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Module State of the Art Research of Psycho-Social Aspects of APA (2002)


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Title: Module State of the Art Research of Psycho-Social Aspects of APA (2002)

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
  • and maybe as well the most forgotten

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

(No Transcript)
(No Transcript)
Pascal Duquennes
Psychiatric problems
  • 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
  • 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
  • is a form of treatment that has been
    systematically used in Belgium (Flanders) since
  • 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

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
  • in Belgian psychiatric hospitals
  • in special schools
  • in centres for special education for children and

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

And therefore we wanted to open it for students
coming from other countries (in English)
Special Topics
  • Psychomotor therapy in patients with Eating
    Disorders (Anorexia Nervosa)
  • Psychomotor Therapy in psychiatric patients with
    mood disorders or anxiety disorders
  • psychomotor therapy in dementia patients
  • Psychomotor Therapy in Children

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

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

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

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

PMT can start from 2
  • The psychopathological characteristics and the
    objective of PMT will be the normalisation of
    the pathological characteristics
  • DSM IV (diagnostical manual of Mental Diseases)
    lecture of P. Van de Vliet
  • 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
  • The observed psychomotor characteristics for
    example on the basis of the LOFOPT (The Leuven
    Observation Scales for Objectives in Psychomotor
  • this scale is valid and reliable (PhD
    J. Simons)

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

the Leuven Observation Scales for Objectives in
Psychomotor Therapy
  • Adapted Physical Activity Quarterly,

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

For example applied on psychotic patients
  • We see usually deviations in the LOFOPT scores

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

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

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

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

Example of how to use the LOVIPT scales
  • Film Psychomotor Observation and Therapy in a
    psychotherapeutic community which expresses the
    psychomotor characteristics of some psychiatric
  • 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)
  • distorted body experience
  • hyperactivity
  • fear to lose self-control

(No Transcript)
General goals for Psychomotor Therapy
  • rebuilding a realistic self-image
  • curbing hyperactivity, impulses and tensions
  • developing social skills
  • learning how to enjoy the body

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

The systematic evaluation and therapy tools are
  • The videoconfrontation
  • the videodistortion
  • the LOFOPT
  • the body attitude scale
  • the body composition technique
  • the body awareness methods
  • the body enjoyment methods (relaxation massage)
  • 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)
  • reduction of feelings of anxiety, tension and
  • rebuilding an adequate self-esteem through
    regular success-achievements
  • rebuilding an adequate body image and self-esteem
  • confrontation with healthy behaviour and healthy
    movement behaviour
  • (cf lecture and text P. Van de Vliet The
    physical self in clinically depressed patients)

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

Psychomotor Therapy in patients suffering from
  • Is a quickly growing group in the psychiatric
  • is almost a forgotten group
  • 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
  • Try to motivate them and giving them physical
    cognitive and emotional stimuli
  • let them experience that they are still able to
    have success-experiences
  • improve the social interactions

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

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

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

On the motor domain we try
  • To improve the motor abilities and give them some
    movement experiences
  • 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
  • To let find them their own strategy
  • we try to reach them aspects of body concept

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

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

Aspect 2 the child
  • Each exercise starts from a safe place the
    house for which the child is sitting between the
    legs of the adult
  • 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
  • We choose the exercises in such a way that they
    can experience the feeling of success
  • the child is sometimes helping the adult in
    performing the exercises
  • later on the adult helps the child in the

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

Special Olympics
(No Transcript)
General basicmethodological basic principles for
APA in PID with emotional problems
  • Motivating situations making it possible that the
    persons with ID
  • 1. Participate actively
  • 2. Are emotionally involved
  • 3. Have many contacts with each other
  • 4. Experience pleasure
  • 5. Overcome their apathetic behaviour
  • 6. Keep their motor skills at the highest
    possible level

General methodological conditions for PID
  • assessment the first stepevaluation,
    observation and testing of an APA programme

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

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

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

  • the progression in the difficulty of exercises
    should be slow because most PID persons cant
    concentrate very intensively on their task and
    have as well a less developed physical fitness
  • improvements should be awarded with visual and
    concrete awards

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

  • the progression in the difficulty of exercises
    should be slow because most PID persons cant
    concentrate very intensively on their task and
    have as well a less developed physical fitness
  • improvements should be awarded with visual and
    concrete awards

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

basicprinciples in teaching basic motor abilities
in PID
  • 1.take the physical and cognitive possibilities
    into consideration
  • 2. try to provoke positive and successful
    experiences during the first steps of learning.
  • 3. choose progressions based on the actual
    possibilities and define what the PID can or
    cant perform
  • 4. Analyse a complex movement task into simple
    tasks which he can perform
  • 5. Provide the PID with qualitative as well as
    quantitative feedback

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

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

Visual example of good practice the movie
  • A Real Slice of the Action

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

Performance in public
  • danceperformances in public add a supplementary
    significance to it
  • for example the film The

Methodological requirements
  • 1. Know and accept the limitations of pid but
    let them grow in their danceactivities
  • 2. Encourage them always
  • 3. Dont ask unrealistic achievements

  • 4. The demonstrations should be clear very
    concrete and not too long in time and limited to
    one structure per demonstration
  • 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

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

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

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

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

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

Social Problems of the Disabled
  • 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

  • a physical handicap creates a visible stigma that
    tends to be socially discrediting, encouraging
    others to avoid the affected person (Aufesser,
    1982, Hunt, 1966)
  • 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
  • in general sensory disabilities are the least
    stigmatised, physical handicaps rank next, and
    those with mental disorders are the most subject
    to ostracism
  • the cause of disability also influences
  • surprisingly the process can also occur among the
    disabled themselves

  • the more stereotypes are a perceived lack of
    physical attractiveness, intelligence and ability
  • in many instances the entire stereotype is
    inaccurate and inappropriate
  • 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
  • some able-bodied runners have wished to exclude
    wheelchairathletes from events such as the
  • 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
  • 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,

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

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

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

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

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

physical activity may be of considerable
therapeutic and psychological benefit
  • during the early phase of rehabilitation helping
    the patient develop a sense of self-efficacy
  • and an awareness that is it not necessary to
    accept a life of total inactivity and dependency
  • 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
  • involvement in sports holds the prospect of
    desinstitutionalization and reintegration into
    able-bodied society
  • 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)
  • and found that the disabled were particularly
    prone to problems of social adjustment
  • 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
  • of course the results on these paper -and
    pencil-tests depend on the truthfulness of the

because most of the studies were cross-sectional
in type
  • there is no proof as to whether an increase of
    physical activity is responsible for the
    favourable psychological characteristics of
    groups such as wheelchairathletes
  • 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
  • on this personality test Goldberg and Shephard
    didnt find significant differences of test
    scores relative to the general population
  • 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
  • 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
  • and an achievement orientation that has assured a
    willingness to undertake vigorous training

Body Image
  • Tests of body image provide a numerical
    expression of how the self is perceived both
    physically and socially
  • if the image is poor a substantial gap develops
    between the ideal and the perceived image
  • 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
  • although no difference was found between those
    with congenital and those with traumatic lesions
  • Brinkmann and Hoskins noted a poor self-concept
    of hemiplegic patients
  • 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
  • Patrick applied acceptance- of- disability scale
    and the Thennessee self concept scale
  • 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
  • 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
  • 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
  • the locus of control scale examines the extent to
    which an individual perceives an ability to
    control her or his environment
  • external locus of control is assumed when a
    person perceives an event as unpredictable or the
    result of luck, chance or fate
  • 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
  • the average score is almost twice than that
    described for young able-bodied people
  • the locus of control of the spinally injured
    person was uninfluenced by the level of the
    lesion or by habitual physical activity

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

  • many disabled groups such as the blind become
    acutely anxious following the onset of disability
  • they fear that they will be unable to support
  • 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)
  • The POMS test is a simple one page questionnaire
    examining immediate mood state
  • disabled athletes demonstrated the iceberg
    profilewhich is typical for an able-bodied
  • a high score for vigor and low scores for
    tension, depression, fatigue and confusion

Effects of training
  • It is logic that a favourable personality
    increases the ability to undertake training
  • 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
  • in children with mental retardation participation
    in competition (Special Olympics) had a very
    positive impact on self-image and social

For the physically disabled
  • Much depends on the establishment of a training
    program with realistic goals and expectations
  • 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
  • Initial recruitment to an activity class and
    subsequent compliance are major problems even
    with able-bodied subjects
  • well-designed programs attract no more than 20 to
    30 of eligible adults
  • and as many as half of those who are recruited
    drop out of the organised activity within 6 months

Attitudes toward physical Activity
  • the Kenyon instrument examines the instrumental
    value to the individual of a global concept of
    exercise in seven specific domains
  • 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
  • Goldberg and Shephard 1982) found that
    paraplegics perceive five of the seven scales as
    did able-bodied individuals
  • 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
  • M. Cooper (1986) used a paired comparison test to
    rank the main perceived reasons why the disabled
    individual participated in sport
  • 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
  • liking for other team members
  • travel
  • liking for the coach and
  • status

Socialisation into and via Sport
  • disabled individuals generally show poor social
    relationships and a limited integration into
    their immediate society
  • 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
  • but whether it is effective, particularly in the
    long term depends not only on the attitude of
    the disabled individual
  • 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
  • 1. the initiative of the individual participant
  • 2. encouragement of disabled friends (27)
  • 3. of Able-bodied friends (27)
  • 4. or the family (9)

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