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Patient experiences of basic body awareness therapy and the relationship with the physiotherapist
MIND ^ BODY STUDY
Patient experiences of basic body awareness therapy and the relationship with the physiotherapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amanda Lundvik Gyllensten, Lars Hansson, Charlotte Ekdahl Abstract Background and Purpose: To explore the experiences of patients undergoing basic body awareness therapy in psychiatric physiotherapy. In addition, the therapeutic relationship and the concept of the working alliance were examined. Subjects: Two groups of patients participated: patients with schizophrenia (n=6) and general psychiatric outpatients (n=5). Method: A qualitative technique, video taping and interviewing the patients during treatment was used. Results: The most common experience from the treatment was ‘balance and posture’. Other experiences were ‘body movement control’ and ‘awareness and handling of body signals’. Themes central to establishing a good working alliance were identified. Discussion and Conclusions: The impact of balance and posture was discussed and some new hypotheses were generated. r 2003 Elsevier Science Ltd. All rights reserved. Amanda Lundvik Gyllensten PhD, RPT Department of Physical Therapy, Lund University, Sweden Lars Hansson PhD Assistant Professor, Department of Clinical Neuroscience, Division of Psychiatry, Lund University, Sweden Charlotte Ekdahl PhD, RPT Professor, Department of Physical Therapy, Lund University, Sweden Correspondence to: Amanda Lundvik Gyllensten Department of Physical Therapy, Lund University Hospital, SE-221 85 Lund, Sweden Tel.: +46 46222 4804; Fax: +46 46222 4204 E-mail: [email protected] ........................................... Journal of Bodywork and Movement Therapies (2003) 7(3),173^183 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00068-2 S1360-8592/03/$ - see front matter
Background In the last few decades, physiotherapy in psychiatry has been a developing professional field in the northern countries of Europe (Roxendal 1985, Gyllensten & Nilsson 1993, Mattsson 1998). Basic body awareness therapy (Basic BAT) is considered to be one of the main treatment methods of psychiatric physiotherapy (Mattsson 1998). Basic BAT in clinical psychiatric physiotherapy has previously been described (Roxendal 1985, 1995, Skatteboe et al. 1989). The method was developed and
described by the French psychoanalyst and movement teacher (Dropsy 1975, 1988) who synthesized the method inspired both by western movement traditions and the eastern practice of T’ai-chi Ch’uan (T’ai-chi). Basic BAT uses movements, breathing, massage and awareness to try to restore balance, freedom and unity of body and mind. Basic BAT is described as resource oriented, which in this case means working with the resources of the body as a whole. Turning the attention both to the doing and to what is experienced in the movements, the awareness of
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physical and mental aspects of the self is developed. Basic BAT differs from T’ai-chi in that movements are quite simple, focused on the experience of ease, stability and intention (Dropsy 1988, 1999). The treatment modality was developed to be starting exercises for T’ai-chi, and tends to follow the same principles that are embodied in these exercises (Gyllensten & Nilsson 1993). The therapist encourages the patient to move in ways more optimal to postural control, balance, free breathing and coordination (Dropsy 1988, Roxendal 1995). Basic BAT can be used both as an individual and as a group treatment. The encounter and interaction between physiotherapist (PT) and patient have been emphasized as an important tool in Basic BAT (Roxendal 1995, Mattsson 1998, Rosberg 2000, Gyllensten et al. 2000). The importance of interaction between patient and PT is, however, central to the physiotherapy curriculum as a whole (Tyni-Lenne´ 1989, Klaber Mofett & Richardson 1997). In a review of the evidence for interaction effects, five different models explaining the effect of interaction on patient outcome were found. These models concern the quality of communication and patient education, patient compliance, the patient’s perception of control and ability to cope, the PT’s enthusiasm for the treatment and operant conditioning in influencing pain behavior (Klaber Mofett & Richardson 1997). Expert PTs in primary health care believed interaction to be central to patient outcome and interaction skills could be increased by reflection about patients’ experiences (Gyllensten et al. 1999). The concepts of the working alliance and the therapeutic relationship have been thoroughly explored within psychotherapy research to understand and
predict therapy outcome. The therapeutic relationship is considered to consist of three components: the working alliance, a transference configuration and a real (genuine) relationship according to Gelso and Carter (1994). The working alliance can be defined as the patient’s attachment to and identification with the therapist, a kind of relationship resembling the bonded attachment to the primary caregiver (Zetzel 1956). According to Gaston (1990), the working alliance is the patient’s affective bond to the therapist and one part of the therapeutic relationship between patient and therapist. Strupp (1973) emphasized the interactive nature of the relationship, involving both the human qualities of the therapist as a good parent, and the patient’s openness and willingness to learn. This was seen as the base for imitation and identification essential to learning and success in therapy. Horvath and Greenberg define the working alliance as the interaction between patient and therapist. The collaborative relationship between client and therapist, the interactive nature of the relationship and the integration of technical and relational aspects are also emphasized (Horvath & Greenberg 1994). According to Luborsky there are two types of signs indicating the quality of the working alliance. Type 1 signs indicate that the patient experiences the therapist as warm, helpful and supportive and type 2 signs convey a sense of cooperation, working together in a joint effort in dealing with the patient’s problem (Luborsky 1994). Also, in physiotherapy, the therapeutic relationship has been the subject of analysis in an article that elaborated the three components: the working alliance, the transference configuration and the real relationship (Szybek et al. 2000).
Aims of the study The main purpose was to explore the patient’s experiences of Basic BAT in psychiatric physiotherapy. Their experiences of the therapeutic relationship and working alliance with the PT were also focused. The aim was also to study the concept of the working alliance in a physiotherapy context.
Methods and subjects Design The study employs a qualitative design, using the aims and the initial framework to bind the scope of the study and present the initial level of understanding of the phenomena of interest (Miles & Huberman 1994, Shepard et al. 1993). This design aims at generating models focusing on important issues or phenomena connected to physiotherapy (Jensen et al. 1999). The research method used in this study was a qualitative case study with cross-case analysis (Merriam 1988). In a case study, different types of empirical information, such as interviews, documents or observations, are collected. In cross-case analysis, individual case reports are analyzed and then compared in order to find a general explanation that fits all cases. Data in this study consisted of repeated interviews. The data from the interviews were organized using an interview transcription log (Merriam 1988). Low-inference data were obtained by using quotes from the patients’ interviews in order to provide internal validity. The initial framework was based on earlier knowledge of Basic BAT (Roxendal 1985, 1995, Mattsson 1998, Dropsy 1988, 1999) and the clinical experience of one of the researchers. Concerning the therapeutic relationship and the working alliance, the knowledge was mainly
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gained from psychotherapy research (Horvath & Greenberg 1994, Luborsky 1994). The initial framework is presented in Fig. 1. When conducting the first interview with the patients, an interview guide based on the initial framework was used; see Table 1. The interviews were tape recorded in full. The interview guide at the second and third interview consisted of the
Therapeutic relationship
Experience as ExperienceofofPT therapist warm, supportive as warm, supportive helping helping Sense of cooperation sense of cooperation Working together working together
open questions, ‘What did you see in the video?’, ‘Can you tell me about how you experience the treatment now?’ and ‘Can you tell me about the relationship with your PT?’ Before the study began, two video recordings were made and two interviews carried out to test the qualitative data collection methods and gain information and experience.
Basic Body Awareness Therapy Grounding/postural line Centering/breathing Flow Mental awareness Self-confidence Relation to others Relation to reality
Fig.1 Initial theoretical framework. The framework consisted of theories about factors important in the Basic BAT, such as grounding/relation to center line, centering/breathing, flow and mental awareness, and self-confidence, ability to relate to others and reality. Concerning the therapeutic relationship and the working alliance the knowledge was gathered from research in psychotherapy.
Table 1 Interview guide 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
What do you think you need to feel good/better? What do you think about the treatment with Body Awareness Therapy? Do you have a goal for your treatment with Body Awareness Therapy? Is the treatment with Body Awareness Therapy related to your goal, as you see it? Do you perceive the treatment with Body Awareness Therapy as meaningful? Can you tell me about your PT? Follow-up areas Can you tell me about whether you think that your PT is warm or cold as a person? Do you think that she is interested or not so interested in you? Is she capable or not so capable in her work, as you see it? Do you trust her? Do you feel accepted or respected? Do you think that she is a person that can help you? What do you think about the cooperation with your PT? Do you think that you are making any progress? Do you think that she thinks that you are making any progress? What would you tell a friend who had similar problems to yours about this form of treatment? Do you have anything to add about what good physical therapy treatment should be?
Patients The patients were selected to produce a sample with the maximum variation (Merriam 1988, Shepard et al. 1993, Jensen et al. 1999) in order to get a broad understanding of the phenomena from different perspectives. Two groups of patients participating in Basic BAT group therapy were included in the study; see Chart 1. One group was treated at a long-term rehabilitation unit for young patients with schizophrenia. The special unit was based on the cognitive therapy model, using a minimum of medication and a more intensive therapeutic intervention. Besides Basic BAT the patients were working in groups with education, social skills training and cognitive therapy (Svensson 1999). This group is hereafter called the ‘inpatient group’. The other group was treated in general psychiatric outpatient care. The patients were living at home and contracted to participate in 12 sessions. They all had other ongoing contacts with psychiatrist, social worker or psychotherapist. This group is hereafter called ‘the outpatient group’. The diagnostic system used was ICD-10 (Swedish Version of ICD 10, 1996).
Physiotherapists Two PTs, nominated as experts in psychiatric physiotherapy by their peers in a study about expertise in psychiatric physiotherapy in the south of Sweden (Gyllensten et al. 2000) and using Basic BAT in patient groups in January 1998, were asked to participate as therapists in the study. The expert PTs were both female, with many years of clinical practice in psychiatric physiotherapy (average 20 years) and well educated, having both formal and informal education
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Chart 1 Patient characteristics Inpatient group
Outpatient group
Number of patients Diagnosis
6 Schizophrenia (n=6)
5 Anxiety syndrome (n=2) Depressive and anxiety syndrome (n=1) Somatisation syndrome (n=1) Gille de Tourettes syndrome (n=1)
Age (years) Mean Range
30 29–39
45 30–55
Gender Males Females
4 2
2 3
Previous experience of Basic BAT (months) Mean Range
9 3–22
3 0–36
Present intensity in Basic BAT treatment
1.5 hours, three times a week
1.5 hours, once a week
in psychiatric physiotherapy, Basic BAT and T’ai-chi. They were working more than 50% of full time in direct patient contacts. The inclusion criteria for this study were: being a patient to a nominated expert PT in psychiatric physiotherapy and receiving Basic BAT in a group setting. At the onset of the study there were two Basic BAT groups, led by nominated expert PTs that fulfilled the inclusion criteria. The patients in both groups consented to participate. The Research Ethics Committee of the Medical Faculty of Lund University approved the study. The patients were informed about the study both in writing and orally, before giving consent to participation. Procedural steps in data collection Before the first video recording one of the researchers visited and participated in the groups, between one and three sessions in order to become acquainted with the
patients. She also informed the patients and answered questions about the study. The patients in the Basic BAT groups were video recorded and interviewed on several occasions; see Fig. 2. The patients in the ‘inpatient group’ were video recorded and interviewed three times. The first time the data were collected was in January 1998, then after 5 months in June, and then again in November the same year. During the first and second times there were six patients participating, and during the third
time three patients. The patients in the ‘outpatient group’ were video recorded and interviewed twice, once at the beginning of the group in February (session 3) and once in May (session 11), before the termination of the group. There were five patients participating at the first interview occasion in February, and three patients at the second interview. The video camera was placed so as to cover the whole group through the different activities and positions, such as laying on the floor, sitting, standing and sometimes walking, pairwise massage or T’ai-chi. Interviews with the patients were conducted after each video recording. The patients watched parts of the Basic BAT sessions before being interviewed. The emphasis was on the parts where the focus was mainly on the interaction between the PT and the patient. Watching the video and being interviewed lasted between 45 minutes and 2 hours, depending on the endurance and the psychiatric condition of the patient. The patients were interviewed as close to the therapy session as possible, preferably the same or the next day. The patients in the ‘inpatient groups’ were interviewed the same or the next day. For the ‘outpatient group’ the time interval could be up to a week if the patients found it difficult to take time off from work.
Inpatient group Information and consent
Researcher in group
Video 1 interview
treatment 4 months
Video 2 interview
treatment 6 months
Video 3 interview
Outpatient group Information and consent
Researcher in group
Video 1 interview
treatment 2.5 months
Video 2 interview
Fig. 2 Description of data collection. The patients in the inpatient group were interviewed three times, at the onset of the study, after 4 months and after another 6 months. The patients in the ‘outpatient group’ were interviewed at the beginning and the end of a 3-month Basic BAT group. 176
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Procedual steps in data analyses The interviews were tape recorded and transcribed in full. The first step in the analyses was to read the transcription of the interviews as a whole, trying to comprehend how the patients were experiencing the Basic BAT treatment and the therapeutic relationship with their PT. The analysis then concentrated on the patients’ experiences of the Basic BAT. Each interview was treated and coded as a case report. A separate interview transcription log was established for each patient and each interview. An open coding was used, aiming at understanding and conceptualizing the patients’ individual experience of their Basic BAT process. This was accomplished breaking down the interviews into different parts, representing different aspects or units of the experiences. Then these aspects were conceptualized into different categories representing different phenomena (Strauss & Corbin 1990, Merriam 1988). First the Basic BAT process of the patients in the ‘inpatient group’ was analyzed, then the Basic BAT process of the patients in the ‘outpatient group’ and then both groups were analyzed together, performing cross-case analysis (Merriam 1988), in order to identify both specific and common experiences of Basic BAT. The same procedure was then used to explore the patients’ experiences regarding the therapeutic relationship and the working alliance. This process included going back and forth between the original interviews, the transcription logs and cross-case analyses to validate the categorization of the data. The relationships between the categories were organized in themes as the data were synthesized (Merriam 1988, Strauss & Corbin 1990). The process of coding and categorization started
with the first interviews and were revised as the researchers collected and analyzed more data through interviews two and three. In the analytic phase, the two PTs were active. Analyses continued until consensus was reached.
Results The number in parentheses after each quote refers to the informant to which the quote belongs. Informants 1–6 took part in the ‘inpatient group’ and informants 7–11 took part in the ‘outpatient group’.
Basic body awareness therapy (Basic BAT) Four themes were found: (I) ‘Personal involvement’, (II) ‘Balance and posture’, (III) ‘Awareness and handling of body signals’, (IV) ‘Body movement control’, and are presented in Table 2. A presentation of the content of the themes and categories follows. (I) Personal involvement: The category ‘Ability to practice alone’ was found only in the patients (informants 5 and 8) reporting the most profound process in Basic Table 2 The Patients’experiences of Basic BAT.Themes and categories (I)
Personal involvement Ability to practice alone Questions about meaning
(II)
Balance and posture Improved balance and posture
(III)
Awareness and handling of body signals Deepened awareness and interpretation of signals Moving with ease Handling muscular tension
(IV)
Body movement control Feeling of body control Looking good and controlled
BAT (physiologically, psychologically and socially). The category of ‘Questions about meaning’ was found in the group of patients with schizophrenia (informants 1–6) at the first interview. Ability to practice alone Well the most important thing for me is that I have to continue these [exercises] my whole life and not think that this is over and done with. I have to, because otherwise I feel that I more and more fade away into some sleepy state of mind. And not to fade away or stop this process I have to do these exercises all the time, to be able to return back to life and gain strength and to be met as a person by others. To be met by others as an alert persony If we practice we can advance on the road to become more united with our movements yit happens to me when I make the Wave [first movement of the Cheng Man Ch’ing short yang form of T’ai-chi] because I feel sure about how to do it, in T’ai-chi. When I feel sure about how to do a movement in T’aichi, then I feel like I am one with my movements and it happens almost by itself. I don’t have to think so much. But I have practiced the Wave hundreds of times to become united with that movement y and it feels beautiful to do the T’ai-chi form. And it is y it is very important to me to feel that I’m doing something beautiful with my body [cries] (informant 8). In the beginning I did not take this seriously and I wondered what it was about. But then I thought that I really did not have any choice but to involve myself in this. But it took 6 months before I really understood it y and it has made me more mentally present and I will continue with these exercises, because I want to continue improvement in the future as well y So I do some exercises myself y bounce on my feet and y Like spend some minutes every day’ (informant 5). Questions about meaning Exercises like sitting and pressing your foot down into the floor, I don’t think that it is meaningful (informant 3).
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(II) Balance and posture: This theme consisted of the most commonly reported category, ‘Improved balance and posture’. Improved balance and posture I felt good. I was standing still and did not lose my balance or anything like that. No, completely still. I was standing still and my arms were in a good place and my legs in a good place, then I will keep my balance (informant 1). I really think that my balance has improved. And also my knowledge of how to keep my balance. The point of pressure must be on the front of the foot. Sometimes I forget, but then I hear her [the PT’s] voice within. Then I feel that I can move the whole body better if I place the point of pressure on the front foot. I did not feel this before yIn order not to look tired, I have tried to pull myself up, from the shoulders. I thought this was the place to pull myself up. I did not know that the postural balance should start from the legs (informant 8).
(III) Awareness and handling of body signals: This theme consisted of the categories ‘Deepened awareness and interpretation of signals’, ‘Moving with ease’ and ‘Handling muscular tension’. Deepened awareness and interpretation of signals You think about how you treat your bodyyyou feel from the inside where you have your bodyy if I sit in an armchair and I feel some tensiony that you change your position, not just sit there and force yourself and have painy. Regardless of whether you are walking, running or doing whatevery When I sit and write I can feel very tense and before I just continued writing and writing, regardless of the tensions. Now I just let go of the pen and do something else. It is just the point that now you can feel the signals of alarm earlier in a way (informant 11). I want to increase the contact with the body in another way than just sitting and stretching oneself, to be able to feel
the contact with the ball or other things instead. y In order to improve the contact with oneself y I don’t think that I am in reality very much (informant 3). Comments: The patient in the ‘inpatient group’ expressed a lack of this contact, but a wish for it. Moving with ease This feeling of improved ability to move, that I bounce when I walk that I have directly after the group. Then I can feel the bouncing in my steps and I wish that I could keep it always (informant 9). Handling muscular tensions Well, it isy it feels good to notice the difference between being tense and relaxed. It is easier to feel good. I can leave this tension behind. I think that this feels better. Last time at the end of the session I experienced that it felt much smoother really (informant 7).
(IV) Body movements control: This theme consisted the categories ‘Movement control’ and ‘Looking good and controlled’. Feeling of body control I was rather skilled. I have done these exercises before and I have had a lot of time to practicey last yeary Well I performed them rather skillfully (informant 4). Looking good and controlled People in the circus and others like that really have control of themselves. Now I don’t mean you have to be like that, but it looks much better if you have control of your bodyyIt looks much more healthy if one is mentally present and standing straightyand I had much more patience with the exercises. Generally it looks much better. You make a good impression (informant 5).
Other categories in addition were mental presence and concentration, freedom of breathing, a sense of well-being, improvement of self-confidence, gain of strength.
Therapeutic relationship and working alliance The experiences of the therapeutic relationship were structured into three themes: (I) ‘Personal relationship’, (II) ‘Characteristics of the PT’ and (III) ‘Treatment-related factors’, see Table 3. A presentation of the content of the themes and categories follows. (I) Therapeutic relationship: This theme consisted of the categories ‘Trust’ and ‘Faith in that the PT believes in me’. Trust Everything she says I just swallowy You get this feeling that if she says that things are possible, they are possible. You can just trust that things work the way she says they do (informant 9). A lot of trust is needed, because it is a sensitive situation. You don’t just sit there and talk and use your head. The whole of me is at stake (informant 8). Faith in that the PT believes in me Yes I definitely think she does [think that I am making progress]. She gave me a lot of positive feedback today (informant 5).
(II) ‘Characteristics of the PT’ – working alliance: This theme
Table 3 The Patients’experiences of the therapeutic relationship and working alliance. Themes and categories (I)
Therapeutic relationship and trust Trust Faith in that the PT believes in me
(II)
Characteristics of the Physiotherapist – working alliance Warmth Competence Respect/acceptance Encouragement Empathy
(III)
Treatment related factors – working alliance Cooperation Goal orientation Making progress
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consisted of the categories ‘Warmth’, ‘Respect’, ‘Competence’, ‘Empathy’, ‘Interest’ and ‘Encouragement’. Warmth A warm and tender person, that really listens to you (informant 5). I think that I would rather describe her as a cold person (informant 4). Competence You relax just by listening to her voice. It penetrates directly into your soul, if I can put it that way. She has such a smooth quality of ease in her voice. It feels like it spreads to us all. She is really competent and calm. Many good things thereyI think that she really is a good leader. She has great qualities as a leader. She has this calmness also when she is practicing. Here we are five beginners, not skilled at all and still she is calm. I think it is working extremely well (informant 11). Respect/acceptance So you don’t have to do it well to be included, or have to do it in the right way. Possibly she notices the difference between us, but myself, I don’t notice if that person is better or worse y It really isn’t very interestingy’(informant 9). One patient said that she did not feel respected. What I think is worse is what she says or commentsy she has some hard criticisms and I felt very bad about it y it happens that you laugh a little if you relax and think about something else or sort of get lost in your thoughts. I really don’t think that it is dangerous, not hallucinogenic really, in my opinion. I don’t think that you have to increase Liponex [medicine], so then I think that it is a little dangerous to go down [to the BAT group] (informant 4). Encouragement It has worked so well. I mean she really has listened to me. It is not only the bodywork, I have been able to talk about what I feel and I have been treated in such a good way the whole time. So I am
really, really pleased. She has done a great job and shown so much patience to make me feel well. I think that she is fantastic and always in a good mood. She encourages me the whole time. It has meant a lot (informant 8). Empathy We talked the first time and I felt that I had good contact with her and I experienced her as an empathic human being (informant 7).
(III) ‘Treatment-related factors’– working alliance: This theme consisted of the categories ‘Cooperation’, ‘Goal orientation’ and ‘Making progress’. Cooperation She tells me things, but it is a cooperation, because I try to do what she says (informant 6).
Goal orientation Two patients in the ‘inpatient group’ expressed goal orientation later in the treatment (after 5 months training or more). The patients in the outpatient group all described their goal. The goals could be very general or more specific.
Therapeutic relationship and Working alliance
To get well (informant 1). I saw that I was absent-minded. I want that to disappear (informant 5). To become more clear about the situations of tensing up. How to breathe and keep relaxed (informant 11). Making progress Yes, I think I have. Yes it sometimes feels good that I have mastered the movements (informant 4). Yes absolutely. I believe so much in this treatment and I wish for other people to receive such good treatment (informant 8).
These results are presented in the model of the revised framework in Fig. 3.
Discussion As the main focus in this study was to explore the patients’ experiences of Basic BAT, the therapeutic relationship and working alliance with the PT, a qualitative design using frameworks and case studies was found adequate. Important contributions to research from expert practice include an increase of knowledge, the clinical reasoning process, and reflection about
Basic Body Awareness Therapy
I Therapeutic relationship
I Personal involvement
II Characteristics of the PT Working alliance
II Balance and posture
III Treatment-related factors Working alliance
III Awareness and handling of body signals IV Body movement control
Fig. 3 Revised theoretical framework. The revised framework consists of the conceptualized understanding of the factors the patients themselves experienced as important in the treatment with Basic BAT and the therapeutic relationship and working alliance with the PT. 179
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practice and skill acquisition (Jensen et al. 1999, Richardson 1999). Our intention was to explore how the patients treated by expert PTs perceived the treatment and the relationship to their PT. This aimed at adding another dimension to the clinical knowledge in the area. To formulate a revised model or framework, not founded on theory only, but on what the patients actually reported, was seen as a means to understand what was central to them in the Basic BAT curriculum. This in turn we hoped could be used to generate new research hypothesis, founded in clinical experience (Domholdt 2000). A strategic choice of two different groups of patients was made. As the purpose was to explore a wide range of possible experiences of Basic BAT and the therapeutic relationship to investigate if we found any differences and similarities in the experiences of the patients, this strategy was found to be adequate. This practice of a strategic choice is common in qualitative research (Jensen et al. 1999, Shepard et al. 1993). The procedure of making video recordings from the group sessions served the purpose of actualizing the memory of the treatment sessions. With the ‘outpatient group’, there could be up to a week between the Basic BAT group and the interview. In the ‘inpatient group’, the interview was carried out within a couple of hours. As the treatment period is much longer with patients suffering from schizophrenia, the time span for data collection was different for the two groups (see Fig. 2) adjusting to the clinical reality. Patients with schizophrenia have a much longer treatment period than patients in general psychiatric outpatient care. To obtain a rich, manifold description of the phenomena of interest was the objective. Still the quality of the interviews varies a lot. It was
generally much more difficult to get the patients with schizophrenia in the ‘inpatient group’ to speak freely. This resulted in more questions being asked and the answers being shorter. This was especially true for the first interview, but changed in interviews two and three. We have judged the value of the material as adequate and interesting, mirroring one of the difficulties of this group of patients. The analyses of the patients’ process in Basic BAT revealed that a sense of improved balance and stable posture was central. This is in line with theories of Basic BAT (Dropsy 1988, 1999, Roxendal 1995). The patients in this study thus supported the theories of Basic BAT, emphasizing the impact of balance, grounding and center line as important aspects in treatment. The importance of balance has also been focused in other areas of physiotherapy. Balance and postural control was one of the most important factors in identifying patients with musculoskeletal disorders in need of multidisciplinary rehabilitation (Grahn et al. 1996). Balance was improved and falls reduced in older subjects by the use of T’ai-chi exercises (Wolf et al. 1997). Since Basic BAT and T’ai-chi are closely related, the impact of this kind of treatment on balance and postural control seems to be strong. ‘Personal involvement’ appeared to be vital to the ability to practice Basic BAT alone. To continue practice alone is viewed as an important factor in physiotherapy practice in the area, since it is believed to be related to outcome. In psychotherapy research, involvement is considered to be the best predictor of outcome (GomesSchwartz 1978). To be able to understand or create meaning also seemed to be important to be able to involve oneself. This is in line with research from psychotherapy where
factors like motivation are shown to have a great influence on outcome (Lambert & Bergin 1994). The ability to involve oneself more in treatment, found in this study, also seemed to be related to the duration of treatment. The patients who had a longer treatment period of Basic BAT also seemed to be more involved. Perhaps this is related to the fact that to continue treatment one has to be motivated and involved. To fully understand these phenomena more research is needed. In the ‘inpatient group’ the patients had not specifically chosen to participate in Basic BAT, since this was part of the curriculum in which they were expected to participate. This was obvious at the first interview, when some of the patients expressed a difficulty in understanding the meaning of the exercises. This had an impact on motivation and involvement in the therapy. ‘Awareness and handling of body signals’ was the most frequently stated gain from the movement exercises in the ‘outpatient group’. As informant 11 put it (see Results, the category of ‘Deepened awareness and interpretation of signals’), this increase of awareness and contact motivates you from the inside to take care of yourself in a better way. The patients seemed to be able to develop the qualities of improved contact with the body and the self. Generally, the patients in the ‘outpatient group’ expressed many positive benefits from their participation in the Basic BAT group. The experiences seemed to involve not only the body, but also more emotional aspects and selfconfidence. The aim of Basic BAT treatment according to the theories is to help the patients to feel from the inside what is a good balance, and to find ease and freedom when moving. This is done by encouraging the patients to develop their own proprioceptivity, sensitivity and
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awareness. To discover that they themselves possess the tool to feel good within their body, strengthens the experience of self-confidence and trust in the body, according to the same theories (Roxendal 1985, Mattsson 1998, Dropsy 1999). The results from this study indicate that these aspects of the Basic BAT theory seem to be most relevant for the patients treated in outpatient care. To the patients with schizophrenia in the ‘inpatient group’, who had much more basic problems with identity, the experience of, or wish for, contact with and control of the body was more central. The aspect of control of the body is not emphasized in the theories of Basic BAT. This opens the field for some interesting hypotheses about the importance of body and movement control in schizophrenia rehabilitation. Concerning the working alliance, the theme of ‘Characteristics of the PT’ contains factors that can be seen as an expression of type 1 signs of the working alliance, denoting the characteristics of the therapist (Luborsky 1994). This can be due to the interview guide using questions about these factors. The factors do however also feel very relevant in physiotherapy treatment. They are very much like the categories reported by expert PTs interviewed about what they believed to be important in the interaction with their patients (Gyllensten et al. 1999, 2000). The theme of ‘Treatment-related factors’ can be seen as an expression of type 2 signs of the working alliance, according to Luborsky (1994). These signs convey a sense of cooperation, working together in a joint effort in dealing with the patient’s problem, and indicate the quality of the working alliance. Also in physiotherapy goal orientation, cooperation and thought about making progress are
signs of a positive physiotherapy process and a positive working alliance. Three of the six patients in the ‘inpatient group’ (half of the patient group) felt that they had a good working alliance with the PT. Of the remaining patients, one (informant 4) did not develop a good therapeutic relationship with her PT. She did not make any positive remarks about the relationship or interaction, although she experienced that she had mastered the movements. With another patient (informant 3), there seem to have been great difficulties establishing a good working alliance, not only for the PT. This patient generally had problems to remain in rehabilitation at the cognitive long-term rehabilitation unit. Because of intense psychotic suicidal impulses, she was transferred to another ward and was more heavily medicated. Yet another patient (informant 2) expressed a negative opinion of the PT’s ability to help, but had a positive experience of the relation with the PT in general. According to research in psychotherapy, the ability of patients with the diagnosis of schizophrenia to develop a good therapeutic relationship and working alliance seems to be problematic. Less than half of the patients with schizophrenia in a randomized, controlled study of treatment effects of psychotherapy, formed a good working alliance (Stanton et al. 1984, Gunderson et al. 1984). A Swedish study of the therapeutic alliance in a group of long-term mentally ill patients treated at a unit based on cognitive therapy revealed the patients’ ratings of the therapeutic alliance in the initial phase to be good in 38.5% and fair in 57.7% of the cases (Svensson & Hansson 1999). In the ‘outpatient group’ four of the five patients had a positive working alliance with their PT. The
patients in this group had less problems with relationships and they had themselves chosen to participate in the Basic BAT group. This made them more motivated and the forming of the working alliance less problematic. The most problematic aspects to form a positive working alliance seemed to be related to the theme ‘Therapeutic relationship’ and the feeling of lack of trust in the PT or doubts about whether the PT thought that they could make any progress in the treatment. Here is a link to the experiences in Basic BAT where the patients who reported a positive therapeutic relationship also reported that they used the Basic BAT exercises on a daily basis at home. Interestingly, these patients were found in both patient groups. This result is in line with the results from psychotherapy research, where the patient’s qualities of openness and trust are seen as essential for the ability to develop a relationship that is favorable to the learning process (Strupp 1973). This finding generates a new research hypothesis of the relationship between the therapeutic relationship especially trust and outcome in Basic BAT treatment. The concept of the working alliance may serve as tools in the identification and differentiation of factors that help or hinder the development of a good cooperation between patient and PT. Among the different definitions of the working alliance, the definition by Horvath and Greenberg (1994) seems to be best suited for the area of physiotherapy. They emphasize the interaction between the technical and relational aspects in addition to the collaborative relation between patient and therapist. In physiotherapy, where treatment involves working with body-related skills, as well as touch and not only verbal interventions, this seems to be the most applicable. The theories of
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Luborsky (1994) about the different types of the working alliance also seem to be relevant in the area of physiotherapy.
with us, and the expert physical therapists involved in the study.
REFERENCES
Conclusion The study points to the importance of the ability to involve oneself and find the personal meaning with the Basic BAT exercises. Improvement of balance and posture was the most commonly reported therapeutic effect. The patients in the ‘outpatient group’ also expressed that they had developed an awareness that led to an ability to understand and handle signals or sensations from the body in a more positive way. The patients in the ‘inpatient group’ had gained or wanted to gain a better control of the body and movements. The therapeutic relationship and trust in the PT was a critical aspect for the ability to develop a positive working alliance. The concept of the working alliance seemed to be useful also in physiotherapy practice to describe and analyze factors that promote or hinder the development of a good cooperation in treatment. This study added some knowledge about the experience of the patients which generated some new hypotheses to be tested in further research.
ACKNOWLEDGEMENTS The authors thank Va˚rdalstiftelsen, Sweden, the Medical Faculty at Lund University, Sweden and the County of Scania, as well as the Department of Physical Therapy, University of Lund, Sweden for financial aid. We thank Go¨ran Nordstro¨m, the head of the Division of Psychiatry, Lund University Hospital, for making the necessary resources available. We are also grateful to and wish to thank all the patients who shared their experiences and thoughts
Domholdt E 2000 Physical Therapy Research. Principles and Applications. WB Saunders Company, Philadelphia Dropsy J 1975 Leva i sin kropp. [Living in Your Body.] Aldus, Lund Dropsy J 1988 Den harmoniska kroppen. [The Harmonious Body.] Natur och Kultur, Stockholm, Sweden Dropsy J 1999 Human expression – the coordination of mind and body. In: Skjaerven (ed). Bevegelses kvalitet, kunst og helse. [Quality of Movement, Art and Health.] Hogskolen i Bergen, Bergen, Norway, pp 11–24 Gaston L 1990 The concept of the alliance and its role in psychotherapy. Theoretical and empirical considerations. Psychotherapy 27: 143–153 Gelso JC, Carter JA 1994 Components of the psychotherapy relationship: their interaction and unfolding during treatment. Journal of Counseling Psychology 41(3): 296–306 Gomes-Schwartz B 1978 Effective ingredients in psychotherapy: prediction of outcome from process variables. Journal of Consulting Clinical Psychology 46: 1023–1035 Grahn B, Ekdahl C, Borgquist L 1996 Decreased quality of life and increased work environment problems in patients with musculoskeletal disorders. Musculoskeletal Management 2: 15–24 Gunderson JG, Frank A, Katz HM, Vanicelli ML, Frosch JP, Knapp PH 1984 Effects of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment. Schizophrenia Bulletin 10: 564–598 Gyllensten AL, Nilsson MO 1993 Psykiatrisk sjukgymnastik. [Psychiatric physiotherapy.] In: Holmstro¨m E, Johnsson B, Lundbladh K (eds). Sjukgymnastik i historisk belysning. [The History of Physiotherapy.] Studentlitteratur, Lund, Sweden, pp 80–84 Gyllensten AL, Gard G, Hansson L, Ekdahl C 2000 Interaction between patient and physiotherapist in psychiatric care – reflecting the physiotherapist perspective. Advances in Physiotherapy 2: 157–167 Gyllensten AL, Gard G, Salford E, Ekdahl C 1999 Interaction between patient and physiotherapist: a qualitative study reflecting the physiotherapist’s perspective. Physiotherapy Research International 4: 89–109
Horvath AO, Greenberg LS 1994 Introduction. In: Horvath AO, Greenberg LS (eds). The Working Alliance, Theory Research and Practice. Wiley and Sons Inc., New York Horvath AO, Symonds BD 1991 Relation between working alliance and outcome in psychotherapy: a meta-analysis. Journal of Counseling Psychology 38: 139–149 Jensen GM, Gwyer J, Hack LM, Shepard KF 1999 Expertise in Physical Therapy Practice. Butterworth-Heineman, Boston Klaber Mofett J, Richardson P 1997 The influence of the physiotherapist–patient relationship on pain and disability. Physiotherapy Theory and Practice 13: 89–96 Lambert MJ, Bergin AE 1994 The effectiveness of psychotherapy. In: Garfield SL, Bergin AE (eds). Handbook of Psychotherapy and Behavior Change, 4th ed. Wiley, New York Luborsky L 1994 Therapeutic alliances as predictors of therapy outcomes: Factors explaining the predictive success. In: Horvath AO, Greenberg LS (eds). The Working Alliance, Theory, Research and Practice. Wiley and Sons Inc., New York Mattsson M 1998 Body awareness, applications in physiotherapy. Dissertation, Department of Psychiatry and Family Medicine, University of Umea˚, Umea˚, Sweden Merriam SB 1988 Case Study Research in Education. Jossey-Bass, San Francisco Miles MB, Huberman AM 1994 Qualitative Data Analysis, 2nd ed. Sage Publications, Beverley Hills, CA, pp 18–22 Richardson B 1999 The way forward – how and why. Advances in Physiotherapy 1: 13–16 Roseberg S 2000 Body, being and meaning in a physiotherapeutic perspective [Kropp varande och mening i ett sjukgymnastiki perspektiv]. Dissertation Department of Social Work. University of Gothenburg, Sweden. Roxendal G 1985 Body awareness therapy and the body awareness scale, treatment and evaluation in psychiatric physiotherapy. Dissertation, Department of Psychiatry, University of Gothenburg, Gothenburg, Sweden Roxendal G 1995 Psykosomatisk sjukgymnastik [Psychosomatic physiotherapy] In: Sivik T, Theorell T (eds). Psykosomatisk medicin. [Psychosomatic Medicine.] Studentlitteratur, Lund, Sweden, pp 293–312 Shepard K, Jensen G, Schmoll B, Hack L, Gwyer J 1993 Alternative approaches to research in physical therapy: positivism
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and phenomenology. Physical Therapy 73: 88–101 Skatteboe UB, Friis S, Kvamsdal Hope M, Vaglum P 1989 Body awareness group therapy for patients with personality disorders. Psychotherapy and Psychosomatics 51: 11–17 Stanton AL, Gunderson JG, Knapp PH, Frank AF, Vannicelli ML, Schnitzer R, Rosenthal R 1984 Effects of psychotherapy in schizophrenia: I. Design and implementation of a controlled study. Schizophrenia Bulletin 10: 521–551 Strauss AS, Corbin J 1990 Basics of Qualitative Research. Sage Publications, Newbury Park, CA Strupp HH 1973 The interpersonal relationship as a vehicle for therapeutic
learning. Journal of Consulting Clinical Psychology 41: 13–15 Svensson B 1999 Treatment process and outcome for long-term mentally ill patients in a comprehensive treatment program based on cognitive therapy. Dissertation, Department of Clinical Neuroscience, Lund University, Division of Psychiatry, Lund, Sweden Svensson B, Hansson L 1999 Therapeutic alliance in cognitive therapy for schizophrenic and other long-term mentally ill patients: development and relation to outcome in an in-patient treatment programme. Acta Psychiatrica Scandinavica 99: 281–287 Swedish version of International Statistical Classification of Diseases and Related Health Problems 1996 Tenth Revision
(ICD-10). Almqvist and Wiksell Uppsala, Sweden Szybek K, Gard G, Linde´n J 2000 The physiotherapist–patient relationship: applying a psychotherapy model. Physiotherapy Theory and Practice 16: 181–193 Tyni-Lenne´ R 1989 To identify the physiotherapy paradigm. A challenge for the future. Physiotherapy Theory and Practice 5: 169–170 Wolf S, Barnhart H, Ellison G, Coogler C 1997 The effects of T’ai-chi and computerized balance training on postural stability in older subjects. Physical Therapy 77: 371–381 Zetzel E 1956 Current concepts of transference. International Journal of Psychoanalysis 37: 369–375
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Amanda Lundvik Gyllensten, Lars Hansson, Charlotte Ekdahl Abstract Background and Purpose: To explore the experiences of patients undergoing basic body awareness therapy in psychiatric physiotherapy. In addition, the therapeutic relationship and the concept of the working alliance were examined. Subjects: Two groups of patients participated: patients with schizophrenia (n=6) and general psychiatric outpatients (n=5). Method: A qualitative technique, video taping and interviewing the patients during treatment was used. Results: The most common experience from the treatment was ‘balance and posture’. Other experiences were ‘body movement control’ and ‘awareness and handling of body signals’. Themes central to establishing a good working alliance were identified. Discussion and Conclusions: The impact of balance and posture was discussed and some new hypotheses were generated. r 2003 Elsevier Science Ltd. All rights reserved. Amanda Lundvik Gyllensten PhD, RPT Department of Physical Therapy, Lund University, Sweden Lars Hansson PhD Assistant Professor, Department of Clinical Neuroscience, Division of Psychiatry, Lund University, Sweden Charlotte Ekdahl PhD, RPT Professor, Department of Physical Therapy, Lund University, Sweden Correspondence to: Amanda Lundvik Gyllensten Department of Physical Therapy, Lund University Hospital, SE-221 85 Lund, Sweden Tel.: +46 46222 4804; Fax: +46 46222 4204 E-mail: [email protected] ........................................... Journal of Bodywork and Movement Therapies (2003) 7(3),173^183 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00068-2 S1360-8592/03/$ - see front matter
Background In the last few decades, physiotherapy in psychiatry has been a developing professional field in the northern countries of Europe (Roxendal 1985, Gyllensten & Nilsson 1993, Mattsson 1998). Basic body awareness therapy (Basic BAT) is considered to be one of the main treatment methods of psychiatric physiotherapy (Mattsson 1998). Basic BAT in clinical psychiatric physiotherapy has previously been described (Roxendal 1985, 1995, Skatteboe et al. 1989). The method was developed and
described by the French psychoanalyst and movement teacher (Dropsy 1975, 1988) who synthesized the method inspired both by western movement traditions and the eastern practice of T’ai-chi Ch’uan (T’ai-chi). Basic BAT uses movements, breathing, massage and awareness to try to restore balance, freedom and unity of body and mind. Basic BAT is described as resource oriented, which in this case means working with the resources of the body as a whole. Turning the attention both to the doing and to what is experienced in the movements, the awareness of
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physical and mental aspects of the self is developed. Basic BAT differs from T’ai-chi in that movements are quite simple, focused on the experience of ease, stability and intention (Dropsy 1988, 1999). The treatment modality was developed to be starting exercises for T’ai-chi, and tends to follow the same principles that are embodied in these exercises (Gyllensten & Nilsson 1993). The therapist encourages the patient to move in ways more optimal to postural control, balance, free breathing and coordination (Dropsy 1988, Roxendal 1995). Basic BAT can be used both as an individual and as a group treatment. The encounter and interaction between physiotherapist (PT) and patient have been emphasized as an important tool in Basic BAT (Roxendal 1995, Mattsson 1998, Rosberg 2000, Gyllensten et al. 2000). The importance of interaction between patient and PT is, however, central to the physiotherapy curriculum as a whole (Tyni-Lenne´ 1989, Klaber Mofett & Richardson 1997). In a review of the evidence for interaction effects, five different models explaining the effect of interaction on patient outcome were found. These models concern the quality of communication and patient education, patient compliance, the patient’s perception of control and ability to cope, the PT’s enthusiasm for the treatment and operant conditioning in influencing pain behavior (Klaber Mofett & Richardson 1997). Expert PTs in primary health care believed interaction to be central to patient outcome and interaction skills could be increased by reflection about patients’ experiences (Gyllensten et al. 1999). The concepts of the working alliance and the therapeutic relationship have been thoroughly explored within psychotherapy research to understand and
predict therapy outcome. The therapeutic relationship is considered to consist of three components: the working alliance, a transference configuration and a real (genuine) relationship according to Gelso and Carter (1994). The working alliance can be defined as the patient’s attachment to and identification with the therapist, a kind of relationship resembling the bonded attachment to the primary caregiver (Zetzel 1956). According to Gaston (1990), the working alliance is the patient’s affective bond to the therapist and one part of the therapeutic relationship between patient and therapist. Strupp (1973) emphasized the interactive nature of the relationship, involving both the human qualities of the therapist as a good parent, and the patient’s openness and willingness to learn. This was seen as the base for imitation and identification essential to learning and success in therapy. Horvath and Greenberg define the working alliance as the interaction between patient and therapist. The collaborative relationship between client and therapist, the interactive nature of the relationship and the integration of technical and relational aspects are also emphasized (Horvath & Greenberg 1994). According to Luborsky there are two types of signs indicating the quality of the working alliance. Type 1 signs indicate that the patient experiences the therapist as warm, helpful and supportive and type 2 signs convey a sense of cooperation, working together in a joint effort in dealing with the patient’s problem (Luborsky 1994). Also, in physiotherapy, the therapeutic relationship has been the subject of analysis in an article that elaborated the three components: the working alliance, the transference configuration and the real relationship (Szybek et al. 2000).
Aims of the study The main purpose was to explore the patient’s experiences of Basic BAT in psychiatric physiotherapy. Their experiences of the therapeutic relationship and working alliance with the PT were also focused. The aim was also to study the concept of the working alliance in a physiotherapy context.
Methods and subjects Design The study employs a qualitative design, using the aims and the initial framework to bind the scope of the study and present the initial level of understanding of the phenomena of interest (Miles & Huberman 1994, Shepard et al. 1993). This design aims at generating models focusing on important issues or phenomena connected to physiotherapy (Jensen et al. 1999). The research method used in this study was a qualitative case study with cross-case analysis (Merriam 1988). In a case study, different types of empirical information, such as interviews, documents or observations, are collected. In cross-case analysis, individual case reports are analyzed and then compared in order to find a general explanation that fits all cases. Data in this study consisted of repeated interviews. The data from the interviews were organized using an interview transcription log (Merriam 1988). Low-inference data were obtained by using quotes from the patients’ interviews in order to provide internal validity. The initial framework was based on earlier knowledge of Basic BAT (Roxendal 1985, 1995, Mattsson 1998, Dropsy 1988, 1999) and the clinical experience of one of the researchers. Concerning the therapeutic relationship and the working alliance, the knowledge was mainly
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gained from psychotherapy research (Horvath & Greenberg 1994, Luborsky 1994). The initial framework is presented in Fig. 1. When conducting the first interview with the patients, an interview guide based on the initial framework was used; see Table 1. The interviews were tape recorded in full. The interview guide at the second and third interview consisted of the
Therapeutic relationship
Experience as ExperienceofofPT therapist warm, supportive as warm, supportive helping helping Sense of cooperation sense of cooperation Working together working together
open questions, ‘What did you see in the video?’, ‘Can you tell me about how you experience the treatment now?’ and ‘Can you tell me about the relationship with your PT?’ Before the study began, two video recordings were made and two interviews carried out to test the qualitative data collection methods and gain information and experience.
Basic Body Awareness Therapy Grounding/postural line Centering/breathing Flow Mental awareness Self-confidence Relation to others Relation to reality
Fig.1 Initial theoretical framework. The framework consisted of theories about factors important in the Basic BAT, such as grounding/relation to center line, centering/breathing, flow and mental awareness, and self-confidence, ability to relate to others and reality. Concerning the therapeutic relationship and the working alliance the knowledge was gathered from research in psychotherapy.
Table 1 Interview guide 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
What do you think you need to feel good/better? What do you think about the treatment with Body Awareness Therapy? Do you have a goal for your treatment with Body Awareness Therapy? Is the treatment with Body Awareness Therapy related to your goal, as you see it? Do you perceive the treatment with Body Awareness Therapy as meaningful? Can you tell me about your PT? Follow-up areas Can you tell me about whether you think that your PT is warm or cold as a person? Do you think that she is interested or not so interested in you? Is she capable or not so capable in her work, as you see it? Do you trust her? Do you feel accepted or respected? Do you think that she is a person that can help you? What do you think about the cooperation with your PT? Do you think that you are making any progress? Do you think that she thinks that you are making any progress? What would you tell a friend who had similar problems to yours about this form of treatment? Do you have anything to add about what good physical therapy treatment should be?
Patients The patients were selected to produce a sample with the maximum variation (Merriam 1988, Shepard et al. 1993, Jensen et al. 1999) in order to get a broad understanding of the phenomena from different perspectives. Two groups of patients participating in Basic BAT group therapy were included in the study; see Chart 1. One group was treated at a long-term rehabilitation unit for young patients with schizophrenia. The special unit was based on the cognitive therapy model, using a minimum of medication and a more intensive therapeutic intervention. Besides Basic BAT the patients were working in groups with education, social skills training and cognitive therapy (Svensson 1999). This group is hereafter called the ‘inpatient group’. The other group was treated in general psychiatric outpatient care. The patients were living at home and contracted to participate in 12 sessions. They all had other ongoing contacts with psychiatrist, social worker or psychotherapist. This group is hereafter called ‘the outpatient group’. The diagnostic system used was ICD-10 (Swedish Version of ICD 10, 1996).
Physiotherapists Two PTs, nominated as experts in psychiatric physiotherapy by their peers in a study about expertise in psychiatric physiotherapy in the south of Sweden (Gyllensten et al. 2000) and using Basic BAT in patient groups in January 1998, were asked to participate as therapists in the study. The expert PTs were both female, with many years of clinical practice in psychiatric physiotherapy (average 20 years) and well educated, having both formal and informal education
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Chart 1 Patient characteristics Inpatient group
Outpatient group
Number of patients Diagnosis
6 Schizophrenia (n=6)
5 Anxiety syndrome (n=2) Depressive and anxiety syndrome (n=1) Somatisation syndrome (n=1) Gille de Tourettes syndrome (n=1)
Age (years) Mean Range
30 29–39
45 30–55
Gender Males Females
4 2
2 3
Previous experience of Basic BAT (months) Mean Range
9 3–22
3 0–36
Present intensity in Basic BAT treatment
1.5 hours, three times a week
1.5 hours, once a week
in psychiatric physiotherapy, Basic BAT and T’ai-chi. They were working more than 50% of full time in direct patient contacts. The inclusion criteria for this study were: being a patient to a nominated expert PT in psychiatric physiotherapy and receiving Basic BAT in a group setting. At the onset of the study there were two Basic BAT groups, led by nominated expert PTs that fulfilled the inclusion criteria. The patients in both groups consented to participate. The Research Ethics Committee of the Medical Faculty of Lund University approved the study. The patients were informed about the study both in writing and orally, before giving consent to participation. Procedural steps in data collection Before the first video recording one of the researchers visited and participated in the groups, between one and three sessions in order to become acquainted with the
patients. She also informed the patients and answered questions about the study. The patients in the Basic BAT groups were video recorded and interviewed on several occasions; see Fig. 2. The patients in the ‘inpatient group’ were video recorded and interviewed three times. The first time the data were collected was in January 1998, then after 5 months in June, and then again in November the same year. During the first and second times there were six patients participating, and during the third
time three patients. The patients in the ‘outpatient group’ were video recorded and interviewed twice, once at the beginning of the group in February (session 3) and once in May (session 11), before the termination of the group. There were five patients participating at the first interview occasion in February, and three patients at the second interview. The video camera was placed so as to cover the whole group through the different activities and positions, such as laying on the floor, sitting, standing and sometimes walking, pairwise massage or T’ai-chi. Interviews with the patients were conducted after each video recording. The patients watched parts of the Basic BAT sessions before being interviewed. The emphasis was on the parts where the focus was mainly on the interaction between the PT and the patient. Watching the video and being interviewed lasted between 45 minutes and 2 hours, depending on the endurance and the psychiatric condition of the patient. The patients were interviewed as close to the therapy session as possible, preferably the same or the next day. The patients in the ‘inpatient groups’ were interviewed the same or the next day. For the ‘outpatient group’ the time interval could be up to a week if the patients found it difficult to take time off from work.
Inpatient group Information and consent
Researcher in group
Video 1 interview
treatment 4 months
Video 2 interview
treatment 6 months
Video 3 interview
Outpatient group Information and consent
Researcher in group
Video 1 interview
treatment 2.5 months
Video 2 interview
Fig. 2 Description of data collection. The patients in the inpatient group were interviewed three times, at the onset of the study, after 4 months and after another 6 months. The patients in the ‘outpatient group’ were interviewed at the beginning and the end of a 3-month Basic BAT group. 176
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Procedual steps in data analyses The interviews were tape recorded and transcribed in full. The first step in the analyses was to read the transcription of the interviews as a whole, trying to comprehend how the patients were experiencing the Basic BAT treatment and the therapeutic relationship with their PT. The analysis then concentrated on the patients’ experiences of the Basic BAT. Each interview was treated and coded as a case report. A separate interview transcription log was established for each patient and each interview. An open coding was used, aiming at understanding and conceptualizing the patients’ individual experience of their Basic BAT process. This was accomplished breaking down the interviews into different parts, representing different aspects or units of the experiences. Then these aspects were conceptualized into different categories representing different phenomena (Strauss & Corbin 1990, Merriam 1988). First the Basic BAT process of the patients in the ‘inpatient group’ was analyzed, then the Basic BAT process of the patients in the ‘outpatient group’ and then both groups were analyzed together, performing cross-case analysis (Merriam 1988), in order to identify both specific and common experiences of Basic BAT. The same procedure was then used to explore the patients’ experiences regarding the therapeutic relationship and the working alliance. This process included going back and forth between the original interviews, the transcription logs and cross-case analyses to validate the categorization of the data. The relationships between the categories were organized in themes as the data were synthesized (Merriam 1988, Strauss & Corbin 1990). The process of coding and categorization started
with the first interviews and were revised as the researchers collected and analyzed more data through interviews two and three. In the analytic phase, the two PTs were active. Analyses continued until consensus was reached.
Results The number in parentheses after each quote refers to the informant to which the quote belongs. Informants 1–6 took part in the ‘inpatient group’ and informants 7–11 took part in the ‘outpatient group’.
Basic body awareness therapy (Basic BAT) Four themes were found: (I) ‘Personal involvement’, (II) ‘Balance and posture’, (III) ‘Awareness and handling of body signals’, (IV) ‘Body movement control’, and are presented in Table 2. A presentation of the content of the themes and categories follows. (I) Personal involvement: The category ‘Ability to practice alone’ was found only in the patients (informants 5 and 8) reporting the most profound process in Basic Table 2 The Patients’experiences of Basic BAT.Themes and categories (I)
Personal involvement Ability to practice alone Questions about meaning
(II)
Balance and posture Improved balance and posture
(III)
Awareness and handling of body signals Deepened awareness and interpretation of signals Moving with ease Handling muscular tension
(IV)
Body movement control Feeling of body control Looking good and controlled
BAT (physiologically, psychologically and socially). The category of ‘Questions about meaning’ was found in the group of patients with schizophrenia (informants 1–6) at the first interview. Ability to practice alone Well the most important thing for me is that I have to continue these [exercises] my whole life and not think that this is over and done with. I have to, because otherwise I feel that I more and more fade away into some sleepy state of mind. And not to fade away or stop this process I have to do these exercises all the time, to be able to return back to life and gain strength and to be met as a person by others. To be met by others as an alert persony If we practice we can advance on the road to become more united with our movements yit happens to me when I make the Wave [first movement of the Cheng Man Ch’ing short yang form of T’ai-chi] because I feel sure about how to do it, in T’ai-chi. When I feel sure about how to do a movement in T’aichi, then I feel like I am one with my movements and it happens almost by itself. I don’t have to think so much. But I have practiced the Wave hundreds of times to become united with that movement y and it feels beautiful to do the T’ai-chi form. And it is y it is very important to me to feel that I’m doing something beautiful with my body [cries] (informant 8). In the beginning I did not take this seriously and I wondered what it was about. But then I thought that I really did not have any choice but to involve myself in this. But it took 6 months before I really understood it y and it has made me more mentally present and I will continue with these exercises, because I want to continue improvement in the future as well y So I do some exercises myself y bounce on my feet and y Like spend some minutes every day’ (informant 5). Questions about meaning Exercises like sitting and pressing your foot down into the floor, I don’t think that it is meaningful (informant 3).
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(II) Balance and posture: This theme consisted of the most commonly reported category, ‘Improved balance and posture’. Improved balance and posture I felt good. I was standing still and did not lose my balance or anything like that. No, completely still. I was standing still and my arms were in a good place and my legs in a good place, then I will keep my balance (informant 1). I really think that my balance has improved. And also my knowledge of how to keep my balance. The point of pressure must be on the front of the foot. Sometimes I forget, but then I hear her [the PT’s] voice within. Then I feel that I can move the whole body better if I place the point of pressure on the front foot. I did not feel this before yIn order not to look tired, I have tried to pull myself up, from the shoulders. I thought this was the place to pull myself up. I did not know that the postural balance should start from the legs (informant 8).
(III) Awareness and handling of body signals: This theme consisted of the categories ‘Deepened awareness and interpretation of signals’, ‘Moving with ease’ and ‘Handling muscular tension’. Deepened awareness and interpretation of signals You think about how you treat your bodyyyou feel from the inside where you have your bodyy if I sit in an armchair and I feel some tensiony that you change your position, not just sit there and force yourself and have painy. Regardless of whether you are walking, running or doing whatevery When I sit and write I can feel very tense and before I just continued writing and writing, regardless of the tensions. Now I just let go of the pen and do something else. It is just the point that now you can feel the signals of alarm earlier in a way (informant 11). I want to increase the contact with the body in another way than just sitting and stretching oneself, to be able to feel
the contact with the ball or other things instead. y In order to improve the contact with oneself y I don’t think that I am in reality very much (informant 3). Comments: The patient in the ‘inpatient group’ expressed a lack of this contact, but a wish for it. Moving with ease This feeling of improved ability to move, that I bounce when I walk that I have directly after the group. Then I can feel the bouncing in my steps and I wish that I could keep it always (informant 9). Handling muscular tensions Well, it isy it feels good to notice the difference between being tense and relaxed. It is easier to feel good. I can leave this tension behind. I think that this feels better. Last time at the end of the session I experienced that it felt much smoother really (informant 7).
(IV) Body movements control: This theme consisted the categories ‘Movement control’ and ‘Looking good and controlled’. Feeling of body control I was rather skilled. I have done these exercises before and I have had a lot of time to practicey last yeary Well I performed them rather skillfully (informant 4). Looking good and controlled People in the circus and others like that really have control of themselves. Now I don’t mean you have to be like that, but it looks much better if you have control of your bodyyIt looks much more healthy if one is mentally present and standing straightyand I had much more patience with the exercises. Generally it looks much better. You make a good impression (informant 5).
Other categories in addition were mental presence and concentration, freedom of breathing, a sense of well-being, improvement of self-confidence, gain of strength.
Therapeutic relationship and working alliance The experiences of the therapeutic relationship were structured into three themes: (I) ‘Personal relationship’, (II) ‘Characteristics of the PT’ and (III) ‘Treatment-related factors’, see Table 3. A presentation of the content of the themes and categories follows. (I) Therapeutic relationship: This theme consisted of the categories ‘Trust’ and ‘Faith in that the PT believes in me’. Trust Everything she says I just swallowy You get this feeling that if she says that things are possible, they are possible. You can just trust that things work the way she says they do (informant 9). A lot of trust is needed, because it is a sensitive situation. You don’t just sit there and talk and use your head. The whole of me is at stake (informant 8). Faith in that the PT believes in me Yes I definitely think she does [think that I am making progress]. She gave me a lot of positive feedback today (informant 5).
(II) ‘Characteristics of the PT’ – working alliance: This theme
Table 3 The Patients’experiences of the therapeutic relationship and working alliance. Themes and categories (I)
Therapeutic relationship and trust Trust Faith in that the PT believes in me
(II)
Characteristics of the Physiotherapist – working alliance Warmth Competence Respect/acceptance Encouragement Empathy
(III)
Treatment related factors – working alliance Cooperation Goal orientation Making progress
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consisted of the categories ‘Warmth’, ‘Respect’, ‘Competence’, ‘Empathy’, ‘Interest’ and ‘Encouragement’. Warmth A warm and tender person, that really listens to you (informant 5). I think that I would rather describe her as a cold person (informant 4). Competence You relax just by listening to her voice. It penetrates directly into your soul, if I can put it that way. She has such a smooth quality of ease in her voice. It feels like it spreads to us all. She is really competent and calm. Many good things thereyI think that she really is a good leader. She has great qualities as a leader. She has this calmness also when she is practicing. Here we are five beginners, not skilled at all and still she is calm. I think it is working extremely well (informant 11). Respect/acceptance So you don’t have to do it well to be included, or have to do it in the right way. Possibly she notices the difference between us, but myself, I don’t notice if that person is better or worse y It really isn’t very interestingy’(informant 9). One patient said that she did not feel respected. What I think is worse is what she says or commentsy she has some hard criticisms and I felt very bad about it y it happens that you laugh a little if you relax and think about something else or sort of get lost in your thoughts. I really don’t think that it is dangerous, not hallucinogenic really, in my opinion. I don’t think that you have to increase Liponex [medicine], so then I think that it is a little dangerous to go down [to the BAT group] (informant 4). Encouragement It has worked so well. I mean she really has listened to me. It is not only the bodywork, I have been able to talk about what I feel and I have been treated in such a good way the whole time. So I am
really, really pleased. She has done a great job and shown so much patience to make me feel well. I think that she is fantastic and always in a good mood. She encourages me the whole time. It has meant a lot (informant 8). Empathy We talked the first time and I felt that I had good contact with her and I experienced her as an empathic human being (informant 7).
(III) ‘Treatment-related factors’– working alliance: This theme consisted of the categories ‘Cooperation’, ‘Goal orientation’ and ‘Making progress’. Cooperation She tells me things, but it is a cooperation, because I try to do what she says (informant 6).
Goal orientation Two patients in the ‘inpatient group’ expressed goal orientation later in the treatment (after 5 months training or more). The patients in the outpatient group all described their goal. The goals could be very general or more specific.
Therapeutic relationship and Working alliance
To get well (informant 1). I saw that I was absent-minded. I want that to disappear (informant 5). To become more clear about the situations of tensing up. How to breathe and keep relaxed (informant 11). Making progress Yes, I think I have. Yes it sometimes feels good that I have mastered the movements (informant 4). Yes absolutely. I believe so much in this treatment and I wish for other people to receive such good treatment (informant 8).
These results are presented in the model of the revised framework in Fig. 3.
Discussion As the main focus in this study was to explore the patients’ experiences of Basic BAT, the therapeutic relationship and working alliance with the PT, a qualitative design using frameworks and case studies was found adequate. Important contributions to research from expert practice include an increase of knowledge, the clinical reasoning process, and reflection about
Basic Body Awareness Therapy
I Therapeutic relationship
I Personal involvement
II Characteristics of the PT Working alliance
II Balance and posture
III Treatment-related factors Working alliance
III Awareness and handling of body signals IV Body movement control
Fig. 3 Revised theoretical framework. The revised framework consists of the conceptualized understanding of the factors the patients themselves experienced as important in the treatment with Basic BAT and the therapeutic relationship and working alliance with the PT. 179
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practice and skill acquisition (Jensen et al. 1999, Richardson 1999). Our intention was to explore how the patients treated by expert PTs perceived the treatment and the relationship to their PT. This aimed at adding another dimension to the clinical knowledge in the area. To formulate a revised model or framework, not founded on theory only, but on what the patients actually reported, was seen as a means to understand what was central to them in the Basic BAT curriculum. This in turn we hoped could be used to generate new research hypothesis, founded in clinical experience (Domholdt 2000). A strategic choice of two different groups of patients was made. As the purpose was to explore a wide range of possible experiences of Basic BAT and the therapeutic relationship to investigate if we found any differences and similarities in the experiences of the patients, this strategy was found to be adequate. This practice of a strategic choice is common in qualitative research (Jensen et al. 1999, Shepard et al. 1993). The procedure of making video recordings from the group sessions served the purpose of actualizing the memory of the treatment sessions. With the ‘outpatient group’, there could be up to a week between the Basic BAT group and the interview. In the ‘inpatient group’, the interview was carried out within a couple of hours. As the treatment period is much longer with patients suffering from schizophrenia, the time span for data collection was different for the two groups (see Fig. 2) adjusting to the clinical reality. Patients with schizophrenia have a much longer treatment period than patients in general psychiatric outpatient care. To obtain a rich, manifold description of the phenomena of interest was the objective. Still the quality of the interviews varies a lot. It was
generally much more difficult to get the patients with schizophrenia in the ‘inpatient group’ to speak freely. This resulted in more questions being asked and the answers being shorter. This was especially true for the first interview, but changed in interviews two and three. We have judged the value of the material as adequate and interesting, mirroring one of the difficulties of this group of patients. The analyses of the patients’ process in Basic BAT revealed that a sense of improved balance and stable posture was central. This is in line with theories of Basic BAT (Dropsy 1988, 1999, Roxendal 1995). The patients in this study thus supported the theories of Basic BAT, emphasizing the impact of balance, grounding and center line as important aspects in treatment. The importance of balance has also been focused in other areas of physiotherapy. Balance and postural control was one of the most important factors in identifying patients with musculoskeletal disorders in need of multidisciplinary rehabilitation (Grahn et al. 1996). Balance was improved and falls reduced in older subjects by the use of T’ai-chi exercises (Wolf et al. 1997). Since Basic BAT and T’ai-chi are closely related, the impact of this kind of treatment on balance and postural control seems to be strong. ‘Personal involvement’ appeared to be vital to the ability to practice Basic BAT alone. To continue practice alone is viewed as an important factor in physiotherapy practice in the area, since it is believed to be related to outcome. In psychotherapy research, involvement is considered to be the best predictor of outcome (GomesSchwartz 1978). To be able to understand or create meaning also seemed to be important to be able to involve oneself. This is in line with research from psychotherapy where
factors like motivation are shown to have a great influence on outcome (Lambert & Bergin 1994). The ability to involve oneself more in treatment, found in this study, also seemed to be related to the duration of treatment. The patients who had a longer treatment period of Basic BAT also seemed to be more involved. Perhaps this is related to the fact that to continue treatment one has to be motivated and involved. To fully understand these phenomena more research is needed. In the ‘inpatient group’ the patients had not specifically chosen to participate in Basic BAT, since this was part of the curriculum in which they were expected to participate. This was obvious at the first interview, when some of the patients expressed a difficulty in understanding the meaning of the exercises. This had an impact on motivation and involvement in the therapy. ‘Awareness and handling of body signals’ was the most frequently stated gain from the movement exercises in the ‘outpatient group’. As informant 11 put it (see Results, the category of ‘Deepened awareness and interpretation of signals’), this increase of awareness and contact motivates you from the inside to take care of yourself in a better way. The patients seemed to be able to develop the qualities of improved contact with the body and the self. Generally, the patients in the ‘outpatient group’ expressed many positive benefits from their participation in the Basic BAT group. The experiences seemed to involve not only the body, but also more emotional aspects and selfconfidence. The aim of Basic BAT treatment according to the theories is to help the patients to feel from the inside what is a good balance, and to find ease and freedom when moving. This is done by encouraging the patients to develop their own proprioceptivity, sensitivity and
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awareness. To discover that they themselves possess the tool to feel good within their body, strengthens the experience of self-confidence and trust in the body, according to the same theories (Roxendal 1985, Mattsson 1998, Dropsy 1999). The results from this study indicate that these aspects of the Basic BAT theory seem to be most relevant for the patients treated in outpatient care. To the patients with schizophrenia in the ‘inpatient group’, who had much more basic problems with identity, the experience of, or wish for, contact with and control of the body was more central. The aspect of control of the body is not emphasized in the theories of Basic BAT. This opens the field for some interesting hypotheses about the importance of body and movement control in schizophrenia rehabilitation. Concerning the working alliance, the theme of ‘Characteristics of the PT’ contains factors that can be seen as an expression of type 1 signs of the working alliance, denoting the characteristics of the therapist (Luborsky 1994). This can be due to the interview guide using questions about these factors. The factors do however also feel very relevant in physiotherapy treatment. They are very much like the categories reported by expert PTs interviewed about what they believed to be important in the interaction with their patients (Gyllensten et al. 1999, 2000). The theme of ‘Treatment-related factors’ can be seen as an expression of type 2 signs of the working alliance, according to Luborsky (1994). These signs convey a sense of cooperation, working together in a joint effort in dealing with the patient’s problem, and indicate the quality of the working alliance. Also in physiotherapy goal orientation, cooperation and thought about making progress are
signs of a positive physiotherapy process and a positive working alliance. Three of the six patients in the ‘inpatient group’ (half of the patient group) felt that they had a good working alliance with the PT. Of the remaining patients, one (informant 4) did not develop a good therapeutic relationship with her PT. She did not make any positive remarks about the relationship or interaction, although she experienced that she had mastered the movements. With another patient (informant 3), there seem to have been great difficulties establishing a good working alliance, not only for the PT. This patient generally had problems to remain in rehabilitation at the cognitive long-term rehabilitation unit. Because of intense psychotic suicidal impulses, she was transferred to another ward and was more heavily medicated. Yet another patient (informant 2) expressed a negative opinion of the PT’s ability to help, but had a positive experience of the relation with the PT in general. According to research in psychotherapy, the ability of patients with the diagnosis of schizophrenia to develop a good therapeutic relationship and working alliance seems to be problematic. Less than half of the patients with schizophrenia in a randomized, controlled study of treatment effects of psychotherapy, formed a good working alliance (Stanton et al. 1984, Gunderson et al. 1984). A Swedish study of the therapeutic alliance in a group of long-term mentally ill patients treated at a unit based on cognitive therapy revealed the patients’ ratings of the therapeutic alliance in the initial phase to be good in 38.5% and fair in 57.7% of the cases (Svensson & Hansson 1999). In the ‘outpatient group’ four of the five patients had a positive working alliance with their PT. The
patients in this group had less problems with relationships and they had themselves chosen to participate in the Basic BAT group. This made them more motivated and the forming of the working alliance less problematic. The most problematic aspects to form a positive working alliance seemed to be related to the theme ‘Therapeutic relationship’ and the feeling of lack of trust in the PT or doubts about whether the PT thought that they could make any progress in the treatment. Here is a link to the experiences in Basic BAT where the patients who reported a positive therapeutic relationship also reported that they used the Basic BAT exercises on a daily basis at home. Interestingly, these patients were found in both patient groups. This result is in line with the results from psychotherapy research, where the patient’s qualities of openness and trust are seen as essential for the ability to develop a relationship that is favorable to the learning process (Strupp 1973). This finding generates a new research hypothesis of the relationship between the therapeutic relationship especially trust and outcome in Basic BAT treatment. The concept of the working alliance may serve as tools in the identification and differentiation of factors that help or hinder the development of a good cooperation between patient and PT. Among the different definitions of the working alliance, the definition by Horvath and Greenberg (1994) seems to be best suited for the area of physiotherapy. They emphasize the interaction between the technical and relational aspects in addition to the collaborative relation between patient and therapist. In physiotherapy, where treatment involves working with body-related skills, as well as touch and not only verbal interventions, this seems to be the most applicable. The theories of
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Luborsky (1994) about the different types of the working alliance also seem to be relevant in the area of physiotherapy.
with us, and the expert physical therapists involved in the study.
REFERENCES
Conclusion The study points to the importance of the ability to involve oneself and find the personal meaning with the Basic BAT exercises. Improvement of balance and posture was the most commonly reported therapeutic effect. The patients in the ‘outpatient group’ also expressed that they had developed an awareness that led to an ability to understand and handle signals or sensations from the body in a more positive way. The patients in the ‘inpatient group’ had gained or wanted to gain a better control of the body and movements. The therapeutic relationship and trust in the PT was a critical aspect for the ability to develop a positive working alliance. The concept of the working alliance seemed to be useful also in physiotherapy practice to describe and analyze factors that promote or hinder the development of a good cooperation in treatment. This study added some knowledge about the experience of the patients which generated some new hypotheses to be tested in further research.
ACKNOWLEDGEMENTS The authors thank Va˚rdalstiftelsen, Sweden, the Medical Faculty at Lund University, Sweden and the County of Scania, as well as the Department of Physical Therapy, University of Lund, Sweden for financial aid. We thank Go¨ran Nordstro¨m, the head of the Division of Psychiatry, Lund University Hospital, for making the necessary resources available. We are also grateful to and wish to thank all the patients who shared their experiences and thoughts
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