Module State of the Art Research of Psycho-Social Aspects of APA (2002) general introduction Prof. H. Van Coppenolle, co-ordinator

Psycho-Social Aspects are maybe the most important ones in APA u and maybe as well the most forgotten

There are two major groups of persons with a disability involved in the psychosocial approach of APA u 1. The psychosocial approach of APA in persons with psychiatric and intellectual problems (psychomotor therapy) u 2. The psychosocial approach of persons with a physical disability

Pascal Duquennes

Psychiatric problems u What is the scientific (systematic) way using movement activities (psychomotor therapy) for persons a psychiatric problems (depression, anorexia nervosa, schizophrenia, dementia) ?

Basic scientific (systematic) principles and concrete Applications of Psychomotor Therapy in Psychiatric Patients

Psychomotor Therapy u tries to have therapeutic effects on psychiatric patients (for example depressed patients, patients with eating disorders (anorexia nervosa) and different personality problems

Psychomotor Therapy for adult Psychiatric Patients u is a form of treatment that has been systematically used in Belgium (Flanders) since 1965 –in that year a post-graduate course was started at the KU Leuven (and is now also open for international students) –this form of treatment attempts to act systematically on the body perception and the behaviour in order to achieve therapeutic objectives

A New International Specialisation Programme in Psychomotor Therapy

A Postgraduate Specialisation programme in Psychomotor Therapy exists since 1964 in the Faculty of Physical Education and Physiotherapy at the K.U. Leuven

During these 36 years 500 specialists were trained who work now: u in Belgian psychiatric hospitals u in special schools u in centres for special education for children and adults :

This specialisation program at a university level is unique u In Belgium u in Europe u in the whole world

And therefore we wanted to open it for students coming from other countries (in English)

Special Topics u Psychomotor therapy in patients with Eating Disorders (Anorexia Nervosa) u Psychomotor Therapy in psychiatric patients with mood disorders or anxiety disorders u psychomotor therapy in dementia patients u Psychomotor Therapy in Children

The program consists of : u A period of 6 month’s practice in Psychomotor Therapy in several clinical settings (children and adults) u depressed patients u anxious patients u eating disorders u schizophrenia u autism u learning disorders and intellectual deficiency

and a program of 8 theoretical and practical lectures ( 60 credits)

PMT can start from 1: u theories in therapy such as: u biological therapy u psychological forms of therapy such as: u behaviour therapy, u supporting therapy, u cognitive therapy, u psychotherapy

but this approach was not individualised on the psychomotor characteristics u of the patient u and moreover was quite speculative u because most theories on which this approach was based are quite speculative and unscientific as well

PMT can start from 2: u The psychopathological characteristics and the objective of PMT will be the normalisation of the pathological characteristics u DSM IV (diagnostical manual of Mental Diseases): lecture of P. Van de Vliet u the great advantage of PMT is the basic motivating power of movement activities for most psychiatric patients (72%) (PhD H. Van Coppenolle)

PMT can start from 3: u The observed psychomotor characteristics : for example on the basis of the LOFOPT (The Leuven Observation Scales for Objectives in Psychomotor Therapy) u this scale is valid and reliable (PhD J. Simons)

The Leuven Observation Scales for objectives in Psychomotor Therapy (general approach for all psychiatric patients u emotional relations u self-confidence u activity u relaxation u movement control u focusing on the situation u movement expressivity u verbal communication u social regulation ability

the Leuven Observation Scales for Objectives in Psychomotor Therapy u Adapted Physical Activity Quarterly, 1989,6,

We prefer this third approach because then the PMT therapist u Works on a systematic way u tries to counteract the deviations on the LOFOPT scales u works on an practical and concrete basis (observations) u because the psychomotor characteristics expressed in the LOFOPT are the expression of the basic personality

For example: applied on psychotic patients u We see usually deviations in the LOFOPT scores for:

the 9 groups of therapeutic objectives improving: u 1. emotional relations (-) u 2. self-confidence u 3. Activity (-) u 4. relaxation u 5. movement control u 6. focusing on the situation (-)

other therapeutic objectives u 7. movement expressivity (-) u 8. verbal communication (-) u 9. social regulation ability(-)

PMT in psychotic patients tries u To motivate as much the patients for participation by making the situations (working against apathy and indifference) u attractive (3 different situations in one session) u funny u co-operation stimulating (include everybody) u expression (verbal) stimulating

The warm empathic contact of the therapist is very important u Directive (handle the group in a directive way) u all the time stimulate them verbally by talking loudly and every 15 seconds) u trying to have a personal warm relation with them

Example of how to use the LOVIPT scales u Film “Psychomotor Observation and Therapy in a psychotherapeutic community” which expresses the psychomotor characteristics of some psychiatric patients u and how these characteristics are observed and scored on the LOVIPT scales

Psychomotor therapy in patients with Eating Disorders (Anorexia and Bulimia Nervosa) (Ph D M. Probst) u distorted body experience u hyperactivity u fear to lose self-control

General goals for Psychomotor Therapy u rebuilding a realistic self-image u curbing hyperactivity, impulses and tensions u developing social skills u learning how to enjoy the body

FILM ” Psychomotor Therapy in Anorexia Nervosa Patients” u An example of the way the techniques of evaluation and psychomotor therapy u First Prize on the International Filmcontest in Berlin (1989)

The systematic evaluation and therapy tools are u The videoconfrontation u the videodistortion u the LOFOPT u the body attitude scale u the body composition technique u the body awareness methods u the body enjoyment methods (relaxation massage) u cf article Body Experience and Body Composition in Anorexia Nervosa Patients, Issues in Special Education and Rehabilitation)

Psychomotor Therapy in psychiatric patients with mood disorders or anxiety disorders

Therapeutic Goals (PhD P. Van de Vliet-Jan Knapen) u reduction of feelings of anxiety, tension and depression u rebuilding an adequate self-esteem through regular success-achievements u rebuilding an adequate body image and self- esteem u confrontation with healthy behaviour and healthy movement behaviour u (cf lecture and text P. Van de Vliet: The physical self in clinically depressed patients)

Film: “Fitness as Psychomotor Therapy in Depressive Patients” u Shows the specific and systematic evaluation methods and Psychomotor Therapy in depressive patients u Magna Cum Laude Award” International Filmcontest Hanover 1992 u CF First Thenapa CD-ROM

Psychomotor Therapy in patients suffering from dementia u Is a quickly growing group in the psychiatric hospitals u is almost a “forgotten group” u for which as well PMT can be useful by trying to keep them at the highest possible level in general psychomotor functioning

The basic fundamentals for Psychomotor therapy are: u Try to motivate them and giving them physical cognitive and emotional stimuli u let them experience that they are still able to have success-experiences u improve the social interactions

Psychomotor Therapy in Children: psychomotor aspects (Dr. J. Simons) u Movement anamnesis u psychomotor observation and diagnostics u motor development u body co-ordination and laterality u manual dexterity u writing abilities u body image u orientation in space and time u self-esteem and physical competence

Global approach of the personality of the child in psychomotor therapy u The objectives are situated as well in the motor domain u the motor-cognitive domain u the social-affective domain

Practical organisation u We work with the own body and the body of the others u we manipulate the situation on 3 aspects

On the motor domain we try u To improve the motor abilities and give them some movement experiences u because most of the children with psychiatric disorders have motor developmental problems

On the motor-cognitive domain we let them experience different styles of motor learning u To let find them their own strategy u we try to reach them aspects of body concept

On the motor-affective domain the objectives are: u Working with an adult u trusting him or her again u working with other children u focusing attention to adults u improving self-esteem

Aspect 1: the therapy room u Each session starts with exercises on bodyconcept and ends with the same type of exercises u by doing this the child becomes aware of the aspect TIME u the room is structured by using mats and the children have to stay on it

Aspect 2: the child u Each exercise starts from a safe place “the house” for which the child is sitting between the legs of the adult u by doing this we try to get the feeling of safety and as well to focus their attention on the movement situation

Aspect 3: exercises u We choose the exercises in such a way that they can experience the feeling of success u the child is sometimes helping the adult in performing the exercises u later on the adult helps the child in the exercises

Intellectual deficiency u What are the positive aspects in sports and APA for persons with an intellectual handicap?

Special Olympics

General basicmethodological basic principles for APA in PID with emotional problems u Motivating situations making it possible that the persons with ID : u 1. Participate actively u 2. Are emotionally involved u 3. Have many contacts with each other u 4. Experience pleasure u 5. Overcome their apathetic behaviour u 6. Keep their motor skills at the highest possible level

General methodological conditions for PID u assessment :the first step”:evaluation, observation and testing of an APA programme”

what must firstly been evaluated before starting up an individualised APA programme for PID ? u cardiovascular fitness u the basic motor abilities u the play and sportspecific abilities u the general behaviour during APA activities

An individualised APA program in PID can be started up for u the improvement of the general fitness u the improvement of the basic motor abilities u moving in the water (aquatics) u moving on music (dance) u for psychological reasons (cfr supra)

Methodological aspects for improving the PF u the importance of the feeling security and well-being during the program

u the progression in the difficulty of exercises should be slow because most PID persons can’t concentrate very intensively on their task and have as well a less developed physical fitness u improvements should be awarded with visual and concrete awards

² u The activities must be attractive u an exercise session should include a warming up, a real fitness program and a cooling down part u the fitnesspart should consist most of aerobic exercises u the frequency should be : 3 à 4 times a week u circuittraining is indicated

u the progression in the difficulty of exercises should be slow because most PID persons can’t concentrate very intensively on their task and have as well a less developed physical fitness u improvements should be awarded with visual and concrete awards

“steps leading to movement withdrawal” in PID u 1. lack of movement opportunities and experiences u 2. inadequate mover u 3. unsuccessful in games and sports u 4. not selected by peers to play u 5. withdraws from movement experiences u 6. leads to sedentary lifestyle

basicprinciples in teaching basic motor abilities in PID

u 1.take the physical and cognitive possibilities into consideration u 2. try to provoke positive and successful experiences during the first steps of learning. u 3. choose progressions based on the actual possibilities and define what the PID can or can’t perform u 4. Analyse a complex movement task into simple tasks which he can perform u 5. Provide the PID with qualitative as well as quantitative feedback

methodological basicprinciples in moving in the water u Christie (1985) calls water a great equaliser that lessens the evidence of disability u This new-found success and movement achievement for PID can prove to be fun, rewarding, motivational, and most important, a positive experience

Exercises in the water can progressively be adapted for every PID u From getting acquainted in the water until correct swimmingtechniques and competition (SO) u security is of course a basic rule

Visual example of good practice: the movie: u A Real Slice of the Action

Methodological aspects in dance in PID

Advantages of danceactivities u music is an extra attractive element for PID who in many case have a good sense of rhythm u the learning process of creative dancestructures has a cognitive value

Performance in public u danceperformances in public add a supplementary significance to it u for example the film “The Merrymakers”

Methodological requirements u 1. Know and accept the limitations of pid but let them grow in their danceactivities u 2. Encourage them always u 3. Don’t ask unrealistic achievements

u 4. The demonstrations should be clear very concrete and not too long in time and limited to one structure per demonstration u 5. the danceteacher must use a teachingstyle in which the pid feel themselves well in order to develop in an optimal way all their personality aspects

u make maximal use of demonstrations to teach new skills u use in a maximal way visual materials as posters, video, etc.

u make maximal use of demonstrations to teach new skills u use in a maximal way visual materials as posters, video, etc.

Physical handicap u what are the benefits of participation in sports on the psychological and social domain when I am physically handicapped ? (blind, deaf, amputee, heartdisease, etc.)

CF “I am not Disabled” (First jh-CD-ROM)

Research data are mostly based on questionnaires u if I want to know what the meaning of a handicapped person about sportsparticipation is, then I have to ask him, her u so all data are based on meanings of the persons themselves because there is no other way u but hese impressions are the only meaningful ones because nobody else can speak for them

on the other hand questionnaires have weak points u do the persons tell the truth u do they understand the questions? u are there motivated to fill out the questionnaire in a serious way?

Personality, Behaviour and Social adjustment of persons with a handicap u R. Shephard (“Fitness in Special Populations”) Human Kinetics, 1990, pp )

Social Problems of the Disabled u The disabled individual faces many discouragement's during daily life. Schooling is hampered, employment prospects are poor, and the person faces much stigmatisation and stereotyping

Stigmatisation u a physical handicap creates a visible stigma that tends to be socially discrediting, encouraging others to avoid the affected person (Aufesser, 1982, Hunt, 1966) u often the handicapped persons are regarded as unproductive or socially deviant, and civilisations have considered them to be punished by the deity or a witch, or possessed by the devil (Adedoja,1987, Goffman, 1963)

unfortunately able bodied children seem to develop negative stereotypes of the disabled u in general sensory disabilities are the least stigmatised, physical handicaps rank next, and those with mental disorders are the most subject to ostracism u the cause of disability also influences perceptions u surprisingly the process can also occur among the disabled themselves

Stereotyping u the more stereotypes are a perceived lack of physical attractiveness, intelligence and ability u in many instances the entire stereotype is inaccurate and inappropriate: u the disabled are thus placed in special schools, and sheltered workshops, when in fact they are well able to cope with normal education and employment opportunities

negative stereotypes have contributed to conflicts over ownership of athletic contests u some able-bodied runners have wished to exclude wheelchairathletes from events such as the marathon u such exclusion immediately has an adverse impact on the majority of the handicapped participants who wish to be judged on their overall competitive performance rather than as blind or paraplegic patients

Lifestyle and Disability u the social problems faced by the disabled often cause a reactive depression and this can lead to an adverse lifestyle (abuse of tobacco, alcohol and drugs) (Nelipovich, 1983; Nelipovich §Parker, 1981)

Employment u despite negative stereotypes many employers, many supposed “cripples” are better motivated and more productive than their able-bodied peers u nevertheless employment prospects for the average disabled person remain relatively poor

Habitual Activity u following spinal trauma the leisure satisfaction of the injured individual in general decreases (Price, 1987) u participation in sports was likely to decrease relative to the individual’s pre-trauma situation

influence of the sportsorganizations for the disabled u among the various clinical types of disabilitythe least active group where those affected by multiple sclerosis (maybe because for this group no special sportsorganizations exist)

alcohol consumption u it is very difficult to obtain accurate information on alcohol consumption from self-reports u Kofsky a,d Shephard found that 68% of their sample of paraplegics described themselves as no more than occasional drinkers u only 12 % admitted taking more than six alcohol drinks per week

Personality of the Disabled u inevitably the social problems tend to have an adverse influence not only on the lifestyle but also on the manifest personality of the disabled person u although some disabled athletes have as high a level of selfactualisation as the able- bodied

disturbed personality u many disabled people show evidence of maladjustment, retarded emotional development, social alienation, feelings of depression, etc. u immediately following spinal injury, ego strength is low and depression scores are very high u in subsequent months they have big problems adjusting to their handicaps

physical activity may be of considerable therapeutic and psychological benefit u during the early phase of rehabilitation helping the patient develop a sense of self- efficacy u and an awareness that is it not necessary to accept a life of total inactivity and dependency u subsequent participation in sports competition is also important to many disabled people not only for the physical gains

but because of the social respect, approval and prestige that is gained u involvement in sports holds the prospect of desinstitutionalization and reintegration into able-bodied society u Tucker found that the Cattell personality test of physically handicapped persons reflected greater intelligence, more introversion,and less practical attitude than able-bodied subjects

Harper used the Minnesota Multiphasic Personality Inventroy (MMPI) u and found that the disabled were particularly prone to problems of social adjustment u other studies involved standard psychological tests, body image scales, locus of control tests, the status of blind athletes with reference to anxiety levels and mood states u of course the results on these paper -and pencil- tests depend on the truthfulness of the subjects

because most of the studies were cross-sectional in type u there is no proof as to whether an increase of physical activity is responsible for the favourable psychological characteristics of groups such as wheelchairathletes u or whether initially favourable psychological characteristics have allowed such subgroups to undertake more vigorous activity subsequent to the onset of their disability

Cattell Test Scores u on this personality test Goldberg and Shephard didn’t find significant differences of test scores relative to the general population u wheelchairathletes however were distinguished from more sedentary paraplegics on the factors intelligence, venturesomeness and tough-mindedness

wheelchairathletes differed from the general wheelchairpopulation on factor H (shy versus venturesome) u this could imply that much of the achievements that mark the disabled athlete is due not to some peculiarity of physiological endowment but rather to a strength of personality u and an achievement orientation that has assured a willingness to undertake vigorous training

Body Image u Tests of body image provide a numerical expression of how the self is perceived both physically and socially u if the image is poor a substantial gap develops between the ideal and the perceived image u early research suggested devaluation of self in various types of disability

Harper (1978) found that paraplegics often had problems of selfperception and poor body image u although no difference was found between those with congenital and those with traumatic lesions u Brinkmann and Hoskins noted a poor self- concept of hemiplegic patients u after a period of training the researchers reported significant gains on several subscales on the Tennessee self-concept scale

This subscales were: identity, physical self, personal self and social self u Patrick applied acceptance- of- disability scale and the Thennessee self concept scale u 5 months after their first competition novice wheelchairathletes showed a significant improvement on this scale

The Kenyon/Mc Pherson instrument is one measure of body image u It develops scores for items such as “My body is as I would like to be” and “ The real me “ from a series of Likert scales, spanning contrasting adjectives such as beautiful and ugly

Goldberg and Shephard (1982) found that u the gap between the perceived and desired body image was larger in moderately actively spinally injured than in those who had achieved the status of wheelchair athletes

Locus of Control u the locus of control scale examines the extent to which an individual perceives an ability to control her or his environment u external locus of control is assumed when a person perceives an event as unpredictable or the result of luck, chance or fate u internal locus of control is deduced if events are seen as contingent upon personal behaviour

The locus of control of wheelchair- disabled individuals is usually external u the average score is almost twice than that described for young able-bodied people u the locus of control of the spinally injured person was uninfluenced by the level of the lesion or by habitual physical activity

Self-Actualisation u formal measurements of self-actualisation in elite ISOD competitors, using the personal orientation inventory of Shostrom demonstrated fairly high levels of selfactualisation u relative to non-elite competitors the subjects scored higher

Anxiety u many disabled groups such as the blind become acutely anxious following the onset of disability u they fear that they will be unable to support themselves u several reports suggest that the blind competitors particularly prone to anxiety during competition because of lack of normal visual cues

Profile of Mood States (POMS) u The POMS test is a simple one page questionnaire examining immediate mood state u disabled athletes demonstrated the “iceberg profile”which is typical for an able-bodied competitor u a high score for vigor and low scores for tension, depression, fatigue and confusion

Effects of training u It is logic that a favourable personality increases the ability to undertake training u and that an increased ability to perform daily activities and live an independent life would have a positive influence on the body image and psychological profile u in children with mental retardation participation in competition (Special Olympics) had a very positive impact on self-image and social interactions

For the physically disabled u Much depends on the establishment of a training program with realistic goals and expectations u trainers must take into account of inherent shifts in mood state and avoid making excessive physical or emotional demands that could damage an already fragile self- image

Exercise Motivation and Compliance u Initial recruitment to an activity class and subsequent compliance are major problems even with able-bodied subjects u well-designed programs attract no more than 20 to 30% of eligible adults u and as many as half of those who are recruited drop out of the organised activity within 6 months

Attitudes toward physical Activity u the Kenyon instrument examines the instrumental value to the individual of a global concept of exercise in seven specific domains u a series of contrasting adjectives (e.g. good/bad) rate the corresponding concepts (e.g.,( good/ bad ) rate the corresponding concepts (e.g. exercise as a means for fitness and health)

Delforge ( 1973) found no differences between handicapped and nonhandicapped students u Goldberg and Shephard 1982) found that paraplegics perceive five of the seven scales as did able-bodied individuals u wheelchairathletes showed more interest than the general population in exercise “as a pursuit of vertigo” and “exercise as an ascetic experience”

Perceived reasons for participation u M. Cooper (1986) used a paired comparison test to rank the main perceived reasons why the disabled individual participated in sport u the first seven reasons were in order: challenge of competition, fun and enjoyment, love of sport, fitness and health, knowledge and skills relating to sport, contribution to sport, and the team sport atmosphere

These seven items were all ranked significantly higher than items such as: u liking for other team members u travel u liking for the coach and u status

Socialisation into and via Sport u disabled individuals generally show poor social relationships and a limited integration into their immediate society u potential expressions of maladjustment include shyness, timidity, fearful behaviour and other forms of withdrawal, concealment, refusal to recognise the reality, and actual delusions

Involvement in sport can sometimes help the process of integration u but whether it is effective, particularly in the long term depends not only on the attitude of the disabled individual u but also on the reaction of physical education majors and society as a whole

the primary perceived stimuli to sports involvement of a group of disabled athletes were u 1. the initiative of the individual participant (29%) u 2. encouragement of disabled friends (27%) u 3. of Able-bodied friends (27%) u 4. or the family (9%)

Hopper (1986) suggested however that: u other factors such as career and domestic happiness may have had a larger impact upon self-esteem than did success in wheelchaircompetition