Article

PSYCHOMOTOR THERAPY FOR
ADOLESCENTS WITH PSYCHOTIC DISORDERS:

-A DIATHESIS STRESS APPROACH-

Claudia Emck, psychomotor therapist
Academisch Ziekenhuis Utrecht
Department of Psychiatry
P.O. Box 85500
3508 GA Utrecht
The Netherlands
E-mail: c.emck@psych.azu.nl (AZU)
or c.emck@windesheim.nl (Master PMT)

Paper read at the 1st European Congress for Psychomotor Activity
"Psychomotor Activity and Human Development"
Marburg, Germany, September 19-21 1996


Summary
In this contribution I will focus on the treatment we (Utrecht, Academic Hospital, department of Psychiatry) administer to those adolescents who suffer from psychotic disorders. The presented method is focused on teaching the patiënt to manage stress, in order to prevent a relapse in psychosis. For PsychoMotorTherapy the model turns out to be a useful tool for structuring activities and interventions. I will first present the diathesis-stress model, followed by a description of the three fases of treatment of psychotic disorders. I will then turn to a more detailed description of treatment in relation to:

A. Prodromes and syndromes.
B. Internal and external stressors
C. Protective factors
D. Behavioural factors.


Introduction
Psychotic disorders are characterized by delusions, hallucinations, disorganized speech, disorganized or catatonic behaviour and negative symtoms (APA 1994).
Some statistics: In 75% the onset for psychotic disorders is between 16 and 25 years (Verhulst 1994). In Sweden it was found dat 0.5% of all youth developed psychotic characterstics in adolescence. Among those patients with psychotic disorders, 60% showed the symptoms before the age of 18 (Gillberg et al. 1986). 40 till 60% of the adolescents will relapse within one year (Eussen & Duyx 1992).

Diathesis-stress approach
For the treatment of adolescents, we depart from the diathesis-stressapproach (Zubin 1988). It postulates that a person may have a specific vulnerability that, when acted upon by some stressful environmental influence, allows the symptoms of schizophrenia to develop (Kaplan & Sadock 1991:324).

Founded on this approach, Linszen of the University Hospital Amsterdam has constructed a model for treatment (Linszen 1986). In Utrecht, we use this model to teach the patient to manage stress and to prevent relapse caused by stress.
For each patient a profile is made up which consists of the following elements.

Diathesis-stress profile: categories

Prodromes: change of thnking or feeling as precursor of psychosis

Symptoms: distorted thinking or feeling; psychotic characteristics

Internal stressors: feelings or thoughts resulting in fear and confusion; internal conflict.

External stressors: environmental stimuli resulting in tension, fear or confusion. These stressors can be situations, people or objects.

Protective abilities: behavior and mental activities enchancing self esteem or creating structure.

Protective activities: activities resulting in pleasent feelings or the creation of structure.

protective environmental factors: situations, people or objects resulting in safe and relaxed feelings or the creation of structure.

Deficient desirable behaviour: behaviour and mental activities attainable for the patient by training

Existing undesirable behaviour: behaviour resulting in negative reactions, criticism and ineffectiveness.

Diathesis-stress profile:
example male patiënt - 17 years

Prodromes: overactive behaviour, restlegs leggs and headaches

Symptoms: delusions of grandeur, incoherent speech and mixed negative symptoms

Internal stressors: self criticism, agressive thoughts and low self esteem

External stressors: critical father, friends in the pub who press P. to drink beer

Protective abilities: motor abilities, assertivness and politeness to females

Protective activities: hockey, tennis, palying guitar,biking and dancing

protective environmental factors: hockey club, tennis friend, guitar, specific biking route, mother and sister

Deficient desirable behaviour: self control in drinking, regulate agression and negotiate with authorities (like school teachers)

Existing undesirable behaviour: impulsive drinking, impulsive motor behaviour: working off agression and oppositional behaviour

Treatment

The treatment of psychotic adolescents in our setting can be distinguished in three phases:

1. the acute phase:
reduction of positive symptoms is focus of treatment
2. the psycho-education phase:
recognition and acceptance of disorder and symptoms
3. the rehabilitation phase:
attempts to social reintegration of patient.
These phases partly overlap.


phase I
In this phase the patient is admitted to a closed unit. Medication, the presentation of structure and stress reduction are the primary means to combat the symptoms.
Psychomotor therapy contributes by:

a. - monitoring the response to medication
- observing (reduction of) the symptoms in psychomotor situations
- to discuss the subjective experiences with the patient
- observing possible side effects, in particular motor functioning

b. the presentation of movement activities providing structure
-short duration
- limited sensory stimuli
---- auditive: too much noise should be avoided (for example: avoid loud banging balls)
---- visual: there should not be a lot of moving material or many people moving around
---- tactile, kinesthetic and proprioceptive: no exercise with much bodily contact, limited body awareness exercise, no complicated coordination exercises.
- clear and simple instructions

c. the presentation of movement activities reducing stress
- activities in which the patient feels competent
- activities focused on physical relaxation
- activities that result in the experience of success

The psychomotor-therapy takes place in small groups. Individual treatment is offered if the patient is too vulnerable to participate in group activities (florid delusions / hallucinations) or shows too much inadequate behaviour (uninhibited sexual or aggressive behaviour).

Phases II & III: psycho-education and rehabilitation.
These phases take place during part time treatment. The patients visit the hospital in shifts, like some mornings or afternoons per week. The model I presented is discussed with the patient and is the foundation for the treatment.
The patient participates in psychomotor group therapy twice a week. In one of the two sessions the social aspects of motor movement are emphasized (interaction: teamwork, assertiveness, taking of social accomodation problems in joining a sports club outside the hospital setting). The other session is focused on individual activities and the subjective experience of these activities (physical fitness, motor abilities, motor competence, ..... ) In both sessions attention is paid to individual vulnerability, stressors and protective factors. Basing myself on the diathesis-stress model I will now demonstrate how this comes about in relation to:

A. Prodromes & Symptomes
B. Internal & External stressors
C. Protective factors: abilities, activities, environmental factors
D. Behavioural factors



A. Prodromes & Symptoms

A1. The targets at the level of prodromes and symptomes are
1. recognition of bodily signals associated with stress
2. to acquire an adequate response to prodromes and symptomes

Targets at this level concur with the research and recommendations of DuBois (1990). He found that body experience ['Körper Erleben'] of adolescents was determined by body awareness ['Körper Empfinden'] and not by body image ['Körper Anschauung']. Prior to the acute phase almost all psychotic youth experience a stage in which body awareness is disturbed. These manifestations are:
- alienation of own body
- frightful bodily sensations
- blurring of subjective body boundaries

Body image is often underdeveloped though not distorted. According to Du Bois, reality testing can be improved by stimulating body awareness and developing body image. Next, it is important to make the concern of bodily sensations a subject of discussion.

A2. The procedure is the presentation of three different kinds of exercises:

1. Short, structured body oriented exercises with an impressional character. These exercises preferably occur standing-up and often have a dynamic quality in which alternate muscular groups are used.
Examples: Pesso's barometer, Jacobson's method of relaxation, Brooks' sensory awareness.

2. Interactional exercises, in which the focus of attention alternates between impressional and expressional. Tension is gradually increased until recognition takes place and patient can stop or change the exercise.
Examples: to throw a ball over blindly, increase or decrease distance in badminton.

3. Structured individual expressional exercises. The patient learns to control his strength, to spread his energy and to discharge his aggression in a safe symbolic way (self control).
Examples: gradual increased bouncing with the use of the voice, followed by gradual decrease until silence; controlled kicking against cushions.

These exercises are performed within the group, either individually or in pairs. Next, a discussion will take place among the group members in which experiences are exchanged. If necessary, the therapist gives feed back. If possible, mirrors and video can be applied although the latter is often too stressful for paranoid patients. The therapist directs the discussion to the recognition of signals of tension and the way the patient can react on these signals.


B. Internal & External stressors

B1. The targets at the level of stressors are:
1. Recognition of individual sources of tension:
internal: thoughts, feelings
external: people, situations, objects.
2. To acquire adequate responses.

>From developmental psychology and psychodynamic theory we know that adolescence brings forth a lot of conflict and crisis. Though therapy with these adolescents must be supportive, it doesn't mean that internal conflicts are ignored. Coping with these internal stressors, along with the external stressors from daily life, is very important and also very difficult for this population. Stress-coping theories are helpful to understand and to intervene in the stress-reactions of the adolescents.


B2. The procedure implies a controlled presentation of movement arrangements, discussing and practising coping-strategies. Either an actual or a symbolic stressor can be included. I will give you some examples with stressors:

Movement arrangement Indoor rugby Training circuit

Possible stressor External: visual, auditve and tactile stimuli Internal: agressive feelings or thoughts; self deception External: appeal to affective ability; mirrors Internal: fear of failure; self criticism; to feel looked at by others.

C.Protective factors: abilities, activities, environmental factors

C1.The targets at the level of protective factors are:
1. The recognition of individual protective factors
2. The ability to apply these factors.

Actually, this concerns the learning of appropriate coping behaviour. This involves both emotion focused coping, or stress-response regulation, and problem focused coping, or to affect the stressing situation (Lazarus & Folkman 1984).
Emotional focused coping, may consist of the application of a protective activity in situations of stress (for example, running) or to seek protective environmental factors (for example, to visit the familiar swimming pool).
Problem focused coping appeals to protective abilities, like assertiveness. For example, during therapy the patient asks if the other group members can take the game seriously instead of fooling around.

Motor abilities can function as protective factors. In particular, if the patient is aware of specific ablities - he may a good tennis player, for example - these may enhance his self esteem. In this respect, Harter (1982) distinguishes the feeling of motor competence from social and cognitive feeling of competence. Strong feeling of competence increases self esteem and decreases feelings of stress. Stress-reduction, as explained above, is very important to prevent relapse in this population.

Finally, the emphasis on protective factors concurs with Rotter's theory (1966) of locus of control. If the patient learns to apply his protective factors, he acquires an internal locus of control, the realization that he can influence events. The self esteem can be enhanced and stress can decrease.


C2.The procedure at the level of protective factors is as follows.

Protective activities.
In the first place, a variety of movement situations will be presented. For each situation, the response of the group members regarding tension, relaxation, fear, confusion, self-confidence and structure is discussed.
Protective activities arise from subjective experience and can be detected by the therapist through self-disclosure of the patient and proper observation. The therapist should be perceptive when relaxation of the patient takes place. The following questions should be asked:

1. Which activity brings you relaxation, rest or pleasant feeling?
Examples: playing tennis, fitness or a specific relaxation exercise.

2. Would it be possible to apply this at home during periods of stress?
The application of protective activities is a form of emotion focused coping. A transfer to daily life is essential for successful stress-management.

Protective abilities.
For protective abilities it is important to use feed back of other group members because adolescents take opinions of peers seriously. The therapist may ask the group about the specific skills of a patient while using the areas of competence of Harter:

1. motor: attacking, defending, scoring, physical condition, concentration, balance, flexibility
2. social: teamwork, opposition, stimulating others, key playing, accept defeat, assist, fooling around, social accomodation
3. cognitive: insight into the game, game sense, the making of rules, keeping up of the scores, changing tactics.

Protective abilities have beneficial effects if the patient applies them explicitly in therapy, at home and in other situations. As protective abilities strengthen the sense of competence, they affect self esteem and reduce harmful stress reactions.

Protective environmental factors
These factors can also be detected by asking for experiences and observing the patient. It is not the activities that are analyzed, but the situation.
Questions to ask by the therapist:
1. In what kind of situations do you feel comfortable?
Are there similarities in these situations, for example
alone-------------------in pairs/group
task situation-------- free situation
outdoor----------------indoor
3. Can you create these situations within the therapy, at home or somewhere else?
This last question refers to an internal locus of control.

Feedback from the observing therapist is presented like the following examples:
"Is it correct that you will relax after doing some laps (swimming) if your rhythm is not interrupted? Is that also the case in your work? / school? / daily life?"
"It seems that you smarten up in competition, is that correct? Do you need this also in other situations in order to become active?"


D. Behavioural factors
Deficient desirable behaviour & existing undesirable behaviour.

D1.Target at this level is learning and unlearning of behaviour and cognitions. Use is made of the peer group and movements situations serve as a secure area of exercise.

D2. In the procedure the therapist focuses on one personal target that has been agreed upon with the patient. A personal target is an item on behavioural level that results in stress (for example, self control, being assertive or making contact). Next, appropriate exercises are presented. Experiences of success will be guaranteed by the way the therapist organizes the learning situation. The patient learns to handle an adequate style of attribution (Abrahamson et al. 1978). With reference to the principle of successive approximation, every attempt to change behaviour into the desired direction will be positively labelled. The group gives feedback and has a function with the modelling (Bandura 1986). Finally, the transfer to daily life will be discussed. Examples:

1. personal target self control:
Deficient desirable behaviour = stop on time or adjust
Existing undesirable behaviour = continue too much, too tough, too long.
Examples: respond to body signals, accommodate in a social way in games, control impulses on the trampoline.

2. personal target assertiveness:
Deficient desirable behaviour = stand up for myself
Existing undesirable behaviour = withdrawal, excessive adjustment
For example: during football, attack more and kick scores; use your force while romping and in judo; at basketball, ask for the ball; make suggestions et cetera.


CONCLUSION

The presented method is focused on teaching the patiënt to manage stress, in order to prevent a relapse in psychosis. It is hard to say to what extent this method will contribute to this goal. We only started to apply this method this year.
The various professional therapists within our department are trying to apply the model without losing their specific identity. For PMT the model turns out to be a useful tool for structuring activities and interventions (Emck 1995). Also for adolescents, the application of the model gives them something to hold on. However, I learned that evaluation within the group should be brief; to experience the activities and to practice behaviour should be given priority. Casual remarks - in clear language - are often more effective than extensive evaluations afterwards. The introduction and explanation of the model takes time, but it directs common frame of reference and the testing of reality that has to be stimulated.



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