1. Module State of the Art Research of Psycho-Social Aspects of APA (part 2) general introduction Prof. H. Van Coppenolle, co-ordinator

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

3. 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.) u excellent visual tool: “the awarded film ( Medal of Peace of the United Nations):” “I am not Disabled” u “The Winners”: “Everybody wins”

4. Psychological problems u What are the benefits of participation in APA and sports (psychomotor therapy) when I have psychological problems (depression, anorexia nervosa, schizophrenia) ?

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

6. These three groups of persons with a handicap u will be the subjects of research in this psycho-social area

7. 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 u so all data are based on meanings of the persons themselves because there is no other way u but these impressions are the only meaningful ones because nobody else can speak for them

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

9. Personality, Behaviour and Social adjustment of persons with a handicap u R. Shephard (“Fitness in Special Populations”) Human Kinetics, 1990, pp.201-221)

10. 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

11. 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 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)

12. unfortunately able bodied children seem to develop negative stereotypes of the disabled u in general sensory disabilities are the least stigmatised u 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

13. Stereotyping u the most 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

14. 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

15. 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)

16. 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

17. 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

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

19. smoking habits u the proportion of smokers among the wheelchair disabled substantially exceeded provincial norms u the heavy smokers were predominantly those with a type B personality on the Rosemann scale: they intended to have an external locus of control, there were also trusting, shy and of below average intelligence

20. 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

21. 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

22. 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

23. 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

24. 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

25. Harper used the Minnesota Multiphasic Personality Inventory (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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Goldberg and Shepard (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

34. 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

35. 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

36. 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

37. 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

38. 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 vigour and low scores for tension, depression, fatigue and confusion

39. 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

40. 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

41. 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

42. 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)

43. 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”

44. 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

45. 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

46. 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

47. 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

48. 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%)

49. 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

50. Psychomotor Therapy for Psychiatric Patients –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 –this form of treatment attempts to act systematically on the body perception and the behaviour in order to achieve therapeutic objectives

51. Observation Scales in Psychomotor Therapy

52. the Leuven Observation Scales for Objectives in Psychomotor Therapy u Adapted Physical Activity Quarterly, 1989, 6, 145-153

53. originally u psychomotor therapy goals were imposed or set by general therapy theories such as: u psychoanalysis u phenomenology u behaviour therapy, etc.

54. but this approach was not individualised u towards 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

55. therefore u the therapeutic objectives are no longer based on these general theories u but on a specific observation method during movement situations u because everyone moves according his personality u and this movement behaviour can offer useful indications for PMT

56. development of the scales u an observation method should only give information about those aspects that are directly related to the goals u 213 therapeutic goals for PMT were derived from literature u and named in 9 categories of goals who are important for psychiatric patients

57. 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

58. other therapeutic objectives u 7. movement expressivity u 8. verbal communication u 9. social regulation ability

59. in a second phase these objectives were made operational as observation items

60. by the following steps u a definition of each item u for each item a 7 point scale was established from -3 to + 3 u the disturbed behaviour can present itself as an excess or as a lack u the zero score corresponds with non disturbed behaviour

61. to operationalize further u general descriptions of the -2 and the + 2 scores were developed on the basis of adjectives u for example: underemotional relations are revealed in contact that is apathic, inhibited, detached, refusing, inaccessible, too formal

62. more specific descriptions u more specific descriptions were developed on the basis of very specific descriptions of behaviour for the - 2 and + 2 scores u for example: emotional underrelating can be revealed in the following descriptions u the patient does not react and shows no interest in contact if he is contacted by others

63. reliability of the observation scales (inter and intra) u was for the general LOFOPT ranging from 0.74-1.00 u for the specific LOFOPT: 0.70-0.98

64. Body Experience and Body Composition in Anorexia Nervosa Patients Issues in Special Education & Rehabilitation. Vol.8, No. 2, 1993, pp. 35-39

65. Introduction: a disturbed body experience is a central element in the AN syndrome u it is one of the four diagnostic criteria in DSM III Revised u it has a perceptual and an affective component u nevertheless studies indicate no significant over or underestimation of body measures u no significant difference from estimates by controls

66. these studies don’t refer to body composition u which is an important element because it can affect body satisfaction and perception u body experience has not been studied before and after a therapeutic program u this was the reason of this study we carried out with 43 AN patients

67. mean and range of age, height, weight, percentage of fat mass and fat free mass on admission u age:(years): 22.8 12.8-37.6 u height (cm): 162.6 140.0-178.0 u weight:(kg) :39.7 23.4-52.1 u fat mass (%): 12.2 1.2-4.3 u FFM (kg): 34.922. 22.2- 43.3

68. method u the subject group was re- evaluated after a therapeutic program: 21 patients u mean duration of hospitalisation: 159 days (range 117-184)

69. procedure u body experience was evaluated by the distortion technique u and by a self report instrument: the Body Attitude Questionnaire which examine body image satisfaction

70. the video distortion technique u a video camera is linked to a color monitor u using a potentiometer in the monitor: a distortion (widening or narrowing) of max. 33% can be achieved u the extent of the distortion is displayed by a voltmeter u a dummy was used as lifeless control u the subject can turn a dial to widen or narrow her image

71. 4 tasks u adjust the thin or fat body image in full frontal and profile positions until she thought it represented her real image u third task: estimate the dummy in order to know whether the subject showed a more general perceptual disturbance or poor estimation abilities u finally the subject was asked to adjust her own frontal image to her ideal image

72. for each of these four tasks u the subjects were asked to perform six trials ad random u alternating between trials initially with a thin image and trials initiating with a fat image u the composite score was the sum of the six trials

73. the Body Attitude Test u consists of 20 items which examine body dissatisfaction u the maximum score is 100 u the higher the score the more dissatisfied the subject is with her body u the items are scored on a 5 point scale

74. Body Composition u was measured with densitometry techniques which uses the underwater weighing technique

75. the Psychomotor Program u Tries to influence the disturbance of the body image u through confrontation with and awareness of the body it attempts to alter the negative body experience in a more positive attitude u the movement situations consist of relation and confidence- improving techniques, non- verbal expression, body oriented sensory awareness and social skill exercises

76. results: body experience perception u significant underestimation was found on the four estimation tasks u but also the control dummy object was as well significantly underestimated, suggesting that a general perceptual disturbance could be the basis of the underestimation

77. body experience: ideal body measures u the ideal body measures correspond with the actual thin body appearance u this indicates that prior to a therapeutical program anorectic patients are satisfied with their emaciated bodies

78. body experience: dissatisfaction u the mean score on the BAQ was high: 46 u and differed significantly from the control group of 103 students u they are dissatisfied with their body

79. relation between body experience and body composition u no significant relationship between body composition and scores on the body attitude questionnaire u some significant correlations with data from the videodistortion technique:

80. significant relations u the higher the weight, fat and fat free mass, the more the ideal images measures were narrowed u the less fat mass anorexics have the more they underestimate their measures this increases the perceptual disturbance

81. body experience after therapy u a decrease of the underestimation of body measures was noticed in frontal, profile and dummy estimations u patients ideal image adjustments continue to show significant underestimation u this means that after a considerable weight gain (39.3- 50.6) their basis wish to become thinner has not changed

82. body satisfaction after therapy u the mean dissatisfaction score on the BAQ decreases from 47.1 to 33.7 u this means that following the therapeutical program the patients were less dissatisfied with their body

83. EXAMPLES OF GOOD PRACTICE Different Films illustrating the theory concerning psychosocial aspects of APA

84. u “ I am not disabled” u “Psychomotor observation and therapy in a psychotherapeutic community” u Psychomotor therapy with anorexia nervosa patients” u “Fitnesstraining as psychomotor therapy in depressive patients u “A real slice of the action”