Transcript Module Psycho-Social Aspects of APA

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
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 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
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 adults
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 month’s 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 well
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 Therapy)
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,
1989,6,145-153
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
For example: applied on
psychotic patients
We
see usually deviations in
the LOFOPT scores for:
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
session)
 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 patients
 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

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 Patients”
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
depression
 rebuilding an adequate self-esteem through regular
success-achievements
 rebuilding an adequate body image and selfesteem
 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 patients
 Magna Cum Laude Award” International
Filmcontest Hanover 1992
 CF First Thenapa CD-ROM
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
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
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 domain
the motor-cognitive domain
the social-affective domain
Practical organisation
We
work with the own
body and the body of the
others
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
exercises
Intellectual deficiency
What
are the positive
aspects in sports and APA for
persons with an intellectual
handicap?
Special Olympics
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
step”:evaluation, 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 can’t concentrate very intensively
on their task and have as well a less
developed physical fitness
 improvements should be awarded with
visual and concrete awards
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

the progression in the difficulty of
exercises should be slow because most PID
persons can’t 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
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
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 can’t
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 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
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 Merrymakers”

Methodological requirements
Know and accept the limitations
of pid but let them grow in their
danceactivities
2. Encourage them always
 3. Don’t ask unrealistic
achievements

1.

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
make maximal use of
demonstrations to teach new skills
use in a maximal way visual
materials as posters, video, etc.

make maximal use of
demonstrations to teach new skills
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
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)
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
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
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
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)
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
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 individual’s
pre-trauma situation
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)
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
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 ablebodied
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
physical activity may be of considerable
therapeutic and psychological benefit
 during
the early phase of rehabilitation
helping the patient develop a sense of selfefficacy
 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 penciltests depend on the truthfulness of the subjects
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 didn’t 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
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
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 selfconcept 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 wheelchairdisabled 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
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
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
Profile of Mood States (POMS)
 The
POMS test is a simple one page
questionnaire examining immediate mood
state
 disabled athletes demonstrated the “iceberg
profile”which is typical for an able-bodied
competitor
 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
interactions
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 selfimage
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

status
for the coach and
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 (29%)
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
wheelchaircompetition