAM providers are already losing ground. Compared to counterpart
physiotherapists and chiropractors, massage therapists in many Canadian
provinces experience disproportionate service tax, barriers to insurance coverage,
Chapter I
Past, Present and Prophecy
exclusionary health care policy, and negative public and media perception
(Google “massage insurance fraud”). They are snubbed by gatekeeper health
professions or exploited by profiteer large rehab and spa facilities. Massage
therapist professional associations don’t currently possess the resources or
political leverage to overcome these obstacles. I contend that for decades our
professional identity, our training and education, our position with government,
insurance companies and other health care providers and our image in the public
eye have all been depreciating.
Imagine, however, the momentum generated by a united front of CAM
professions working together. Individually, none has a chance competing
with or joining mainstream medicine – there’s too much political opposition.
However, by collaborating and pooling resources and maintaining real working
relationships with mainstream medicine, there is opportunity for mutual benefit.
As gatekeeper, medical doctors could realize better profit margins and costsavings overseeing and working with CAM counterparts in their medical clinics
and hospitals. CAM practitioners would enjoy well-oiled business models and
could concentrate on providing care instead of marketing, billing and operations.
Citizens could finally enjoy and benefit from the vast knowledge and experience
afforded by a truly integrated health care system.
Now is the time. Talk to the leaders of your professional associations, schools
and regulatory bodies and press them to open a dialogue across North America.
Encourage them to approach other CAM professions and eventually conventional
medicine associations to stage a coup and change the face and the relationships
of public health care.
This article appeared originally in Massage Therapy Canada Spring 2011.
Massage Therapist Practice • Start • Sustain • Succeed©
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