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

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

• general introduction
• Prof. H. Van Coppenolle, co-ordinator

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Psycho-Social Aspects are maybe the most
important ones in APA

• and maybe as well the most forgotten

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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

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Pascal Duquennes
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Psychiatric problems

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

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

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

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Psychomotor Therapy for adult 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 (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

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A New International Specialisation Programme in
Psychomotor Therapy

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

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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
  adults

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This specialisation program at a university level
is unique

• In Belgium
• in Europe
• in the whole world

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

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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

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

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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

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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
  well

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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)

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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
  Therapy)
• this scale is valid and reliable (PhD
  J. Simons)

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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

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the Leuven Observation Scales for Objectives in
Psychomotor Therapy

• Adapted Physical Activity Quarterly,
  1989,6,145-153

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We prefer this third approach because then the
PMT therapist

• Works on a systematic way
• tries to counteract the deviations on the LOFOPT
  scales
• works on an practical and concrete basis
  (observations)
• because the psychomotor characteristics expressed
  in the LOFOPT are the expression of the basic
  personality

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For example applied on psychotic patients

• We see usually deviations in the LOFOPT scores
  for

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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 (-)

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other therapeutic objectives

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

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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
  session)
• funny
• co-operation stimulating (include everybody)
• expression (verbal) stimulating

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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

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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
  patients
• and how these characteristics are observed and
  scored on the LOVIPT scales

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Psychomotor therapy in patients with Eating
Disorders (Anorexia and Bulimia Nervosa)
(Ph D M. Probst)

• distorted body experience
• hyperactivity
• fear to lose self-control

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General goals for Psychomotor Therapy

• rebuilding a realistic self-image
• curbing hyperactivity, impulses and tensions
• developing social skills
• learning how to enjoy the body

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FILM Psychomotor Therapy in Anorexia Nervosa
Patients

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

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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)

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Psychomotor Therapy in psychiatric patients with
mood disorders or anxiety disorders
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Therapeutic Goals
(PhD P. Van de Vliet-Jan Knapen)

• reduction of feelings of anxiety, tension and
  depression
• 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)

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Film Fitness as Psychomotor Therapy in
Depressive Patients

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

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Psychomotor Therapy in patients suffering from
dementia

• Is a quickly growing group in the psychiatric
  hospitals
• 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

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The basic fundamentals for Psychomotor therapy
are

• 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

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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

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Global approach of the personality of the child
in psychomotor therapy

• The objectives are situated as well in the motor
  domain
• the motor-cognitive domain
• the social-affective domain

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Practical organisation

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

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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

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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

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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

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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

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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

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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
  exercises

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Intellectual deficiency

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

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Special Olympics
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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

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General methodological conditions for PID

• assessment the first stepevaluation,
  observation and testing of an APA programme

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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

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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)

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Methodological aspects for improving the PF

• the importance of the feeling security and
  well-being during the program

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• 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

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²

• 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
  exercises
• the frequency should be 3 à 4 times a week
• circuittraining is indicated

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• 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

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steps leading to movement withdrawal in PID

• 1. lack of movement opportunities and
  experiences
• 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

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basicprinciples in teaching basic motor abilities
in PID
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• 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

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methodological basicprinciples in moving in the
water

• 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
  experience

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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

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Visual example of good practice the movie

• A Real Slice of the Action

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Methodological aspects in dance in PID
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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

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Performance in public

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

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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

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• 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
  aspects

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

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

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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.)

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

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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?

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Personality, Behaviour and Social adjustment of
persons with a handicap

• R. Shephard (Fitness in Special Populations)
  Human Kinetics, 1990, pp.201-221)

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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

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Stigmatisation

• 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)

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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
  perceptions
• surprisingly the process can also occur among the
  disabled themselves

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Stereotyping

• 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

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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
  marathon
• 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

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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,
  1981)

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Employment

• 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

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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

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influence of the sportsorganizations for the
disabled

• 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)

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alcohol consumption

• it is very difficult to obtain accurate
  information on alcohol consumption from
  self-reports
• 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

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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
  person
• although some disabled athletes have as high a
  level of selfactualisation as the able-bodied

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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
  high
• in subsequent months they have big problems
  adjusting to their handicaps

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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

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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

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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
  subjects

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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

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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

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wheelchairathletes differed from the general
wheelchairpopulation on factor H (shy versus
venturesome)

• 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

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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

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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

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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

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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

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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

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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

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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

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Self-Actualisation

• 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

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Anxiety

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

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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
  competitor
• a high score for vigor and low scores for
  tension, depression, fatigue and confusion

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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
  interactions

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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

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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

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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)

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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

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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

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These seven items were all ranked significantly
higher than items such as

• liking for other team members
• travel
• liking for the coach and
• status

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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

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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

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the primary perceived stimuli to sports
involvement of a group of disabled athletes were

• 1. the initiative of the individual participant
  (29)
• 2. encouragement of disabled friends (27)
• 3. of Able-bodied friends (27)
• 4. or the family (9)

118
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
  wheelchaircompetition