Valérie-Anne O'Callaghan
A manual work session requires several things at once: entering a new space, lying down in the presence of someone, allowing physical contact, remaining still for a long time, and trusting that whatever happens will be tolerable.
For a nervous system that processes sensory information more intensely and with less filtering, each of those points deserves attention. None of them are obvious.
I'm writing this from two perspectives. I've worked with my hands for over a decade, and I recently received a diagnosis of autism spectrum disorder with high abilities. These two perspectives have changed how I conduct sessions.
Why the stretcher is a demanding environment
It is advisable to list what is being asked for, because in everyday practice it becomes invisible.
Lying on your back leaves the body in the position of least available control. Closing your eyes, which is often suggested, removes a pathway for information. Prolonged immobility eliminates the possibility of self-regulation through movement, which is one of the most common strategies used by many neurodivergent people. And physical contact comes from another person, with a pressure and rhythm that the recipient cannot control.
Porges (2011) described neuroception: the nervous system automatically and preconsciously assesses whether the environment is safe. In this context, an organism with low sensory thresholds can register threat signals even when no real threat exists, and without the person expressing it as fear.
The most common outcome is not that someone gets up and leaves. It's that they stay put, cooperate, say that everything is fine, and leave the session more tired than when they arrived.
The warning before contact
It's the simplest change and the one that makes the biggest difference.
Decide where you're going to place your hands before you do. Every time, not just the first time. A system that anticipates contact processes it differently than one that receives it without warning, because prediction reduces the magnitude of the prediction error, and with it, the defensive response.
In practice: warning, brief pause, contact. Three seconds that make a big difference.
And the same happens when you withdraw your hands. A contact that disappears without warning leaves the system searching for where it went.
Pressure and type of contact
Here, individual differences are significant, and it's best to ask rather than assume.
Deep, sustained contact with firm, predictable pressure is generally better tolerated than light, superficial contact. This is the most common pattern, and the explanation makes sense: firm, stable pressure provides clear feedback, while light touch is unpredictable and triggers the hand.
It's best to avoid intermittent contact, the kind that appears and disappears several times at the same point. And it's advisable to keep your hand still for a few seconds before starting to work, so the system can register its location before it begins to move.
Regarding clothing: working in it significantly reduces the workload for many people, and it doesn't significantly alter what can be done in most cases. It deserves to be offered as an option without having to be requested.
The rhythm
Slower at the start and more deliberate in the transitions.
Changing zones without transition forces a sudden reorganization of attention. Announce the change, wait, and then move.
And allow time at the end. Getting up from the stretcher and out onto the street in two minutes is a sudden transition. A couple of minutes sitting down before getting up, at your own pace, prevents a lot of subsequent dysregulation.
Regarding duration: a shorter, more easily tolerated session is more productive than a long, exhausting one. Forty minutes with good energy are worth more than sixty minutes of stamina.
The consultation environment
What is almost never reviewed, and conditions everything else.
The light. Fluorescent lights and direct overhead lighting are unpleasant for many people. Warm, indirect light, with the option to dim it, is preferable.
The sound. The hum of an appliance, a clock ticking, a conversation from the next room. It's worth listening to your own consultation in silence once, paying attention to what's playing in the background. And offer the option of working with or without music, because for some, music is helpful, while for others it's just another stimulus to manage.
The smell. Essential oils, air fresheners, cleaning products. A pleasant scent for most people can be unbearable for someone with hyperosmia. Use neutral products and ask before using any oil.
The temperature. A cold massage table is an intense stimulus. A blanket is readily available without having to ask for it.
The predictable. The consultation should resemble the previous one. Changes in layout are more disorienting than they seem.
Communication
Ask specific questions. "How are you doing?" is a difficult question for someone with interoceptive difficulties or alexithymia. "Is this pressure comfortable for you?" allows for a response.
Offer closed options instead of open ones. "Do you prefer to lie on your back or on your side?" works better than "just lie down however you're comfortable.".
Explain before you act. What am I going to do, why, how long will it take? Uncertainty consumes resources.
And make it clear from the beginning that it's possible to stop. And truly, beyond mere politeness: saying "enough" won't cost anything and won't require justification. Many neurodivergent people have learned to endure discomfort out of a sense of obligation, and without that explicit permission, they won't use it.
On the gaze and the word
Two minor details that are greatly appreciated.
Avoid demanding eye contact during the conversation. Looking away while speaking can actually help you think clearly, and is not a sign of disinterest.
And allow for silence. Many neurodivergent people need more time to process a question and formulate an answer. Filling that pause with another question restarts the process.
What doesn't change
It's worth saying this, because this type of text can sound like something completely different is needed.
The techniques are the same. The assessment is the same. What changes is the packaging: the warning, the pace, the environment, the communication. And that packaging determines whether the nervous system of the person on the treatment table can receive the treatment or will spend the session managing the situation.
A body under surveillance doesn't readily process what's being done to it. Reducing that surveillance isn't preparation for the job. It's part of the job.
A note on the evidence
What I have described comes from three sources: the literature on sensory processing and interoception in autism, the framework of polyvagal theory, and my own practice. The first part is documented. The specific application to manual work has not been systematically studied, so I offer it as what it is: reasoned clinical practice, theoretically grounded but without supporting trials.
If you work with your hands and care for neurodivergent people, you've probably come to many of these things on your own. Putting them in writing gives them a place.
Sources and references
Craig, A.D. (2009). How do you feel? Interoception: the sense of the physiological condition of the body. Nature Reviews Neuroscience, 10, 59-70.
Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Books. PhD in medical psychology and biophysics, creator of Somatic Experiencing.
Markram, K. and Markram, H. (2010). The intense world theory: a unifying theory of the neurobiology of autism. Frontiers in Human Neuroscience, 4, 224. École Polytechnique Fédérale de Lausanne.
Ogden, P. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. WW Norton.
Porges, SW (2011). The Polyvagal Theory. WW Norton. Neuroscientist, Indiana University.
Schleip, R. (2003). Fascial plasticity: a new neurobiological explanation. Journal of Bodywork and Movement Therapies, 7(1), 11-19. Fascia Researcher, University of Ulm.