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The physiotherapists' experience of Basic Body Awareness Therapy in patients withschizophrenia and schizophrenia spectrum disorders.

Hedlund, Lena; Lundvik Gyllensten, Amanda

Published in:Journal of Bodywork & Movement Therapies

DOI:10.1016/j.jbmt.2012.10.008

2013

Link to publication

Citation for published version (APA):Hedlund, L., & Lundvik Gyllensten, A. (2013). The physiotherapists' experience of Basic Body AwarenessTherapy in patients with schizophrenia and schizophrenia spectrum disorders. Journal of Bodywork & MovementTherapies, 17(2), 169-176. https://doi.org/10.1016/j.jbmt.2012.10.008

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Journal of Bodywork & Movement Therapies (2013) 17, 169e176

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/jbmt

THERAPEUTIC PROCESSES

The physiotherapists’ experience of Basic BodyAwareness Therapy in patients with schizophreniaand schizophrenia spectrum disorders

Lena Hedlund, RPT, MSc*, Amanda Lundvik Gyllensten, RPT, PhD

Department for Physiotherapy, Faculty of Medicine at Lund University, P.O. Box 157, 221 00 Lund, Sweden

Received 10 March 2012; received in revised form 18 September 2012; accepted 1 October 2012

KEYWORDSSensory motor;Self-recognition;Self-development;Meta-cognition;Body-mind therapy

* Corresponding author. Tel.: þ46 46E-mail address: lena.hedlund@med

1360-8592/$ - see front matter ª 201http://dx.doi.org/10.1016/j.jbmt.201

Summary Background: Scandinavian physiotherapists (PT) treat patients with schizophreniaand schizophrenia spectrum disorder, mainly because of the latter’s bodily difficulties. Onecommonly used method is Basic Body Awareness Therapy (BBAT), targeting the difficulties withsensory motor dysfunction and disembodiment. The aim of the study is to describe the phys-iotherapist’s experiences of using BBAT for patients with Schizophrenia.Method: In a qualitative study, eight physiotherapists, who use BBAT when treating patientswith schizophrenia were interviewed. The interview transcriptions were analysed accordingto content analysis.Results: Three stage related themes were created: “encountering” “discovery towardsembodiment”, and “inner space towards outer world”. In “encountering” the PTs describedimportant aspects at the beginning of treatment. “Discovery towards embodiment” revealedhow the PTs conceived that the patients’ attention is directed toward their own body and theirbodily experiences. The theme, “inner space towards outer world” reflects the PTs experienceof the changes achieved and how patients turn their attention to the outside world as a morecompetent self.ª 2012 Elsevier Ltd. All rights reserved.

Background

Physiotherapists in Sweden often meet patients withschizophrenia because of the latter’s disturbed body image

222 00 00..lu.se (L. Hedlund).

2 Elsevier Ltd. All rights reserved2.10.008

and movement disorders. In these encounters the physio-therapists assess body image, perception and movementquality. They can offer a number of treatment methods,including Basic Body Awareness Therapy (BBAT), which wasdeveloped in Scandinavia (Hedlund and Gyllensten, 2010).BBAT is a holistic method that focuses on body awareness asa basic level of self-awareness. The theoretical backgroundincludes philosophical theories described by Merleau-Ponty

.

Table 1 Characteristics of the informants.

Working place Gender andage

Workexperience asphysiotherapists

Work withactual groupof patients

Southern andcentral partsof Sweden,five differentcities

All female,between 30and 67 yearsold, mean41 years

6e31 years,mean 13 years

3e31 years,mean 11years

170 L. Hedlund, A.L. Gyllensten

(1962), developmental theories of sensory motor functionas in Piagets’ cognitive development (Gerbhardt et al.,2008) and Self-development as in Daniel Sterns descrip-tion of the infant’s stages toward a Self (Stern, 1985). BBATconsists of simple exercises in stillness and movements. Theexercises are performed in lying, sitting, standing orwalking positions and the emphasis is on the direct expe-rience in the moment-to-moment situation. The move-ments are focused on the experience of ease, stability andintention. The principles are to work with increasinggrounding, postural stability, centered coordination, andawareness of the body, the self and the present moment.When working with BBAT the physiotherapists alwaysaddress the patient and are interested in how the personperceives his/her body and movement. This bodily-basedself-experience is both verbalized by the patient andconfirmed by the physiotherapist as a means for reflection(Hedlund and Gyllensten, 2010).

Schizophrenia and schizophrenia spectrum disordersinclude several symptoms and dysfunctions. The psycho-pathology of schizophrenia is also elaborated in terms ofdisturbance of the minimal or basic bodily self, disem-bodiment, the loss of intentionality, agency and delusion ofcontrol (Kaiser and Weisbrod, 2007; Cermolacce et al.,2007; Jeannerod, 2009). There is increasing researchtoday concerning first-rank symptoms, difficulties with self-recognition, self-development and meta-cognition(Schimansky et al., 2010; Lysaker et al., 2007, 2010;Gebhart et al., 2008; Waters and Badcock, 2010). Self-development and self-recognition are assumed to origi-nate from the bodily level (Frith et al., 2000; Kircher andLeube, 2003; Gerbhart et al., 2008). The importance ofsensory motor development and function, proprioceptionand multisensory integration toward a developed andcontinuously integrated self-experience are described byTsakiris et al. (2010) and Gerbhart et al. (2008). De Haanand Fuchs (2010) point out the need of further researchregarding whether and how body-oriented and movement-oriented therapies might strengthen the embodiment ofpatients with schizophrenia.

Other studies within psychiatric community care haveshown that BBAT can aid the development of a more posi-tive experience of the body and the self (Gyllensten et al.,2003). Studies concerning BBAT in patients with schizo-phrenia are, however, very few. Roxendal (1985) showedimproved movement behaviour and increased gaze andsexual interest within 17 patients with schizophrenia.

The treatment process involves three components; thetherapist, the patient and in between them, the method.Clinically, a treatment method usually needs to be adaptedby the therapist to the unique patient or group exercisingit. In a qualitative study patients described their experi-ence of BBAT and different treatment effects. The resultshowed changes in four areas; affect regulation, increasedbody awareness and self-esteem, effects described ina social context and effects on the ability to think. As anexample of affect regulation, the patients described howthe exercise led to increased feelings of vitality andinterest. They felt in better contact with their body expe-riences and the present moment. They experienced betterpostures, which for some were associated with a betterself-esteem and feelings of integrity. Finally, the patients’

also expressed that exercise resulted in better ability toconcentrate and the experience of having “clearer”thoughts (Hedlund and Gyllensten, 2010).

The aim of the present study is to describe thephysiotherapists’ perspective and experience of theirwork, in terms of how they describe; a) the treatmentwith BBAT in patients with schizophrenia and schizo-phrenia spectrum disorders and b) how they describetheir experience of the treatment benefits for the groupof patients.

Method

Informants

Clinical physiotherapists participated in the study. Inclusioncriteria were:

1) working mainly with patients diagnosed with schizo-phrenia for at least 3 years and

2) participating in Basic Body Awareness Therapy educa-tion, at least step 2 in the method (for more informationabout the education, seeHedlund andGyllensten, 2010).They were recruited through a nomination procedure byrequesting the assistance of the Institute of Basic BodyAwareness Therapy in Sweden. The institute was askedfor suggestions for skilled practitioners working withpatients with schizophrenia and nominated eight phys-iotherapists in southern Sweden. All nominated physio-therapists were interviewed. Their characteristics areshown in Table 1. This study compliedwith stipulations inthe Swedish Act, the Ethical Review of ResearchInvolving Humans (SFS, 2003), and the principle ofinformed consent was applied.

Interview technique and interview process

A semi structured interview guide was used. It consisted ofboth open questions and more concrete, specific questions(see Table 2). The interviews were tape recorded andtranscribed by the first researcher and were then sent backto the physiotherapists for a check of the content. Onephysiotherapist made some clarifications. Each interviewtook between one and 2 h to conduct and took place at thephysiotherapists’ out-patient unit. The interviews wereconducted according to Kvale’s (1989) criteria for a highqualitative interview.

Table 2 Interview guide with semi-structured questions.

1. Why do you use Body Awareness Therapy when treatingpatients with schizophrenia and similar diseases?

2. Who determines the goal of the treatment?3. How do you know that the patient is involved in the

treatment?4. Do the patients have their own favourite exercises?5. Do patients do daily exercises with Basic Body

Awareness?6. What are the benefits of treatment with Basic Body

Awareness?

Table 3 Steps in content analysis.

Activity Result

Reading all interviewsseveral times.

From “chaos” to briefknowledge of content.

Comparing meaning unitsin a single interviewwith two otherprofessions; onepsychologist and oneoccupational therapist

Good concordance(over 85 percentageconcordance)

Writing down all theinformants’ statementsexactly on a paper.

Greater feeling for thematerial, being able tofind different statementsand the descriptions of thecontexts

Cut out all statementswith meaning units.

De-contextualisation.

A rough coding of thewhole transcribed textin a cross analysis

Six major areas, forexample “theory”,“treatment effects”and “process descriptions”

A more precise codingwith second author.Back and forwardchecking process.

37 different codes emerge.The codes that describethe process dominate.

Seeking for categoriesusing manifest contentanalysis, with secondauthor. Back and forwardchecking process.

22 categories.

A higher abstraction ofcategories with secondauthor. Back and forwardchecking process. Peerreview.

Re-contextualisation.Finding 7 categories.Need for further analysis.

Even greater abstraction,latent content analysis.First author selectedthemes, checked bysecond author. Back andforward checking process.

Finding 3 themes and 9categories.

Checking the final results tothe context in all interviews

Small adjustments to thecategories.

Writing the report, picking outquotations representing thecategories.

Article.

Basic Body Awareness Therapy and schizophrenic patients 171

The process of analysing the transcriptions

The transcribed text was analysed in accordance withcontent analysis, with inspiration from both the manifestand latent versions (Malterud, 1998; Graneheim andLundman, 2004). The stepwise process of analysis andsteps to increase the trustworthiness are presented in Table3.The researcher had initially decided to use manifestcontent analysis, which entails the text being systemati-cally reduced into meaning units, which is an existing wordin the text that represents or is central to the meaning ofthe sentence. The nature of the material revealed a needto adjust the method, both in terms of making a preliminaryclassification before selecting meaning units, and further,to also include latent content analysis. When using latentcontent analysis the underlying meaning of the text isinterpreted and used (Graneheim and Lundman, 2004). Thefinal results, with themes and categories are presented inTable 4.

The pre-understanding of researchers

Both researchers have experience in psychiatric out-patientcare. The first author has worked with the actual group ofpatients for 23 years. The researchers are also welleducated in the BBAT method.

Result

Three main themes were created. They were “Encoun-tering”, “Discovery towards embodiment” and “Innerspace towards outer world”. Almost all of the informants’answers to questions 1e5 (see Table 2) are represented inEncountering, question number 6 in Inner space towardsouter world. The third theme; Discovery towardsembodiment mostly represent the information about thetreatment process and the physiotherapists’ skill inadjusting the method specifically to the needs of thepatient.

Encountering

Theoretical frameworkThe physiotherapists mainly use the normal self-development and sensory motor development as a modelfor understanding what the problems are and what the

resources and strengths are for each individual. The self-concept is used in various ways by physiotherapists, espe-cially when assessing the patient’s need for better contactwith their true self, their feelings, needs, limits and bodyboundaries. In order to be able to feel and recognizefeelings is important, especially the experience of vitality.One physiotherapist said;

‘if you are bent double, you will not have access toenergy, both the rhythm exercises and flow exercises,the heel rebound will start your vitality and through thatvitality you’ll have access to yourself.’

Table 4 The themes and their respective categories.

Encountering Discoverytowardsembodiment

Inner spacetowards outerworld

� Theoreticalframework

� Difficulties andpossibilities

� Participation andgoal setting asa way tostrengthen theexperience of self

� Non-verbal andverbal interaction

Exercises theprocess ofdiscoveryGuidance forsensing andbeing presentin the body

Finding structureIncreased contactwith the sensingselfTurning attentionto the worldoutside

172 L. Hedlund, A.L. Gyllensten

Difficulties and possibilitiesThe physiotherapists stated that they meet a uniqueperson, with a narrative history and a certain personalitywith inherent or acquired difficulties. They focused onthe patient’s resources, which included an inherent driveto develop as a person. Different physical, emotional,interpersonal and cognitive difficulties are described bythe physiotherapists. They provided a description of thepatients as having a high level of fear, lack of vitality,high level of ambivalence and feelings of emptiness. Thepatients are described as having difficulties with standingup for themselves and having a “false self”, in need ofdefense mechanisms toward genuine feelings andpersonal needs. Some patients use a kind of intellectu-alization to avoid contact with feelings. The physio-therapists also provided a description of differentsensory motor dysfunctions and lack of sensory connec-tion with the body, lack of anchor and grounding in thebody, lack of body boundaries, fragmented perception ofbody and self as well as hypersensitivity. One informantexplained;

‘the patients have a fragmented sense of themselves,the experience of themselves as a whole unit is oftenbroken, and a disability to feel their body boundaries.Some of them talk about feeling “skinless”, not to knowwhere they begin or end.’

The physiotherapists described that it usually takesa long time before attachment occurs and that the qualityof therapeutic alliance varies over time due to crises andprogress in the treatment.

Participation and goal setting as a way to strengthen theexperience of selfThe physiotherapists talked about the need of the patient’sparticipation in order to establish a goal from the firstencounter. The physiotherapists need a goal to find thegenuine motivation for change within the patients. Thepatient’s own goal is superior in relation to the physio-therapist’s assessments although they try to integrate thepatient’s goal with the physiotherapeutic perspective. Thepatient’s goals often change over time due to a bettercontact with themselves.

After some initial BBAT exercise led by the physiother-apist, the patients are mainly allowed to choose the BBATexercises they prefer. The physiotherapists believe thepatient’s choices arise from an inherent need and allowsthem to be more involved in themselves. The involvementis shown in several ways: by the patient’s reflections, bythe choice of exercise or by doing exercises at home ashomework or through the body language or just by comingto treatment. One physiotherapist said;

‘I see it, in their eyes, they are there, calming downwhen the integration appears. You can see in the eyes,like a little sigh and then they don’t struggle that des-perately. and then, the fact that they reflect over theexercise.’

Non-verbal and verbal interactionAll physiotherapists saw themselves as an importantcollaborator with the patient. They support the patients toexplore themselves when exercising BBAT. The physio-therapists think it is important to convey hope, trust andthe possibility of change.

The physiotherapists observe the patient’s bodylanguage and mental state. They interact on a non-verballevel by using empathy and emotional contagion. Onephysiotherapist said;

‘I put myself in that body position. Then I get differentsuggestions on what’s going on and I can give suggestionsto the patient.Is it like this. or like this today? I useempathy or read the body language and I really try to be“here and now” in the treatment.’

Physiotherapists encourage the patients to verbalize anddifferentiate their experiences. The focus on verbalizing isalso a way to stimulate the patient’s ability to reflect overtheir own experiences and thus get a distance to them andunderstand their personal context. One physiotherapistsaid;

‘The patients start to reflect about what is happeningand through reflecting over what goes on in the body indifferent situations, at home or where ever they are.Then they spontaneously start to reflect...and askwhy.’

The physiotherapists are aware that words might hindera more genuine experience. By continuing the exercise insilence, the patients have an opportunity to experiencethat every affect decreases after a while by letting it passand instead hold on to the awareness of the body and thepresent.

Discovery towards embodiment

Exercise the process of discoveryMost of the physiotherapists declared that it was importantto provide exercises that lead to a pleasant experienceinitially, as a way of motivating the patient. One physio-therapist explained;

‘Yes, I think life is hard as it is. Especially for the young Imeet. They were about to start out in life and then theysuffered from a tough breakdown, leaving them doubtful

Basic Body Awareness Therapy and schizophrenic patients 173

and with low self confidence and self-esteem. So I thinkwe have to start with something good. Then, by expe-rience, after managing a few steps, those things that aredifficult surface naturally.’

Some physiotherapists talked about the need forinducing curiosity and courage when doing BBAT. Thepatients need the courage to experience different feelingsand sensations.

All major changes are connected to a temporaryincreased confusion or anxiety. When the patient’s atten-tion drifts away the physiotherapist clarifies this. In orderto encourage the patients to challenge their anxiety, thephysiotherapist can clarify the choice that has to be made,by asking; what makes you develop most?

Guidance for sensing and being present in the bodyCatching and maintaining the patient’s attention is impor-tant according to the physiotherapists. They observe inwhat mental states the patients perform their exercises,and guide their attention individually towards the body.One physiotherapist explained;

‘You test it individually, because they find themselvesand their presence in different ways, by focussingdifferently in the exercises. Some of them work easilyfrom the centre of the body. Others just need the centreline or the grounding so it’s very different.’

All the physiotherapists declared that the basis for beingattentive and present at the moment in time is the contactwith the sensing body. They think that it is important tocontextualize the different sensations and to put the bodyin its spatial context.

The physiotherapists sometimes relate to their ownexperiences of BBAT. Through their own process with BBAT,the physiotherapists have knowledge about how thedifferent exercises affect the body and how to deal withbodily experiences. They study the patient’s body languagein order to ensure that the patients are all right. If thepatient has a strong bodily defence he/she is met withgreat caution. The physiotherapist usually also strengthensthe body defences initially in order to increase thepatient’s feeling of security. They think it is important toachieve an anchoring in the body before exposure todifferent difficulties. One way of coping is described by oneof the physiotherapists;

‘The main thing is to do the exercise in contact with thecentre line, to be in balance and not in your compen-sated position, to be grounded instead and in balance,anatomically. There you find your strength.’

Most progress comes slowly but sometimes it appears asa sudden “therapeutic moment”. One physiotherapistsaid;

‘All these mysterious exercises.. you can make a jokeabout making sounds and strange movements thatyou’re not used to. But then, suddenly, it’s not so sillyany more... because. Aha!... then you’re motivatedand you do not need to say so much. The patient doesnot say so much but shows up every week. Somethinghas started, which was felt deeply and genuinelyinside.’

Inner space towards outer world

Finding structureThe physiotherapists talked about changes when thepatients found their postural balance. The patient’s self-esteem increase, they look prouder when leaving thetreatment, become more active and start to stand up forthemselves. The contact with the postural balance alsogives the patients something to “hold on to” among otherpeople as one physiotherapist reported;

‘The contact with the centre line makes it easier for herto relate to herself, when she is out. She feels moresecure and dares to meet other people without being soafraid.’

The physiotherapists experienced that paranoidthoughts and commentary hallucinations can decreasewhen the patients experience postural balance. Sometimeseven voices can decrease, both in strength and frequency.The physiotherapists also described how BBAT strengthensthe body as a whole and integrated unit. Patients find theirstillness and become calmer and more relaxed, increasetheir wellbeing and clearness in thoughts. One physiother-apist said;

‘Those patients who are fragmented, and have nopossibility to pull themselves together, when they findthe centre in movement and learn to control theirmovement so they can choose between moving the bodymore peripherally or centrally, then the mental abilityto focus also appears.’

Increased contact with the sensing selfBy working with BBAT the physiotherapists reported thattheir patients started to sense more. Body movementsincrease the sensory input which sometimes leads to thefeeling of being more alive and vital. When anchored orgrounded in the body the patient’s ability to differentiatetheir sensations increases.

‘When they move toward their line of balance and standon their legs and I don’t know what, find their centreline, they report more and more different experiences...breathing, movement, different feelings in theirbodies.’

The physiotherapists described a complex mechanismincluding becoming calmer, changes in awareness and bodyfunctions that they believe leads to more differentiatedsensations. The physiotherapists thus think that thepatients have a better chance of feeling what is reallythere, inside them.

‘I think they make connections better, between whathappens and how it feels inside. That life affects mesomehow, something affects me, what I do, how Ithink.’

Turning attention to the world outsideThe physiotherapists described how their patients turntowards the outer world when they developed a better self-recognition and self-esteem from working with the body.The physiotherapists described an increased engagement,

174 L. Hedlund, A.L. Gyllensten

vitality and courage within the patients, which leads to anincreased interest in socializing and taking care of them-selves in a better way. The importance of daring to relateto others is described by one physiotherapist;

‘They do not have so many contacts. They are veryafraid to let others close to themselves and they haveenough with all their symptoms.but if you get moresecure in yourself then you dare to let people comecloser to you. You start to listen more to signals from thebody and you can speak up more easily and then youdare to invite others.’

On a perceptual level, the ability to differentiate innerlife from outside is exemplified by one physiotherapist;

‘I think he has learned to differentiate between fantasy,reality and hallucinations, maybe not the way I do but heunderstands there is a difference but exactly what thatmeans to him I don’t know. But to be part of this world,to stand on your legs and sometimes look other people inthe eyes, I definitely believe that it has helped him to bein this world after being so trapped in his own world.’

After psychosis there is also a lot of anxiety connectedwith the body and the experiences from it. Becoming moreactive, even spontaneously starting to exercise, is reportedby the physiotherapists, due to increased self-engagementand less anxiety towards one’s own bodily experiences.

Discussion

Method

Eight physiotherapists, who met the inclusion criteria, werenominated and all were interviewed. Eight can be seen asa small sample of informants, these had, however a veryspecialized experience in order to conform with the inclu-sion criteria and as a group had worked for a mean ofeleven years. The researcher used a semi structuredinterview method. During the interviews the physiothera-pists’ also provided descriptions of their work as a complexprocess with the patients, what they did when they tried toengage and guide their patients toward increased embodi-ment. This probably demonstrates the complex reality ofthe physiotherapists’ work and their willingness to tellabout their experience.

The first researcher’s own experience of both thetreatment method and type of patients led to a pre-understanding which naturally has had an impact on theresearch process; from the planning of the study to thewritten article. In order to increase the trustworthiness theimpact of the pre-understanding needed to be minimized orcontrolled. One way was by using interpretations andverification during the interview thereby checking that thefirst researcher had correctly understood the physiothera-pists’ points of view, instead of filling out empty spaceswith pre-understanding. The transcribed interviews werealso sent back to the informants in order to check thecontent. Furthermore, the selection of meaning units inone interview was compared with that performed by twoother professionals; one psychologist and one occupationaltherapist, resulting in more than 85% concordance. Finally,

most of the analysis was carried out together with thesecond researcher. This thus allowed both to question eachother’s analysis.

Results

The purpose of the study was to describe the physiothera-pists’ experiences of their work, in terms of how theydescribe the treatment with BBAT and how they describetheir experience of the treatment benefits for patients withschizophrenia and schizophrenia spectrum disorders. Thephysiotherapists also gave a rich description of thepatients’ difficulties and possibilities for recovery, whichare linked to exercising BBAT. The given descriptions arevery optimistic, both concerning the patients’ ability torecover and how they benefit from treatment. The phys-iotherapists describe both the method and the patientswith a great level of engagement. There are of courseseveral possible explanations for their optimistic view. Oneis that it really reflects important aspects and treatmentpossibilities for the patients, which also has been shown inother studies, including the patients’ own experience ofthe treatment (Hedlund and Gyllensten, 2010; Gyllenstenet al., 2003). Another possibility is, of course, that thephysiotherapists overestimate the value of their work.When working closely with patients over a long period oftime it is also difficult to have a meta-perspective, todiscriminate different treatment benefits from sponta-neous recovery or the impact from other treatments.

When analysing the material, three different stageswere discovered; Encountering, Discovery towardsembodiment and Inner space towards outer world. Inreality the treatment process is, of course, not thatdifferentiated into stages and neither are the descriptionsof treatment benefits clearly separated from the treatmentprocess. It can instead be described as a circulative processwith many steps working in parallel. However, makinga stage-wise description has the benefit of sorting out thedifferent aspects and thus clarifying the existence ofdifferent components, which are important for theprofessional development of psychiatric physiotherapy. Thepragmatic validity of the study will thus finally be assessedby colleagues.

The themes are now discussed separately in the orderthe physiotherapists described the treatment process.

Encountering

One theoretical starting point is self-development anda belief in the ability to develop. Piaget’s sensory motordevelopment is one basic framework for the work withsensory motor function. As a medical hypothesis, Gerbhartet al. (2008) make a comparison between Piaget’s cognitivedevelopment and the basic disease mechanism in psychoticdisorders. The authors present parallels between thepatients’ disturbance in perception and a child’s normaldevelopment. The patients still have, for example, diffi-culties separating subjectivity and objectivity, whendecentralizing their perception of themselves and theworld, resulting in difficulties in adjusting to reality. In

Basic Body Awareness Therapy and schizophrenic patients 175

relation to this, BBAT provides the opportunity for workingwith the earliest levels in Piaget’s cognitive development.

The physiotherapists think every patient is unique and inorder to attain this “uniqueness” the patients participationis needed. Every patient has their own combination ofresources, shortcomings and personality. The individualizedperspective may, however, also have the benefit of main-taining the physiotherapists’ own engagement towardsevery unique patient. The physiotherapists really need tobe attentive in order to be able to carry out the treatment,which is mostly based on non-verbal communication. Theimportance of their own body awareness for the physio-therapists must not be underestimated. The knowledge isused to support, guide and help complete the patients’ lackof words for their different kinds of body experiences,leading to a mutual process of reflection and better affectregulation. This is in line with earlier studies, focussing onthe interaction between physiotherapist and patient(Hedlund and Gyllensten, 2010). The ability to reflect uponone’s own feelings and thoughts, are defined as one basiccomponent of meta-cognition and mentalization (Lysackeret al., 2007). BBAT includes making reflection over one’sown body experiences, which is important for affect regu-lation, self-knowledge and in mutual relationships but alsoto prepare patients to benefit from other verbal interven-tions, such as psychotherapy (Hedlund and Gyllensten,2010).

Discovery towards embodiment

The physiotherapists think that pleasurable experiences area good start for discovering the inner self. Curiosity is usedto engage and establish an open mind that decreases orneutralizes the fear of sensing. The physiotherapistsdescribe how they guide the patient to turn the attention tothe inner self. The patients often have difficulties withattention and the physiotherapists have developeddifferent strategies to enhance the patients’ ability toremain attentive. Attention is needed in BBAT in order tomake changes on a bodily level.

When focussing on the bodily experiences it is importantto contextualize the different sensations. The physiother-apists do this in several ways, with a focus on integratingbody and mind spatially, but also in a narrative way. It isimportant to know why you have a certain feeling or bodysensation, and in what way you are affected by otherpeople or by your earlier life experience. Knowing why maygenerate a feeling of self-coherence and that you are theprotagonist in your own life. This has also been proposed asbeing an important intervention against psychotic dis-continuance (Lysaker et al., 2007).

Inner space towards outer world

Working with bodily changes seems to be a slow process butcontains some important therapeutic moments accordingthe physiotherapists. The physiotherapists described thatpatients report feelings of being; “whole and integrated”,calmer and with clearer thoughts. Studies within embodiedcognition give an interesting explanation to these integra-tive experiences. Research has examined the role of

multisensory integration towards body-ownership andsuggests that multisensory integration together with theinternal model of the body (body-scheme) is the majormechanism behind the experience of the body as beingone’s own (Waters and Badcock, 2010). This is interesting,especially in the light of research claiming that patientswith schizophrenia have basic disturbances on this basiclevel of self (Waters and Badcock, 2010; de Haan and Fuchs,2010). The physiotherapists try to increase the experienceof integration by physical exercise. They thus establish aninner space for the patients. In addition, moving the bodyworks through complex afferent and efferent signals,following the willed intention to move. The intention andits efferent spreading results in a feeling of agency, which isalso said to make a major contribution to self-recognitionand when disturbed lead to basic symptoms seen inschizophrenia (Tsakiris et al., 2010). These mechanisms:body ownership, body scheme and agency, are all impor-tant for basic levels of self-recognition. Furthermore, theyseem to be activated or facilitated in BBAT and thus lead tothe experience of being whole, alive and with a strongerself, as reported by the physiotherapists.

The connection between emotions and body language isused in a two-way manner by the physiotherapists, both toincrease the awareness of the sensing self but also toregulate the different affects, increasing feelings of vitalityand decreasing anxiety and other discomforts. The bodilychange in postural balance is described as inducing a betterself-esteem (Hedlund and Gyllensten, 2010). The physio-therapists in this study also experience that posturalbalance and movement coordination in contact with thecentre of the body, both contributes to mental stability.

Clinical implicationsQualitative studies provide the opportunity for systemati-cally describing professional experiences of using a methodwith a specific group of patients. The results from this studyinclude descriptions of mechanisms in the BBAT treatmentin patients with schizophrenia and schizophrenia spectrumdisorder that later can be followed up and verified in otherstudies.

Conflict of interest statement

There are no conflicts of interest in this study.

Acknowledgements

This study was funded by County Council of Scania,Sweden.

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