The Bodyworker's Toolbox
An Evolutionary Process for Adding Modalities

By Shirley Vanderbilt

Just as a house is built from the ground up, on a firm foundation, so must your practice be based on a solid platform of knowledge and experience in the basics of massage and bodywork. But when it comes to adding windows of opportunity, it’s important to consider expanding your range. Creating a toolbox of modalities is an evolutionary process requiring thoughtful assessment of how best to meet the needs of your clients. It is also a means for staying competitive in an expanding market of integrative health.

What’s in your toolbox of modalities? How big does it need to be? I asked a variety of massage and bodywork practitioners and educators across the country. Their responses, although reflecting the diverse nature of the industry, point to a common denominator: What you carry in your toolbox depends on the type of practice you want. And to build a practice, you definitely need to keep adding to your toolbox.

James Waslaski of The Center for Pain Management in North Richland Hills, Texas, spends much of his time bringing together massage and medical practitioners at worldwide seminars and retreats. His pain-free healing approach encompasses techniques from a variety of modalities. Waslaski sees as the missing link in our industry the ability to collaborate and learn from other medical practitioners such as orthopedists, surgeons, chiropractors, physical and occupational therapists, nutritionists and psychologists. “I try to encourage therapists to become more eclectic learners and more open-minded,” he says.

Waslaski’s goal is to gather leaders from every modality and see how each uses their techniques. “I want therapists to have a multi-disciplinary perspective on treating conditions, even bringing in Eastern energy healing. I don’t think any one modality is the answer to multiple patients’ needs.”

According to Whitney Lowe, founder of the Orthopedic Massage Education and Research Institute in Bend, Ore., relaxation massage can probably be accomplished with a few techniques or modalities. But for health-oriented work, having a larger toolbox is really helpful. “It depends on the environment and setting in which you are working,” Lowe says. “It’s far more important when you are dealing with pain and injury clients.”

Keith Eric Grant, head of sports and deep tissue massage at McKinnon Institute in Oakland, Calif., says, “It’s often a good idea to branch yourself out. The more techniques you can bring to bear, the more different ways you can discover to work on resistant problems. For example, using positional release for taking tension off the muscle and seeing if that relaxes, then going on to a muscle energy technique. In that sense, there’s a progression of sorts of different modalities. You can also throw in trigger point or neuromuscular.” Whether it’s knowing how to provide supportive touch and being present with an abuse or trauma victim, or combining a variety of techniques in treating a physical injury, he points out it’s the ability to move between. “As you work with a technique,” Grant says, “learn how to make it flow and how to make the transition from one part to another; change the tempo. It’s not just a technique. Everything has a rhythm, everything has a dance.”

Using more than one modality expands the total number of clients you can provide meaning to, Grant says. “You may find in different subpractices, you are using some of the same techniques.” Subpractices were addressed by Grant in a recent article published in Massage Today (Jan. 31, 2003). Although his article is focused on guidelines for licensing, the delineation of subpractices is very applicable to our discussion of expanding modalities. “Across the total scope of practices,” Grant writes, “there are different needs for details of anatomy and clinical technique; skills of basic touch and human presence; formality of personal appearance; business skills; and interpersonal skills of communication, psychology and sociology. In many of the areas, communication skills and understanding of the applicable psychology may be as or more important to outcomes than particulars of massage technique.”1

First Build the Foundation
At what point will you be ready to take on more modalities? Our therapists agree the first step is “cementing” that foundation. David Weinstock, co-developer of neuromuscular reprogramming at Alive & Well! Institute of Conscious Bodywork in San Anselmo, Calif., says, “What I find is that many of our beginning students take too many kinds of courses at the same time. The Chinese have a saying: Too many knives without enough sharp edges. Take a couple of things and get good at them before you add more to your toolbox. My students say they know a lot of things, but in fact when they go to use them, they just don’t have the necessary practice time. Bodywork is not an intellectual exercise, it’s a practice exercise.”

Jeff Burch, a certified advanced Rolfer in Eugene, Ore., cites Ida Rolf who said one should practice for 5 years before expanding into other areas. He admits he actually waited 20 years. “I would say this applies not only to bodywork but virtually any discipline. It’s a good idea to get a thorough grounding in one idea before moving to another.”

Waslaski says what’s missing in massage and bodywork training is mentorship and internship programs. “The only way you’re going to become proficient,” he says, “is to have a mentor.” A weekend workshop just doesn’t suffice. How valuable is mentorship? “Invaluable is the right word,” Weinstock says. “Unfortunately, there’s not enough of that. I try to encourage it among my students.” Burch agrees on this point. If he were designing a training program, one thing he would include is mentorship for the recently graduated Rolfer. “There is so much experience best passed on in a clinical setting where you deal with the actual situations presented by the client in front of you, and best shared one on one.”

“With everything,” Grant says, “it takes practice and experience to cement it. Mentorship and apprenticeship are good things.” For example, after reviewing books and videos, he prefers to observe the individual using their technique. “Having looked at it before made it easier, but I wanted to see how they organized it, how their body worked, what they said about it to real people in real life.”

In his Massage Today column, Grant cites the 80/20 rule, noting in day-to-day work, therapists will likely be using 20 percent of their subpractice “domain-specific knowledge and skills” for 80 percent of their tasks. “The implication is that, if a person entering the subpractice comes with this 20 percent of the subpractice down cold, they will be able to accomplish much without having to stop constantly to consult a mentor or information resource. In all likelihood, they will have much more time and leeway to accumulate incrementally via experience the subsequent 80 percent of skills and knowledge.”2

Adding Windows and Doors
So many modalities, so little time. How much is too much? When are you stretching it to the limit? I asked this of Grant. “At least if you’re doing it over a span of time you can learn a great deal. It’s important to learn one thing well and integrate that in, then learn something else.” For example, when learning languages, “It’s really hard to learn all the languages at once. You end up speaking a kind of polyglot. If you know the technique as pure technique, it’s kind of like riding a bicycle - you can learn to ski, learn to skateboard. They are all kinetic skills and they interrelate. As you become familiar with how a joint feels, you can use that both in active and passive action. Over a career a person can learn and use a lot of different things and at any time they may be favoring three or four.”

Lowe considers adding modalities both a concern and challenge. “I have seen situations where the practitioner might try to take on so many things and end up operating outside their scope of practice. It’s a delicate balance,” he says, and one in which the therapist should know when to refer if it’s beyond her range of skill.

“You need to have a lot of tools in your toolbox,” Weinstock says, “but what I find I’m much more comfortable with is my limitations. When I was younger, I didn’t think I had any limitations. But the older I get, I know when to stop, when to say when, when to refer out. I don’t think any one of us can help everybody. I know lots of my younger students make those mistakes. It’s experience. All of us who have been doing it for 20 years or more would say the same thing, I think, although I know I can’t speak for everyone.”

Stocking the Toolbox
There are many side paths on the evolutionary road to building a toolbox. Some lead to workshops and seminars, some to the library and others to a mentor or supervisor in your chosen subpractice. Not all learning paths necessarily aim toward a specific modality; they can also include a variety of supplemental skills, such as psychology or communication. When building your toolbox, it’s important to take into account all areas of your practice that may be affected by your skills, or lack thereof. A thoughtful choice demands knowledge of what is practical, necessary or just plain good to have. To this end, we include some guidelines for a variety of paths you might choose to follow.

From Relaxation to Pain Relief
As Lowe points out, basic relaxation massage can likely be accomplished with a small repertoire of modalities and techniques. But if you’re taking on clients with chronic pain, sports injuries or orthopedic problems, the “one-size-fits-all” approach is not likely to work well for you or the client.

Waslaski advises therapists to avoid a tunnel-vision approach. To bring the body back into balance, he recommends several orthopedic components, including myofascial release, neuromuscular skills, trigger point work and active isolated stretching. In addition, the therapist should be well grounded in functional assessment, anatomy and pathology.

What has Burch added to the toolbox? “The two primary things are craniosacral therapy and visceral manipulation.” Noting that Ida Rolf studied extensively with osteopaths, he says osteopathic-derived modalities mix well with Rolfing or structural integration. “Rolfing and other forms of structural integration are not defined by the method, but by their goal,” Burch says. The Rolfer uses quite a range of different methods to get the job done. Among other methods he would add are movement education, Feldenkrais Method, body-mind centering and continuum.

Weinstock’s neuromuscular reprogramming students are required to have a certain level of skill and experience before entering the program. “Of course, some good advanced palpatory anatomy, some deepening of anatomy skills. Then you can get into more technical bodywork such as neuromuscular reprogramming, or other muscle techniques.” From there, he recommends deep tissue and sports massage. Would he also add energy work? “Sometimes the client comes fresh from a serious accident, and then energy work is appropriate in that case right away, something noninvasive. Sometimes when you’re doing physical work and you’re doing the best you can and they don’t get better, that’s a good time to do some emotional work. An emotional block can impede the course of physical rehabilitation. It’s also important to know when what you know is inappropriate and when to refer out.”

A mainstay of spa treatment, relaxation massage is now giving way to new modalities and more flexible roles for therapists. According to Steve Capellini, author and spa expert from Miami, Fla., an expanded toolbox can make a big difference. “Most spas offer several modalities,” Capellini says. “Whichever offers the most can get booked the most.” He notes in addition to the popular Swedish massage, spa owners are also looking for therapists trained in craniosacral therapy, acupressure, shiatsu and reiki. Sports massage is also sometimes included. Specific spas do embrace other energy modalities, but Capellini cautions against limiting oneself too much with a specialty such as tui na. “Although,” he adds, “it would depend on the spa.”

Marian Urban of The Sterling Institute in Santa Fe, N.M., a leader in the medical spa movement, says working in medical spas calls for a whole new resume. “This is an area where massage therapists will definitely have to check their toolbox,” she says. The therapist will be dealing with doctors, medical procedures and prescriptions, and should understand how these factors affect their treatment. “My therapist better know what type of treatment I had and know what can and can’t be done.”

Urban emphasizes the need for training in medical anatomy, noting therapists are now beginning to recognize its importance in medical spa work. Modalities showing up in this evolving field include craniosacral, polarity, Ortho-bionomy and Rolfing. “Those are the people the medical spas are going to grab. Those are the tools in the box you are looking for.” But when it comes to training, Urban says, “We’re talking more than a weekend training,” not just an introduction, but many hours.

From Birth to Death
Sandy Ventura Gordon of Bodyworkers Association for the Birthing Year, Inc. (B.A.B.Y.) in White Bluff, Tenn., knows a lot about birthing babies. Gordon trains massage birth assistants to work in a supportive role with clients from pregnancy through delivery. “The optimal thing,” Gordon says, “would be for therapists to educate themselves about labor and birth.” This can be accomplished through formal training and self-education. In addition to pregnancy massage skills, the therapist should have an awareness of prenatal bonding, “and all that it encompasses,” Gordon says. Everything within the mother’s environment and emotional state has a profound effect on the child, including associations with auditory sounds. Gordon has even used hypnobirthing, in which the mother’s visualizations stimulate the baby to turn into proper delivery position.

“Forms of energy work are real beneficial,” Gordon says, as well as modified neuromuscular work, although some portions are inappropriate. “In shiatsu, there are certain points to be aware of that overstimulate the pregnancy; also certain points of acupressure - but there’s controversy even in that.”

In rare cases of a baby’s death, an understanding of the process of grief is an essential tool for the therapist. For expanding grief work skills, Gordon suggests sitting in on support groups for parents who have lost children or seeking out information at a hospice. But with a healthy delivery and good outcome, the qualified therapist can go a step further offering infant massage training and lactation and neonatal care. “Having the same person working with the mother through the whole process - the bond and the trust is just so powerful.”

For more than nine years the Health Center of Integrated Therapies at Longmont United Hospital in Colorado has been offering massage and other bodywork therapies to patients, both in the hospital setting, and on an out-patient basis at the center. Program manager Michelle Bowman, a nurse and acupuncturist, has overseen the program’s growth from a few massage therapists to an array of integrative practitioners. “My overall status in hiring,” Bowman says, “is the more training and diversified skills you bring in, the more your chances of being hired.” She notes this holds true for other hospital-based programs as well. “It’s lovely when I get a massage therapist who is also trained in yoga, tai chi or acupuncture. I can use them in more than one role. Most of the time, people are wanting an integrated approach to healing. The more integrated you are in your knowledge base, the more integrated you can be for your clients.”

For pre- and postnatal work, Bowman only hires therapists certified in maternal massage. “We require 1,000 hours of training to work at our hospital, and we want to see that they have some kind of training related to the field. It’s advantageous to have some type of internship in a hospital or medical setting,” or having a mentor with hospital experience. “You are working on really significant medical issues - working on people who usually have some type of chronic illness such as cancer.” Familiarity with medical equipment and how to work around it is important as well.

Eastern modalities play a large part in the center’s integrative approach. Although Bowman is always interested in hiring therapists with this experience, she says a basic level of training or a weekend workshop just won’t do. For reiki she prefers therapists trained at master level, or at least level II.

As our aging population has grown, so has the popularity of geriatric massage. Sharon Puszko, owner and director of Day-break Geriatric Massage Institute in Indianapolis, Ind., says geriatric massage should definitely be added to the therapist’s toolbox for aging challenges. “Specifically in the geriatric modality, one of the big considerations is the aging body,” she says. “With that, of course, comes different physical challenges, for example arthritis, joint replacement or Alzheimer’s,” as well as skin changes and risk of bruising.

“You don’t want to do things like deep tissue or sports massage,” Puszko says. “Even if it’s a robust person, they’re still aging.” Day-break’s geriatric modality has been developed with these concerns in mind, limiting treatment to a half-hour. Although other modalities such as craniosacral therapy, Therapeutic Touch, Swedish massage and Trager Approach can be integrated with geriatric massage, this approach emphasizes fluffing techniques as opposed to long, stripping strokes. “It’s very important to know what medications they’re on before you start,” Puszko adds, recommending a course on massage therapy and medications.

Although Day-break doesn’t teach energy work, “it’s fine to use it,” Puszko says. “Many geriatric people are not as comfortable with that as they are with other mainstream approaches. It’s not something you’d generally use on the initial visit.”

For more than 20 years, Mary Rose has supervised the massage program at HospiceCare of Boulder and Broomfield Counties in Colorado. She developed a specific approach, called Comfort Touch, for working with the elderly and terminally ill. Derived from acupressure and shiatsu, this approach also includes elements of integrative massage, “being aware of the whole person.”

Rose suggests although therapists can draw from their own experience, using whatever modalities seem appropriate, it’s best to learn how to adapt those techniques for this population. “An understanding of the body - anatomy and physiology - is helpful in having an awareness of what is going on, particularly in changes in the body.” Shiatsu and acupressure are especially helpful, she notes, because the techniques are more easily adapted to the elderly than Swedish massage, which has strokes that can be damaging to fragile bodies.

The hospice environment is substantially different than that of a massage treatment room. Clients have limited mobility, “so we keep logistics very simple,” Rose says. Clients are usually clothed, either in a wheelchair or bed, and there’s no use of lotion or oil. Proper body mechanics come into play as massage tables are rarely used - something massage therapists are not used to, Rose says.

Between birth and death, there are the seemingly unavoidable human conditions of trauma or abuse. Rare is the therapist who has not encountered a client afflicted by these challenges in some form. Chris Smith, developer of Trauma Touch Therapy at Colorado School of Healing Arts in Lakewood, Colo., says it’s important to know how trauma physiologically affects the body. Trauma Touch is a unique approach to working with the client, but can be used with any modality. “There’s a lot of academic understanding of trauma that has to occur,” Smith says, “as well as understanding of oneself.” Victims of trauma and abuse tend to dissociate with touch. “Our goal is to keep them present with whatever modality we’re using. Therapists also have to know themselves very well because it’s not unusual to have the therapist dissociate along with the client.”

In addition to trauma training, Smith advocates networking with psychology experts as a means of supporting the client’s needs. “Our good wishes and compassion - it’s just not enough. That’s usually the Achilles’ heel of most therapists who work with abused clients. They end up overstepping the boundaries. In some ways, there is a lot of crossover between body and mind, but everybody has their specialities. We need to stay with bodywork.”

Hammering It In
So here we have some basic guidelines for expanding your toolbox. Start with a firm foundation, be clear about your goals and choose wisely, and recognize and respect the limits of your training. But, Whitney Lowe says, “Don’t lose sight of the fact that any single modality can be incredibly deep. I would say I’m known as a moderately decent authority on orthopedic massage. Yet I still feel like I have barely scratched the surface in this niche. Even a single area can be extremely deep if you explore it.”

Lowe’s sage advice sums it all up: “Broaden your skills, but at the same time get really good at something.”

References
1 Grant, Keith Eric. Swimming Upstream Toward Effective Practice. Available at www.massagetoday.com/columnists/grant. Accessed Feb. 24, 2003.
2 Ibid.

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