Towards the recovery of a sense of self: An interpretative phenomenological analysis of patients’ experience of body-oriented psychotherapy for schizophrenia

Abstract

Objective: Increasing evidence supports the efficacy of body-oriented psychotherapy (BPT) for schizophrenia. Yet, so far no research has investigated outcome in relation to therapy process: Why and how BPT is effective. In this study, we qualitatively explore participants’ experience of a manualized BPT for schizophrenia to shed light on the process of therapeutic change. Method: We conducted in-depth interviews with 6 participants who completed a 10-week BPT group intervention. Interviews explored participants’ experience of change and helpful aspects of therapy and were analysed using interpretative phenomenological analysis. Findings: We identified six master themes across the interviews: (i) Being a whole: body-mind connection; (ii) Being agentic and being able; (iii) Being unique and worthy: Being accepted for who one is; (iv) Changing interactions: Engaging in authentic interpersonal contact; (v) Being part of a group: Feeling integrated; and (vi) Hope and investing in the future. Conclusion: We discuss the clinical implications for each theme and bring the findings together by describing therapeutic change in schizophrenia as a recovery of sense of self at different but interlocked levels. Moreover, we put forward recommendations for both specific and common factors for schizophrenia therapy.

Clinical or methodological significance of this article: The clinical significance of this study is twofold. On the one hand, the findings of this analysis might inform the theory and practice of BPT and might directly feedback into a further development of the manual guidelines. On the other hand, common helpful factors have been identified thatmight also be relevant for the more general clinical practice concerning patients with schizophrenia.

Here, we summarize our key messages for the clinical practitioner emerging from the findings:

1. The inclusion of bodily aspects and a focus on pre-reflective experience in psychotherapy can help persons with schizophrenia recover the sense of being a body-mind unity.

2. Empowering persons with schizophrenia, instead of instructing them, seems to foster a sense of agency and self-confidence, which are crucial to the recovery process.

3. A twofold therapeutic stance characterized by openness towards the other and authenticity was experienced by patients as facilitating the rapport building. This might help persons with schizophrenia engage in the relation.

4. Social inclusion might enhance therapeutic change and recovery in schizophrenia. Group therapy might be helpful for fostering a feeling of social belonging, but the inclusion in the wider social and community context remains a critical issue.

5. The experience of joyful moments in psychotherapy might positively contribute to therapeutic change in that it fosters a sense of hope for the future.

Overall our paper contributes to the literature aiming at expanding the range of therapeutic modalities, focussing on the creation and use of mixed models of therapy within and beyond talking practices.

Resumo

Objetivo: Evidências crescentes apóiam a eficácia da psicoterapia orientada ao corpo (BPT) para a esquizofrenia. No entanto, até agora nenhuma pesquisa investigou resultado em relação ao processo terapêutico: Por que e como o BPT é efetiva. Neste estudo, nós qualitativamente exploramos a experiência dos participantes de uma BPT manualizada para a esquizofrenia para lançar luz sobre o processo de mudança terapêutica. Método: Realizamos entrevistas em profundidade com 6 participantes que completaram uma intervenção de grupo de BPT de 10 semanas. Entrevistas exploraram a experiência de mudança dos participantes e aspectos úteis da terapia e foram analisados usando análise fenomenológica interpretativa. Resultados: Identificamos seis temas principais nas entrevistas: (i) Ser um todo: conexão mente-corpo; (ii) ser agente e ser capaz; (iii) Ser único e digno: Ser aceito por quem é; (iv) Mudando interações: Envolvendo-se em autêntico contato interpessoal; (v) Fazer parte de um grupo: Sentir-se integrado; e (vi) Esperança e investindo no futuro. Conclusão: Discutimos as implicações clínicas para cada tema e reunimos as descobertas descrevendo a mudança terapêutica na esquizofrenia como uma recuperação do senso de si em diferentes mas interligados níveis. Além disso, apresentamos recomendações para fatores específicos e comuns para a terapia da esquizofrenia.

Significância clínica ou metodológica deste artigo: O significado clínico deste estudo é duplo. Por um lado, os resultados desta análise podem informar a teoria e a prática da BPT e podem retroalimentar diretamente desenvolvimento de diretrizes para manuais. Por outro lado, foram identificados fatores úteis comuns que também podem ser relevantes para a prática clínica mais geral com pacientes com esquizofrenia.

Aqui, resumimos nossas principais mensagens para o clínico que emergiram das descobertas:

(1)	A inclusão de aspectos corporais e um foco na experiência pré-reflexiva em psicoterapia pode ajudar pessoas com a esquizofrenia a recuperar a sensação de ser uma unidade corpo-mente.
(2)	Empoderar as pessoas com esquizofrenia, em vez de instruí-las, parece promover um senso de agência e autoconfiança, que são cruciais para o processo de recuperação.
(3)	Uma postura terapêutica dupla caracterizada pela abertura em relação ao outro e autenticidade foi experimentada pelos pacientes como facilitadores do desenvolvimento do rapport. Isso pode ajudar pessoas com esquizofrenia a se engajar na relação.
(4)	A inclusão social pode melhorar a mudança terapêutica e a recuperação na esquizofrenia. A terapia de grupo pode ser útil para promover um sentimento de pertencimento social, mas a inclusão no contexto social e comunitário mais amplo permanece uma questão crítica.
(5)	A experiência de momentos alegres em psicoterapia pode contribuir positivamente para a mudança terapêutica, na medida em que promove um senso de esperança para o futuro.

Em geral, o nosso trabalho contribui para a literatura com o objetivo de expandir a gama de modalidades terapêuticas, focando na criação e uso de modelos mistos de terapia dentro e além das práticas de fala.

目的：有越來越多研究證據支持身體取向心理治療(BPT)對思覺失調症之效能，但目前尚未有研究探討其療效與治療歷程的關聯，亦即尚未探討BPT何以有效及其效能發揮的方式。本研究以手冊化BPT應用於思覺失調症患者，並對參與者的經驗進行質性探索，以明瞭治療性改變之歷程。方法：我們對六位完成十週BPT團體處遇的參與者進行深度訪談，以探索參與者的改變經驗及對治療感到有助益的面向，並對資料進行詮釋現象學分析。結果：由訪談找到六項主題，包括 (i)整體感：身心相連；(ii)感到獨樹一格與具有能力(iii)感到獨特與具有價值：感到如其所是地被接納；(iv)改變人際互動：投入於真摯的人際接觸；(v)感到自己是團體的一份子：有整合感；及(vi)有希望感並嚮往未來。結論：我們討論各項主題之臨床意涵，並將研究發現加以彙整，以思覺失調症患者在各個不相同但環環相扣之層次上的自我感之復原，來描述其治療性改變，此外，我們也對思覺失調症患者之治療的特殊性及普遍性因素提出建議。

Keywords:

• process research
• psychosis/severe mental illness
• qualitative research methods
• body-oriented psychotherapy
• interpretative phenomenological analysis

Palavras-chave:

• pesquisa de processos
• psicose / doença mental grave
• métodos de pesquisa qualitativa
• psicoterapia orientada ao corpo
• análise fenomenológica interpretativa

關鍵詞:

• 歷程研究
• 精神病／重度心理疾患
• 質性研究法
• 身體取向心理治療
• 詮釋現象學分析

Acknowledgements

We would like to gratefully acknowledge all participants of this study and the body-oriented psychotherapist Ariane Konrad, for her clinical work and the many inspiring conversations. Many thanks also to Laura Mehl for transcribing the interviews. We are also grateful to Heribert Sattel, Sabine Koch, and all the voluntary students and co-workers that coordinated and helped organizing the larger clinical trial in which this qualitative study is embedded. Finally, we would like to thank the Editor and the Reviewers for their helpful and thoughtful comments on the paper.

ORCID

Laura Galbusera http://orcid.org/0000-0002-0459-2803

Notes

1 The participant who dropped out was a woman diagnosed with a schizoaffective disorder. Her younger age, different needs and expectations might have contributed to the interruption of treatment.

2 To preserve confidentiality, the ethnicity and mother tongue of this participant will not be specified.

3 During the BPT treatment, participants did not receive other types of psychotherapy on a regular basis.

4 Before the beginning of the intervention, the therapist and co-therapists participated in a training workshop on the BPT manual, held by Frank Röricht and Nina Papadopoulos. LG is a clinical psychologist, the other co-therapist was a novice.

5 At this stage, aspects of para- and nonverbal behaviour, emotional tone of conversation and the specific feelings and impressions of the interviewer were integrated in the analysis. To this purpose, LG wrote detailed minutes immediately after each interview. Although the IPA guidelines do not require such a detailed integration of the recollection of interview in the coding procedure, those recollected aspects provide important information about the implicit and relational context of the elicited data, which we believe is extremely important for the analysis process (see also Galbusera & Fellin, 2014)

6 See, for example, the first quote reported in the theme “Being a whole: Body-mind connection.”

7 The master themes were significantly present in all interviews and are grounded in several quotes from all participants. However, due to space limits, each theme will be presented here only with few exemplary quotes. More wording has been used to describe some themes, as it was required by the complexity of some topics. Yet, it is important to stress that all six themes are equally relevant.

8 Although an intersubjective component of the therapist’s empowering stance is present in this theme, we still decided to categorize it under the “bodily dimension” of therapeutic change. This is mainly because of the strong emphasis on the body and action which participants put in describing agency and their experience of it. The three dimensions of therapeutic change presented here have been separated for conceptual purposes but, when looking at the complexity of the accounts, one can often notice that these boundaries are blurred.

9 For a more detailed discussion on this twofold therapeutic stance see Galbusera and Kyselo (2017).

10 See Smith et al. (2009) and Lyons and Coyle (2016).

Additional information

Funding

This work was supported by the Marie-Curie Initial Training Network “TESIS: Towards and Embodied Science of Intersubjectivity” [grant number FP7-PEOPLE- 2010-INT, 264828].