Psychomotor Therapy as an Additive Intervention for Violent Forensic Psychiatric Inpatients: A Pilot Study

Figures & data

Figure 1. Study design: measures applied at the pretreatment, posttreatment and follow-up assessment.

Table 1. Mean scores and effect sizes on primary outcome measures in the total group (N = 27), the ART+PMT group (n = 16), and ART+sports group (n = 11).

Variable	Subscale	Group	Pretreatment	Posttreatment	Follow-up	Pretreatment vs. Posttreatment Cohen's d [95% CI]	Pretreatment vs. Follow-up Cohen's d [95% CI]
AQ-SF	Total aggression	Total (n = 25)	29.20 (5.89)	29.12 (8.29)	28.72 (8.32)	0.01 [−0.54, 0.57]	0.07 [−0.49, 0.62]
	(MCID = 1.18)	PMT (n = 14)	29.50 (5.50)	31.71 (7.31)^−	29.43 (8.73)	−0.34 [−1.09, 0.40]	0.01 [−0.73, 0.75]
		Sports (n = 11)	28.82 (6.62)	25.82 (8.61)^+	27.82 (8.08)	0.39 [−0.36, 1.14]	0.14 [−0.61, 0.88]
NAS	Anger	Total (n = 25)	84.56 (11.50)	81.76 (11.05) ^+	82.08 (11.06) ^+	0.25 [−0.31, 0.80]	0.22 [−0.34, 0.78]
	(MCID = 2.30)	PMT (n = 14)	88.07 (9.68)	84.29 (10.52) ^+	82.29 (13.10) ^+	0.37 [−0.37, 1.12]	0.46 [−0.13, 1.05]
		Sports (n = 11)	80.09 (12.50)	78.55 (11.34)	81.82 (8.38)	0.13 [−0.71, 0.97]	−0.16 [−1.00, 0.67]
OSAB	Aggressive	Total (n = 27)	17.81 (6.10)	17.56 (6.52)	16.33 (4.57) ^+	0.04 [−0.49, 0.57]	0.27 [−0.26, 0.81]
	behavior	PMT (n = 16)	18.06 (6.10)	18.63 (6.28)	17.44 (5.22)	−0.09 [−0.79, 0.60]	0.11 [−0.58, 0.80]
	(MCID = 1.22)	Sports (n = 11)	17.45 (6.15)	16.00 (6.84) ^+	14.73 (2.94) ^+	0.22 [−0.62, 1.06]	0.56 [−0.29, 1.42]
	Social behavior	Total (n = 27)	31.15 (5.99)	33.81 (6.15) ^+	33.74 (5.17) ^+	−0.44 [−0.98, 0.10]	−0.46 [−1.00, 0.08]
	(MCID = 1.20)	PMT (n = 16)	29.56 (6.06)	35.25 (6.60) ^+	35.75 (4.22) ^+	−0.90 [−1.63, −0.17]	−1.19 [−1.94, −0.43]
		Sports (n = 11)	33.45 (5.32)	31.73 (4.98) ^−	30.82 (5.19) ^−	0.33 [−0.51, 1.18]	0.50 [−0.35, 1.35]

Note. MCID = minimum clinically important difference, AQ-SF = Aggression Questionnaire Short Form, NAS = Novaco Anger Scale, OSAB = Observation Scale for Aggressive Behavior, UCL = Utrecht Coping List, − = Clinically meaningful deterioration in comparison to the pretreatment assessment, + = Clinically meaningful improvement in comparison to the pretreatment assessment.

Table 2. Mean scores and effect sizes on secondary outcome measures of the total group (N = 27), the ART+PMT group (n = 16), and ART+sports group (n = 11).

Variable	Subscale	Group	Pretreatment	Posttreatment	Follow-Up	Pretreatment vs. Post treatment Cohen's d [95% CI]	Pretreatment vs. Follow-up Cohen's d [95% CI]
UCL	Active problem	Total (n = 20)	17.60 (2.62)	18.00 (3.29)	17.20 (2.65)	−0.13 [−0.76, 0.49]	0.15 [−0.47, 0.77]
	solving	PMT (n = 9)	18.11 (2.62)	18.56 (3.78)	17.33 (2.69) ^−	−0.14 [−1.06, 0.79]	0.29 [−0.64, 1.22]
	MCID = 0.52)	Sports (n = 11)	17.18 (2.68)	17.55 (2.95)	17.09 (2.74)	−0.13 [−0.97, 0.71]	0.03 [−0.80, 0.87]
	Social support	Total (n = 20)	14.25 (2.43)	14.15 (3.12)	14.80 (3.50) ^+	0.04 [−0.58, 0.66]	−0.18 [−0.80, 0.44]
	(MCID = 0.49)	PMT (n = 9)	14.22 (1.56)	14.78 (3.46) ^+	15.44 (2.30) ^+	−0.21 [−1.14, 0.72]	−0.62 [−1.57, 0.33]
		Sports (n = 11)	14.27 (3.04)	13.64 (2.87) ^−	14.27 (4.29)	0.21 [−0.63, 1.05]	0.00 [−0.84, 0.84]
	Expression of	Total (n = 20)	6.90 (1.52)	7.55 (1.47) ^+	7.35 (1.18) ^+	−0.43 [−1.06, 0.19]	−0.33 [−0.95, 0.29]
	emotions	PMT (n = 9)	6.89 (1.05)	7.22 (1.30) ^+	7.56 (1.01) ^+	−0.28 [−1.21, 0.65]	−0.65 [−1.60, 0.30]
	(MCID = 0.30)	Sports (n = 11)	6.91 (1.87)	7.82 (1.60) ^+	7.18 (1.33)	−0.52 [−1.37, 0.33]	−0.17 [−1.00, 0.67]
	Reassuring	Total (n = 20)	11.40 (2.09)	11.60 (2.52)	11.65 (2.18)	−0.09 [−0.71, 0.53]	−0.12 [−0.74, 0.50]
	thoughts	PMT (n = 9)	11.22 (1.30)	12.33 (2.00) ^+	12.33 (1.94) ^+	−0.66 [−1.61, 0.29]	−0.67 [−1.62, 0.28]
	(MCID = 0.42)	Sports (n = 11)	11.55 (2.62)	11.00 (2.83) ^−	11.09 (2.30) ^−	0.20 [−0.64, 1.04]	0.19 [−0.65, 1.02]
	Palliative	Total (n = 20)	18.80 (3.24)	19.05 (3.80)	18.40 (2.87)	−0.07 [−0.69, 0.55]	0.13 [−0.49, 0.75]
	response	PMT (n = 9)	20.00 (2.69)	20.11 (2.93)	18.89 (2.93) ^−	−0.04 [−0.96. 0.88]	0.39 [−0.54, 1.33]
	(MCID = 0.65)	Sports (n = 11)	17.82 (3.43)	18.18 (4.33)	18.00 (2.90)	−0.09 [−0.93, 0.74]	−0.06 [−0.89, 0.78]
	Avoidance	Total (n = 20)	17.65 (2.43)	17.15 (2.52) ^+	16.50 (2.09) ^+	0.20 [−0.42, 0.82]	0.51 [−0.12, 1.14]
	(MCID = 0.49)	PMT (n = 9)	18.00 (2.96)	17.44 (1.74) ^+	16.56 (2.40) ^+	0.23 [−0.70, 1.16]	0.53 [−0.41, 1.47]
		Sports (n = 11)	17.36 (2.01)	16.91 (3.08)	16.46 (1.92) ^+	0.17 [−0.66, 1.01]	0.46 [−0.39, 1.30]
	Passive	Total (n = 20)	12.55 (2.33)	12.30 (2.49)	12.15 (1.93)	0.10 [−0.52, 0.72]	0.19 [−0.43, 0.81]
	response	PMT (n = 9)	12.56 (2.60)	13.67 (2.60) ^−	12.11 (1.76)	−0.43 [−1.36, 0.51]	0.20 [−0.72, 1.13]
	(MCID = 0.47)	Sports (n = 11)	12.55 (2.21)	11.18 (1.83) ^+	12.18 (2.14)	0.68 [−0.18, 1.53]	0.17 [−0.67, 1.01]
KBSQ	Bodily Awareness	Total (n = 20)	9.45 (2.78)	9.85 (2.37)	10.25 (2.51) ^+	−0.15 [−0.78, 0.47]	−0.30 [−0.93, 0.32]
	(MCID = 0.56)	PMT (n = 9)	9.22 (3.42)	9.89 (2.37) ^+	10.56 (2.74) ^+	−0.23 [−1.15, 0.70]	−0.43 [−1.37, 0.50]
		Sports (n = 11)	9.64 (2.29)	9.82 (2.48)	10.00 (2.41)	−0.08 [−0.91, 0.76]	−0.15 [−0.99, 0.68]

Note. MCID = minimum clinically important difference, UCL = Utrecht Coping List, KBSQ = Kijvelanden Bodily Sensations Questionnaire, − = Clinically meaningful deterioration in comparison to the pretreatment assessment, + = Clinically meaningful improvement in comparison to the pretreatment assessment.

Table 3. Main results of the binary logistic regression analyses predicting completers versus drop-outs out of PCL-R scores.

	Completers (n = 27) vs. drop-outs (n = 6)
Variable	Subscale	B	OR [95% CI]	P
PCL-R	Total	0.35	1.41 [1.02, 1.96]	.037
	Interpersonal	0.45	1.57 [1.01, 2.43]	.046
	Affective	1.36	3.89 [0.78, 19.41]	.098
	Lifestyle	1.24	3.45 [1.15, 10.31]	.027
	Antisocial	0.21	1.24 [0.83, 1.86]	.302

Note. PCL-R = Psychopathy Checklist – Revised.

Table

Sessions	Description and goals
1–6	Improving the awareness of bodily sensations. Patients are instructed to focus on their sensory perceptions in order to recognize possible changes within the body. During these exercises the patients can be at rest (e.g., focusing on breathing), but physical changes are also often provoked using physical exercises. During the homework assignments, patients are instructed to report a situation in which they focused exclusively on their sensory perceptions. Furthermore, learning to focus on bodily sensations is practiced repeatedly during the whole treatment program.
7–11	Practicing coping techniques, including (1) breathing exercises, (2) Jacobson's progressive muscle relaxation technique (1934, 1938), (3) reassuring thoughts, and the (4) time-out procedure. Every technique coping is practiced during the session, but also as homework assignment on the ward. All coping techniques are repeatedly practiced during the whole treatment program and during session 11, all techniques are practiced again in one single session.
12–13	Exercises that evoke an impulsive reaction to explore how a patient tends to respond during elevated levels of arousal (in a safe and structured treatment environment).
14–16	The personal triggers of frustration are explored for every individual patient. These triggers are first verbally explored and skills to cope with these situations are subsequently practiced during exercises (e.g., role-playing).
17	Exercises to provide insight in impulsive reflexes which are associated to aggression.
18–19	Patients practice communication skills during elevated levels of physiological arousal.
20–25	The aggression profile of each individual patient, which includes triggers which can lead to high levels of anger, possible reaction tendencies during anger, and protective skills which can help to decrease the level of anger. These protective skills are also practiced during these sessions.

Table

Sessions	Description and goals
1–5	Anger control. Participants learn to recognize and manage feelings of irritation and anger more adequately. For that purpose, five aspects of problem situations are analyzed, namely (1) event, (2) thoughts, (3) feelings, (4) behavior, and (5) consequences
6–10	Social Skills Training. The focus is on the improvement of prosocial skills. Five skills are selected by the patients from a list of twelve skills. For each exercise, the patients receive a hand-out with possible targets (‘What do you want to achieve?’) and criteria (‘Where do you pay attention to?’).
11–15	Moral Reasoning Training. Patients take note of the prevailing norms and values and learn how to solve moral problematic situations.
16–20	Prosocial thinking. Knowing how to convert cognitions which may lead to antisocial behavior into cognitions which may lead to prosocial behavior. Five distorted cognitions are discussed, namely putting you in another's place, self-centeredness, minimizing, assuming the worst, and blaming others.
21–25	Character formation. Learning to focus on the short-term and long-term consequences of prosocial and antisocial behaviors. This is done on the basis of five themes, namely accountability, subservience, respect, cooperation, and honesty.
26–30	Prosocial network. Learning how to engage in prosocial contacts and how to hold off or to end antisocial contacts. Five problem situations are practiced, namely making acquaintance, making an appointment, intensifying a contact, informing others about your offense, and responding on a rejection.
31–35	Attitude towards women. Male patients learn how to behave towards women. Participants practice five problem situations, namely showing your need to intimacy, responding on a rejection, responding on approaches, intensifying the relation, and dealing with relational problems.