This article presents and analyzes results from the database of information about Rolfing clients treated at Núcleo De Atendimento, PesquisaEducação em Rolfing® (NAPER), which is the research and education center of the Brazilian Rolfing® Association (ABR). I will present a brief history of the creation and development of NAPER. I will also describe the creation and development of the instruments and protocol used to document client processes, as well as the format and development of the database.
SHORT HISTORY OF NAPER, FORMERLY CALLED “PROJETO AMBULATORIO DE ROLFING”
The Projeto Ambulatorio de Rolfing, today called NAPER, was created in September 1998 by a group of independent Certified Rolfers unrelated to the administration of ABR. During that year’s annual meeting these Certified Rolfers discussed:
With these concerns in mind, they designed and created The Projeto Ambulatorio de Rolfing (hereafter, The Project).
The idea implemented was collective and shared treatment, as is done in our Rolfing trainings. The setting was that Certified Rolfers would work on clients at the same time, allowing the exchange of ideas concerning body reading, techniques and process flow. The sessions would be at a reduced fee, enabling people who do not have the means to pay for a session in a private practice the opportunity to receive Rolfing. The client cases would be documented, shared and discussed, not only with the objective of achieving professional improvement, but also to generate knowledge about Rolfing.
Since its inception, the objectives of The Projeto Ambulatorio de Rolfing have been:
1-Educational: professional development for Rolfers through the exchange of experience during sessions, discussion of cases, supervision from more advanced Certified Rolfers, workshops, etc.
2-Social: sessions at a lower cost.
3-Research: to generate knowledge about Rolfing through the vast number of clients treated within The Project, who would give us permission to use the information concerning their processes.
In 1998, 1999 and 2000, the office hours of The Project were restricted to only one or two days per week, with few scheduled appointments. Not until 2001 did the financial and administrative organization become more structured, making it possible to rent our own space with four tables. This also allowed us to schedule clients five days a week, six hours per day.
In 2002, the Project changed its name to Núcleo de Atendimento, PesquisaEducação em Rolfing® (NAPER), which translates into English as Center for Treatment, Education and Research in Rolfing, and is a name that better describes its purpose. (For the rest of this article, I will use the name NAPER to refer to the project throughout its entire history.) This once informal and independent group is now an official organization within the ABR; it is recognized in the bylaws of ABR, as well as having its own bylaws.
In 2004, of the eighty-eight Certified Rolfers present in our community in Brazil, twenty-eight had worked at NAPER. This shows that a significant portion of the community of Rolfing professionals had already been involved. And if we take into consideration that of the eighty-eight Certified Rolfers in Brazil, the number working in the state of São Paulo was around forty, then we see that a majority of the Certified Rolfers in the state and city of São Paulo had participated. These twenty-eight Rolfers had seen 653 clients in six years and four months.
CLIENT TREATMENT PROTOCOL DOCUMENTS FOR CLIENT PROCESSES
Since its inception, there were concerns regarding communication between Certified Rolfers concerning each client’s process, particularly when it came to continuity (maintenance sessions/post-ten work). There were also issues of which terminology and which instruments would be used for recording and communicating clients’ processes.
In the beginning, NAPER used the same questionnaire that ABR used for clients interested in becoming models for Rolfing® trainings. It was a simple form that asked for demographic information, main health conditions, and goals for the Rolfing process.
Over time, the group noticed more and more the importance of organizing, homogenizing and standardizing a common way of obtaining important information to enable the managing, reflection on and recording of the client’s process. There was tremendous research potential given the number of clients who received Rolfing each year. This led us to develop more sophisticated questionnaires.
Today, the Client Treatment Protocol Documents at NAPER are comprised of the following: Initial Interview, Sessions Report, Client’s Report, Rolfer’s Report, Client Contract, and “before” and “after” photos.
In the Initial Interview, in addition to creating rapport with the client, we collect information about the reason for seeking Rolfing®; complaints in regard to pain; somatic, emotional and health histories; physical habits; how the client heard about both Rolfing and NAPER; age; profession; level of education; address, telephone and e-mail contact information.
The Sessions Report is base on the “SOAP notes” model, taught in Rolfing trainings and used by North American professionals for the reimbursement of sessions by health plans. In this document the Rolfer records every session: feedback from the client; body reading observations; the objective and the techniques used in the session; the results obtained, and suggestions and plans for future sessions.
In the Client’s Report, at the end of the series, the client evaluates his or her own process: the intensity and frequency of pain, how he or she perceives the changes (physical, functional, emotional, etc.) in both his or her body and life. In addition to evaluating the efficiency of Rolfing, clients evaluate the treatment setting of NAPER and the Certified Rolfer who treated them.
The Rolfer’s Report, contains a final report of the client’s process, dealing with: the client’s objectives at the start of the process; the Certified Rolfer’s evaluation of the structure, function, emotional status and history of the client; description of the objective(s); description of the strategies and techniques used to achieve the objective(s); the results obtained; and recommendations given to the client regarding post-series activities.
The Client Contract is an explanation of NAPER’s objectives and the treatment rules: collective treatment (more than one client per scheduled appointment), Certified Rolfers discussing the case, sharing of information on the client’s process, the importance of showing up for scheduled sessions, session cancellation policy, payment conditions, etc. If the client agrees with these rules, he or she signs the contract. In every client’s file are before and after photos and, in some cases, intermediate photos as needed.
DEVELOPMENT OF THE DATABASE
I personally came to NAPER in 2000 as the first official Research Coordinator. My vision was to organize the data collection protocol, improve communication among Certified Rolfers about our clients, and collect information about the Rolfing process and its benefits.
The work of conceptualizing and building the database was possible, in part, due to significant prior experience in two fields: Prior to becoming a Certified Rolfer I received degrees in Sociology and Anthropology from the University of Campinas; and then for ten years I owned a market research company. In this way, I linked my previous experience and education with the needs and research possibilities of NAPER, bringing in technical elements that were largely foreign to the Rolfing community so that the design of the database was done with pertinence and precision, and thus able to contribute to the development of Rolfing research in Brazil.
At the end of 2000 I presented the first (manual) tabulation of a sample of the database, including basic demographic information such as gender, age, profession, etc. at NAPER’s Annual Evaluation Meeting. The report included everyone treated to date.
The second (manual) tabulation was reported using the entire database in 2002. Paula Mattoli and I coordinated all the Certified Rolfers involved to organize the information from the four Client Treatment Documents from 1998-2002. These results were first presented at the ABR Annual Meeting of 2003 and subsequently published in Rolfing Brasil (ano VII, número 19, Março 2006).
The results of this development phase of the database still did not allow for any cross-referencing of information, something that would enable a more consistent and sophisticated analysis of the data. I started to envision the construction of a computerized database, a task that would require more work and – most challenging – money, since we would have to hire workers specialized in computation and statistics.
As part of the second phase, a large portion of the development was the engineering of the questions. The most difficult task was establishing parameters for the questions of the four client treatment protocol documents, which over the years were becoming more and more sophisticated with the passing of time.
In 2004, Pedro Prado, who has always supported NAPER, took over the database project. His work with the database is part of his doctoral degree dissertation.
In 2004-2005, I reorganized the guidelines for the tabulation of results of NAPER’s Client Treatment Protocol Documents and tabulated the files of the 653 clients who had already passed through NAPER through December 2004.
The structure for organizing and receiving information has already been formatted. The data of clients treated through 2004 has been tabulated and entered and the first results completed.
Now, each year, we enter information from the new clients seen during that period, as well as track clients who return for post-ten sessions.
ORGANIZATION AND CONSTRUCTION OF THE DATABASE
For the construction of the database, I used the four instruments from NAPER’s Client Treatment Protocol: Initial Interview, the Rolfer’s Report, the Client’s Report and the Sessions Report. I then selected the important questions and information that would be used to build two tabulation guidelines: one for the quantitative (closed-ended) questions and another for the qualitative (open) questions.
This selection of information resulted in two products:
1)A quantitative database, which contains the results of the closed, objective and quantifiable questions.
2)A qualitative database, which contains the transcription of the open, subjective and qualitative answers of the clients (I will not present those results here).
The quantitative database gave us five different categories of information:
1)Demographic information, which allows us to identify what type of client seeks out Rolfing®. It includes information such as: gender, sex, age, profession, level of education, place of residence.
2)Data on why clients sought out Rolfing, complaints with regard to pain/discomfort (the location, intensity and frequency of the pain), type of pathology they present, etc.
3)Data which supplies us with a somatic, emotional, health and habit history of the clients, (information on the basis of which we, during the process, develop the client’s treatment plan). This data permits us, at the end of the process, to evaluate and compare the results and the efficiency of Rolfing at various levels: in relation to the structure and function of the complaints of the client; to the pathologies which he/she presents; to the emotional and/or cultural situation in which he/she finds him/herself, etc.
4)Information on how the client learned of Rolfing and how he/she came to NAPER.
5)Data regarding the client’s satisfaction of results with NAPER, which includes an evaluation of the Certified Rolfer, and specific information about the efficacy of Rolfing presented through the evaluation of the intensity and frequency of the pain/discomfort after the process.
Not all of the collected data will be presented in this article. Let’s go on to the presentation of the first results, which come from the years 1998-2004, followed by commentary and interpretation.
NUMBER OF CLIENTS TREATED PER YEAR
See Figure 1.
The number of clients treated at NAPER varied during these six years of existence, depending on the circumstances. In 1998, 1999 and 2000, it was only possible to see clients a few hours per day, two days a week. In 2001, we started to schedule clients during a six-hour period daily, Monday through Friday. This may explain the 45% increase in clients from 2001 to 2002. The number of clients treated also varied in accordance with the number of Certified Rolfers working at NAPER. Additional factors that contributed to the increase or decrease in the number of clients were such things as NAPER moving its office, a decrease or increase in marketing dollars spent, etc.
See Figure 2.
The majority of clients treated at NAPER are women. This fact seems to correlate with the reality of a Certified Rolfer’s private practice, just as it does with that of other holistic complementary therapies, psychotherapies and massage therapy.
See Figure 3.
The majority of NAPER’s clients are adults who are economically active (see also the table of professions). We have few children and adolescent clients, as well as few senior citizens. Although children and adolescents have fewer structural and functional problems, the exact opposite is true of senior citizens. Those over sixty years of age have a higher probability of suffering from structural and functional problems, and yet they do not constitute a significant percentage of NAPER’s clients.
Note: For this report, I did not make a comparison of age distribution in the Brazilian population, especially in the age groups over sixty, which would given greater depth to the analysis.
CLIENT MARTIAL STATUS
See Figure 4.
The predominant marital status of NAPER’s clients is single – 50%. This fact needs to be cross-referenced with other factors to be better understood, something that will be considered in the future.
CLIENT EDUCATIONAL BACKGROUND
See Figure 5.
NAPER’s clients have a high level of education: 80% of them have an incomplete university education or higher level of education. Rolfing® is a new and relatively unknown therapy in Brazil, and our potential clients have good access to information.
NAPER clients, specifically, do not have a high economic standard, but they have a high cultural standard. The majority of them come from the middle class in terms of salary groups, but have a high standard of cultural and information consumption. In Brazil, these two standards hold very different meanings. “Economic standard” is defined in terms of earnings while “cultural standard” is defined in terms of access to information (cable TV, internet, newspapers, books, magazines, music, theatre, etc.).
Unfortunately, clients with lower incomes do not reach NAPER, which seems to be due more to limited access of information than to the prices of our sessions, which are significantly lower than the market average.
CLIENT PROFESSIONAL BACKGROUND
See Figure 6.
The majority of NAPER’s clients are economically active, with a slight prevalence for self-employment over employment by others.
HOW DID YOU LEARN ABOUT ROLFING?
See Figure 7 (this question allowed multiple answers; consequently, the total sum is not 100%).
We asked NAPER clients how they learned about Rolfing. We discovered that many learned from other clients who had received Rolfing, whether at NAPER or in a private-practice setting. I concluded, through careful analysis of the Rolfer´s reports, the category of “unidentified person” is completely comprised of clients who already have been through the Rolfing process. As a result, 54% of NAPER’s clients learned of Rolfing through clients who had already received Rolfing.
On the other hand, we have only a small percentage of clients who learned about Rolfing from the recommendation of other professionals (doctors, physiotherapists, psychotherapists, etc): only 12%, which reveals our low level of penetration in these professional markets.
If we take into consideration that we have a low visibility in the media – newspapers, magazines, radio and TV – we can say that these means of communication are efficient in educating the public. A percentage of 9 (seen in the chart) may seem low in comparison with other categories; however, in six years of NAPER, the few times the media covered Rolfing it generated a significant number of clients.
WHO REFERRED YOU TO NAPER?
See Figure 8 (this question allowed multiple answers; consequently, the total sum is not 100%).
The majority of NAPER clients come to us from clients who went through the Rolfing process at NAPER: 43%. If we add to this the 10% of clients who come to us from individuals who received Rolfing in private practice, we have 53% of our clients coming from former Rolfing clients. This confirms what we already know in the Rolfing community – that clients generate clients. We also find a good percentage of Rolfing colleagues recommending NAPER. In Brazil the session price is often negotiated, and if an agreement cannot be reached the client is often referred to NAPER.
Note: the percentages of recommendation of NAPER by other professionals and through the media are almost identical to the percentages of how the clients learned about Rolfing. Undoubtedly, if we had more penetration in the media and a greater visibility and credibility with other professionals, we would have two other important client-generating channels acting in our favor. This is easy to say yet difficult to implement. But we could investing in more efficient and global ways of generating clients, as well as, in more objective forms of promoting Rolfing and its benefits, and depend less on the generation of clients through clients – which is a slower, more personal process.
THE REASON FOR SEEKING ROLFING®
See Figure 9 (this question allowed multiple answers; consequently, the total sum is not 100%).
We asked clients the reason why they sought out Rolfing. The answers were open and subjective in character. We transformed these open-ended answers into categories that we use in Rolfing and divided the categories into structural, functional, emotional, energetic, spiritual and cultural. In addition we also saw responses for maintenance and interest in the technique (becoming a Certified Rolfer).
We found that the majority of the clients, 96%, seek Rolfing treatment for structural reasons – bad posture, chronic pain, scoliosis, spine deformity, etc. Following that, the second-largest group seeking Rolfing were those with functional problems: 37%. In third place we find problems of an emotional/psychological nature, with 18%.
Rolfing, in terms of the technique, directly addresses the body, the integration of the somatic structure, so it should not come as a surprise that the highest percentage of people who seek Rolfing treatment have structural problems. However, the 18% of clients who seek Rolfing because of emotional problems is noticeable.
We know, in practice and in theory, that reorganizing, balancing and integrating the physical structures also affects other aspects of being (emotional, intellectual, cultural and spiritual) in the same way. In these results we have direct recognition, from the party mostly affected by our work – the client – that this is true, since we find clients seeking Rolfing treatment to deal with emotional issues.
COMPLAINTS IN RELATION TO PAIN
See Figure 10.
We asked clients if they had any problems in relation to pain or physical discomfort for which they sought out Rolfing. We discovered that 75% of NAPER’s clients seek Rolfing to alleviate pain.
Even though Rolfing was not originally designed to be a “second-paradigm” technique (that is, work done to cure symptoms, or “fix-it work”), but rather a “third-paradigm” method (that is, one that is based on integration and holism), we know, as do our clients, the great capacity of Rolfing to alleviate pain. When reorganizing the myofascial structures and promoting a change in the movement patterns harmful to the equilibrium and body fluency in the gravitational field, chronic pain and injuries resulting from repetitive movements diminish and disappear.
DID YOU COMPLETE THE ROLFING PROCESS?
See Figure 11.
We found that 83% of the clients who went through the Rolfing process at NAPER completed their processes. The other 17% abandoned the process at some point. I think this rate of abandonment is high compared to a Certified Rolfer´s private practice; however, the conditions under which the sessions are offered at NAPER are quite specific and not always easily accepted by some clients: collective sessions, with many clients and many Certified Rolfers; a body reading in which several Rolfers analyze every client; a not very flexible schedule; etc.
NUMBER OF SESSIONS PER CLIENT
See Figure 12.
Of the processes carried out at NAPER, 38% are comprised of ten sessions, with Certified Rolfers following the classic Rolfing “Ten-Series” protocol.
Another 40% of the processes are comprised of more than ten sessions. Clarification should be made that the processes with nine sessions or less not only correspond to the clients who abandoned their processes, but also include clients who returned for “post-ten” work, as well as those who make specific agreements for fewer than the classic ten sessions.
NUMBER OF CLIENTS WHO RETURN FOR MAINTENANCE SESSIONS
See Figure 13.
Unfortunately, the number of clients who do not return for sessions of maintenance/post-ten work is quite high. This, undoubtedly, is an area to be explored by NAPER.
DEGREE OF CLIENT SATISFACTION WITH THE PROCESS
Did you achieve your objectives?
See Figure 14.
For the clients who completed their processes, the degree of satisfaction is very high. Of the clients who went through the Rolfing process at NAPER, 91% say they achieved their objectives completely and 9% say they more or less achieved them. No client said he or she had not achieved his/her objectives at all.
It should be taken into consideration that the opinions of the clients who did not complete the process are not included in these statistics.
DEGREE OF CLIENT SATISFACTION WITH THE CERTIFIED ROLFER™
How was your experience with your Certified Rolfer?
See Figure 15.
The Certified Rolfers have a 100% approval rating from their clients. All clients who conclude the process say it has been fantastic to work with their Certified Rolfers. Again, it should be stressed that clients who stopped the process for any reason do not complete the Client’s Report, which contains this question.
DO YOU THINK THAT ROLFING HELPED YOU IN OTHER ASPECTS OF YOUR BEING?
(Emotional, Sociocultural, Spiritual, etc.)
See Figure 16.
At the end of the process, we ask clients if they perceived any changes in other aspects of their lives due to Rolfing®. This question is directed to our holistic conceptualization of Rolfing. We know that the body is the channel we work with, and we know that if the body organizes itself, that reflects in the other areas of a being – the emotional, spiritual, intellectual and cultural. As a result, we see that 83% of the clients recognize that Rolfing had influenced them in other aspects of their lives.
INTENSITY OF PAIN AFTER THE ROLFING PROCESS
See Figure 17.
We ask clients about the intensity of pain or discomfort they might be feeling, both before the process, (in the Initial Interview), and after the process (in the Client’s Report). We cross-referenced this information and found that 76% of NAPER clients noted a decrease in the intensity of pain for which they sought Rolfing. Another 18% stated that the pain/discomfort disappeared. Only 6% stated that the intensity of their pain/discomfort remained the same after finishing the process. This data is quite significant. We have quite a low failure rate – 6% – within the perspective of the second paradigm (curing symptoms).
This is only a partial analysis of the information available in this database. There is much more information in it and an even greater possibility of cross-referencing data. We also have information from the qualitative database that has yet to be analyzed. Moving forward we will continue to update the database with new client information, allowing us to become more consistent and efficient with this information.
As advice to NAPER from this analysis, we have two main items. (1) work more on following up with clients so they will return for post-ten work. This could create a nice flow of clients to NAPER and would allow for some valuable follow-up on the efficacy of Rolfing. (2) Work on the marketing of Rolfing and NAPER in the media, so that more people can be exposed to it, learn about it, talk about it, and eventually become clients.
Editor’s Note: This article is a translation of “PerfisAvaliações dos Clientes do NAPER – Núcleo de Atendimento, PesquisaEducação em Rolfing” published in Rolfing Brasil, ano VII
Profiles and Evaluations of Rolfing Clients in the Núcleo de Atendimento, PesquisaEducação em Rolfing (NAPER) Brazil