Frank Röhricht

Body oriented psychotherapy. The state of the art in empirical research and evidence-based practice: A clinical perspective

The heterogeneous field of body oriented psychotherapy (BOP) provides a range of unique contributions for the treatment of mental disorders. Practice based clinical evidence and a few empirical studies point towards good efficacy of these non-verbal intervention strategies. This is particularly relevant for those disorders with body image aberration and other body-related psychopathology, but also for mental disorders with limited treatment response to traditional talking therapies, e.g. somatoform disorders/medically unexplained syndromes, PTSD, anorexia nervosa or chronic schizophrenia. However, the evidence base is not yet sufficiently developed in order to get BOP recognised as suitable mainstream treatment by national health services and their commissioning bodies. Strong academic links are urgently required in order to support practitioners in their efforts to evaluate the clinical work in systematic research. The field would greatly benefit from the development of international higher education training in integrated clinical body psychotherapy, enabling practitioners to obtain a masters degree. From a scientific perspective, projects on the interface between neuroscience and psychotherapy research should be conducted in order to understand more fully the therapeutic processes in BOP, particularly with regard to emotional processing, movement behaviour and body/self perception. Qualitative research is needed to further investigate the specific interactive therapeutic relationship, the dynamics of touch in psychotherapy and the additional self-helping potential of creative/arts therapy components. Provided that these requirements will be fulfilled, BOP could be established as one of the main psychotherapeutic modalities in clinical care, alongside other mainstream schools such as psychodynamic, cognitive-behavioural and systemic.

Specific body image pathology in acute schizophrenia

Despite a wide phenomenological interest in body image pathology in schizophrenia, there has been little systematic empirical research. This study aimed at establishing the specificity of body image pathology in patients with schizophrenia, its changes during acute treatment, and its association with other symptom factors. Cognitive (thoughts/beliefs regarding the body--body concept), affective (body satisfaction--body cathexis) and perceptual (body size estimation--body schema) facets of body image and psychopathology were assessed in in-patients with paranoid schizophrenia (N = 60), schizoaffective disorder (N = 19), depressive disorder (N = 40) and anxiety disorder (N = 28) at admission, and after 2 and 4 weeks of treatment. Body size perception was also assessed in a sample of healthy subjects (N = 44). Patients with paranoid schizophrenia/schizoaffective disorder showed under-estimation of lower extremities at each time point. They expressed a higher degree of body concept disturbances at admission, but not at later stages. In a factor analysis, body perception and body concept loaded on distinct factors, which were separate from positive symptoms, negative symptoms, and anxiety. Patients with acute paranoid schizophrenia and schizoaffective disorder seem to have a specific and consistent disturbance of body size perception, which might indicate a dysfunction of sensory information processing.

Ego-pathology, body experience, and body psychotherapy in chronic schizophrenia

OBJECTIVES In a recent pilot RCT, looking at the efficacy of body oriented psychological therapy (BPT) in patients with chronic schizophrenia, a marked improvement in negative symptoms was found in the treatment group. To date, there have been no studies to evaluate the therapeutic processes, correlates and predictors of change in-patients receiving BPT. The aims of this study are to address three specific questions, namely how: (1) Ego-pathology and (2) Body experiences, may change during the treatment (BPT). We also looked at: (3) If these pathologies, and/or changes in them, or other characteristics are associated with specific clinical outcomes. DESIGN Analysis of data obtained within a pilot randomized controlled trial. METHOD In a sample of patients with a diagnosis of chronic schizophrenia, allocated to receive a course of body oriented group psychotherapy, certain parameters were assessed pre- and post-treatment: (1) Ego-pathology, using the ego-pathology inventory (EPI); (2) Body experiences, (size perception/image marking procedure - IMP, body image/body distortion questionnaire - BDQ, and body cathexis/visual-analogue-scales - VAS); and (3) Common symptom factors, using the Positive And Negative Symptom Scale (PANSS). Subjective experiences were also recorded. RESULTS Four out of six ego-pathology symptom scores improved over the course of therapy (t=2.9-3.5, p<.05-.01). Amongst the measures of body experiences, only the body perception indices of the lower extremities changed significantly from underestimation pre-therapy (BPI median 92.3), becoming accurate estimates post therapy (BPI median 101.1). Contrary to the hypothesis a reduction of negative symptoms in chronic schizophrenia patients was not associated with systematic improvements of ego-pathology or body experiences. The strongest predictor of change was a high score of ego-demarcation pre-treatment (beta=0.89, p<.001). CONCLUSIONS In patients with chronic schizophrenia, body oriented psychological interventions may be effective for both positive therapeutic changes in ego-pathology and negative symptoms, even though these effects are not necessarily related. High scores of ego-pathology at baseline predicted a poor treatment outcome. This finding deserves more systematic studies, as it could potentially identify patients with poorer prognosis and underpin the development of new intervention strategies. Further studies are required to clarify more precisely the exact nature of the processes in BPT.

An exploratory randomized controlled trial of body psychotherapy for patients with chronic depression.

BACKGROUND Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. This is the first randomized controlled trial designed to evaluate the effectiveness of Body Psychotherapy (BPT) in patients with chronic depression. METHODS Patients with chronic depressive syndromes (more than 2 years symptomatic) and a total score of ≥ 20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. BPT was manualized, delivered in small groups in 20 sessions over a 10 weeks period, and provided in addition to treatment as usual. In an intention to treat analysis, primary outcome were depressive symptoms at the end of treatment adjusted for baseline symptom levels. Secondary outcomes were self-esteem and subjective quality of life. RESULTS Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7, 95% confidence interval 1.0-16.7). Secondary outcomes did not show statistically significant differences. When the scores of the waiting group before and after BPT (as offered after the waiting period) were also considered in the analysis, the differences with the initial waiting group remained significant. CONCLUSIONS The results suggest that BPT may be an effective treatment option for patients with chronic depression. Difficulty recruiting and subsequent attrition was one of the limitations, but the findings merit further trials with larger samples and process studies to identify the precise therapeutic mechanisms.

Effectiveness and cost-effectiveness of body psychotherapy in the treatment of negative symptoms of schizophrenia – a multi-centre randomised controlled trial

BackgroundNegative symptoms of schizophrenia are frequently associated with poor long term outcomes. Established interventions have little, if any, positive effects on negative symptoms. Arts Therapies such as Body Psychotherapy (BPT) have been suggested to reduce negative symptoms, but the existing evidence is limited. In a small exploratory trial a manualised form of group BPT led to significantly lower negative symptom levels both at the end of treatment and at 4 months follow-up as compared to supportive counseling. We designed a large multi-site trial to assess the effectiveness of a manualised BPT intervention in reducing negative symptoms, compared to an active control.Methods/DesignIn a randomised controlled trial, 256 schizophrenic outpatients with negative symptoms will be randomly allocated either to BPT or Pilates groups. In both conditions, patients will be offered two 90 minutes sessions per week in groups of about 8 patients over a period of 10 weeks. Outcomes are assessed at the end of treatment and at six months follow-up. The primary outcome is severity of negative symptoms, as measured by the Positive and Negative Symptom Scale (PANSS), whilst a range of secondary outcome measures include general psychopathology, social contacts, and quality of life. We will also assess the cost-effectiveness of the intervention.DiscussionThe study aims to evaluate the effectiveness of a promising form of group therapy which may help alleviate negative symptoms that are associated with unfavourable long-term outcomes and have so far been difficult to treat. If the trial is successful, it will add a new and effective option in the treatment of negative symptoms. Group BPT is manualised, might be attractive to many patients because of its unusual approach, and could potentially be rolled out to services at relatively little additional cost.Trial registrationCurrent Controlled Trials ISRCTN84216587

Functional relaxation as complementary therapy in irritable bowel syndrome: a randomized, controlled clinical trial.

OBJECTIVES Irritable bowel syndrome (IBS) is a frequently disabling and almost invariably distressing disease with a high overall prevalence. Numerous trials identified the importance of psychogenic and emotional etiological factors, and this is obvious in clinical practice. Although relaxation techniques are frequently recommended, there is still a lack of evidence for their efficacy in the management of IBS. This study therefore aims to determine the efficacy of functional relaxation (FR) in IBS. SUBJECTS The subjects were 80 patients with IBS. INTERVENTIONS Participants were randomly allocated either to FR or to enhanced medical care (EMC: treatment as usual plus two counseling interviews) as control intervention with 2 weekly sessions over the 5-week trial each. Thirty-nine (39) patients completed FR and 39 received EMC. OUTCOME MEASURES An impairment-severity score (IS) was employed as the primary outcome parameter with assessment at baseline, after treatment, and again after 3-month follow-up. RESULTS FR was significantly superior to EMC with a standardized effect size of 0.85. The achieved effects through FR remained stable in terms of psychic and bodily impairment after 3-month follow-up. CONCLUSIONS The results of our trial suggest a positive effect of FR training on subjective functional impairment in the IS, if provided in addition to treatment as usual (TAU). There appears to be a clinically relevant long-term benefit of FR as a nonpharmacological and complementary therapy approach in IBS.

Functional Relaxation and Guided Imagery as Complementary Therapy in Asthma: A Randomized Controlled Clinical Trial

Background: Asthma is a frequently disabling and almost invariably distressing disease that has a high overall prevalence. Although relaxation techniques and hypnotherapeutic interventions have proven their effectiveness in numerous trials, relaxation therapies are still not recommended in treatment guidelines due to a lack of methodological quality in many of the trials. Therefore, this study aims to investigate the efficacy of the brief relaxation technique of functional relaxation (FR) and guided imagery (GI) in adult asthmatics in a randomized controlled trial. Methods: 64 patients with extrinsic bronchial asthma were treated over a 4-week period and assessed at baseline, after treatment and after 4 months, for follow-up. 16 patients completed FR, 14 GI, 15 both FR and GI (FR/GI) and 13 received a placebo relaxation technique as the control intervention (CI). The forced expiratory volume in the first second (FEV1) as well as the specific airway resistance (sRaw) were employed as primary outcome measures. Results: Participation in FR, GI and FR/GI led to increases in FEV1 (% predicted) of 7.6 ± 13.2, 3.3 ± 9.8, and 8.3 ± 21.0, respectively, as compared to –1.8 ± 11.1 in the CI group at the end of the therapy. After follow-up, the increases in FEV1 were 6.9 ± 10.3 in the FR group, 4.4 ± 7.3 in the GI and 4.5 ± 8.1 in the FR/GI, compared to –2.8 ± 9.2 in the CI. Improvements in sRaw (% predicted) were in keeping with the changes in FEV1 in all groups. Conclusions: Our study confirms a positive effect of FR on respiratory parameters and suggests a clinically relevant long-term benefit from FR as a nonpharmacological and complementary therapy treatment option.

Changes in body image and health-related quality of life following breast reduction surgery in German macromastia patients: a new tool for measuring body image changes.

Health insurance funds in Germany are increasingly reluctant to fund the cost for reduction mammaplasty. However, several studies have already demonstrated the beneficial effects of breast reduction on symptom relief and health-related quality of life. More specifically, the psychologic and social consequences of breast reduction surgery were also recently evaluated. Relating to the contemporary debate on financial restraint, the present article describes a follow-up study conducted in a sample of 40 patients undergoing reduction mammaplasty. The purpose of the investigation was to assess indicators of health-related quality of life following reduction mammaplasty. Furthermore, the study aimed to assess body image changes and to test a new assessment instrument, Digital-Body-Photo-Test (DBPT), in comparison with a well-validated body image measure (Color-a-Person Body Dissatisfaction Test, CAPT) (concurrent validity). As hypothesized, the findings indicate significant improvements in health-related quality-of-life measures and body-image characteristics. The substantial improvement of body-image satisfaction of all body areas suggests a generalized positive effect of reduction mammaplasty on overall body image. The strong association between the DBPT and the CAPT scores in this study indicates that DBPT is an efficient and valid new tool for measuring body-image changes relating to patients’ evaluations of their average satisfaction of specific body parts or areas and their overall appearance acceptance.

‘Dancing down memory lane’: Circle dancing as a psychotherapeutic intervention in dementia—a pilot study

Background: There is increasing recognition that psychological interventions for people with dementia and their carers are of value. Neuropsychological considerations and an exploration of the literature point towards the potential benefits of non-verbal, body-oriented interventions to work psychotherapeutically with people as their cognitive abilities deteriorate. Method: A total of 18 people (11 people with moderate-to-severe dementia and 7 family carers) consented to partake. Measures were completed before and after the group therapy (45 minutes once a week for 10 weeks). Weekly progress monitoring sheets were completed and participants were interviewed after the group for their views. Results: The therapeutic intervention had a positive impact on participants’ general well-being and mood, including improving people’s concentration and communication with others. Discussion: The results of the pilot study support using therapeutic circle dance as a body-oriented psychological intervention for people with dementia and their carers. Further studies with more stringent methodologies in larger samples are required.

Management of medically unexplained symptoms: outcomes of a specialist liaison clinic

Aims and method Service utilisation and clinical outcomes of a newly developed specialist primary-secondary care liaison clinic for patients with medically unexplained symptoms (MUS) were evaluated in a cross-sectional and feasibility pilot study. The impact of body-oriented psychological therapy (BOPT) was explored in a small cohort of patients with an identified somatoform disorder. Results Of 147 consecutive referrals, 113 patients engaged with the assessment process. Of patients with MUS, 42% (n = 45) had a primary diagnosis of somatoform disorder, 36% (n = 38) depressive disorder, and depressive symptoms (even subsyndromal) mediated the effect of somatic symptoms. A marked variation of presenting complaints and service utilisation across ethnic groups was noted. A significant reduction in somatic symptom levels and service utilisation was achieved for patients undergoing BOPT. Clinical implications A high proportion of patients with MUS have undiagnosed and therefore untreated mental disorders. New and locally derived collaborative care models of active engagement in primary care settings are required. Patients with somatoform disorder may benefit from BOPT; this requires further evaluation in adequately powered clinical trials.