Article

Directives for psychomotoric therapy with serious depressed patients

by Inge Otten and Lillian Luijerink

Summary
We both work on a psychiatric department of a general hospital. At this department we have to deal with the serious depressed patient a lot. Serious depression is accompanied by severe loss of hope and energy. These patients often don't believe that therapy will be helpful. A lack of commitment and motivation exists. Therefore working as a psychomotor therapist in this situation requires special skills. In this article we will address the question; what interventions, strategies, and attitudes can a therapist use working with seriously depressed patients? With the help of the 'Dordts Strategic Model' hypotheses are formulated concerning aetiology and maintenance of depression. We then develop goals for treatment. A patient profile is formulated for the seriously depressed patient group through specific psychomotor assessment. Psychomotor treatment directives will be presented for the seriously depressed patient group. The directives contain the following issues: individual or group therapy, how to formulate a work agreement between patient and therapist, what kind of attitude and interventions are appropriate, and which activities can be used.


The 'Dordts Strategic Model'
To answer the main question: what interventions, strategies and attitudes could a therapist use working with serious depressed patients thorough, it was necessary to study a wide range of literature. Each theory has its own vision on origin and maintenance of depression. We didn't wan to restrict ourselves by one theory. Therefore we looked for a model where all theories could fit in. We found the 'Dordts Strategic Model. This model was originally developed for assessment/ treatment of the individual patient. His complained/ disfunctioning is reviewed on six levels. Each level gives it's own view on the aetiology and the maintenance of the disfunctioning. Therefore on each level a workhypotheses is formulated. The workhypotheses forms a theoretical base for patient treatment goals. Instead of an individual patient we have placed the depressive patientgroup in this model.

Level	Work hypothesis	PMT treatment goals
1. social aspects	Patient depression is caused by problems in his social environment. His social skills are poor and/ or social interactions are poor. Therefore a social isolation exists.	Patient and therapist come to a therapeutic contact/ interaction.
2. Family system aspects	Problems and pathological interaction in the home situation lead to a destructive way of problem coping or solving (survival strategy). This causes depression and/ or maintenance of the depression.	-
3. Behavioural/ cognition aspects	Depression is caused by depressive schemes and structural 'misinterpretation', addressing misfortune to internal, global and steady origins (=negative attribution)	* Patient senses positive body and motion experiences. * Patient explores irrational cognition's and thoughts
4. psychodynamic aspects	Depression exists due to fending off mourning caused by loss of a loving object or serious injury of self-appreciation. Because there is no normal process of mourning a long-term internal psychological conflict exists accompanied by inward directed anger, muscle tension and energy blockades resulting in a depression.	* Patient can recognise underlying emotions as anger, sadness and fear. * Patient becomes aware of muscle tension.
5. personality aspects	Personality disorders; mainly borderline-, narcissistic-, avoiding- and dependent personality disorders, create a higher vulnerability for maintenance of a depression.	-
6. biological aspects	Depression is caused by disregulation of bio-physiological processes, mainly by neurotransmitters in the brain. Lack of physical activity has a negative influence on neurotransmitter processes and therefore stimulates depression. A negative circle exists.	* Patient is motivated to be physical active. * General condition/ energy level of the patient is increased.

The work hypotheses are suitable for the complete depressive patientgroup. So not only for the serious depressed patients, but also for the moderate and mild depression. For our article we selected only the treatment goals for the serious depressed patients.

Main thesis and workagreement
To get a workagreement between the patient and the therapist, we first formulated a main thesis. We think that the depression is maintained by a lack of activities. Activities of movements contribute to an increase energy level, promote social interaction and encourage the patient to express emotions. Therefore increase of activities of movements have a positive effect and decreases the depression. This main thesis forms a base for the work agreement between the therapist and the patient. It is essential to find a sentence, or several sentences which gives on the one hand an explanation for the problem of the patient, on the other hand it has to be an exceptance for therapy. This way the patient is able to see the meaning of therapy and eventionally might be able to take responsibility.

Psychomotor therapy practice
Al the theory is nice, but until now it doesn't say much about the psychomotor therapy in specific. We therefor asked ourselves the question which items are relevant for the serious depressed patient. The following items were found:

* Expression of emotions;
* Social interaction;
* Experiences and feelings of the patient;
* Postural presentation;
* Presentation of movements.

Based on these items we came to a patient profile. Therefore we looked at the serious depressed patient during our therapy. We saw that the patients expressed no or almost no emotions. When emotions were expressed it was an expression of cheerlessnes/ dullness. Underlying emotions were not expressed. We also saw that there was a high level of passivity, which only could be broken by a lot off afford and stimulation of the therapist. The patients showed a low energy level and poor interaction with others (both verbal and non-verbal) and had negative or no perspectives for the future. There was also a low self-esteem or appreciation. Looking at the postural presentation we saw that posture was pointed inward, head and shoulders flexed forward, spine banded, knees pushed against or crossed over each other, poor grounding and eyes looking downwards. In the presentation of movements there was almost no movement initiatives, movements were decreased, retarded, low energetic and flabby.

General directives for therapy
Knowing the workhypotheses, treatment goals, relevant items and the patient profile, we can look at the general directives for therapy. The first question we wanted to answer was do we want to see the patient individual or in a group? Considering the fact that the patient has difficulties making contact, we choose for a individual start. Putting the patient in a group immediately we think is too overwhelming. He will be confronted with his handicap and this will stimulate the tendency to isolate. Because a group can also have a positive effect, we chose for attending to a group as soon as possible. By seeing the patient individual for too long the patient might get focussed on the therapist, with danger of dependency.
Looking at the attitude of the therapist we find it important to be supportive, inviting and hope giving. Depressive behaviour easily awakes negative feelings by the other. The patient probably already had to deal with these reactions in his daily situation. This increases depressive feelings. Therefore it is important for the therapist not to show irritation or negative feelings toward the patient.
With our interventions we want to stimulate and help the patient to explore his own experiences and emotions. We also think that it is important to mention visible (positive) changes, especially in posture and movements. We are convinces that there is a relation between positive changes in posture and movements and positive changes in mood. In our interventions we try to emphasise things in this direction to the patient. Every step the patient takes in relation to positive behaviour has to be reinforced. Hereby it is important to address progression to patient's own actions.


Directives for activities
At last we want to show some directives for activities. We choose not to show a list of concrete activities, because we think this isn't possible. We can give a few examples, but we're confinced that which activity you choose depends on the context of that specific moment/ situation. Therefor we selected directives. By choosing an activity you can make a link with patients history of movements or interests. The activity you chose has to be manageable, you have to be sure that there is a high change of success. We prefer physical activities that lodge an appeal to energy level and condition, encourage an upward posture and stimulate interaction.

Conclusion
Al this information together gives us directives for psychomotor therapy with serious depressed patients. We've tried to put together our practical experiences and the theory we found about depression. For the future of the psychomotor therapy we think it's important that we can give the practical things we do a theoretic base/ explanation. At this way we can built on our profession and give it a solid position in the health care!