Dr. Ida Rolf (the originator of Rolfing structural integration) organized her sessions into three phases: preparation, differentiation, and integration. In this excerpt from Advanced Myofascial Techniques, Til Luchau, a Certified Advanced Rolfer, examines how “preparation” might be applied to other kinds of hands-on work as well.

What is Preparation?

Preparation is defined as “the action or process of making ready.”1 Although preparation for hands-on work needs to include the physical aspects of “making ready” (such as relaxing excessive muscle tone, “warming up,” or mobilizing superficial layers before working deeper structures, etc.), these physical considerations are only part of the picture.
“Making ready” as a preparation begs the question: Ready for what? As practitioners, we need to know our context and aim to know how to prepare. In fact, one of the most important (and most overlooked) parts of the preparation phase is gaining clarity about the purpose and goals of the work itself—the client’s reasons for seeking work, and their hoped-for results; one’s own goals, priorities, and aims as a practitioner; and, most importantly, how these two areas (the client’s and the practitioner’s priorities) intersect (or diverge).

Ask, Listen, and Clarify

Many manual therapists are most comfortable working nonverbally at what Dr. Rolf called “the silent level of the flesh”2 (Image 1), and are often keen to get to work with their hands. Taking time to ask, listen, and clarify what the client wants from the work, and then exploring and discussing how this matches what you think you can deliver, is indispensable verbal preparation for your hands-on work together (Image 2). These considerations are small examples of a “biopsychosocial” approach, which describes a whole-person, body-mind, context-dependent perspective on pain and symptoms.3

From Biopsychosocial to Socio-Psycho-Bio

Many conditions that were previously thought of as primarily physical complaints (such as temporomandibular joint dysfunction or TMJD) are now more accurately seen as being biopsychosocial phenomena, where the physical symptoms are only the most obvious aspects of a more complex, interdependent interplay of structure and function, and also of emotions, perceptions, beliefs, lifestyle, habits, social factors, and more.4
In the preparation phase of our Advanced Myofascial Techniques approach, we reverse the ordering of “biopsychosocial” so that it becomes “socio-psycho-bio.” Before we can be maximally effectual in our biological or physical goals, the social aspects of the working relationship need to be established. This “social” level incudes all the interpersonal interactions that enable the physical work to be effective: building rapport and trust, and establishing the tone, boundaries, and style of the therapeutic coalition. Therapeutic effectiveness—in both physical medicine and in other fields—has been shown to correlate with the strength of the practitioner-patient alliance.5 Patient compliance, or the client’s willingness to adhere to the practitioner’s suggestions between sessions, is strongly influenced by this social rapport as well.
These interpersonal, social-level aspects dovetail with the inner, intrapersonal, psychological considerations of our “socio-psycho-bio” progression. These intrapersonal aspects include the client’s mood, receptivity, optimism, or pessimism; their largely unconscious assessment of the situation’s safety or risk; and their conceptualizations, stories, expectations, and ideas about their presenting issues.

Fostering Emotional Ambience

Chronic symptoms—especially those that haven’t responded well to other interventions—can be laden with difficult feelings (depression, hopelessness, etc.), self-perpetuating fears and limitations (such as the fear of movement), or fixed attitudes and belief structures. Our scope of practice as manual therapists doesn’t typically include direct psychological work per se, which requires a different kind of training, sensitivity, and therapeutic paradigm. But we can have enormous influence on our client’s perspective and mind-set about their symptoms through our own approach and attitude.
In this realm, preparation can mean fostering an emotional ambience that makes the desired change more likely, largely by cultivating those attitudes in ourselves and in our client interactions. Some of these states include curiosity, respect, warmth, patience, gentleness, and humor.

Hands-On Work

The psychological aspect of preparation could be defined within hands-on work as fostering the internal conditions necessary for change to occur. This would, of course, include readying oneself as a practitioner by becoming mentally, physically, and emotionally present, available, and primed for the work.
Once we are ready for the hands-on portion of the work, preparation takes on a more biological or physical meaning. Often, using the metaphor of body-as-onion, we start working with superficial layers of the body in preparation for deeper work, such as in the Superficial Cervical Fascia (or “Mother Cat”) technique.6
Another preparatory strategy we use is influenced by the work of Jan Sultan, one of the teachers Ida Rolf originally chose to teach her work. This preparatory strategy is to address the periphery of the body (the appendicular extremities and girdles) before working with axial issues.

Primed for the Work

Although preparation for hands-on work needs to include the physical aspects of “making ready,” these physical considerations are only part of the picture. As discussed, our aims at the preparation stage for the Advanced Myofascial Techniques approach also include becoming mentally, physically, and emotionally present, available, and primed for the work.
To accomplish these goals, practitioners should:
• Initiate a therapeutic alliance through listening, giving information, and building rapport.
• Assess and understand the issues at hand.7
• Increase tissue viscoelasticity, hydration, and temperature to literally or metaphorically “warm up” the tissues, such as in the Superficial Cervical Fascia (or “Mother Cat”) technique.8
• Reduce motor tonus through autonomic calming (for example, the Vestibular Orienting technique),9 heightened proprioception (such as in the Vertebral Mobility technique),10 or postural reflex stimulation via Golgi tendon organ responses, as in the Posterior Digastrics technique.11
Taking the time to prepare thoroughly, in all senses of the word, will help make your work more efficient, effective, and satisfying—to both you and your client.

Autonomic Nervous System Arousal

A related aspect of preparation has to do with the client’s state of autonomic nervous system (ANS) arousal (above). Sympathetic “fight-or-flight” states, like those accompanying anxiety, fear, unresolved trauma, or pain, can be aggravated by hands-on work that is too direct, too fast, or too deep. “Preparation” may involve calming and modulating these responses before proceeding with any direct or pressure-based work. When there is a high level of sympathetic (fight-or-flight) activation, addressing this state itself often takes precedence over structural goals.
Whether this ANS arousal is related to unresolved traumatic responses, chronic pain, anxiety, or the stresses of daily life, an on-alert, hyperaroused, and hypersensitive state precludes learning and change, and, as stated above, can be aggravated by aggressive hands-on work. Fortunately, there are very effective hands-on and proprioceptive approaches to ANS arousal.1
Note
1. To see examples of these approaches, refer to the Massage & Bodywork articles “Working with The Vestibular System” (March/April 2014, page 114) and “Working with Whiplash” (March/April 2010, page 108).

9 Ways to Prepare

Prepare Your Workspace
1. Make sure it is neat, warm, and welcoming.

Prepare Yourself
2. Begin your work rested, fed, and focused.
3. Leave time to preview your notes, plans, techniques, anatomy, etc.
4. Prepare your own mind-set, using practices that foster receptivity, presence, and adaptability.

Prepare Your Client
5. Set the tone with your first interactions (scheduling, phone discussions, website, etc.).
6. Communicate a sense of professionalism and safety.
7. Invite and model a mood of receptivity, clarity, and openness. Listen.
8. Find out what your client wants, what motivates them, and how they experience any problems they want to address.    
9. Prepare your client when your session or series is drawing to a close. (“We have a few minutes left. Is there anything in particular that would help you feel complete for now?”)

Notes

1. Merriam-Webster, “Preparation,” accessed December 2015, www.merriam-webster.com/dictionary/preparation.
2. Don Hanlon Johnson, “Presence,” in Healers on Healing, eds. Richard Carlson and Benjamin Shield (New York: Putnam, 1989), 133.
3. Francesc Borrell-Carrió et al., “The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry,” Annals of Family Medicine 2, no. 6 (2004): 576–82, doi:10.1370/afm.245.
4. Steven J. Scrivani et al., “Temporomandibular Disorders,” The New England Journal of Medicine 359, no. 25 (2008): 2,693–705, doi:10.1056/NEJMra0802472; for more information, see “Working with the TMJ” in Massage & Bodywork (July/August 2009).
5. Rafael Zambelli Pinto et al., “Patient-Centred Communication is Associated with Positive Therapeutic Alliance: A Systematic Review,” Journal of Physiotherapy 58, no. 2 (2012): 77–87, doi:10.1016/S1836-9553(12)70087-5.
6. For more information on this technique, see “Working with the Scalenes” in Massage & Bodywork (January/February 2011, page 108).
7. For more information, see “Working with the Cervical Core” in Massage & Bodywork (March/April 2009, page 123) or “Lateral Pterygoid Assessment” in Advanced Myofascial Techniques (vol. 2, page 158).
8. For more information, see “Working with the Scalenes” in Massage & Bodywork (January/February 2011, page 108).
9. For more information, see “Working with the Vestibular System” in Massage & Bodywork (March/April 2014, page 114).
10. For more information, see “Vertebral Mobility” in Massage & Bodywork September/October 2016, page 106).
11. For more information, see “The TMJ Part II” in Massage & Bodywork (September/October 2009, page 128).