Therapeutic processes
and outcomes in
body psychotherapy research
Dr. Frank Röhricht MD
Unit for Social and Community Psychiatry
Queen Mary University of London
London / UK
Crossing Borders:
Symposium: “other therapy”
EAP congress 2008 in Nice




Integral self-therapy (“novel approach”)
Utilization of therapeutic dogs for depression and
anxiety
Autogenic psychotherapy
Packing therapy in children and adolescents with
autism:
“Wrapping the patient with his under-clothes, using
towels previously wet in clod water. The patient is then
wrapped with blankets to help the body warm up.”
There is more wisdom in your body
than in your deepest philosophy.
-Friedrich Nietzsche. German classical Scholar, Philosopher
and Critic of culture, 1844-1900.
Outline




Some basic facts
Findings from other research areas relevant for the
evaluation of BPT
Outcomes from research re efficacy and processes
in BPT
1. overview, 2. examples (SD/schizophrenia)
Outlook/The way forward
Body psychotherapy – basic facts





Google: >25000 hits (first
765 pages relevant)
USABP (> 500 members),
peer-reviewed journal
EABP (>600 members in
21 countries)
8th International Congress
of BPT 11/2008 in Paris
3x MA Somatic Psychology
in USA




Medline: 20 hits (one
relevant); PsyInfo 179
(89)
Term BPT not fully
established
No state accreditation
Not represented on
mainstream congresses
On the outside:
Focussing
Hakomi
Functional
Relaxation
Biodynamic
psychotherapy
Psychomotricity
Body mind
approach
Tai-Chi
Analytical
Body psychotherapy
Eutonie
Character Analytic
Vegetotherapy
Biosynthesis
Dance &
Movement
Rolfing Therapy
Thymopraktik
Concentrative
Movement therapy
Feldenkrais
BodyBehaviour
therapy
Yoga
Bioenergetics
Core-Energetics
Shiatsu
What is Body Psychotherapy?



The common underlying assumption is that the body is the
whole person and there is a functional unity between mind
and body. (EABP)
Based on an holistic view of the human being, on the unity
of body and mind, psychomotricity integrates the cognitive,
emotional, symbolical and physical interactions in the
individual’s capacity to be and to act in a psychosocial
context. (EFP)
DMT is the psychotherapeutic use of movement and dance
through which a person can engage creatively in a process to
further their emotional, cognitive, physical and social
integration. (ADMT-UK)
Therapist’s perspective




I am doing a good job, because my patients get
better
I am an experienced therapist and know best
what to do when
For BPT: “I can sense the blocked energy, and I
will make it flow again”
Randomised controlled trial of physiotherapy
versus advice for low back pain (N=286)
Oswestry disability index
P=.17
2-months
P=.31
P=.28
6-months
12-months
Frost et al. BMJ 2004
Improvement
3.0
2.5
2.0
1.5
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
Advice only (N=142)
Worsening
Mean Change From Baseline
Physiotherapy (N=144)
RCT physiotherapy/advice for low back pain:
Patient’s perceived benefit
Patient perceived benefit
P=.006
P=.025
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Improvement
Mean Change From Baseline
P=.001
2-months
6-months
Physiotherapy
Frost et al. BMJ 2004
12-months
Advice only
Re-Search


Scientific research relies on the application of
the scientific method, a harnessing of
curiosity. This research provides scientific
information and theories for the explanation
of the nature and the properties of the world
around us. It makes practical applications
possible. .
Probability is the likelihood or chance that
something is the case or will happen.
Wikipedia – the free encyclopaedia
From inside
What do we know already?
– a systematic overview:
Thematic emphasis for theory of
Body psychotherapy





Developmental psychology (body-ego)
Phenomenology of body experience
Specific illness characteristics (i.e. Body
image disorders)
Methodological considerations re
Intervention technique
(Affective) neuroscience and motor
behaviour
Neuroscience and Psychotherapy

“From the perspective of neuroscience,
psychotherapy can be understood as a specific
kind of enriched environment designed to
enhance the growth of neurons and the
integration of neural networks”
Cozolino, 2002
Neural growth and integration on
psychotherapy are enhanced by:
1. Establishment of a safe and trusting relationship
2. Gaining new information and experiences across the
domains of cognition, emotion, sensation, behaviour
3. Simultaneous or alternating activation of neural
networks, that are inadequately integrated
4. Moderate levels of stress or emotional arousal
alternating with periods of calm and safety.
5. Integration of conceptual knowledge with emotional
and bodily experience.
Body psychotherapy
How does it work?
– the intervention strategy:
Intervention techniques common to
all BPT’s





Body/experience regarded as important therapeutic
medium
Therapeutic relationship centered around
immediate self/body experience, involving touch
and psychomotor expression
Gestures, posture, spontaneity and movement
pattern therapeutically utilised
Emphasis on ‚healthy‘ personality traits, ressources,
self-regulation
Working with tension dynamics and affect
regulation
Basic hypotheses, BPT offers/acts upon:





specific tools for specific problems, symptoms
a unique, interactive therapeutic relationship
a multidimensional approach
BPT operates at the centre of emotional processing
and motor (expressive) behaviour
BPT relates directly and intrinsically to strengths,
capabilities and creativity
Outline
Some basic facts
 Findings from other research areas relevant for
the evaluation of BPT
 Outcomes from research re efficacy and processes
in BPT
1. overview, 2. examples (SD/schizophrenia)
 Outlook/The way forward

Anxiety disorder

Body perception negatively
correlated with anxiety levels
(Compton 1969, Röhricht & Priebe 1996)

Phobic anxietydepersonalisation syndrome
(Tucker et al. 1973, Noyes et al. 1977)

Body image satisfaction low in
anxiety patients
(Marsella et al. 1981, Löwe & Clement 1998)


Bermuda-Triangle: Anxietytension headache-anger
Grounding, body-awareness,
boundary articulation, fightflight impulses
Depression



Range of somatisation
symptoms (chest pressure, pain,
etc.)
Motor retardation, lack of drive
energy and motivation
Negative body cathexis, somatic
depersonalisation and boundary
loss correlated with degree of
anxiety symptoms (Röhricht et al. 2002)
Anorexia Nervosa:




Severe body image aberration,
overestimation of body sizes
Negative body cathexis with
hostile attitudes
Control and manipulation of
bodily functions (e.g. excessive
exercising, vomiting)
Movement analysis:
What else do we know?

Neuropsychology: movement and emotional
experiences are biologically and experientially
associated ( ‘a moving experience’ Trimble 1997)
Outline




Some basic facts
Findings from other research areas relevant for the
evaluation of BPT
Outcomes from research re efficacy and processes in
BPT
1. overview, 2. examples (SD/schizophrenia)
Outlook/The way forward
Evaluation of BPT-1


Numerous cohort studies with various methods
1970 - 1998 in healthy samples, neurosis, drug
abuse: increase in body satisfaction, self-perception,
self-esteem and muscular tension (Fisher 1996)
Dance/Movement therapy vs. waiting list:
Reduction in depression and anxiety for BPT group
(Brooks & Stark 1989)

Movement therapy for patients with depression,
neurosis, mania, schizophrenia: general wellbeing
improved, complaints reduced in BPT group, no
effect on specific symptoms (Weber et al. 1994)
Dance/Movement therapy vs. waiting
list in depression and anxiety
80
75
70
pre BEC
pre CG
post BEC
post CG
65
60
55
50
SOM
O-C
ins-soc DEPR
ANX
Inpatient body oriented
psychotherapy in Eating disorder
Evaluation of the Effectiveness of BodyPsychotherapy in Out-Patient Settings
EEBP-study main outcome:
Specific examples:
Evaluation of BPT
in psychosomatic disorders
Bioenergetic exercises in inpatient treatment of
Turkish immigrants with chronic somatoform
disorders: A randomized, controlled study
Bioenergetic exercises
versus : mean changes
pre-post
P=.28
3.0
2.5
2.0
1.5
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
SCL-90 scales
BEC CG
Frost et al. BMJ 2004
Improvement
SCL-90
P=.31
Worsening
Mean Change From Baseline
P=.17
Functional relaxation versus
Terbutaline/Placebo in Asthma
60 days before/after therapy
Diagnostic headache diary
Change of intensity and duration pain
Functional relaxation versus
unspecific isotonic relaxation in
chronic tension headache
16
14
12
10
8
6
4
2
0
15.7
11.711.4
13
10.1
9.8
5.8
UIR
eFR
0.6
pain
days
before
pain
days
after
pain
hours
before
pain
hours
after
Pilot study: Bodymind approach
(group work) for patients with
medically unexplained symptoms
CORE-OM mean scores for subscales
MYMOP mean scores for each element from
baseline to follow-up
baseline to follow up
Payne et al. in preparation
Specific example 2:
Evaluation of BPT
in schizophrenia
CMT-study, Jung 2002
N=18 acute schizophrenia inpatients
BPI: Gesunde, Schizophrene im Verlauf n=18
120
BPI in %
110
100
90
80
1
Gesunde
2
Schiz Aufnahme
3
Schiz 4 Wochen
Evaluation of BPT in schizophrenia


Body-ego-technique” vs. Music therapy: improvement of
psychopathology scores and sign. > re. affective contact as
well as motility (Goertzel et al. 1965)
Movement and Drama therapy vs. SC in chronic sch. (RCT):
for BPT sign. improvement of social behaviour and
restlessness; psychopathology better in both groups
(Nitsun et al. 1974)


Body centred PT vs. OT in acute schizophrenia (RCT): only
for those patients with body image disorder in BPT group
sign. > improvement of ego-disturbances (Maurer 1976)
Body perception training in schizophrenia: improved social
competencies/body size perception, reduced anxiety (Seruya
1977)
Changes BPI following Concentrative
movement therapy/TAU
BPI im Verlauf: Patiennten ohne KBT
120
120
110
110
BPI in %
BPI in %
BPI im Verlauf: KBT-Teilnehmer
100
100
90
90
80
80
Kopf
Rumpf
KBT Aufn.
KBT 4 Wo
Beine
Gesunde
Kopf
Rumpf
N-KBT Aufn.
Jung 2002
N-KBT 4 Wo
Beine
Gesunde
From A to Z
Negative symptoms in schizophrenia


Sass and Parnass : These symptoms (or rather
signs, since they mostly involve behavioral
observations) include poverty of speech, affective
flattening, apathy and anhedonia, and a general
inattentiveness to the world.
empirical research shows that patients who display
flat affect actually report an intense emotional
reactivity that contradicts their lack of overt
affective expression
(Bouricius 1989; Berenbaum and Oltmanns 1992; Kring, Kerr, Smith et al. 1993; Hurlbut
1990)
Hypotheses: How can BPT potentially
address negative symptoms
in schizophrenia



Self-defensive strategies, active withdrawal in
response to perceived threats and/or
disintegrative ego-processes (“Totstell-Reflex”)???
Hence: 1. ego-consolidation, enhanced body
perception (periphery) boundary articulation as
precondition for:
2. enhanced motor expression/emotional
processing = enhanced social participation/QoL
Demographic characteristics
BOT group
 N=24
38.9 (21-55)
12.1 (2-31)
3.7 (1-12)
16.4 (10-21)
12/12

Age
Duration of illness
No admissions
School left
Gender f/m
SC group
 N=21
37.7 (20-55) n.s.
10.8 (2-30) n.s.
4.4 (1-12) n.s.
17.0 (15-22) n.s.
11/10 n.s.

Clinical baseline characteristics
BPT group
 N=24
16.5 (7-24)
23.4 (16-35)
39.1 (26-54)
11.4 (6-15)
11.6 (0-23)
49.3 (28-70)
1.4 (0-6)

PANSS-pos
PANSS-neg
PANSS-gen
Anergia
EPP-total
MANSA
EPS-total
SC group
 N=21
13.1 (7-29) n.s.
24.6 (12-34) n.s.
38.6 (21-62) n.s.
11.8 (7-16) n.s.
8.2 (0-23) n.s.
47.8 (28-62) n.s.
1.7 (0-8) n.s.

Outcome measures 1
PANNS-negative scores
25
24
23
22
21
20
19
18
17
16
15
24.6
23.4
23.3 23.2
18.9
initial
after treatment
6-month follow-up
18.2
P<.001
T=5.3, df=22
BPT (N=24)
n.s.
SC (N=21)
Outcome measures 2
BPRS anergia scores
15
14
13
12
11
10
9
8
7
6
5
11.9
11.4
8.9
12
11.1
initial
after treatment
6-month follow-up
8.4
P<.001
T=5.3, df=22
BPT (N=24)
SC (N=21)
Outcome measures 3
Reduction psychopathology scores / %
20
19.4 24.1
15
8.4 9.1
10
5
3.9 3.6
3.2
0
-5
-10
BPT
SC
1.4
PANSS-neg
Anergia
PANSS-pos
PANSS-gen
Outcome measures 4
MANSA scores
60
55
50
52.9
49.3 49.4
47.8
49.8
51.1
initial
after treatment
6-month follow-up
45
40
35
30
n.s.
BPT
n.s.
SC
Outcome measures 5
clients assessment of treatment
40
38
36
34
32
30
28
26
24
22
20
44
39
36
31
P=.07,
t=1.9
df=25
CAT after
treatment
P<.05,
t=2.4
df=27
HAS-P after
treatment
32
25
P=.05,
t=2.0
df=27
HAS-T after
treatment
BPT
SC
Outcome measures 6
Reduction Ego-psychopathology scores


In experimental group significant reduction in
EPP-scores pre/post for the subscales:
demarcation, consistency, activity and body
(p<.05, t=2.2-3.6, df=23)
No significant reduction in EPP-scores within
the control group
Predictors of Treatment Response



Dependent variable:
% reduction BPRS anergia:
Independent variables:
No of attended sessions, number prev. hospitalisation,
age, gender, VAS-scores, EPP-scores, employment status,
age leaving education, MANSA-scores, PANSS-scores at
admission
85% of total variance explained by: onset of
illness (beta .57, p<.01), EPP-demarcation
(beta -.57, p<.01) and VAS-small (beta .35,
p<.05)
Summary of findings:
The next step:
BPT-RCT Assessments 2
Mediating/Process measures:





Movement Psychodiagnostic Interview (MPI),
(analysis of movement behaviour on the basis of
videotapes from assessment interview)
Rating scale for emotional blunting (SEB)
Differential Emotions Scale (DES−IV)
Semi−structured phenomenological interview
Video observation of therapy sessions
Outline
Some basic facts
 Why is there a need for more/other and
nonverbal/BPT therapies
 Findings from other research areas relevant for
the evaluation of BPT
 Outcomes from research re efficacy and
processes in BPT
 Outlook/The way forward

Advances:


Neuroimaging and BPT
Process research:


What are the active ingredients?
Differential therapeutics
When is which therapy working better?
 When is combined therapy working better?
 Which therapists characteristics work?


BPT
Thank you!