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Identities of alternative medicine practitioners

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Title:
Identities of alternative medicine practitioners
Physical Description:
Book
Language:
English
Creator:
Estevez, Mychel
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
Publication Date:

Subjects

Subjects / Keywords:
Massage
Therapists
Professionalization
Professionalism
Biomedicine
Dissertations, Academic -- Sociology -- Masters -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: The purpose of this research was to collect and analyze information from massage therapists on how they construct their identities. It is meant to be a starting point in giving voice to a group of alternative health practitioners who have been marginalized and misunderstood. It also helps us to understand what it means (to them) to be massage therapists and practitioners of "alternative medicine." This study was conducted through semi-structured interviews with five licensed massage therapists in two metropolitan areas in Florida. Massage therapists work at the micro level to boost the image of themselves and their form of "alternative" medicine. They do this by pulling professionalizing tactics from general business practices and from biomedicine. They also pull from "alternative" belief systems, balancing the two in a bid to construct their practice as legitimate and "alternative" professional health care.
Thesis:
Thesis (M.A.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
System Details:
Mode of access: World Wide Web.
System Details:
System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Mychel Estevez.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 82 pages.

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University of South Florida Library
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University of South Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 002029087
oclc - 436869974
usfldc doi - E14-SFE0002876
usfldc handle - e14.2876
System ID:
SFS0027193:00001


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ABSTRACT: The purpose of this research was to collect and analyze information from massage therapists on how they construct their identities. It is meant to be a starting point in giving voice to a group of alternative health practitioners who have been marginalized and misunderstood. It also helps us to understand what it means (to them) to be massage therapists and practitioners of "alternative medicine." This study was conducted through semi-structured interviews with five licensed massage therapists in two metropolitan areas in Florida. Massage therapists work at the micro level to boost the image of themselves and their form of "alternative" medicine. They do this by pulling professionalizing tactics from general business practices and from biomedicine. They also pull from "alternative" belief systems, balancing the two in a bid to construct their practice as legitimate and "alternative" professional health care.
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Identities of Alternative Medicine Practitioners by Mychel Estevez A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Sociology College of Arts and Sciences University of South Flor ida Major Professor: Laurel Graham, Ph.D. Committee: Jennifer Friedman, Ph.D. Chris Ponticelli, Ph.D. Date of Approval: April 7 2009 Keywords: massage, therapists, professionalization, professionalism, biomedicine Copyright 2009, Mychel Estev ez

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Acknowledgments I would like to acknowledge the role that my thesis committee, Laurel Graham, Jennifer Friedman, and Chris Ponticelli played in the creation and fruition of this project and thank them for it. Additionally, I would like to offer my heartfelt gratitude to Laurel Graham who continuously encouraged me and worked with me to develop my capabilities in the field of sociology both in her classroom and for the duration of this thesis. I would also like to thank my parents for th eir continued support in my academic endeavors.

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i Table of Contents Abstract ii i Chapter 1: Historical Contexts, Professional Status, and Identity 1 Professionalization of a Field 4 A Professional Identity 5 Chapter 2: Methods 7 Cha 11 Countering Myths 11 Building Upon a Valuable Tradition 18 Chapter 4: Distinguishing Massage from Biomedicine and the Factory Model 21 The Factory Model 21 The Biomedical Mo del 25 Problematizing Biomedicine 25 29 29 Integrating Biomedicine with Alternative Practices 31 34 Chapter 5: Professional Business Practices 41 Establishing Old fashioned Professional Etiquette and Wise Business Practices 41 Using professional tactics to fight myths of sex and gender 43 Minimizing risk to maximize safety 45 Performing competence and professionalism by borrowing from Biomed icine 50 Borrowing biomedical practices 50 Understanding the boundaries of their own competence 52 Engaging in self critique 57 Chapter 6: Crafting a professional identity of massage therapists 59 62 Forms of expertise not commonly found in biomedicine 60 Working with energy 60 Using intuition 62 Viewing whole selves 65 Forms of emotion work/healing/caring not commonly found in Biomedicine 67 67 69 Using touch 70 Approaching Clients as Equals 73 Chapter 7: Conclusion: Professional Identity of Massage Therapists 76

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ii References 78

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iii Identities of Alternative Medicine Practitioners Mychel Estevez ABSTRACT The purpose of this research was to collect and analyze information from massage therapists on how they construct their identities. It is meant to be a starting point in giving voice to a group of alternative health practitioners who have b een marginalized and misunderstood. It also helps us to understand what it means (to them) to be massage semi structured interviews with five licensed massage therapis ts in two metropolitan areas in Florida. Massage therapists work at the micro level to boost the image of professionalizing tactics from general business practices and from biomed icine. They

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1 Chapter 1: Historical Contexts, Professional Status, and Identity During and just after the Middle Ages, medicine was a decentralized, haphazard craft with no well established schooling or certification processes. Healers came in a variety of forms depending on location and tradition. There were witches in Europe, Shaman in North Amer ica, voodoo practitioners, and a whole variety of ancient forms of One of the popular practices today is massage therapy. The practice of massage has been around for as long as p eople have touched. While massage therapy has great utility for healing, it has also been pushed away as a viable form of medicine because it has been constructed as sexual and unprofessional. As a result, massage therapists currently work to professionali The professionalization of modern medicine brought all of these extraneous practices under one umbrella an d defined them as illegitimate (see Wardwell, 1994; Baer, 1989; Spence and Ribeaux, 2004; Johnson and Blanchard, 2006; Hufford, 2003). At the elevated in importance and came to be regarded as authoritative The patient was to the authority of the government for their own good. This did not cause alternative forms of medicine and health care to die out, but it did push them to the periphery and marginalize them in society. As modern bureaucratic institutions have formed around medicine, forms of alternative health care have struggled to be seen as legitimate. This struggle has ma inly occurred in two ways. First, through the professionalization of some forms of alternative medicine. Second, through struggles against the dominant discourse of what medicine is supposed to be. The bureaucratic system of medicine has fostered a dramati c growth in alternative forms of medicine as people disengaged from biomedicine in the past decade to forty years (depending on the source) in Western societies (Hildreth and Elman, 2007; Johnson and Blanchard, 2006; Murray and Shepherd, 1993; Valerand,

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2 Fo uladbakhsh, and Templin, 2003). These alternative practitioners seek to carve out a niche for themselves in a bureaucratic system that has long denied their legitimacy. The practitioners themselves have interesting perspectives on how they go about this a nd on how their form of health care can neatly fit into the larger health care system. Modern Western discourses are often thought to be rational, scientific, and simply correct The Western discourse of medicine is no exception. Modern Western medicine is also known as biomedicine, OM (orthodox medicine), allopathy, CMT (conventional medical treatment), conventional medicine, and EBM (evidence based medicine). Western medicine is considered the norm (or standard) for assessing all medicine in our societ alienating, and objectifying (Thompson, 2003 : 82/98) and (Cartwright, 2007 : 1693) does not work, tries to co opt it and force it into a biomedical perspective The development of and Ribeaux, 2004 : 115). This can be alienating for the people using the system (Broom and Tovey, rejection of other perspectives [non western, non scientific] an d an insistence that biomedicine was the chief force that had led to the huge improvements in public : 115). This rejection by biomedicine end ed up leading to a lawsuit by chiropractic doctors where the courts found various biomedical organizations guilty of violating the Sherman Antitrust Act (Villanueva Russell, 2005 : tioned to change the scope of acceptable behavior but it did not change the culture. The set of ideas which marginalized other forms of medicine is still common today. While this may seem almost like a clash of wills, it does have very practical consequen ces for people. People may be restricted from seeing the practitioner of their choice by their insurance providers or may be unwilling to see alternative practitioners to help them manage pain because of a social perception that alternative practitioners a re

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3 conventional medicine and contrast it with an ideal type of CAM. The two discourses are defined in opposition to one another, so that we can identify the criteria th at separate s them by drawing upon the published literature. Where conventional medicine can be : 83) characterizes natural health red to be disease centered whereas alternative medicine is patient centered (Broom and Tovey, 2007 : : 267). Alternative medicine is described as individualized, empowering, egalitarian, in depth, personal, : 1697) while OM is often characterized by patients feeling power less and helpless while the physician tr ies to pigeonhole their illness into a general category. Furnham and Forey (1994 : 458) believe that along with the increased use of regard to both the p ractice associated with, and the efficacy of, conventional medicine. Yet comparatively few studies have considered lay or even professional attitudes toward seems that most if not all practices of CAM lack a fully formed instituti onal identity. While t hey are marginalized, many modalities are growing in popularity. Some want to claim to certain legitimizing features of biomedicine but still want to be seen as practitioners, especially massage therapists which is the focus of this study This tension is one of the main points of this thesis: how do massage therapists work on balancing these ambiguities/ contradictions in their practices ? This ambiguity leads t o their active efforts to define their identity as professional massage therapists by moving b etween standard images of a health care professional and an innovative vision of what an alternative health care professional can be. Since biomedicin institut ional identity is possibilities for constructing an institutional identity. This leads us to the question of how real massage therapists negotiate that professional identity for themselves in the absence o f institutional support.

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4 For the past few centuries, biomedicine, as the dominant force, has framed the discussion of CAMs. But cultural changes have left biomedicine less powerful and hegemonic than it was historically. This has opened up the possibil ity for other fields to patients become consumers who increasingly insist on making some of their own choices regarding medicine, but also a wide array of CAM modalitie s are now challenging the dominance of biomedicine, essentially by breaking through the old boundaries and into Professionalization of a Field At the macro level, v arious fields of alternative medici ne have contributed to this shifting of the boundaries by drawing upon some of the very same techniques of professionalization that have allowed mainstream biomedicine to dominate the discourse of medicine. Professionalization involves practitioners creat ing societies and organizations and standards to follow, governing themselves and their practices, and making themselves exclusive so not everyone can practice. Saks (2001) names professionalization as one of two recent developments that are changing the s tatus of enhance their legitimacy in the division of labour in relation to orthodox health through the concept of social closure or exclusion when groups gain a monopoly of sorts Despite some professionalization, m ost if not all groups with claims to medi cal expertise are subordinate to biomedicine. When CAM modalities professionalize, they are in a sense stealing some turf from biomedicine because biomedicine has staked a claim on all things medical. However, biomedicine is no longer hegemonic enough to a dequately police those boundaries: other social forces (including public demand) are pushing to allow different CAM modalities to be seen as legitimate medical options. Many of macro level hallmarks of professionalization are becoming a reality in the field of massage therapy massage therapists have developed state wide organizations, educational facilities and standards including lifelong continuing

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5 massage the individual massage therapists also engage in interpersonal strategies to professionalize their image and grow their businesses. My focus will be on these more micro level and i ndividual strategies that massage therapists employ to build their businesses safely and to fight the (negative) myths about massage therapy and massage therapists. A Professional Identity At the micro level, o resource for CAM modalities as they attempt to professionalize. To be a professional is to (Foley, 2005: 194). Professionalization minimizes some of t he differences between biomedicine and CAMs and makes CAMs more legitimate in our society. As Baer (1989 : by which alternative practitioners internalize some, if not many, of the philosophical nd so they become more acceptable (Saks, 2006 : 90 ). Clarke et al. (2004 : 332 ) make a similar claim, saying In her study of midwives Foley identifies three types of identit ies in social movements: individual, collective, and public (2005 : 186). The work accomplished by massage therapists (and other types of practitioners) to advance their field and move towards acceptance can be looked at as a type of social movement. In this thesis, I will explore how enables practitioners to use their individual biographies as a mechanism for creating professional identities. While this does involve working with the collective and pub lic identities it does not put them at the forefront (Foley, 2005 : 186). I am not looking at their organizations their group interactions or how they are portrayed by the public I am looking at how massage therapists perceive their own professional expe riences. I listened to them talk about their work and

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6 themselves in order to explore how they construct their identities as massage therapists and how they strategically perform professional identity for others and for themselves Individual identity wor identity (2007). Personal identity narratives are micro level stories produced by (Loseke, 2007: 662). However as Loseke points out, personal narratives cannot be entirely separated from cultural or other forms of narratives because they are mutually constitutive. This is why we will see massage therapists pulling from the narratives of alternative systems of med icine and from biomedicine (macro levels) in their formulations of their personal/ individual identities. The next section describes my research methods. Then I will discuss the history and mythologies surrounding massage therapy. I will follow that with a chapter on massage therapists perceptions of biomedicine in contrast with their own ideologies of they use in general to be professional in their calling. Following t hat, I will look at how be a professional massage therapist.

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7 Chapter 2: Methods Doctors, patients, and practitioners all make claims about themselves and about their authority. However, the content of the claims depends on how they see themselves in relation to the medical system(s). Even though there appears to be some re search which is addressing CAMs much of this focus has been limited to assessing que stions of their patients such as who uses CAMs and why. There has been research conducted on patients as consumers and how they view of western model doctors as well as alternative and complementary medicine. But there has yet to be much done on the views of CAM practitioners with the exception of some recent work on the trend towards and views of integration 1 (for example, Ben Ayre et al., 2008; Barrett et al, 2004; Barrett et al, 2003). Even then, most of the work on views of integration is from the persp ective of biomedical practitioners (i.e. Ruggie, 2005) My study will add to the literature on practitioners of alternative medicines. Massage therapy is one of the most prevalent forms of CAMs in the United States. Barrett cites two different studies, The fact that it is so popular makes it that much more important to look into the identities constructed by the massage therapists themselves to s ee if we can identify what makes this form of medicine popular. Since I wanted to learn about how massage therapists construct their own identities as massage therapists, I used semi structured one on one interviews with licensed massage therapists to ga ther my data. Semi structured interviews was the and phenomena that are only par tially understood by the researcher (Shih, 2007: 134). I had a general idea of what I wanted to know about but I wanted to know about it from 1 Integration meanin g the movement towards biomedicine and forms of CAMs coming together. There are different models of integration and some people argue that integration is not actually occurring. I will discuss this concept more later in the thesis.

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8 issues and questions that I was interested [in] that was necessary for respondents to tell me about the key issues that they identified as open ended structure was important in my project because my research focus shifted in the course of the interviews as I learned about what mattered to my interviewees I originally thought I was going to explore how massage therapists construct themselves as alternative medical practitioners. But early i n the interview process I shifted my focus on to what was important to them. In particular, I ended up looking at what they view as their professional identity, their strategies and beliefs. Throughout the writing of this thesis, I tried to give voice to the massage therapists I interviewed who are often marginalized by the dominant medical system. I feel that by listening and by showing their agency and how they construct what it is that biomedical model. I in the sense of acting for them (Fine, 1998: 149) T he massage therapists have strategies that they use to help themselves I am taking what they have to say about themselves rather than simply writing a bout them or what others have to say about them. The interviews lasted between 40 minutes and an hour and forty minutes. My participants included five practicing massage therapists, one male and four females reflecting the fact that, a ccording to the Ame rican Massage Therapy Association 85% of massage therapists are female (http://www.amtamassage.org/news/MTIndustryFactSheet.html). All subjects self identified as massage therapists although they practiced different forms of massage, the biggest split be management massage. Four out of 5 of the massage therapists in my sample were self employed and Again, this reflec ts the demographic data: t he American Massage Therapy Association sole practitioners or independent contractors account for the largest percentage of practicing therapists (92 percent) (http://www.amtamassage.org/news/MTIndustryFactSheet.ht ml). This sample excludes

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9 massage therapists actively working in the spa industry and those working in massage therapy chains 2 at the time of the interview. Participants were recruited using a snowball technique in two metropolitan areas in Florida. I int erviewed a massage therapist I knew who in t urn referred me to a friend forwarded me the information from some of those who responded which, of course, limits my sample t o people whom he knew and felt appropriate for my study. I am not entirely sure what standards he used to screen people he sent to me. I was also unable to include some of his contacts either because we could not find a mutually acceptable time and place f or an interview or because they never responded to me Everyone knew how I came into contact with them. There was one person who I came into contact with through a hair stylist because she is also a cosmetologist. When I met each interviewee, I told him or her a bit about my background and that this was a thesis project for my Master s degree. They generally were deligh ted to be part of a study on massage therapy, felt that I was doing something great, and that more should be done. I also made sure to give them their IRB consent forms and to explain that they could pause and or end the interview at any time. All participants signed the form before the start of the interview. I also explained that the interview would be tape recorded to make sure that they we re okay with that. I began each interview by asking easy question s such as for general demographic information that would allow us to develop a rapport I got similar responses to my inquiry for demographic information in all of the interviews : age, length of practice, location, and education. I started off the interviews with a list of questions that I felt should be answered based on my background research. After the initial starting question(s), I did not have a set order of questions because I let the massage therapists control the flow of discussion and asked them questions based on their narratives. I consulted my list of questions throughout to keep track of the main themes I was interested in, and when the conversation started to slow down I would use another question to start it up again, sometimes in a different direction. I included questions on their practices, their 2 National or regional

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10 they do, and so on. I also adjusted question content within the interviews so that sequence and the actual questions would make sense in the context(s) of the interviews. All of the participants had been practicing massage for approximately 3 to 30 years at the time of the interview. The re was also a wide range of age differences between the participants although age and time practicing do not always reflect each other. For example, massage therapy is not always a career learned as a (relatively) young adult. Some people come into it when they are older. I would argue that this sample, while extremely small, should be fairly typical as far as age, gender, education and work background. That being said, this is not a generalizable sample.

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11 Chapter 3: lace the Myths Massage therapists are very aware of the history of their profession. My interviews reveal that massage therapists are aware of the stereotypes and negative perceptions about massage therapy and that they actively work to carve out a more positive identity and image for their field. : 187). I will be looking a t the individual negotiations of the massage therapists I interviewed as they worked to change the negative perceptions and stereotypes about massage therapy and massage therapists. What do massage therapists perceive to be the myths about massage therapy how have they arrived at this perception, and how do they challenge them? Countering Myths Historically, massage therapy has been marginalized because it has been associated with sex. Nicholls and Cheek (2006 : to explain how massage therapy or physiotherapy came to their current existence, specifically in Great Britain. They look at massage therapy from the Victorian era and the a number of channels of resistance to the orthodox Victorian imagina Cheek, 2006: 2339). They explain how the British Medical Journal basically facilitated the creation of a scandal where it came to be public knowledge that many massage establishments were associated with prostitution T his seems to be where the sexual connotations of the words masseuse and masseur came to exist. The following is what Thomas had to say about the history of massage which, to him, predates the Victorian er a:

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12 one of the big, what we would call doctor physicians of ancient history, of ancient Rome [who] highly believed in the efficacy of touch therapy. He would often prescribe massage he was one of the first ever to codify his applications and the results of his applications and even at that time there were always snide remarks about massaging and brothels, and sexual connotations to touch so I ially in America, where we have a really skewed belief system about touch and what is good touch and what is bad touch hard for us to differentiate between what is sensual and sexual. Sensual meaning pertaining to the senses, like touch, smell, but w e often equate that to sexuality. So I think and people may use special lighting or lotions that have a specific essential as opposed to a healing environment. You So I think some of those myths, another S and those are thing s that are a point of frustration because how do you change a cultures view? [laughs], how do you do that? So a lot of it is, one person at a time. You do the best that you can and you dispel these myths through your actions more than just by telling peopl e I think people are more apt to try to change their attitude if you can show them instead of telling them. 3 As this one respondent saw, the sexualized myths about massage therapy are going to change slowly. It is up to massage therapists to destabilize these myths by presenting to the public a very professional style of massage and by insisting that they want to be seen as professionals. It is quite clear from my interviews that t he sexual connotation attached to massage therapy poses problems for massag e therapists. If massage therapy were separated from the sexualization, both sex workers and massage therapists would have 3 In the quotations taken from the interviews the italicized writing is my comments and questions. The normal script is the interviewee speaking.

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13 more legitimacy and safety and would not have to deal with the gray areas/ blurred lines of who is willing to do what. At least this is what Megh an had to say about the subject: You know if they wanted to call that [she had just finished describing places that were more geared to sex than to professional massage ] a And see that as legitimating massage therapists? protecting and legitimizing the sex trade for what it is... and allowing people to call it what it is would take a lot of the gray area away from a lot of other people [those other people being l egitimate massage therapists] Emerson (1970) discusses the work necessary to distinguish between sexual and non sexual touch in the context of gynecological exams Doctors and nurses who conduct gynecological exams have to be very careful in constructing what they do as professional because they are dealing with sexualized parts of the body. Emerson explains how a in the gynecological exam (1970: 77, 81). Massage th erapists use many of these techniques as well, but not all of them. of depersonalizes and desexualizes the gynecological exam ( Emerson 1970: 78, 81). Massage therapists would find that tactic to violate their basic assertion that every client deserves personalized care and thereby reject it. The sexualization of massage therapy is also a gender issue. There is still a widespread perception that massage therapy is a female job due to the sexual innuendos that have come to be associated with massage and to gender stereotypes. The gender and normal ize hands : 558). The stereotype of women and not men as emotional, nurturing, touchy, creates an expectation that only women should be massage therapists. Men who are massage therapists instead may face a typ which is t outside of prescribed social norms or standards of gender. Male massage therapists who are often perceived as acting

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14 outside of gendered norms face stigma that they mu st be homosexual. Thomas income as well: stigma against and fear of homosexual ity may keep other men from using their services. At times male massage therapists may also be perceived as threatening by potential female clients who vulnerable (lying down, unclothed). People associate d with female clients, especially reiterates these themes through a story about a woman who did not show up for her appointment one day: cond part of her voicemail was outlining what had happened that Saturday, that weekend. Apparently, her husband was going to drop her off alone, in a rehab because of the connotation that there was a sexual possibility that it could become sexual if no one else was there. So even though she had gotten improvements, and if I remember correctly, she had gone to other health c it w as one of those Not only is it more difficult to get male clients, it may also be more difficult to be hired in general because, as one subject put it, the spa industry is notorious for preferring (yo ung) women when hiring Instead of professionally setting appointments in a gender neutral fashion, spa receptionists may ask if the client prefers a male or female therapist. Thomas was against this practice, feeling that professional tr aining is professional training, and the sex of the therapist should not be come an issue Thomas: And the stigma is is two fold. One, as a male therapist, and one just as a

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15 one of the fields that benefits the female gender because that seems to be the reasons I went into practice for myself anybody else anymore and the second reason was because I know how difficult it was to go out into the field and be hired at a spa as a male appointments at the spa, [for the receptionist] to ask the person, the client, what they woul d prefer, a male or a female therapist. I find that amusing, l awyer, you just want a good one definitely out there. perceptions about gender issues in massage are right even though she is looking at it from a position of gender privilege : look vulnerable. Me being a female, that makes it easier for them, just because of familiarity, maybe they would think that I would understand their bodies better than a man would. Kind of like going to a gynecologist. Some wom en feel comfortable only seeing a woman gynecologist. Some women think it s preference but for whatever reason, women just tend to feel more comfortable with women. And, I mean, men too. Men kind of get the a man touching me dominated profession. Because of peoples comfort levels if you have

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16 In t his case, Emma seems to accept these personal feelings held by the client as natural but Thomas, who is at a disadvantage due to these gender and sexual stereotypes, does not. Massage therapists want to fight the myth that massage is a sexual practice bec ause they take pride in being health care practitioners They fight to replace th e sexual image with one showing massage as healing and healthy by using techniques of professionali sm and by claiming professional status for their practice(s). One of the way s they fight the myths is through education as every person they come across, whether a client or not, can learn about massage and its health benefits With every person who re people who can change those myths. They also shatter these myths through the act of effect (according to massage therapists all massages have therapeutic qualities whet her the purpose is medical or relaxation) Massage therapists are using the continued progress of their profession to further distance themselves from historical notions of what massage therapy is or does in the process of legitimizing themselves. This is reflexive: the more they work, the more the legitimate they become, and more legitimacy creates more opportunities to work. Progress also relates to language massage therapists do not like to be referred to as masseuses or masseurs because these terms are reflective of a historical era that they would prefer to leave behind. A ll of my interviewees self i dentified as massage therapists which is a more legitimate term in their minds. Masseuse and masseur are words whose meanings run from simply being old fas hioned and inaccurate to insulting, sexualized, and inappropriate. For example, those phrases really upset Emma who explained that to me, the people who perform sexual acts during m behavior. Massage therapists, it sounds more professional, I went to school. they work i n closed doors People, like men are always going

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17 happens. I know of men who would frequent those kinds of establishments. And so to me, those are masseuses. So do you think t misunderstanding or a miscommunication than about what the difference is and what services are being performed? want to be affil iated with that term. Right. distance yourselves. ha masseuses work in massage parlors [massage parlors being on level with brothels] Thomas on the other hand, was not as disturbed by the terms, but he still did not care for them He explained: French spin on an English word. I think, d them personally offensive. I just prefer the roblem, or find them offensive... e the respect that we do today The sexual connotations are a big deal though. discussed by Nicholls and Cheeks (2006), organizations, certification processes and standards, and so on were formed to regulate massage in 1894 (in Great Britain) These standards were borrowed from the biomedical institution (s) which had already establishe d or used many of these tactics and are tactics or techniques associated with As that older interpretation of massage therapy contributed to the

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18 belief that massage therapy is sexual, the original massage organizational body, the Society of Trained Masseuses, basically restricted massage therapy from being performed on male clients and from bein g performed by males (2006 : 2342). Sexual myths of the past still work against massage therapists in our culture today which is arguably hypersexualized in a lot of ways, especially when it comes to touching. According to Oerton (2004 : 306 to skin contact is associated with the collapsing of spatial distance between bodies, and tends to be reserved for those with family member or maybe by a doctor, i s sexual. This is part of why there is so much confusion about massage therapy and whether or not it is a front for prostitution The stigma about massage therapy is carried over from the stigma associated with sex. Some p eople erroneously think that massa ge therapy is sexual because massage therapists must touch their clients in order to help them Interviewees also noted that there are other myths about massage the rapy besides the sexual ones. Thomas ge therapist has to hurt the client for the client to feel that they were being adequately associa ted with media presentations of massage therapists as well. On TV massage thera pists are portrayed as flaky, spacey people (such as on the television show, Friends) They are portrayed as abnormal people who are unable to keep track of time, appointments, and are inept and kind of child like. The massage therapists I spoke with worke d to counteract these images by making sure that they embodied the opposite of what is often portrayed in the media about them. Another myth that massage therapists try to dispel is that massage is not done by big blonde women who hurt them or by little ex otic Asian women w hich is part of the sexual fetishizing of massage. Building Upon a Valuable Tradition Massage therapists push away from the sexualized history and draw upon the 4 history Massage has been dealing with negative and sexual perc eptions for a 4 mas sage is a natural, sustainable, and age old modality.

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19 negative perceptions of massage therapy, massage therapists borrow credibility from the long standing existence of massage therapy as one of the worl such, there is the belief that massage is so old and so natural it has already been proven to be effective. Although i t does not fit into the W estern model of scientific proof so it is not well received in the system of biomedicin e to many people the longevity is proof of efficacy in and of itself. If it did not work, it would not be around after all of this time. E ven though the medical establishment may refuse to acknowledge the history of massage therapy (or various other forms of alternative and complementary medicines) as proof of their legitimacy, their rich history and longevity can be used to support these practices as effective modes of care (Thompson, 2004). Massage therapy is seen as a first choice or first response fo r many conditions or injuries. As Thomas said, around longer than chiropractic, longer than osteopathy and I think of it as ernative, I see it as It is non invasive and perceived of as less risky than many, if not most, biomedical By drawing upon the instinctive aspect of massage, therapists reveal that it is not simply something learned in school. To massage something is an instinct and a natural response to harm Their education allows them to channel that instinct in specific ways in order to amplify its efficacy. Massage in and of itself is original and natural, and there is a sense of pride in that. Massage therapy, which as Thomas states is the is inherently sustainable. It has been practiced for as long as hum ans have touched with different levels of acceptability depending on the society. With our high levels of rationality and sexual repression it has encountered barriers preventing easy acceptability within mainstream medicine Massage therapists are sensiti them and their profession. They are fully aware that it is a profession that has been, and still is to a certain degree, stigmatized. By pushing away from the sexual myths and

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20 invoking a historical sense of touch that is safe, comfortable and healing, massage therapists work to improve their professional status and foster the holistic tradition that they believe in.

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21 Chapter 4: Distinguishing Massage from Biomedicine and the Factory Model Doctors are a part of a very bureaucr atic capitalist system in the United States. They often cannot take the time f o r lengthy interact ions with patients because they are constrained by a system that rese Massage therapists oppose the formulaic approach used in biomedic ine which reduces people to body parts to be acted upon. This approach is one where people are pushed in and out with little communication, time, or personal attention. This is also characteristic of the spa industry and of massage therapy chains accordin g to the massage therapists I interviewed. Massage t herapists set themselves up to avoid these problems by controlling their own schedules. This chapter describes how massage therapists construct the differences between their own beliefs and practices and those of both biomedicine and what I call the The Factory Model The spa industry is looked at as a kind of factory. This view was shared by massage therapists who had and had not ever worked in a spa environment. Those massa ge therapists who had worked in spas had been dissatisfied and left the spa industry by the time I spoke with them. Massage therapists enter this profession because they want to help people and provide a service that they believe is important. But in the s pas the massage therapists are constrained by the nature of the job and the scheduling practices in that business environment. Th e massage therapists was not what they had gone into massage for. Th ey generally expressed a desire or need to establish a rapport with their clients over the long term or even just be able to take time to know them and their needs in general. This need relates to their views of massage and how it is supposed to work. They cannot meet their own ideals when they work in the spas. Emma talked about her work in a spa as follows:

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22 U people. At the hotel I used to work at, I did 12 hour days, like 3 days a week. And I would do back to back, Saturday and Sunday; Sunday I was the only massage therapist there so I would be booked solid 11 on Saturday plus another 11 on Sunday. Come Monday I would be so exhausted; I could barely get out of bed sometimes. Like, I of that, like if I ever ran into anybody that I worked on, whether it was a great session or not, they wo uld be like on me this time touched and who appreciates my work as opposed to a bunch of namele ss people who are just going through a revolving door Scheduling is a major reason why most of my interviewees chose to work for themselves or at least not to work for spas. They want to control the quality of the massage exercise for their clients and t o protect their craft. To provide quality massages they cannot overdo or overextend themselves to such an extent that they lack the energy to provide a quality service Thomas: I find from feedba ck from them [other massage therapists that he my 4 th or 5 th really just going recipe type massage than a compassionate art [laughs]. S o I think that was in [a sub unquote a money making machine. I just wanted to be able to pay my that practice, I never wanted [to get] to this point, [of] regretting it. Like

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23 every patient that I have and I think the universe sends me patients for a reason. Most of them feel that there is a maximum number of massa ges they can accomplish in a day or period of time without sacrificing quality. Being effective is very important to them because that is how they are able to gain positive reinforcement from the clients or from knowing they are doing a good job. When see ing fewer clients and spending more time on those clients, it gives the massage therapists more opportunity to build satisfaction in their professional relationships with the ir clients. Rebecca: I guess I re ally prefer working for myself someone else in the field of massage obviously they take a lot more of the Because like there at the [hotel spa she worked at] never see them again. So I kind of wanted to get more into one on one like continuing clients that I would see more than once, where you can kind of see results and you do grow more b ecause you have to learn more different things that come up, whereas you might not be dealing with that. relaxi ng people minutes in and out, you gotta get them off the table in 50 minutes and then It felt kind of like a factory. The massage therapists with whom I spoke wanted to control the number of their clients so that they could protect their energy level. They want to provide a quality service so they can feel good about themselves as professionals. Massage therapi sts come to realize that the number of massages that they do in a day affects their energy and emotions.

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24 Thomas: people in 1 day amo unt of focus and attention after the fifth one because it does take a They have to deal with the timing. Controlling their schedule is a physical issue bec ause too many massages and too much energy output leads to a feeling that their own bodies are affected. This relates to ideas of wholeness and whole bodies as well which are discussed in more detail in a later chapter The careful scheduling of clients is also a part of how massage therapists care f or their own bodies. Since they want to teach their clients to self care, they must do it for themselves as well. T he ability to create a workable schedule comes from knowing yourself and knowing what you can handle effectively and professionally. Massage therapists view the movement towards chain massage as problematic because scheduling too many clients compromises their ability to do a good job. These massages may be bad for the therapists too because it ma kes them feel bad about themselves if they think that their massages may not be up to par. Even so, the massage therapists with whom I spoke do not seem to blame the therapists for working at chains or at the spas for that matter. My interviewees could sympathize with the economic necessity that might cause someone to work at a chain or spa, as Priscilla demonstrates: They can go to work at Massage Envy and be busy all day long doing the in a for busy people. They come in, they get done, and they get out. That supporting it so it must be working. D o you think that that could be a problem for massage, like how do you think that works with what massage is supposed to do or be? I think that our profession is against it because it a gainst it in that respect. But people who work for them are happy to have

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25 a job. Because I knew somebody who went to work there and I said, you they pay well and they give vacations th ere and I think that it probably is helping massage get out there a little drive through then let them have it you know [laughs] Although then t here is a perception that c hain massage therapy businesses do not provide an optimal massage experience because there is not enough time and interaction. A t the same time, these chains are providing massage therapists with work and are promoting and normalizing this business in society. No longer is massage therapy something to seek out, clandestine, or problematic. Now it is being promoted as something close to a fast food chain where busy people can get in and out with minimal effort. The Biomedical Model There seems to be a belief am specifically health problems, are caused by biomedicine. Thompson (2004 : 164) explains illness inducing imbalances th explain how massage therap ists position themselves against this over medicalized way of being and how they feel this contributes to other issues such as when patients become Problematizing Biomedicine Massage therapists believe that the de from the drugs and interventions prescribed and performed by biomedical practitioners. The massage therapists feel that people are being both overmedicated and given

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26 medications that make them feel worse. This, in turn, causes people to have to take other or more medications. It is seen as an unsustainable mode of treatment in contrast to the inherent sustainability of massage therapy as discussed in the previous chapter. According to Emma: ith our [conventional] medicine. I believe that, again, we take these trees down in the rainforest and we make all of these [about] 7 different medicines, 9 different medicines. A lot of these older clients that I have, different things medicine just because a doctor says here this is going to make you feel better, not thinking abou t contraindications and how all these medicines medicine in order to take care of one problem but then you have to take this third medicine in order to combat side effects from this medi cine but effect. You have all of these other problems associated with just your medicines alone. Biomedicine is pushing people to consume medication that causes side effects which th en require more medicine to counteract some of the side effects. This gets very expensive for the patient and is difficult to afford. Massage therapy is much more affordable and sustainable. However, my interviewees also believe that as long as people ar e content to take their pills and keep suffering, our society is not going to change. The biomedical model d oes not facilitate change. Massage therapists perceive that biomedicine encourag es people to stay passive and continue the same bad habits that may have pushed them into ill health to begin with. Biomedicine is still a dominant institution in our society and as such people often trust their doctors advice and assume that there are not any other alternative for gaining health. our society which my respondents believed about the general public where people often choose to only use medicine to deal with problems like diabetes.

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27 Meghan: And they were [people with diabetes] under medication, told by medication. Which is sad. Thomas more generally explains how massage therapists separate themselves from the biomedicine discipline through their holistic approach to health as well as explaining the importance of creating relationships with their clients. He conceive s of health and interaction between massage therapists and their clients as different from the relations of biomedicine I try to convince them [the clients] that me as much information as they can and me bringing my experience into the situation and we work together I want to get pa [My] approach is to a more a ctive healing. By facilitating w just here to facilitate what you ar e already capable of and they understand [the clients] standing T come to me, I want them to know that this is a different situation, with me, them know that they are in c themselves to where they are and they need to get themselves out of that. They are capable of doing that. Thomas looks at what he does as changing the actual beliefs of people who use massage the rapy. He believ es that t he client has to accept responsibility and work on themselves as well. He tries to facilitate their journey to good health. This is purposeful strategy which creates a distinction between massage therapists and biomedicine The body can heal itsel f as long as people do what needs to be done to enable that health.

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28 In addition to seeing massage therapy as a sustainable form of health care, massage therapists also view massage as a form of preventative medicine. They believe that if people use massa ge before they are sick (or even when they are sick) then people will not need to use biomedicine as much because massage therapy helps build the immune system. Massage therapists believe that they are engages in a profession which provides a public servic e keep your muscles limber and lubricated and, again with the flexibility and the range of motion. When you are stretched out, you feel good and your chance of injury and complications something and then you are kind of like trying to cope with the... the aftereffects of whatever it is that you are trying to deal with. because e healthy for you. A holistic approach to health is one of the main ways massage therapists distinguish themselves from biomedicine. Th ey work to share this holistic approach to health with their clients. Massage therapists believe that t he interconnected ness of mind, body and spirit is critical to help ing people According to Aakster (1986 : 267) matter of the simultaneous (and closely interrelated) maintenance of an inter nal and Instead medical practitioners often focus on isolated symptoms rather than seeking out the complex causes of illness. Since the root causes may be neglected (or ignored if they a re not part of the physical body), the patients often must go back for more treatments, take more medication, or just endure their condition without improvement.

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29 Massage therapists actively work to develop rela tionships with their clients and with other professionals: this fits into one of the main ways that massage therapists push away from biomedicine and factory model. They actively work to empower their clients, by teaching them how to control their own heal One of the goals is showing the clients what their bodies are capable of, thus physically and emotionally necessarily to heal but to give the client the tools they need in order to keep themselves healthy. Education is a tool used to empower people. All of my interviewees felt that it was extremely important to share knowledge with their clients. E ducation is critical within their profession of knowledge with people outside of the profession. It is that willingness to share that sets massage therapists apart from conventional medical professionals who routinely keep their knowledge to themselves, in effect protecting their authority over others. This sharing of knowledge is basically a part o f the service being offered. As Thomas said: Things that they [the clients] are not aware of because of, in a lot of othe r different medical care practices, the focus is largely on medicine and pills and drug interactions and or surgery but not about how to empower the I find my job is, to show them [the clients] those options and give them good resources that they need to go to so that they can help themselves. Massage therapists share knowledge yet retain a specialized position of having that knowledge in order to keep people coming back This spe cialized position is based on the fact that they have an education that allows them to perform this service that people want to use. Massage therapists have to keep a careful balance because in order to keep clients, massage therapists need for their clien ts to rely on them even though they profess to be empowering clients to heal using their own natural abilities Massage therapists need to foster this reliance in order to have steady work. But it may not be as much of a contradiction as it seems: they are giving people exactly what they are looking for according to Richardson (2004 : 1051

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30 information provision might lead them to a better understanding of their condition and to Several of my interviewees shared the disappointment they sometimes felt when, after a client had already left, they thought of something they could have s aid or done to help the client further. This led to self disappointment which reflects on how important their work is to them. Some of my interviewees made it a point to say that the information they share is not always specifically massage oriented. It m ay be anything that they think is useful or interesting to the client. Conveying information informally through e mail or phone calls is also a way to keep in touch with clients, and this enhances their ability to remind clients to schedule appointments. I t is a way to keep the nterests at heart, and this helps to keep the client coming back. There is also a language shift from patients to clients that really shows the differences between how biomedical and alternative practitioners view people under their care rather than attempt to empower their patients and disassociate themselv es from traditional biomedicine. Thomas prefers because the term patient for a lot of people neurolinguistically makes them, labels them as having a problem. So I try to use terminolo more positive and more empowering for the patients. So clients, it sounds are technically patients. Massage falls under medical care practitioners in the state of Fl orida T hey are technically patients but clients is the term that I prefer to use. Or guests, sometimes I call them guests. It would certainly be acceptable within the bounds of his profession as a h ealth care provider to call clients patients but he consciousl y chooses the term client so that they see themselves as active participants in their own healing, not because of his perceptions of what that word means. Emm a also prefers the term client:

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31 No, to me they are called clients. etween patients and clients? preference. Another of the empowering aspects of massage therapy is that massage therapists actively p lace importance on what their clients feel which also enables the client to actively participate and have a voice in their own care This reflects some of the literature which shows that one of the main critiques of biomedicine (especially with regard to w Flesch, 2007). Feedback is very important to massage therapists not only because of the empowerment and cooperation aspect but also because it gives them useful information so that they can help their client better Integrating Biomedicine with Alternative Practices There is a feeling among massage therapists that biomedicine is holding integration 5 n the door They, the massage therapists, are willing to work with biomedicine for the good of peopl e despite the fact that the people with whom I spoke were opposed to a medical model. They still want to be viewed as legitimate and given their rightful p lace as health care providers who successfully help people In some ways and places they are the strengths of massage therapy. The status of massage therapy ( and some other CAMs) has changed though. Doctors may now receive formal knowledge about other forms of medicine besides biomedicine while in school. This is facilitating a slow move towards further integration as more people and doctors come into contact w ith different CAMs. This helps with the legitimization of massage therapy because as other types of professional health care practitioners accept massage therapy, it increases and legitimizes its status as professional. 5 Integration between biomedicine and massage therapy or even CAMs in general.

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32 been reading. And I think that they [doctors educated in different forms of medicine] see the, the benefits and the efficacy of such therapie W working as a team and they see the bigger picture instead of this God doctors that are more well rounded in their education and have possibly perspective about it than the old school o n the verge of retiring doctor like completely their perspective of what massage was 40 years ago and Mass age therapy is accepted more in part because insurance companies are starting to recognize its utility and are starting to promote it as a viable option for gaining or keeping health. For example, Meghan said, happily, insurance companies are now paying f or a little bit of stuff. Some insurance companies will pay for 12 or 20 massages a year. I nsurance companies may be a big legitimiz er of massage therapy because if insurance companies will pay for something, especially if it is for cheap preventative care then that carries over into other areas. Most of my interviewees did not deal with insurance companies but they noted it as a positive trend in society. This connects to the larger culture where education and changes in the ways that we look at bodies an d at nutrition are changing how we look at medicine. Insurance companies would not use massage therapy or promote its use if it was not becoming more mainstream and acceptable. This reflects the c hanging cultural consciousness massage is becoming more main stream and is effective in preventing problems. I nsurance companies may see the benefit of preventative health care so they can minimize their costs and b e more willing to spend money on massage therapy in order to not have to spend more money for health p roblems that could have been helped, alleviated, and/ or prevented. Despite a more welcoming approach by insurance companies to massage therapists, there are still gatekeepers. This takes the form of oversight and control by doctors. Winslow and Kroll (19 98 : no page

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33 alternative health care often require physician referral for these services, highlighting the same time, that l egitimation is contingent on agreement and approval on the part of biomedical professionals. But, there is still a push on the part of insurance companies to find and use medical treatments that cost less, which is often a characteristic of alternative mod alities such as massage therapy Klimenko et al. (2006 : 266 ) also found edged sword for all providers, with insurance companies sometimes being perceived as mandating what can be done and thus placing obstacles in the way of There are other signs from biomedicine that massage therapy is gaining some legitimacy as a profession Some medical institutions are bringing massage therapists (or even other types of practitioners) into hospitals and medical centers for e xample to work. More doctors are sending referrals to massage therapists which may reflect the changing perception of massage therapy as less sexual and more professional Massage t herapists look at this acceptance as a foot in the door towards their r ight ful place as health care practitioners even though they know that it is limited and conditional. A problem with integration seems to be the lingering positivist discourse that still characterizes much of biomedicine. M assage therapists, and CAM practitio ners in general, are still subordinate to medical practitioners. It is obvious to massage therapists that there is not active cooperation between professionals who are considered equals. The research shows that many biomedical doctors try to take over and control access to and : 169 certain forms of CAM gain professional recognition, the efforts of established medicine to contain the threat of CAM have shifted from denouncement to cautious acceptance, provided that alternative practitioners are regulated, educated, and professionalized in the There is a lso a sense on the part of CAM practitioners, that biomedicine co opt s the more acceptable aspects or techniques of alternative medicine. Some of the research is showing that while some doctors accept the presence of CAM practices, they still feel that biomedical doctors should be primary, should control diagnoses, and should remain in control of the entire institution and discourse of health and medicine. W hile some

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34 doctors may refer patients to alternative medicine, they still control to these practitioners. Doctors act as ers by the tactic of co optation allo ws the doctors and the nurses to contain the pressures of public demand for CAM. It increases the scope of their professional roles, permits them to maintain their dominant structural interests and limits the need for the repressed interests (both CAM and the public) to strive for integrative healthcare ( Kelner et al. 2004 : 922 ) In short, by co opting CAM, biomedical practitioners retain control over medicine in our society : they seemingly giv e patients what they want while marginaliz ing CAM practitioner s. Shuval (2006 : 1785 They use certain health of their patients they still do not let practitioners and CAMs share an equal professional standing nor do they allow patients to have more control. As Boon et al. (2004 : conventional medicine does not result in integrative healthcare since this does not represent an acce ptance and integration of the holistic principle that tend to characterize optation or assimilation of pieces of a whole system of care, removed 6 In some cases, people use CAMs because they feel alienat ed from the orthodox system and from doctors. For example, reasons why so many patients [in Norway] consult both doctors and alternative practi tioners may result from the phenomenon that doctors diagnose and treat diseases as they define them from their biomedical point of view. The patients, however, are 6 I am not saying that this is true in all cases. There are some medical practitioners who want to integrate and some CA M practitioners who do not. But these negative perceptions of integration seem to be the most common.

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35 h ow one group (patients) is disenfranchised, so to speak, by the biomedical field and how they negotiate the ir dissatisfaction b y using both types of medici ne. Furnham and Smith (1988: 685 ) suggest e may do so from disenchantment with, and bad experiences of, conventional medical practitioners, It seems that in many cases, the attitudes of conventional medical practiti oners are driving their patients away Dissatisfied with traditional medicine, people look for alternative approaches which push them in the direction of massage therapy (or other CAMs). For issues, he found that doctrinaire, draconian, disempowering, and degenerative: forever locking them into a world of physical limitations and dependencies on medical techno of holistic well : 170). Richardson (2004) found a similar complaint from patients about the hopelessness instilled by biomedical practitioners. People dislike their disempowered position in t he biomedical model and since they may not be able to do something about it, they find an alternative. This may be at least partly because the most common problems in the United States are those that are often dismissed as unimportant and paid the least at tention by biomedicine (Fraser Dunfield, 1996). Spe nce and Ribeaux (2004: progress of biomedicine in solving these new types of medical problems has been associated with a growing skepticism and a turning to alternativ want help with their common problems, not just highly specialized problems which require expensive solutions a n d highly trained medical personnel This is exemplified in : 983 ]any patients suffering from chronic pain, allergies, musculo skeletal, psychosomatic and functional conditions appear to be disappointed with the treatment they receive from orthodox medicine and constitute a large proportion of the clientele of the alter A major gap in biomedicine is the tendency of biomedical professionals to place labels on people who a gap that biomedicine is not filling which massage therapists are giv en the opportunity to work within (Kelner et al., 2006). For example, pain management is a fairly common problem

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36 that doctors often prefer not to deal with because patients become addicted to opiates. find relief through massage therapy. Priscilla has changed her focus from relaxation focused massage therapy to specifically working on people in pain. Part of her reason for doing so is the desire to fix at one point: I have actually been in pain all my life. I had a birth defect and one of my always hurt because chiropractors, d beliefs A couple of th e massag e therapists mentioned that many of the ir clients are people that biomedical doctors can no longer help who experience chronic pain. These disempowered patients can become empowered clients when they come to massage therapy. Several stories provid e telling examples : Thomas: Sometimes I have had people who were on 2 or 3 meds when they came in. I can think of one that came in for migraines and she was on anti inflamatories, anti was on 2 or 3 different types of medicine and by the t ime she was done after about 4 months of massage therapy, cranial sacral and stuff like that, she was, I think, on one of the meds and that was very infrequent, only when she desperately needed it so an example of the power that massage can have as far as reducing some of the medications doing SET work [Struc tural Energetic Therapy, a modality she practices] and one of my clients had his hips replaced and the first one went fine but the second one just never went into place and he was still hobbling and in pain when he came down on the leg. And I did him 4 tre atments and

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37 one, second time doing his hip, halfway through, he goes, huh, the pain is gone. It went and it never came back. [knocks on wood] That was a year ago, but that was like wow, that was a great success. T hat was probably my best success in the, with the SET work, having somebody that was told ... pr obably going to be in pain for the rest of your life. And then he was out, boom, just like that, 4 treatments. Even though massage therapists cannot prescribe drugs they take pride in helping people biomedicine cannot. Their practical success is proof of xed mentality. They take pride in helping people get off unnecessary medications so that they can take control of their bodies and have an active role in getting well This active role is somethin modalities for. massage therapists are seeing their client base grow. Not only are people turning to alternative medicine, including massage therapy on their own, apparently unhappy with care received elsewhere, but traditional physicians are beginning to refer patients. While it is unclear why doctors refer people to CAMs we can hypothesize that physicians either view massage therapists a s a more professional or legitimate practice, or they do not want to treat anymore. In this sense, physicians are identifying massage therapists as a sort of dumping g round. For massage therapists who have had doctors a sign of disrespect toward both the practitioner and the client. Thomas: I think a lot of health care providers that I have dealt with in the past, who h ave referred to us, have kind of sent us their hopeless cases, the

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38 E ven if massage therapists cannot cure a person, there is still a perception that they can help someone live a better and healthier life. Massage therapists have to deal with their own professional limitations and the limitations of the client. They do not claim to cure or heal (in fact they often claim the opposite): lives and health. They cannot be held accountable for not fixing something that biomedicine could not help but when they do help an individual, they are immensely proud of their abilities. Goin g back to issues discussed in the section on integration of biomedicine and CAMs, depending on what condition a client has, massage therapists may have to receive permission from the doctor(s) to practice on the client. This process could be infantilizing to both the client and the practitioner as well as delegitimizing. If the practitioner expresses that caution on their own, it could be seen as a sign of how professional they nts is also a way for doctors to keep control and keep massage therapy from growing. Priscilla explicitly told me that most doctors will not give permission. She had one client who was given permission and she made it clear that his doctor had his best int erests at heart, silently implying that doctors who do not give permission may not hav e the best interests of the clients at heart. In the end, opposition to biomedicine is a it is also a way of professionally repr biomedicine are problematic, then massage therapists need to oppose those practices in order to keep their clients empowered and enabled. It would be misleading to say that all massage therapists oppose b iomedicine. Most of them believe that there is a time and place for it, just not to the degree that it is currently used. Massage therapy is not entirely alternative or biomedical M assage therapists borrow from both frameworks. As massage therapy adheres to professional ideals it becomes more legitimate I ts other professional beliefs about etc allow it to keep on being from the biomedical model. Massage therapy, as a field, holds beliefs and practices that are unlikely to lead them into a purely orthodox practice Thomas and others spoke of this.

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39 Thomas: I do think that massage can be a marriage of both. A happy of theories such as energy and fluid systems and stuff like that and still be western enough that massage is dynamically the opposite of western medicine; I think there is a time... Priscilla: I definitely wanted to be able to help people. But, when I had not gonna fool aro und with somebody giving me an alternative for a lump definitely a need for them for doctors and surgery and for serious drugs. ve, in the last 200 years turned away from things that have worked for thousands of years and gone for the quick fix of chemical drugs. Which is in some cases good and in others So what would you s ay the role of alternatives should be and the role of orthodox ? Well alternative, or I like the word complementary, as opposed to alternative because that means either or while complementary, I mean I used oils along with my, when I was having radiation fo r breast cancer so for things like aromatherapy and Reiki and all that in the main hospitals in the door. now, I mean, I get calls all the time wanting, in the cancer ward, wanting to set up maybe diffusers or doing a ___ study o r something. So yeah, term instead of alternative because we could work right beside doctors just But people just need to realize that but a lot of our people, people today, we

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40 last 200 years, if we get sick we call a doctor instead of looking at what it is and maybe we could just take a day of f of work and nip that cold in the bud instead of getting antibiotics that kill all of the bacteria anyway and people, I think people are swinging back around because people have gott are, people are looking at other things now Meghan: I noticed that in this [IRB] medicine and some people talk about complimentary medicine and I li ke practicing, which has grown out of pharmaceutical industries, really. You know someone has the bad luck of breaking a bone definitely would go to a hospital and get it taken care of. But as far as preventative medicine I actually much more traditional, much more founded in basics than t given credit for. So do you think then that there needs to be a return to more basic lifestyles? I think there needs to be a blending. A blending? America is not very good with preventative medicine. True. good with letting someone get sick or selling an idea of the disease and then getting them as a lifelong customer on some sort of a treatment. get you on some pharmaceutical and it comes with three side effects so more and three more These therapists are clear that they somehow weave together their own alternative training and background with that of more orthodox medicine in order to best help a patient.

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41 Chapter 5: Professional Business Practices Massage therapists use existing techniques of professionalism in their relationships with clients. They construct themselves as experts at relaxation or in pain management depending on their such as basic etiquette and marketing techniques specific to their modality to create the image of a professional, manage risk, and set boundaries. In order to negotiate and redefine their pl ace in the larger medical context, massage therapists mix new and distinctive ideas of what a professional massage therapist should be with traditional, mainstream medical notions of what a professional health care provider is. I focus on strategies they h including old fashioned professional etiquette, networking, marketing, and the actual business practices they develop I divide these techniques into: 1) general business practices and 2) pr actices associated with healthcare. Establishing Old fashioned Professional Etiquette and Wise Business Practices CAMs are using strategies and resources in ways similar to those previously taken by established professions ( Kelner et al. 2006: 2618 ). Ho wever, those strategies and resources need to be reworked in order to be effective in the present. Massage therapists have already accomplished, at least in Florida, some of the strategies that any field uses as it becomes a profession T hey have developed professional associations such as the American Massage Therapy Association, licensing procedures and standardized tests and curricula along with institutions such as massage schools that teach them how to be Many of th eir strategies though, are much more subtle and are found at a micro or personal level These are Professional etiquette and practices are

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42 myth bust ing tools for therapists. These may not seem like tactic s or strategies because practices such as being on time are not out o f the ordinary for anyone But in the context As Meghan massage therapists need to deal with the stereotypes that exist. To destabilize these images and myths, massage therapists borrow from what the American public already They strive to distinguish themselves from an informal labor market where haphazard service practices and unpredictability are the norm. Standard business practices such as tightening cancellation policies, becoming someone who is more confident in her/his abilities/expertise and charging the current market price for services seem to be hallmarks of personal progress in becoming truly professional massage therapists. M assage therapists claim what they are due and enf orc e professional standards. This comes with time, practice, experience, education and so on. As Rebecca describes: people I trade with too. There is a difference, too, in the way I de al with therapists feel bad charging people when you first start, you feel like, here [Now] a cancellation policy mos t spas do that, and a lot of people I know. But o operate it like a business. Which sometimes stinks. So there is also the realization that they are in a business and they need to make money to survive She is becoming more like the other professionals as she gains experience. It is an interesting balan ce because massage therapists want to help people, but as Priscilla says, she wants people she can help but who also can afford to pay her. She must learn to draw a line between those who will pay and those who will not. The others were not so explicit an d, in fact, Thomas specifically said that he was not in private practice for the money. However, he is a special case among my interviewees because massage is not his

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43 primary source of income (teaching massage is). As a result, he can afford literally an d figuratively, to regard his massage therapy practice as a personal calling rather than a way to make a living. Using professional tactics to fight myths of sex and gender My interviewees commented on how sexual myths impacted their massage practices. M assage therapists may encounter clients who attach sexual meanings to a massage T herapists use different professional strategies (e.g. marketing techniques and communication) to counter these beliefs Therapists belie ve that clients should understand and respect that their interactions are of a professional and non sexual nature and that they (the clients) should not cross professional boundary lines. In other words, clients are also expected to be professional act ing as they would when seeking any ot her form of professional care health care or otherwise When clients breach these boundaries massage therapists end up having to deal with any repercussions (e.g., fear, loss of income, communicating the unacceptability of the clients behavior) in order to protect themselves. Rebecca comments on this : [incidents where the client] Were you ac tually doing a massage on him? Yes. Yeah. Trying to into the bathroom to go wash my hands while he was getting off the m like, did I just walk out too early or was he doing that on purpose? That was a severe turmoil. So, I stressed out about it for a few days and then I network; you call your people and

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44 eventually just called his business phone, never tried anything again and I still do it [perform massage] every was just kind of pushing your boundaries? I think he was trying to push it, yeah to see like where that could go So that took a lot of, sharing with other therapists. They do talk about it a little bit when In this story Rebecca shows how she acted professionally to begin with but ultimately responded to inappropriate behavior by communicating with the client and setting more d threatened her livelihood in general and posed a potentially greater problem because his wife was also a client. Emma speaks more generally of her experiences and their effect: When I first became a massage therapist I was always have th people would still take concept of boun massage, so I had a few negative experiences with some male clients very early on in my career that made me almost want to quit, but I kept pursuing it because I feel like this is a big part of my li These examples portray men showing disrespect and disregard for the rules of appropriate massage practices in relation to women therapists, who seem to be keenly aware of similar issues. Rebecca consult ed with peers in the massage community to help identify appropriate actions that would help maintain a professional identity. C ommunit ies in general and massage communities in particular can provide support for members by offering advice from years of accumulated, collective experience.

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45 Minimizi ng risk to maximize safety Because of incidents such as th e se, women therapists are very concerned about safety and minimizing risk. They need to be professional and manage risk at the same time; the two are not always aligned In short, women therap ists feel that they need to be especially careful In a society where men are more likely than women to seek out sexual services from women, women therapists must be more on guard than their male counterparts. Women therapists are simply more vulnerable than men therapists typically are Women therapists often rely on intuition in determining whether there may be a problem with a man/male client. For example, when talking to someon e on the phone, the massage therapist may get a (negative) feeling that the person is looking for something other than what they offer. They then avoid booking appointments with such a person Women therapists may also realize that something is not right when they are physically with a clien t. They might, for example, get a neg This is a trickier situation because they must deal with the person face to face, in a professional manner even though they do not receive the same courtesy as story demonstrates The rapists are well awa re of the potential risks arising from these types of interactions Priscilla shares stories of how she avoid ed new clients: When I had my shop, I had other people do it [work on new clients]. Number one, because I only wanted to work on people that I kn ew. I did not want strangers off the street walking in wanting other than what I was willing to do. You know what I mean? The massage parlor kind of calls. did you have incidents where I personally never have [had a problematic incident] but one o to send them [clients] away once they realized they were getting a legitimate massage [laughs] we never had any real bad incidents. Usually we could weed them out over the phone. Did you get some kind of feeling o r something? t want that.

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46 T Oh. So they would go in, get undressed and then refuse to get under the sheet kind of thing? Yeah. naked on the table Her actions, unlike possibilities av ailable to other therapists, are mediated by the fact that therapist working for someone else. In the end, she changed to doing massage therapy in spa in order to avoid the risks: therapist. Three particular incidents, no, like at least a good handful of assage. You started you said that those incidents happened when you were a young massage therapist. Yes. How did you manage or do you think that you did something that maybe changed the way you were going about things so it only happened when you were younger vs. now? What I did was learned to 3 first ba d experiences that I had, it was, I had been working for an outcall 7 service What I learned from that was, like I said, I was any good, if people were expecting me something el se for me, than why am I here anyway? But I spent a lot money and I put a lot of heart into where I wanted to be in my career and for me to give it up because of 3 going to go b what I did. I held out until I got a hotel job So th at helped me hone my 7 An outcall is similar to a house call. A potential client calls in to a central number and then massage therapists are sent out to wherever the client i home, hotel room, or even a gym. When the interviewees say that they do not do outcalls in mainly means

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47 skills, it helped me become a more confident massage therapist, even awkward because peopl e still kind of insinuate things. But that was the bigg est thing. And now I think that that experience working in the spa and then deciding, to decide to be self employed now and doing mobile sed to be. people but But I have more experience, I hold my ground a little bit better [as happens in outcall services] the go between and I would never do that again. I would never again work for another outcall service. Both Emma and Priscilla show in their narratives how they relied on intuition to keep themselves safe or at least to avoid p otentially harmful situations They avoided working on certain people as a part of their strategies to stay safe and professional. Emma also notes that she was at a stage of developing her professional image and becoming confident in her work. The women I interviewed who have their o wn businesses expressed a need to work on clients known to them personally, were referred to them by acquaintances or were established clients. The referral process serves as a safety tactic. All of the women had their own experiences or knew someone who had had incidences with clients being sexually inappropriate. They managed the risks by rejecting risky behaviors. They required referrals from people who m they kn e w which also place d some accountability onto the clients or professional doing the referrin g.

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48 Some massage therapists, in another tactical move, advertise in perceived safe places where they knew people, such as bank s. Priscilla, for example, conducts chair massage s at a bank. The YMCA is another perceived safe space, as Rebecca said, because she works out there. The following is how Rebecca explains her policy: They [the potential c lients friends with or already know or one of my regular clients. Have you had a problem with that before that made you deci I did have one really weird incident. It wa s when I lived in an apartment know if he was asking for a massage or not, but he dialed my number and he gave me a call. He sounded kind of weird anyway. And then I did go over to do the massage and he was very inappropriate. He was asking me much on the table. So, I just ended the massage. A off the table, pack up and leave and then charge them. So kind of after that I was going to filter a bit more. My interviewees opt not to visit clients in places like hotel rooms, where m a ssages might be desired and/or provided They also refuse outcalls which are perceived of as having high potential for being dangerous, because as Emma says she cannot get a feel for the client if there is a mediator. As Meghan explains : had referrals on the telephone does out houses when I There are some places, like hotels, where certain therapists will put up their card and they will be the person that gets called when someone wants a massage. I actually think a hotel should mixed signals going on. And I did have someone phone up one night I felt so sorry for this man, but at the same time I did not

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49 he sounded disappointed, which made me think that he was actually probably All of the women in this study either had negative experiences with their own clients behaving inappropriately or felt that they had successfully avoided a negative (and potentially dangerous) situation using what I call risk management techniques. By constructing and employing safety measures, they potentially lose business On the flip side they manage to keep themselves safe even if they lose business In the end, most of them market their business by word of mouth through their current clients. So it is important for them to keep their current clients satisfied and to establish good working relationships with them in order to build up their businesses Professional networking is also key. They find safe places and work within those places to get clients. Some therapists use e mail as a way to maintain a client base. Still, w ord of mout h is most predominant strategy, even for Thomas who said: t of my communication with patients and marketing with what people have said about us or people referring people that are already p atients. According to Rebecca: because I do word of mouth, if you do good work and people like what do it. I know some people do advertise. I proba bly could do that route but lly got really people now How did you dev elop such an extensive number of clients? It took a long time. Because, like I said, word of mouth it does take awhile. It really is just getting in with the right people. Like I have this one client, she has just told her whole network of friends and the y all use me.

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50 Providing massage therapy that successfully helps a client and a professional identity enabled my interviewees to build a strong overall reputation so that current clients would refer others. For Rebecca, u sing technology furthered her self image as a professional New technology has helped her keep track of clients and dates. This enhances her professional image. Meghan mentioned using similar techniques while working with chiropractors: being on time, ke eping an accurate appointment schedule and client list, and basically not being flaky both shows professionalism and works against the myth of the ditzy massage therapist. These behaviors are quite common in that most people are taught them as fundamenta l ways of presenting oneself as honest, caring, interested, and in general, professional. They are general principles for success. They are, for example, principles seen in biomedicine. Performing competence and professionalism by borrowing from Biome dicine I n our society, people already have an image of what a health care practitioner health care practitioners in their minds, grants th em a professional status automatically. As a culture, we view health care practitioners as doctors, massage therapists must be professiona lly certified by the state and ea rn a certain number of continuing education credits each year. 8 In other words, massage therapists understand that their training practices are similar to other medical ge therapists to educate people. Borrowing biomedical practices According to Flesch (2007 : 170 optation of biomedical language and certain techniques by CAM practitioners in order to demonstrate legitimacy and dema curr ent trend. Massage therapists use specific practices and define their boundaries in accordance with standards of biomedical professionalism as a

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51 therapists solidify their identi ty as health care practitioners. Most of my interviewees used some kind of intake f orm and initial review process for example. Intake forms are not solely a part of biomedicine. However, in the context of opting cert ain aspects of biomedicine, these processes have meaning. The s e processes and forms give the impression of being professional not only because traditional medicine does the same, but because it suggests to a client that her/his health is seen not as a one time meeting but as a more interactive practice being tracked or monitored over the course of treatment. The form provides, as Priscilla says, the therapist/client to build a relationship that includes a whole medical history: I have an intake form that g ives me all of their medical history and any on time genitals [or] I n her pra ctice, the intake form provides a starting point that includes a statement of professional standards, including such items as cancellation policies. Emma provides another example: I do a brief intake with [the clients] to see what kind of inj uries, or if performing this massage, medications and so forth then when I go to their home. I set up my table, I perform the massage, they pay me and then enient for them to have a massage in their Emma sets it up as a cross between general professionalism and professionalism specific to healthcare. She needs to know the medical information and at the same her service is convenient and efficie nt which are hallmarks of professionalism.

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52 also demonstrates the role of technology in his practice: I want to know as much as possible before they come in and a lot of that I re emphasize when they come in because they do an intake form which is available through the website. I review the information and make sure that ication is for. Here Thomas assumes authority by using the intake forms and from his expressed expertise through his request of a full history. He wants to assure, for example, that a client provides consistent information so that he can better understand her /his needs. This, he believes, enables him to provide the best health care possible. It is tailored to the client. Reference to his website symbolizes his professionalism. Meghan provides a specific example of the importance to know all: When they [clients] come in I have them fill out a questionnaire. And they fill out a basic medical history. I talk to them. I want to find out if they We tend not to treat in the first trim ester of pregnancy Meghan moves beyond the professionalism of a form by incorporating more medical as a professional. Understanding the boundaries of their own competence At the same time massage therapists are pulling useful techniques from biomedicine, biomedicine is controlling massage therapists. Massage therapists have well delineated boundarie s to which they adhere. Sometimes there is resentment (from practitioners against the boundaries) but in many cases the boundaries suit the therapists This is demonstrated when Meghan notes the care that must be taken with pregnant women. I think it depe nds on how and why the boundaries are implemented. If the boundaries are perceived of as being imposed by biomedical practitioners then they may be resented. If the massage therapists use their own judgment to set the boundaries then they are acceptable an d applauded.

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53 CAM is becoming more popular but CAM practitioners still have to carefully negotiate what their authority is relative to practices According to my interviewees, these boundaries are very much internalized by massage therapists T here are dis tinct lines indicating what their knowledge and authority affords them, and where they must tread lightly or not at all. As Shuval (2006 : 1790 ) states (in the context of nurses practicing boundary of or establishes by default, what massage therapists are and are not allowed to do or say as professionals. In other words, if massage therapists want to be professional, they must do what biomedicine does. For example, part of the professional boundaries of being a therapist is to keep personal feelings about biome dicine to themselves and not to prescribe. On the other side, biomedicine constructs the profession of massage th erapy by saying, basically, we can perform this, and therefore you cannot. Priscilla pointed to how extreme it is, for example, that biomedical professionals can prescribe medication, yet massage therapists ng a session. Therapists work around this and similar boundaries by carefully choosing words and instructions. Kelner et al. (2004 : 922 physicians need to be the gatekeepers for other kinds of healt do not seem to oppose that view T hey do not see themselves as being actual medical authorities regardless of their own opinions, expertise, and c ertifications as health care professionals. Being professional includes drawing the line between what they are and are not allowed to do D iagnosing is a definite boundary line they claim to avoid crossing ave you ever recommended that a pati ent steer clear of western place where surgery is important an d you need to have it done. Same thing with medicine, I think that, as much as maybe in class, they may hear us, maybe a negative tinge to some of the stuff I say about medicine and pharmacology, I think there is a time and a place w hen, when medicine is

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54 d supporting a belief that we He also goes on to say that he himself fears doctors at times but he has pushed people to go if he felt it was necessary ; if they had problems that he could not help them with. Emma and Priscilla both spoke in a similar way as well: thing Priscill a: And then, things come up in massage sometimes like, well realize that they have an issue or something so I try to be a guide or a facilitator for that If I can, if I know maybe someone I can refer them to, if they need a counselor or maybe they need a psychic reading or Biomedicine controls m assage therapists when a client uses both biomedicine and massage therapy at the same time. M assage therapists have to tread carefully. While most approve of using biomedicine for some things, there is a feeling that biomedicine, specifically medication, is overprescribed and does not treat underlying causes of many problems. Coordinating care can be difficult if a doctor prescribes or orders something for a client that may limit or preclude therapy service. For examp le, Priscilla explained to me that she cannot practice on people taking painkillers because those clients cannot feel what she is doing and therefore cannot provide the necessary feedback that may prevent her from inadvertently hurt ing them Respecting th e boundaries of biomedicine can mean a loss of income in these instances, and maybe more importantly, the loss of a chance to mak e a person feel better Depending on what the client has, the massage therapist may need permission from the

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55 doctor to practice on him or her Both the client and the practitioner must respect and the practitioner condition, thi s can show how professional they are and how cautious and careful of their client s maintain control stagnating the growth of massage therapy Priscilla told me that most doctors will not give permission. She had one client who was given permission and she made it clear that his doctor had his best interests at hear t. At the same time though, massage therapists offered several stories demonstrating how boundaries can be good for their practices. Thomas shared a s tory about a man who ended up having prostate cancer. Massage therapy was unable to help (before it was diagnosed as cancer) and Thomas acknowledged that what he was doing was not working and referred the client to someone else the end result being a canc er diagnos is This story shows how sense of satisfaction and pride in his knowledge and professional actions to refer the client elsewhere. Rebecca described similar experiences: If someone comes in to you with a back problem like a herniated disk boundaries. Like if som eone should be getting a n MRI on [and] therapists I trade with does that [whatever modality she thinks the client needs but that she does not do] your clients to like other people you know who are really good. You hope

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56 y else too. They appreciate it. Do you think that kind of shows professionalism? Like Thomas, she saw the boundaries as a form of guidance and not as restrictions. It is a part of her professional identity to recognize her own limits and the limits of what massage can and cannot. Emma shared a similar story: I know that when I started practicing Thai massage on my client who I see S ometimes it happens when you give a massage, bones pop and crack and adjus tment. But in her case, it was enough where I was like I really think this is an issue; I really think a chiropractor would be good to consult. I all I said was, your neck is cr injury there; I think it would be in your best interests to get it checked out. it would be advisable for you to get it checked out. These stories and descriptions sh ow how conscious therapists are about constructing the limits of their authority. They may have enough authority to say that there was or may be a problem but not enough to diagnose it. Notice for example, how explicit Em ma was about how she was not diagnosing. In both of these instances the massage therapist did not tell the client what the problem was but suggested other people or experts who might be able help. Clearly a part of being a professional massage therapist is knowing your limits, diagnostic and otherwise As Thomas said One of the things about being a good massage therapist is knowing where just a waste of their time and money and t hey may need someone who is doctor or a therapist.

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57 It is also not a massage therapist s' fault when they are unable to help someone directly as opposed to indirectly by referring the m elsewhere. Priscilla says, it, which some people do, I can only She is a professional but as a professional she is limited to dealing with what the client offer s her to work with Engaging in self critique Some of my interviewees had a problem with t he brevity of their education which constitutes a boundary or limitation on their therapeutic practice. Massage therapists construct themselves as having some authority or specialized knowledge based on their specialized education. Based on that education, their work is a profession deserving of respect and status. However, they themselves criticize their ow n minimal education while rejecting similar criticism from others. They are claiming their weakness and reframing in a way that might benefit the growt h of the profession. Their self criticism allows them to possibly restructure their profession by improving the training process. When inadequate and unprofessional. Rebec ca speaks to possible changes: I honestly think it should be a four be a lot more knowledgeable people out there. S tart off with, like anyone, the two year degree and then the next two years, like I did with Exercise could have full courses on just each modality. So because you go to a continue and learn it. Thomas, in agreement, said

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58 I think that that is a point of frustration for me as a [therapist] as an re teaching is limited information in that in a perfect world, massage would be a 6 year curriculum. You know, marketing and psychology and kinesiology and all this other stuff tha As long as their education can be criticized, the status of their profession cannot be as high as they feel it should or could be in the larger system(s) of medicine. Developing a professional image within the traditional medical system could enable CAMs position themselves in the biomedical model. In trying to professionalize being seen to be professional as opposed to simply being professional (Oerton, 2004b : 545, original emphasis). The difference between those two is perception. Massage therapists can be pro fession al all they want but that does nothing for them if they are not seen as being professional. In our society, biomedical practitioners are professionals and massage therapists are a group trying to enter into that space of legitimacy. They cannot simp ly claim to be professionals; they have to employ the strategies that will boost their own professionalism such as adopting standard business practices, borrowing from biomedical practices, and so on, in order to be seen as professionals. Clarke et al (20 04 : 332) believe that the strategies that are employed it as their task to make others view them as professionals and to change the cultural (and historical) perceptions of what massage therapy is. What makes this complex is that at the same time they want to professionalize to be included under the health care label, they beliefs. This necessit ates crafting a hybrid professional identity linking the orthodox with the alternative.

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59 Chapter 6: Crafting a professional identity of massage therapists In this chapter employed by massage therapist s Massage therapists : 183 ) where they need to be professionals in order to succeed T oo much emphasis on the Emerson, 1970: 80). Oe rton (2004b : 559 identification with both orthodox traditional ways) to the point where they lose their alternative views and practices. They have to constantly negotiate their positions in order to not lean too far in either direction. Massage therapists use specific forms of professionalism that may not be found i n other professions. They have specific types of expertise and beliefs that they associate with being professional massage therapists. These techniques and beliefs show clients how effective and different (in practice and in belief) massage therapy is comp ared to other health oriented professions. These techniques are effective because they function to give both clients and practitioners attention and care that they are not given by the biomedical system. It is clear that while the massage therapists I i nterviewed do borrow some aspects from biomedicine, they also adhere to alternative health practices : 26 ). Here I discuss the forms of expertise they use, specifically energy work, in tuition, and seeing people as complex and whole selves. I also look at the ir use of emo tion work, healing, and touch to facilitate their work. They also attempt to have very interpersonal and egalitarian relationships with their clients, even while maintai therapy.

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60 Forms of expertise not commonly found in biomedicine Working with energy Johnston and Barcan (2006) refer to energy as part of a subtle body model. In the subtle body model, subjectivity is understo od to be comprised of matter consciousness, usually termed energy, which is understood to be a constitutive element of mind and the physical body, as well as to exceed and Barcan, 2006 : 29 ). The concept of whole self will be discussed in the next section but for now, energy work is seen as depending on a whole and coherent body. The massage therapist s need to be present within themselves in order to do adequate work but it is just as important for the client to do the same (2004: 312). Energy and working with energy is a prevalent theme that came up regularly in conversations with massage therapists They all believed in the concept, though to differing degrees For example, Meghan identifies it as light and protection: I try to ask for the energy to protect the person, protect me and do only thing s for the good like a little invocation. Maybe some people might be afraid to call it a prayer or we call it a chant or whatever, but I like open up the channels and hope that So do you practice well like energy work of some sort or? I believe in l evels. Emma explicitly mentions that she practices Reiki 9 which is a form of energy Western concept. According to Emma: 9 Reiki c Reiki treats the whole person including bo dy, emotions, http://www.reiki.org/FAQ/WhatIsReiki.html accessed March 23, 2009 ).

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6 1 I love what I do and I also practice Reiki which is energy work and not a lot of people be lieve in everybody having an energy field. Everything is energy the air we breathe and touching a table, wood is energy and metal is energy and you get different feelings from each one of them. T all people, all objects, we all have different elements and what it is and something just kind of happens and they feel great relief and that has Emma also claim s person. She is just more aware of the energy and has a greater knowledge of the technique than others. Energy is pres ent everywhere, in everyone, in everything, and in e verything we do. Everyone agrees it is there, it is similar in form but a concrete definition is elusive because everyone looks at it differently E nergy is transferred or wielded through touch, making to uch a very powerful tool for the massage therapist. But it is a tool that requires certain conditions to be w i elded efficiently and effectively. This is why knowing themselves and scheduling around their own needs is critical. Making sure that they have t he energy to do good work for their clients contributes to their identity as a professional. Rebecca explained her take on energy: think there are some people who are gifted in that and they pick up on that. n energy work at all. The more you do [massage] the more you your body is made up of energy

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62 [while getting a massage] and she came to work on e. Like she should have just said I he actually does energy work Li ke she wa s just lethargic and like blah ce about, I need more pressure sensitive to people on the table, what i t is they actually want. Because of come to accept it a This notion of energy h elps give meaning to massage therapists and facilitators of health. Rebecca had also been on the receiving end when another massage therapist had not had adequate energy leading to her being very aware of the role of energy. Using intuition Massage ther apists use intuition to guide energy foster ing health by using their related cognitive, affective and somatic processes, in which there is no apparent intrusion of deliberate, ra (H odgkinson et al 2008:4 ). Elements of intuition include being instantaneous, non verbal and non conscious, and insightful (Hodgkinson et al 2008). In short, intuition is based on feeling and reaction. For massage therapists, as with other alternative prac titioners, Floyd and Davis, 2008 : 239 ). It is a form of knowledge or way of knowing that is not given credence by biomedicine because it cannot meet biomedical or scient ific standards.

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63 Gaskin (1996 : 296 ), who is a midwife writes that to pick up signals too subtle to be perceived by the conscious mind, and that the mind can apprehend the gestalt, which may then surface in the form of an int uition, a hunch, or a dream Intuition comes when our subconscious minds pick up and use information that our conscious minds cannot see. Intuition relates to energy but is more physical. Intuition is the when, where, how, how much, and how long to touch. Unlike e nergy that is always present intuition is developed with practice and experience and may be used to channel energy. Rebecca explains how intuition plays out in her work: It [intuition] does play a lot. I mean you could be working on someone and before. You could just be different. And an intuition goes along with knowing kind of what the kay [question asking about a link between energy and intuition] Having a goo d flow to the whole routine I think keeps the the next. That kind of breaks it up. Yeah. And intuition would be knowing rting re going to make for [thing] In her story, Rebecca demon strates how her experiences have en client, and as a result helped her develop intuition. She also shows how she has learned to incorporate energy into her work. Practice is probably equally as important as formal education in massag e therapy because that is where experience comes in and where intuition is able to develop as Thomas claims:

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64 And part of it is that comes with experience, that comes with practice, that comes with seeing hundreds of patients, reaching that level of sensit ivity you do develop over time. And practice of medicine So I do b apply that experience, into everyday situations based on what yo experienced in the past. So would you say that a good massage therapist needs both practice and experience and also to have a well developed intuition? where you have to take the logic of what you understand and, and use to place that at the forefront of your practice is, and sometimes your you when you, you walk down that path again so to speak. But, yeah I do think re using cause and effect paradigms Intuition goes hand in hand with knowledge. Intuition is developed from knowledge joined with practice/experience. As Meghan says: other is intent. And intent is built on intuition because you get feedback from someone. Massage therapy is not just a practice; it is an instinct Massage therapists have paid and been educated in how to channel that instinct in specific ways in order to help people. The intuitive ability of an expert is derived in large part from the large numbers of patterns held in long is also derived from their capacity to recognize salient environmental cues

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65 and rapidly match those cues to comm (Hodgkinso n et al, 2008 : 7 ) This reflects what the massage therapists said: intuition is something that develops as they work on more and more clients. Eventually a massage therapist may not even need to think about performing ce rtain touches; they may do them and attribute it to intuition. T hey may even conceive of it as a natural ability as Emma does: When I was at massage school, I noticed that there are some people that they have to learn to be massage therapists, they have t o learn technique and just kind of get it from scratch. Then there are other people who just kind of know what they are doing already they have that intuitive sense Massage therapists also receiv e cues because they are tuned in to the client and the Floyd and Davis, 2008 : 254 ). It is listening to what the ir own person has too much self doubt to trust and use their instincts. This is a process where the practitioners learn to integrate what they know, what they see, and what they experience to the point w here they do not even have to think about it because they simply react (Davis Floyd and Davis, 2008). Intuition could be considered a part of the whole self mentality in the sense that it requires knowing and listening to yourself and what your instincts s ay Viewing whole selves The whole self mentality is one of the ways CAM practitioners distinguish incorporation of factors other than physical symptoms in the diagnosis an d treatment of illness is what distinguishes alternative healing therapies from orthodox modern Western : 32 ). Klimenko et al. ( 2006 : 259 ) explain that mental, physical, social, and spiritual components of health are not seen as distinct from Broom and Tovey ( 2007 : 1032 ) claim that

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66 [s]cientific evidence and biomedical treatment processes were seen to limit human agency, produce anx iety, and in extreme cases even induce unethical and ultimately counter productive practice. native therapies often work indirectly, they seek to defeat 1986 : 268 ). Holistic medicine, including massage therapy, adheres to the idea that medicine needs to encompass t he entirety of people, spiritually, mentally, and physically. and Barcan, 2006 : 30 ). the artificial spli ( 2004 : 313 ). There is a perception that p eople are turning away from conventional medicine in part out of a desire to be treated as whole human beings a concept that is at the very h eart of message therapy The general belief is that it is impossible not to treat the whole mentally, physically, emotionally, spiritually will bring about changes to all other aspects of the : 30 ). So by working on people through touch, massage therapists are viewing and treating clients as whole beings They are, essentially working on whole people. Meghan, Emma and Thomas provide insight: Meghan: The be flexible not just in your body but in your mind and in your emotions and in everything then you can take what lif e throws at you and kind of dodge it and you can do all of that, and you can live a really good healthy life .Emma: I still know the body is integrated within itself and I try to take care of everything else as well, to provide the best treatment possibl taking care of the body and the emotional and the spiritual self.

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67 Thomas: Everything does interact with everything else and the psychology and the emotional and the physical an d the spiritual are all interconnected T important so I think Th ese massage therapists clearly explain the importance and efficacy of looking at a person as a whole, incorporating many aspects from the physical to the spiritual. There is interconnectedness between our bodies identities, personalities, experiences, and our spiritual and emotional realities. In fact, our emotional states often manifest themselves physically, forcing us to deal with things from our pa st that we might have tried to leave buried Forms of emotion work/healing/caring not commonly found in Biomedicine As can be surmised based on their belief in treating the whole person, massage ther apists work on the physical body while also focusing on the emotional responses or (as well as their own) According to brings out emotional responses that may have nothing to do with a massage therapist or her/his touch. This relates to the role of massage therap ists as facilitators and experts but use a clich. When emotions are silenced they end up poisoning the body, allowing it to weaken and fall ill. An extreme example can be seen in Priscilla breast cancer. Priscilla: It [emotional releases] happens a lot in the SET work. I have one myself just about every time somebod

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68 fell, [muscle] gets just energy, emotion is energy in motion. S here Getting it out is the important thin By facilitating emotional releases through their work on the physical body, massage therapists facilitate the movement of energy. Trieschmann (2001: 31) does not name this emotional release but she does the layers of ou happened to cause her cancer Massage therapists have to deal with their own perceived emotions issues and inadequacies as they work with clients. Johnston and Barcan mention a major concept associated with this : 37 ). Massage therapy does affect practitioners because they are personally invested ; they have exchanged or dealt in energy with that client; they have a relationship. Massage therapists to help the body mind 2006 : 38 ) or simply as facilitators of the b T he attitude that i s needed to do the massage well is energetic, focused, and probably above all else, positive. This is part of the emotion work as well ; the rapists need to work on their own emotions as well as deal with their clients emotions. For example, : In a way, the clients ar e providing a service for the massage therapists. If most massage therapists find it personally rewarding to help people, then the clients are actually providing a service of their own.

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69 line seems to relate to a perceived difference between medical versus wellness massage even among therapists However, because my sample is so small, I do not have enough data to comment definitively. For therapists who did not id entify with the term the term reflects the non professional nature of that label in our society. It also reflects the massage therapist s' percei them in the posi tion of healing somebody But t hey want people to work on themselves with their (the massage therapists ) help. The following are two quotes that reflect both arguments. the years back when I was younger and wanted to be that [healer] when I first got into massage and I wanted to be the healer kind of person. But I had bad habits, I a lways beat myself up for it because how could you be that and the whole thing about being a healer is that the healer has to st beat myself up [she has a tattoo that has meaning to her as a healer] but not right away, have I finally acc epted that. And, and let it be ok that I smoke cigarettes or learn to accept that and, and be that heale r so that I can help other people. [why] anyone who goes into healing professions. We want to

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70 Thomas: I use the term heal that term to be honest with you. I have heard myself be referred to as a What does the term mean to you? To [me] healer goes back to are goin prefer facilitator. Using touch Emerson ( 1970: 76) makes the argument that certain touching can be problematic a nd therefore inappropriate. Since the mythology about massage often focuses on sex, there is often a presumption that touch is about sex. Massage therapists disagree with and fight against that perception. Massage therapists believe in touch as a tool for promoting health. Four out of five of my interviewees worked or were educated in other fields before going into massage therapy Most of them moved into massage therapy because they believed their work was not hands on enough in a holistic and helpful way to suite them Thomas and Meghan express this well: Thomas: Actually, it was my 3 rd career choice. Prior to doing massage, I did physical therapy for 3 years and I tried different settings for physical on like physical hands on with the patient, with the rehab people and I wanted something that was a little more interactive, physically interactive. And one thing led to another, I met people who were in the massage field and I was real inspired by the peop le that I met and I went to school. I went to school for pass through. I how their shoulder feels and I can move that so o n and so on, s kind of hands on

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71 if they use it every day and they do their homework and they do the stuff me joy in knowing that someone else is going through their day a little happier. This was the first career choice for only 1 out of the 5 massage therapist s with whom I spoke. Massage is all about safe touch. One of the reasons therapists love what they do is that they can literally touch people in a health producing way, enabling people to assist in the process of improving their own well embraced within the larger biomedical society. A good massage therapist develops a strong relationship with a client, joining together to build hope and health, although those terms are somewhat ab stract. Thomas addresses this when he spoke about helping bring people back to their bodies so that they can work on other areas of their wholeness and hope and health that benefits them. Thomas speaks very clearly to the specifics behind the work of massage therapists; how they combine the different facets of massage in a way that empowers a client to seek better health. He identifies explicit types of practice: emot ion and energy work, the power of touch and the use of intuition. Thomas shows in this quote: Sometimes what we do as massage therapists is we channel that scattered important in order for them to deal with these perceived stresses. In order doing is bringing body awareness, bringing people back into their spiritual ly or emotionally. I think that the very act of massage, me putting my hands on someone, the laying on of hands as the Bible says, not to get

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72 religious, but towards you, it automatically shifts the attention into that person where of hands on someone, they are the focus for whatever amount of time that Now I also do polari even though you still learn a certain protocol and hand positions and things of that nature, you are still using your intuition or your ability to ly those types of aids. And timing is different also, with those hand positions I may, my intuition may say to stay in a certain hand position for 15 minutes just because I feel like this is layered beings, multi dimensional even. I think that sometimes just laying y our hands on someone can be very comforting, that has happened in some way with some clients where I have a patient accident, with whiplash, with a script, prescription from a doctor. And with car accidents and I switch my technique to something more subtle, these subtle energies, emotions come up. What we call emotional releases relaxation sometimes almost like a hypnosi s type relaxation. And you hit certain parts, with this lady it was chest, I had my hands across her

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73 respiratory diaphragm and she started having an emotional release and at that point the typical protocol is you should ask to continue, if they want to con her some tissue and continued the hand position until she was done with it and then I continued using my intuition to follow different hand positions and, after the session was over, I as ked her if she wanted to talk about it. was subtle modalities, that t abuse to sexual abuse, things that they had forgotten, the why they were having emotional releases and sometimes, in a couple of cases, they started having dreams which is how I believe the body gets rid of emotional releases, is through dreams or nightmares, running, things of that nature that you j the body typically deals with it. Approaching Clients as Equals I have demonstrated some of the differences between massage therapy and the biomedical model Massage therapists focus on the whole bein g; some biomedical people, while the biomedical model, in general, seeks to fix o r cure a particular ailment. Massage therapists construct and present themselves as equal to those whom they are helping to facilitate health.

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74 One way they present themselves to clients is as people who continue the process of becoming whole and health y in the same way their clients do. This presentation of self (Goffman, 1959) earns them credibility and respect; clients view them as experientially familiar, as a receiver, with the process. It grants them a sense of legitimacy As Trieschmann, a psych proposes to serve as a coach during this process has already embarked on such a : 28 ). Thomas offers his thoughts: sage therapist has to do with dealing with your personal demons first, and dealing with your own health issues first, health, you have to be, you have to come from a place of healt taking yoga to help center. job to, is to understand that they are a work in progress as far as health althy. Self improvement is a humanizing aspect of their work. It puts massage therapist s on equal ground with their clients ensuring that one is not above the other because both are doing similar work. C lient s ha ve to accept responsibility for their pro gress toward health As Thompson ( 2003 : 84 ) puts it, A practitioner ha s certain expectation s of their clients. They need to be acti vely working with the practitioners, providing feedback and even doing other things (or even not doing certain things) to improve their own health. This pro active stance suggests a clear shift from viewing the health seeker from a patient to a client. Ma ssage therapy ends up being a tool for people to use in self care. Therapists are the authority on massage but they are trying to maintain that authority even as they show people that they can be their own authority over their own bodies. Thomas delineates

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75 role is to help and facilitate using their expertise, and the client is to take the new knowledge that has been given to them and to use it to make themselves better which is a form of empowerment. This is a contradictory place: the massage therapist does not have authority but they are an authority in setting expectations for clients

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76 Chapter 7: Conclusion: Professional Identity of Massage Therapists Kelner et al. (2003: 917) explains that "[p]rofes sions grow when there are niches in the system into which they can grow. They change when other professions challenge them by threatening their control over particular kinds of work." Massage therapy has found a niche or a gap, stemming from the perceived problems of the biomedical system. To make a home for itself in this niche, it has to balance between what Emerson (1970) describes as "a dissonance of themes and counterthemes," the themes being the dominant discourse associated with biomedicine and the c ounterthemes being the 'alternative' professional identity massage therapists associate themselves with. In order to compete and grow as a "profession," massage therapists have professionalized and asserted a new form of competence that distinguishes their discourse from the dominant discourse. The profession of massage therapy has developed around therapists' beliefs of what health care should be, their vision of professionalism. To my interviewees, it would be unprofessional and hurtful to their clients if they did not embody "alternative" principles and modes of knowing and being. This is consistent with previous literature on the clients (rather than on the practitioners) of alternative medicine Richardson (2004: 1051) found that "themes regarding patients' expectations.desire for a therapeutic/ holistic approach from treatment, wish to improve quality of life, provision of information by caregivers, reduction of the risk of allopathic [biomedical] treatments, need for self help advice, a nd accessibility of such treatments." Murray and Shepherd (1993: 987) also found that "unorthodox practitioners were most appreciated for their 'holistic' view of the patient's constellation of symptoms, personality and lifestyle." That reflects massage t herapists' concern with treatment of the whole self rather than parts. People are aware of the problems with biomedicine. They are reacting to their lack of personhood or even their lack of authority in this discourse when they use "alternative" practices Clearly massage therapists are meeting a need. However, this existing need has not handed massage therapists a ready made market for their expertise. As Foley found with midwives, massage therapists too "must

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77 work at sorting out who and wha t they are because of their marginal status" (2005: 183). Massage therapists "must legitimize their own expertise and authenticity, must be simultaneously professional and alternative. [and] must navigate varied received categories of identity as they enga ge" in their identity work (Foley, 2005: 201). It is through this process that contradictions (such as the one between "alternative" and biomedical models ) are balanced. This thesis has explored the practical and interpretive work massage therapists do in their individual practices to build a business. "Whereas professionalization has traditionally been framed as a process of modeling after medical benchmarks in order to attain legitimacy and recognition, the literature on professionalization m ay need to be expanded to show how a new mobility project is being pursued in the 21st century to gain acceptance." (Villanueva Russell, 2005: 557). My research shows the need to expand definitions of "professionalization" and "professional" beyond the tra ditional ones. Some groups, in this case massage therapists, do not adhere to traditional norms or definitions. New and aspiring "professionals" select some existing (traditional) business practices and useful techniques and combine them with practices use d by biomedical professionals. For massage therapists, those include cancellation policies, intake forms, marketing practices, and basic etiquette. In addition, massage therapists also invoke a "natural" history, holistic logic, and unique forms of expert ise which provide a framework for their "alternative" professionalism. Massage therapists live in a world that "contains multiple and often competing narratives of which few have anything near unanimous and historically consistent moral evaluations" where they must negotiate between professional notions of biomedicine, the needs and desires of their clients, and the philosophies they profess which come from "alternative" medicine (Loseke, 2007: 674). The massage therapists I interviewed combine competing na rratives using traditional and "alternative" ideas of what is professional.

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