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Physiotherapy in Mental Health HCT-199 MSc Physiotherapy Konstantina Kyrou
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Definition of Mental Health “Mental Health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO, 2005) Not merely the absence of mental illness
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Physiotherapy in Mental Health Distinct specialty Biopsychosocial model Evidence-based Client-centred Promotion, Prevention and Rehabilitation Therapeutic relationship Part of a multidisciplinary team For all ages, settings and degrees of severity Probst, Skjaerven, Parker, Gyllensten, IJntema, Catalan Matamoros, (2016). Fisioterapia 38, 49.
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Evidence- Based Practice - Interventions Norwegian Psychomotor Physiotherapy Basic Body Awareness Therapy Cognitive behavioural Therapy Physical Activity Progressive Relaxation Training ‘’Body & Mind as an entity’’
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Norwegian Psychomotor Physiotherapy 1946-Norway : Aadel Bülow-Hansen & Trygve Braatøy Emotions linked to movement restriction, postural changes, autonomous dysfunctions, muscular tension Respiration core to assessment & treatment intension Stabilizing or Relaxing Highly individualized – Not standardized Aim: Embodied Identity (Ekerholt and Bergland 2004; Ekerholt and Bergland 2008)
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Norwegian Psychomotor Physiotherapy Clinical Assessment : “Trial Treatment” Introduction to NPMP Patient History (medical and social) Examination in: Standing Sitting Lying supine/prone Standing Sharing experiences of assessment Clinical reasoning & Goal agreement: patient as part of the process (Probst and Skjaerven 2017)
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Norwegian Psychomotor Physiotherapy Patients Experiences: Sensing body in relation to feelings Change of perspective about past – body displaying life experiences Finding themselves Realizing body & mind connection (Ekerholt and Bergland 2004; Marie Øien et al. 2007; Dragesund and Råheim 2008; Ekerholt and Bergland 2008; Øien 2010; Sviland et al. 2012; Sviland et al. 2014).
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Basic Body Awareness Therapy J.Dropsy : synthesis of multiple approaches Covers a wide spectrum of mental disorders (initially for schizophrenics) Movement quality through Movement Awareness “Threefold Contact Problem”: physical body – internal environment - external environment (Skjaerven et al., 2008; Hedlund and Gyllensten, 2010)
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Basic Body Awareness Therapy Movement Awareness: sensitivity to movement changes, movement coordination & performance in relation to environment Body Awareness Rating Scale (BARS) (Skjaerven et al. ,2015) Movement Quality : movement in relation to space, time and energy Movement Quality Model (MQM) (Skjaerven et al.,2008)
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Basic Body Awareness Therapy Movement Awareness Learning Cycle How to promote movement quality? (Skjaerven et al., 2010)
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Cognitive Behavioural Therapy (CBT) Umbrella Term Mental Health, MSK, chronic pain Integration in Pain Rehabilitation through Operant Learning Theory (Gatzounis et al, 2012) Acceptance & Commitment Therapy (ACT) CBT model
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ACT RFT/ACT model of psychopathology : psychological inflexibility inability to persist or change behaviour in the service of longterm valued ends due to language & cognition interaction (Hayes et al. 2006)
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Psychological Flexibility Model 6 core processes (Hayes et al, 2006)
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ACTivePhysio model Increase physical capacity & function Respond flexibly Group Intervention ACTiveBODY Goal setting with the patient individually Set of functional-adapted activities (Probst and Skjaerven 2017)
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Physical Activity Physical Health Diseases with High Prevalence in the Mentaly Ill (Hert et al.2011) Obesity Metabolic Syndrome Diabetes Mellitus Diabetic Ketoacidosis Cardiovascular Diseases Musculoskeletal Diseases Benefits of Physical Activity (Richardson et al, 2005) Lifestyle Modification Psychotherapeutic effects Social Interaction Confidence
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5A model of behaviour change and counselling (Probst and Skjaerven 2017) Arrange Feedback Follow-ups Support Assist Client-centred care Agree Patient involved in decision-making Advise FITT : Frequency, Intensity, Type, Time Barriers, facilitators, risks Varies in different stages – Transtheoretical Model of Change Assess Current Physical Activity Non-standardized outcome measures Psychosocial factors, family involvement, medical conditions
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Progressive Muscle Relaxation Jacobson (1983) Bernstein & Borkovec (1973) Tension & Relaxation Cycles Stress/anxiety associated with muscle tension Populations with high levels of muscle tension : Anxiety & panic disorders (Jorm et al. 2004) Depression (Jorm et al. 2008) Schizophrenics (Chen et al. 2009) OCD (Twohig et al. 2010) etc.
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Progressive Relaxation Training (Bernstein & Borcovec, 1973) 7 muscle groups Dominant arm Non-dominant arm Facial muscles Neck & throat Chest – Shoulders – Upper Back – Abdomen Dominant thigh-calf-foot Non Dominant thigh calf-foot 4 muscle groups Left and Right arms-hands-biceps Face and neck Chest- Shoulders- Upper Back- Abdomen Left and Right thigh-calf – foot Hold for 5-7 seconds Relaxation by Recall (counting or not) Relaxation by counting alone
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Service Users’ Needs Co-production of public services : a framework (Bovaird, 2007) Ethics-Based Evidence-Based (Thornicroft & Tansella, 2005) Responsiveness – Are people’s needs met? (WHO, 2000) Dignity Autonomy Confidentiality Prompt Attention Quality of Basic Amenities Access to social support networks Choice of care provider
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Service users’ expectations of in-patient mental healthcare (Hopkins et al. ,2009) Safety/Refuge Programming : education on their condition Interpersonal Relationships : value “therapeutic relationship” Need for Privacy Decision – making: “freeing” Available personnel Large spaces, quality food, smoking room, need to be outside Contact with peers, personnel and family
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Why exercise in mental health? The patient’s perspective Weight management Increase physical activity Social interaction Increase energy levels Part of rehabilitation plan Feeling adequate Escaping from illness Hope (Crone & Guy, 2008 ; Hodgson et al, 2011)
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Physiotherapists meeting the needs Management of underlying complex physical co-morbidities Client-centred approach ‘’One-stop-shop’’ Experts in pain, mobility and movement Prevention, Rehabilitation, Promotion of well-being CSP. 2008b. Commissioning Mental Health Services. Chartered Society of Physiotherapists “Physiotherapists have expertise in psychology related to physical knowledge, holding a unique position in their contributions to improving service users’ emotional and physical well-being. With the ‘received’ care of therapists, non critical acceptance and empathy relational attitudes, service users feel valued and empowered: validation is experienced through hands on affirmation. The positive encouragement from therapists is motivating, providing hope and recovery for service users. Exercise, through feel good endorphins, is proven to help people feel better, speeding up recovery; whilst the ongoing physical sense of achievement increases independence. The carer’s perspective is a vital adjunct to physiotherapy as we have the ability to provide essential feedback, especially when service users experience severe and enduring psychological distress. All of these factors contribute to keep service users out of hospital, and reduces anxiety for both service users and carers.” -Service User Statement
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Communication within Mental Health The relationship between physiotherapist and patient could affect positively the treatment outcome (Hall et al, 2010) Levinson, W. et al. 2010. Developing Physician Communication Skills For Patient- Centered Care. Health Affairs 29(7), pp. 1310-1318. doi: 10.1377/hlthaff.2009.0450
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“Therapeutic Relationship” Mental health service user’s perspective (Shattell et al, 2007) Therapeutic Relationship ‘’Know me as a person’’ Concern/care Understanding Active Listening Investing time “Relate to me’’ Feeling Special Physical Connection Self-disclosure by therapist ‘’Get to the solution’’ Skill Focus Participatory decision- making Honesty
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Supportive Communication Emotional support prior to counselling and treatment planning (Feng et al, 2009) Establish rapport through empathy (Norfolk et al, 2007) Superiority of perspective-taking approach (Galinsky et al, 2008) Active listening (Robertson 2005) Intense concentration Attention to verbal - non-verbal cues Set aside personal beliefs and distractions
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Empathy “Interpersonal imagination” Multidimensional : cognitive & affective factors Need for “cognitive empathy” (Norfolk et al, 2007)
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Perspective-taking Cognitive capacity to consider a situation from the other’s perspective “Allows an individual to anticipate the behaviour and reactions of others” ( Davis, 1983, p.115) Absence of affective factor Better to “think for” (perspective-taking) than “feel for” (empathy) (Galinsky et al, 2008)
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Non-verbal Cues Warmth, positivity, attentive listening linked to higher patient satisfaction (Henry et al, 2012) Calm tone of voice, eye contact, smile and touch perceived positively by patient during GP visit (Marcinowicz et al. 2010) Eye contact & active listening : patient-centred communication (Gorawara-Bhat and Cook 2011) Eye contact & Active Listening Smiling Physical contact & touch
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However…. Schizophrenics don’t perceive non- verbal communication (Walther et al. 2015) Patients with generalized social anxiety disorder avoid and fear engaging in eye- contact (Schneier et al. 2011) Need for client-centred communication
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Defusion of aggression or De-escalation Keep an eye for signs & symptoms of anger/agitation Calm and controlled approach Distract the patient Calm down with words Withdraw yourself Self awareness (Cowin et al 2003) Training through observation (Stubbs & Dickens, 2008)
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Therapeutic Use of self Core principal of occupational therapy Fitting the client-centred communication model “The therapist’s planned use of his or her personality, insights, perceptions, and judgments as part of the therapeutic process” (Punwar & Peloquin, 2000)
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Personal Thoughts Need for awareness Evolving specialty Country-specific approaches Lack of adequate education & adhesion to biomedical model  skepticism Service users need and appreciate physiotherapy Personal weaknesses (Gibb’s model)  Incentive to develop Further engagement: psychologically/behaviourally integraded interventions Skills enhancement IOPTMH conferences Conventions/conferences in regions that the field is undeveloped
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Thank you!
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References Bernstein, D. A. and Borkovec, T. D. 1973. Progressive relaxation training: A manual for the helping professions. Bernstein, D. A. et al. 2000. New directions in progressive relaxation training: A guidebook for helping professionals. Greenwood Publishing Group. Bovaird, T. 2007. Beyond engagement and participation: User and community coproduction of public services. Public administration review 67(5), pp. 846-860. Cowin, L. et al. 2003. De-escalating aggression and violence in the mental health setting. Int J Ment Health Nurs 12(1), pp. 64-73. Crone, D. and Guy, H. 2008. 'I know it is only exercise, but to me it is something that keeps me going': a qualitative approach to understanding mental health service users' experiences of sports therapy. Int J Ment Health Nurs 17(3), pp. 197-207. doi: 10.1111/j.1447-0349.2008.00529.x CSP. 2008b. Commissioning Mental Health Services. Chartered Society of Physiotherapists.
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References Dragesund, T. and Råheim, M. 2008. Norwegian psychomotor physiotherapy and patients with chronic pain: patients’ perspective on body awareness. Physiotherapy theory and practice 24(4), pp. 243-254. Ekerholt, K. and Bergland, A. 2004. The first encounter with Norwegian psychomotor physiotherapy: patients' experiences, a basis for knowledge. Scandinavian Journal of Public Health 32(6), pp. 403-410. doi: 10.1080/14034940410029441 Ekerholt, K. and Bergland, A. 2006. Massage as interaction and a source of information. Advances in physiotherapy 8(3), pp. 137-144. Ekerholt, K. and Bergland, A. 2008. Breathing: A Sign of Life and a Unique Area for Reflection and Action. Physical Therapy 88(7), pp. 832-840. doi: 10.2522/ptj.20070316 Feng, B. 2008. Testing an Integrated Model of Advice Giving in Supportive Interactions. Human Communication Research 35(1), pp. 115-129. doi: 10.1111/j.1468-2958.2008.01340.x Galinsky, A. D. et al. 2008. Why it pays to get inside the head of your opponent: The differential effects of perspective taking and empathy in negotiations. Psychological science 19(4), pp. 378-384.
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References Gorawara-Bhat, R. and Cook, M. A. 2011. Eye contact in patient-centered communication. Patient education and counseling 82(3), pp. 442-447. Hall, A. M. et al. 2010. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy 90(8), pp. 1099-1110. doi: 10.2522/ptj.20090245 Hayes, S. C. et al. 2006. Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy 44(1), pp. 1-25. doi: https://doi.org/10.1016/j.brat.2005.06.006 Hedlund, L. and Gyllensten, A. L. 2010. The experiences of basic body awareness therapy in patients with schizophrenia. Journal of bodywork and movement therapies 14(3), pp. 245-254. Henry, S. G. et al. 2012. Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis. Patient Education and Counseling 86(3), pp. 297-315. doi: https://doi.org/10.1016/j.pec.2011.07.006 Hert, M. et al. 2011. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1), pp. 52-77.
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References Hodgson, M. H. et al. 2011. The experiences of people with severe and enduring mental illness engaged in a physical activity programme integrated into the mental health service. Mental health and physical activity 4(1), pp. 23-29. Hopkins, J. E. et al. 2009. Beyond satisfaction, what service users expect of inpatient mental health care: a literature review. Journal of Psychiatric and Mental Health Nursing 16(10), pp. 927-937. doi: 10.1111/j.1365-2850.2009.01501.x Marcinowicz, L. et al. 2010. Patients' perceptions of GP non-verbal communication: a qualitative study. Br J Gen Pract 60(571), pp. 83-87. Marie Øien, A. et al. 2007. Narratives of embodied experiences–Therapy processes in Norwegian psychomotor physiotherapy. Advances in Physiotherapy 9(1), pp. 31-39. Norfolk, T. et al. 2007. The role of empathy in establishing rapport in the consultation: a new model. Medical Education 41(7), pp. 690-697. Probst et al. 2016. Definition of Physical Therapy in Mental Health. Fisioterapia, pp. 38,49.
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References Probst, M. and Skjaerven, L. H. 2017. Physiotherapy in mental health and psychiatry : a scientific and clinical based approach. Edinburgh : Elsevier. Punwar, A. J. and Peloquin, S. M. 2000. Occupational therapy: Principles and practice. Lippincott Williams & Wilkins. Richardson, C. R. et al. 2005. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric services 56(3), pp. 324-331. Robertson, K. 2005. Active listening: more than just paying attention. Aust Fam Physician 34(12), pp. 1053-1055. Schneier, F. R. et al. 2011. Fear and avoidance of eye contact in social anxiety disorder. Comprehensive Psychiatry 52(1), pp. 81-87. Shattell, M. M. et al. 2007. ‘Take my hand, help me out’: Mental health service recipients' experience of the therapeutic relationship. International Journal of Mental Health Nursing 16(4), pp. 274-284.