MIND ^ BODY STUDY

Patient experiences of basic body

awareness therapy and
the relationship with
the physiotherapist
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Amanda Lundvik Gyllensten, Lars Hansson, Charlotte Ekdahl

Abstract Background and Purpose: To explore the experiences of patients undergoing

basic body awareness therapy in psychiatric physiotherapy. In addition, the
therapeutic relationship and the concept of the working alliance were examined.
Subjects: Two groups of patients participated: patients with schizophrenia (n=6) and
general psychiatric outpatients (n=5). Method: A qualitative technique, video taping
and interviewing the patients during treatment was used. Results: The most common
experience from the treatment was ‘balance and posture’. Other experiences were
‘body movement control’ and ‘awareness and handling of body signals’. Themes
central to establishing a good working alliance were identified. Discussion and
Conclusions: The impact of balance and posture was discussed and some new
hypotheses were generated. r 2003 Elsevier Science Ltd. All rights reserved.
Amanda Lundvik Gyllensten PhD, RPT
Department of Physical Therapy, Lund University,
Sweden

Lars Hansson PhD

Assistant Professor, Department of Clinical
Neuroscience, Division of Psychiatry, Lund
University, Sweden
Charlotte Ekdahl PhD, RPT
Professor, Department of Physical Therapy, Lund
University, Sweden
Correspondence to: Amanda Lundvik Gyllensten
Department of Physical Therapy, Lund University
Hospital, SE-221 85 Lund, Sweden
Tel.: +46 46222 4804; Fax: +46 46222 4204
E-mail: gyllensten@sjukgym.lu.se
...........................................
Journal of Bodywork and Movement Therapies (2003)
7(3),173^183
r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S1360-8592(02)00068-2
S1360-8592/03/$ - see front matter
Background
In the last few decades,
physiotherapy in psychiatry has
been a developing professional field
in the northern countries of Europe
(Roxendal 1985, Gyllensten &
Nilsson 1993, Mattsson 1998). Basic
body awareness therapy (Basic
BAT) is considered to be one of the
main treatment methods of
psychiatric physiotherapy (Mattsson
1998). Basic BAT in clinical
psychiatric physiotherapy has
previously been described (Roxendal
1985, 1995, Skatteboe et al. 1989).
The method was developed and
described by the French
psychoanalyst and movement
teacher (Dropsy 1975, 1988) who
synthesized the method inspired
both by western movement
traditions and the eastern practice of
T’ai-chi Ch’uan (T’ai-chi). Basic
BAT uses movements, breathing,
massage and awareness to try to
restore balance, freedom and unity
of body and mind. Basic BAT is
described as resource oriented,
which in this case means working
with the resources of the body as a
whole. Turning the attention both to
the doing and to what is experienced
in the movements, the awareness of

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physical and mental aspects of the
self is developed. Basic BAT differs
from T’ai-chi in that movements are
quite simple, focused on the
experience of ease, stability and
intention (Dropsy 1988, 1999). The
treatment modality was developed
to be starting exercises for T’ai-chi,
and tends to follow the same
principles that are embodied in these
exercises (Gyllensten & Nilsson
1993). The therapist encourages the
patient to move in ways more
optimal to postural control, balance,
free breathing and coordination
(Dropsy 1988, Roxendal 1995).
Basic BAT can be used both
as an individual and as a group
treatment.
The encounter and interaction
between physiotherapist (PT) and
patient have been emphasized as an
important tool in Basic BAT
(Roxendal 1995, Mattsson 1998,
Rosberg 2000, Gyllensten et al.
2000). The importance of interaction
between patient and PT is, however,
central to the physiotherapy
curriculum as a whole (Tyni-Lenné
1989, Klaber Mofett & Richardson
1997). In a review of the evidence for
interaction effects, five different
models explaining the effect of
interaction on patient outcome were
found. These models concern the
quality of communication and
patient education, patient
compliance, the patient’s perception
of control and ability to cope, the
PT’s enthusiasm for the treatment
and operant conditioning in
influencing pain behavior (Klaber
Mofett & Richardson 1997). Expert
PTs in primary health care believed
interaction to be central to patient
outcome and interaction skills could
be increased by reflection about
patients’ experiences (Gyllensten
et al. 1999).
The concepts of the working
alliance and the therapeutic
relationship have been thoroughly
explored within psychotherapy
research to understand and
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Gyllensten et al.
predict therapy outcome. The
therapeutic relationship is
considered to consist of three
components: the working
alliance, a transference
configuration and a real (genuine)
relationship according to
Gelso and Carter (1994). The
working alliance can be defined as
the patient’s attachment to and
identification with the therapist, a
kind of relationship resembling the
bonded attachment to the primary
caregiver (Zetzel 1956). According
to Gaston (1990), the working
alliance is the patient’s affective
bond to the therapist and one part
of the therapeutic relationship
between patient and therapist.
Strupp (1973) emphasized the
interactive nature of the
relationship, involving both the
human qualities of the therapist as a
good parent, and the patient’s
openness and willingness to learn.
This was seen as the base for
imitation and identification essential
to learning and success in therapy.
Horvath and Greenberg define the
working alliance as the interaction
between patient and therapist. The
collaborative relationship between
client and therapist, the interactive
nature of the relationship and the
integration of technical and
relational aspects are also
emphasized (Horvath & Greenberg
1994). According to Luborsky there
are two types of signs indicating the
quality of the working alliance. Type
1 signs indicate that the patient
experiences the therapist as warm,
helpful and supportive and type 2
signs convey a sense of cooperation,
working together in a joint effort in
dealing with the patient’s problem
(Luborsky 1994). Also, in
physiotherapy, the therapeutic
relationship has been the subject of
analysis in an article that elaborated
the three components: the working
alliance, the transference
configuration and the real
relationship (Szybek et al. 2000).
174
Aims of the study
The main purpose was to explore the
patient’s experiences of Basic BAT
in psychiatric physiotherapy. Their
experiences of the therapeutic
relationship and working alliance
with the PT were also focused. The
aim was also to study the concept of
the working alliance in a
physiotherapy context.
Methods and subjects
Design
The study employs a qualitative
design, using the aims and the initial
framework to bind the scope of the
study and present the initial level of
understanding of the phenomena of
interest (Miles & Huberman 1994,
Shepard et al. 1993). This design
aims at generating models focusing
on important issues or phenomena
connected to physiotherapy (Jensen
et al. 1999). The research method
used in this study was a qualitative
case study with cross-case analysis
(Merriam 1988). In a case study,
different types of empirical
information, such as interviews,
documents or observations, are
collected. In cross-case analysis,
individual case reports are analyzed
and then compared in order to find a
general explanation that fits all
cases.
Data in this study consisted of
repeated interviews. The data from
the interviews were organized using
an interview transcription log
(Merriam 1988). Low-inference data
were obtained by using quotes from
the patients’ interviews in order to
provide internal validity. The initial
framework was based on earlier
knowledge of Basic BAT (Roxendal
1985, 1995, Mattsson 1998, Dropsy
1988, 1999) and the clinical
experience of one of the researchers.
Concerning the therapeutic
relationship and the working
alliance, the knowledge was mainly
 Basic body awareness

gained from psychotherapy research open questions, ‘What did you Patients
(Horvath & Greenberg 1994, see in the video?’, ‘Can you tell me
The patients were selected to
Luborsky 1994). The initial about how you experience the
produce a sample with the
framework is presented in Fig. 1. treatment now?’ and ‘Can you tell
maximum variation (Merriam 1988,
When conducting the first me about the relationship with
Shepard et al. 1993, Jensen et al.
interview with the patients, an your PT?’
1999) in order to get a broad
interview guide based on the initial Before the study began, two video
understanding of the phenomena
framework was used; see Table 1. recordings were made and two
from different perspectives.
The interviews were tape recorded in interviews carried out to test the
Two groups of patients
full. qualitative data collection methods
participating in Basic BAT group
The interview guide at the second and gain information and
therapy were included in the study;
and third interview consisted of the experience.
see Chart 1. One group was treated
at a long-term rehabilitation unit for
young patients with schizophrenia.
Therapeutic relationship Basic Body Awareness The special unit was based on the
Therapy cognitive therapy model, using a
minimum of medication and a more
Grounding/postural line intensive therapeutic intervention.
Experience
ExperienceofofPT as
therapist
warm, supportive
Centering/breathing Besides Basic BAT the patients were
as warm, supportive Flow
helping
helping working in groups with education,
Mental awareness
social skills training and cognitive
Sense
sense of cooperation
of cooperation Self-confidence therapy (Svensson 1999). This group
Working together
working together is hereafter called the ‘inpatient
Relation to others group’.
Relation to reality
The other group was treated in
general psychiatric outpatient care.
The patients were living at home and
Fig.1 Initial theoretical framework. The framework consisted of theories about factors contracted to participate in 12
important in the Basic BAT, such as grounding/relation to center line, centering/breathing, flow sessions. They all had other ongoing
and mental awareness, and self-confidence, ability to relate to others and reality. Concerning the contacts with psychiatrist, social
therapeutic relationship and the working alliance the knowledge was gathered from research in worker or psychotherapist. This
psychotherapy.
group is hereafter called ‘the
outpatient group’.
The diagnostic system used was
ICD-10 (Swedish Version of ICD
Table 1 Interview guide 10, 1996).
1. What do you think you need to feel good/better?
2. What do you think about the treatment with Body Awareness Therapy?
3. Do you have a goal for your treatment with Body Awareness Therapy? Physiotherapists
4. Is the treatment with Body Awareness Therapy related to your goal, as you see it?
5. Do you perceive the treatment with Body Awareness Therapy as meaningful? Two PTs, nominated as experts in
6. Can you tell me about your PT? psychiatric physiotherapy by their
peers in a study about expertise in
Follow-up areas psychiatric physiotherapy in the
7. Can you tell me about whether you think that your PT is warm or cold as a person?
8. Do you think that she is interested or not so interested in you? south of Sweden (Gyllensten et al.
9. Is she capable or not so capable in her work, as you see it? 2000) and using Basic BAT in
10. Do you trust her? patient groups in January 1998,
11. Do you feel accepted or respected? were asked to participate as
12. Do you think that she is a person that can help you? therapists in the study. The expert
13. What do you think about the cooperation with your PT?
14. Do you think that you are making any progress?
PTs were both female, with many
15. Do you think that she thinks that you are making any progress? years of clinical practice in
16. What would you tell a friend who had similar problems to yours about this form of psychiatric physiotherapy (average
treatment? 20 years) and well educated, having
17. Do you have anything to add about what good physical therapy treatment should be? both formal and informal education

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 Gyllensten et al.

Chart 1 Patient characteristics time three patients. The patients in

the ‘outpatient group’ were video
Inpatient group Outpatient group recorded and interviewed twice,
Number of patients 6 5
once at the beginning of the group in
Diagnosis Schizophrenia (n=6) Anxiety syndrome (n=2) February (session 3) and once in
Depressive and anxiety May (session 11), before the
syndrome (n=1) termination of the group. There
Somatisation syndrome were five patients participating at
(n=1) Gille de Tourettes
syndrome (n=1)
the first interview occasion in
February, and three patients at the
Age (years) second interview.
Mean 30 45
Range 29–39 30–55
The video camera was placed so
as to cover the whole group through
Gender the different activities and positions,
Males 4 2
Females 2 3
such as laying on the floor, sitting,
standing and sometimes walking,
Previous experience of Basic pairwise massage or T’ai-chi.
BAT (months)
Mean 9 3
Interviews with the patients were
Range 3–22 0–36 conducted after each video
recording. The patients watched
Present intensity in Basic BAT 1.5 hours, three times a 1.5 hours, once a week
treatment week
parts of the Basic BAT sessions
before being interviewed. The
emphasis was on the parts where the
focus was mainly on the interaction
in psychiatric physiotherapy, Basic patients. She also informed the between the PT and the patient.
BAT and T’ai-chi. They were patients and answered questions Watching the video and being
working more than 50% of full time about the study. interviewed lasted between
in direct patient contacts. The patients in the Basic BAT 45 minutes and 2 hours, depending
The inclusion criteria for this groups were video recorded and on the endurance and the psychiatric
study were: being a patient to a interviewed on several occasions; condition of the patient. The
nominated expert PT in psychiatric see Fig. 2. patients were interviewed as close to
physiotherapy and receiving Basic The patients in the ‘inpatient the therapy session as possible,
BAT in a group setting. At the onset group’ were video recorded and preferably the same or the next day.
of the study there were two Basic interviewed three times. The first The patients in the ‘inpatient
BAT groups, led by nominated time the data were collected was in groups’ were interviewed the
expert PTs that fulfilled the January 1998, then after 5 months in same or the next day. For the
inclusion criteria. The patients in June, and then again in November ‘outpatient group’ the time interval
both groups consented to the same year. During the first and could be up to a week if the patients
participate. The Research Ethics second times there were six patients found it difficult to take time off
Committee of the Medical Faculty participating, and during the third from work.
of Lund University approved the
study. The patients were informed
about the study both in writing and
Inpatient group
orally, before giving consent to
Information and treatment treatment
participation. Researcher Video 1 4 months Video 2 6 months Video 3
consent
in group interview interview interview

Procedural steps in data Outpatient group

collection Information and treatment
consent Researcher Video 1 2.5 months
Video 2
Before the first video recording one in group interview interview
of the researchers visited and
participated in the groups, between Fig. 2 Description of data collection. The patients in the inpatient group were interviewed three
one and three sessions in order to times, at the onset of the study, after 4 months and after another 6 months. The patients in the
become acquainted with the ‘outpatient group’ were interviewed at the beginning and the end of a 3-month Basic BAT group.

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Procedual steps in data
analyses
The interviews were tape recorded
and transcribed in full. The first step
in the analyses was to read the
transcription of the interviews as a
whole, trying to comprehend how
the patients were experiencing the
Basic BAT treatment and the
therapeutic relationship with their
PT. The analysis then concentrated
on the patients’ experiences of the
Basic BAT. Each interview was
treated and coded as a case report.
A separate interview transcription
log was established for each patient
and each interview. An open coding
was used, aiming at understanding
and conceptualizing the patients’
individual experience of their Basic
BAT process. This was
accomplished breaking down the
interviews into different parts,
representing different aspects or
units of the experiences. Then these
aspects were conceptualized into
different categories representing
different phenomena (Strauss &
Corbin 1990, Merriam 1988). First
the Basic BAT process of the
patients in the ‘inpatient group’ was
analyzed, then the Basic BAT
process of the patients in the
‘outpatient group’ and then both
groups were analyzed together,
performing cross-case analysis
(Merriam 1988), in order to identify
both specific and common
experiences of Basic BAT. The same
procedure was then used to explore
the patients’ experiences regarding
the therapeutic relationship and the
working alliance. This process
included going back and forth
between the original interviews, the
transcription logs and cross-case
analyses to validate the
categorization of the data. The
relationships between the categories
were organized in themes as the data
were synthesized (Merriam 1988,
Strauss & Corbin 1990). The process
of coding and categorization started
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Basic body awareness
with the first interviews and were
revised as the researchers collected
and analyzed more data through
interviews two and three. In the
analytic phase, the two PTs were
active. Analyses continued until
consensus was reached.
Results
The number in parentheses after
each quote refers to the informant to
which the quote belongs. Informants
1–6 took part in the ‘inpatient
group’ and informants 7–11 took
part in the ‘outpatient group’.
Basic body awareness
therapy (Basic BAT)
Four themes were found: (I)
‘Personal involvement’, (II) ‘Balance
and posture’, (III) ‘Awareness and
handling of body signals’, (IV)
‘Body movement control’, and are
presented in Table 2.
A presentation of the content of
the themes and categories follows.
(I) Personal involvement: The
category ‘Ability to practice alone’
was found only in the patients
(informants 5 and 8) reporting the
most profound process in Basic
Table 2 The Patients’experiences of Basic
BAT.Themes and categories
(I) Personal involvement
Ability to practice alone
Questions about meaning
(II) Balance and posture
Improved balance and posture
(III) Awareness and handling of body
signals
Deepened awareness and
interpretation of signals
Moving with ease
Handling muscular tension
(IV) Body movement control
Feeling of body control
Looking good and controlled
177
BAT (physiologically,
psychologically and socially). The
category of ‘Questions about
meaning’ was found in the group of
patients with schizophrenia
(informants 1–6) at the first
interview.
Ability to practice alone
Well the most important thing for me
is that I have to continue these
[exercises] my whole life and not
think that this is over and done with. I
have to, because otherwise I feel that I
more and more fade away into some
sleepy state of mind. And not to fade
away or stop this process I have to do
these exercises all the time, to be able
to return back to life and gain strength
and to be met as a person by others. To
be met by others as an alert persony
If we practice we can advance on the
road to become more united with our
movements yit happens to me when I
make the Wave [first movement of the
Cheng Man Ch’ing short yang form of
T’ai-chi] because I feel sure about how
to do it, in T’ai-chi. When I feel sure
about how to do a movement in T’ai-
chi, then I feel like I am one with my
movements and it happens almost by
itself. I don’t have to think so much.
But I have practiced the Wave
hundreds of times to become united
with that movement y and it feels
beautiful to do the T’ai-chi form. And
it is y it is very important to me to feel
that I’m doing something beautiful
with my body [cries] (informant 8).
In the beginning I did not take this
seriously and I wondered what it was
about. But then I thought that I really
did not have any choice but to involve
myself in this. But it took 6 months
before I really understood it y and it
has made me more mentally present
and I will continue with these
exercises, because I want to continue
improvement in the future as well y
So I do some exercises myself y
bounce on my feet and y Like
spend some minutes every day’
(informant 5).
Questions about meaning
Exercises like sitting and pressing your
foot down into the floor, I don’t think
that it is meaningful (informant 3).

(II) Balance and posture: This
theme consisted of the most
commonly reported category,
‘Improved balance and posture’.
Improved balance and posture
I felt good. I was standing still and did
not lose my balance or anything like
that. No, completely still. I was
standing still and my arms were in a
good place and my legs in a good
place, then I will keep my balance
(informant 1).
I really think that my balance has
improved. And also my knowledge of
how to keep my balance. The point of
pressure must be on the front of the
foot. Sometimes I forget, but then I
hear her [the PT’s] voice within. Then
I feel that I can move the whole body
better if I place the point of pressure
on the front foot. I did not feel this
before yIn order not to look tired, I
have tried to pull myself up,
from the shoulders. I thought this was
the place to pull myself up. I did not
know that the postural balance should
start from the legs (informant 8).
(III) Awareness and handling of
body signals: This theme consisted of
the categories ‘Deepened awareness
and interpretation of signals’,
‘Moving with ease’ and ‘Handling
muscular tension’.
Deepened awareness and
interpretation of signals
You think about how you treat your
bodyyyou feel from the inside where
you have your bodyy if I sit in an
armchair and I feel some
tensiony that you change your
position, not just sit there and force
yourself and have painy. Regardless
of whether you are walking, running or
doing whatevery When I sit and write
I can feel very tense and before I just
continued writing and writing,
regardless of the tensions. Now I just
let go of the pen and do something else.
It is just the point that now you can feel
the signals of alarm earlier in a way
(informant 11).
I want to increase the contact with the
body in another way than just sitting
and stretching oneself, to be able to feel
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Gyllensten et al.
the contact with the ball or other things
instead. y In order to improve the
contact with oneself y I don’t think
that I am in reality very much
(informant 3).
Comments: The patient in the ‘inpatient
group’ expressed a lack of this contact,
but a wish for it.
Moving with ease
This feeling of improved ability to
move, that I bounce when I walk that I
have directly after the group. Then I
can feel the bouncing in my steps and I
wish that I could keep it always
(informant 9).
Handling muscular tensions
Well, it isy it feels good to notice the
difference between being tense and
relaxed. It is easier to feel good.
I can leave this tension behind. I think
that this feels better. Last time at the
end of the session I experienced
that it felt much smoother really
(informant 7).
(IV) Body movements control: This
theme consisted the categories
‘Movement control’ and ‘Looking
good and controlled’.
Feeling of body control
I was rather skilled. I have done these
exercises before and I have had a lot of
time to practicey last yeary Well I
performed them rather skillfully
(informant 4).
Looking good and controlled
People in the circus and others like that
really have control of themselves. Now
I don’t mean you have to be like that,
but it looks much better if you have
control of your bodyyIt looks much
more healthy if one is mentally present
and standing straightyand I had much
more patience with the exercises.
Generally it looks much better. You
make a good impression
(informant 5).
Other categories in addition
were mental presence and
concentration, freedom of
breathing, a sense of well-being,
improvement of self-confidence,
gain of strength.
178
Therapeutic relationship
and working alliance
The experiences of the therapeutic
relationship were structured into
three themes: (I) ‘Personal
relationship’, (II) ‘Characteristics of
the PT’ and (III) ‘Treatment-related
factors’, see Table 3.
A presentation of the content of
the themes and categories follows.
(I) Therapeutic relationship: This
theme consisted of the categories
‘Trust’ and ‘Faith in that the PT
believes in me’.
Trust
Everything she says I just swallowy
You get this feeling that if she says that
things are possible, they are possible.
You can just trust that things work the
way she says they do (informant 9). A
lot of trust is needed, because it is a
sensitive situation. You don’t just sit
there and talk and use your head. The
whole of me is at stake (informant 8).
Faith in that the PT believes in me
Yes I definitely think she does [think
that I am making progress]. She gave
me a lot of positive feedback today
(informant 5).
(II) ‘Characteristics of the PT’ –
working alliance: This theme
Table 3 The Patients’experiences of the
therapeutic relationship and working alliance.
Themes and categories
(I) Therapeutic relationship and trust
Trust
Faith in that the PT believes in me
(II) Characteristics of the
Physiotherapist – working alliance
Warmth
Competence
Respect/acceptance
Encouragement
Empathy
(III) Treatment related factors – working
alliance
Cooperation
Goal orientation
Making progress

consisted of the categories
‘Warmth’, ‘Respect’, ‘Competence’,
‘Empathy’, ‘Interest’ and
‘Encouragement’.
Warmth
A warm and tender person, that really
listens to you (informant 5).
I think that I would rather describe her
as a cold person (informant 4).
Competence
You relax just by listening to her voice.
It penetrates directly into your soul, if I
can put it that way. She has such a
smooth quality of ease in her voice. It
feels like it spreads to us all. She is
really competent and calm. Many good
things thereyI think that she really is
a good leader. She has great qualities
as a leader. She has this calmness also
when she is practicing. Here we are five
beginners, not skilled at all and still she
is calm. I think it is working extremely
well (informant 11).
Respect/acceptance
So you don’t have to do it well to be
included, or have to do it in the right
way. Possibly she notices the difference
between us, but myself, I don’t notice if
that person is better or worse y It
really isn’t very
interestingy’(informant 9).
One patient said that she did not feel
respected.
What I think is worse is what she says
or commentsy she has some hard
criticisms and I felt very bad about it
y it happens that you laugh a little if
you relax and think about something
else or sort of get lost in your thoughts.
I really don’t think that it is
dangerous, not hallucinogenic really,
in my opinion. I don’t think that you
have to increase Liponex [medicine],
so then I think that it is a little
dangerous to go down [to the BAT
group] (informant 4).
Encouragement
It has worked so well. I mean she
really has listened to me. It is
not only the bodywork, I have
been able to talk about what I feel
and I have been treated in such
a good way the whole time. So I am
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Basic body awareness
really, really pleased. She has
done a great job and shown so much
patience to make me feel well. I think
that she is fantastic and always in a
good mood. She encourages me the
whole time. It has meant a lot
(informant 8).
Empathy
We talked the first time and I felt that I
had good contact with her and I
experienced her as an empathic human
being (informant 7).
(III) ‘Treatment-related factors’–
working alliance: This theme
consisted of the categories
‘Cooperation’, ‘Goal orientation’
and ‘Making progress’.
Cooperation
She tells me things, but it is a
cooperation, because I try to do what
she says (informant 6).
Goal orientation
Two patients in the ‘inpatient
group’ expressed goal orientation
later in the treatment (after 5
months training or more). The
patients in the outpatient group all
described their goal. The goals could
be very general or more specific.
Therapeutic relationship
and Working alliance
I Therapeutic relationship
II Characteristics of the PT
Working alliance
III Treatment-related factors
Working alliance
Fig. 3 Revised theoretical framework. The revised framework consists of the conceptualized
understanding of the factors the patients themselves experienced as important in the treatment
with Basic BAT and the therapeutic relationship and working alliance with the PT.
179
To get well (informant 1).
I saw that I was absent-minded. I want
that to disappear (informant 5).
To become more clear about the
situations of tensing up. How to breathe
and keep relaxed (informant 11).
Making progress
Yes, I think I have. Yes it sometimes
feels good that I have mastered the
movements (informant 4).
Yes absolutely. I believe so much in this
treatment and I wish for other people
to receive such good treatment
(informant 8).
These results are presented in the
model of the revised framework in
Fig. 3.
Discussion
As the main focus in this study was
to explore the patients’ experiences
of Basic BAT, the therapeutic
relationship and working alliance
with the PT, a qualitative design
using frameworks and case studies
was found adequate. Important
contributions to research from
expert practice include an increase
of knowledge, the clinical reasoning
process, and reflection about
Basic Body Awareness
Therapy
I Personal involvement
II Balance and posture
III Awareness and handling of
body signals
IV Body movement control

practice and skill acquisition (Jensen
et al. 1999, Richardson 1999). Our
intention was to explore how the
patients treated by expert PTs
perceived the treatment and the
relationship to their PT. This aimed
at adding another dimension to the
clinical knowledge in the area. To
formulate a revised model or
framework, not founded on theory
only, but on what the patients
actually reported, was seen as a
means to understand what was
central to them in the Basic BAT
curriculum. This in turn we hoped
could be used to generate new
research hypothesis, founded in
clinical experience (Domholdt 2000).
A strategic choice of two different
groups of patients was made. As the
purpose was to explore a wide range
of possible experiences of Basic BAT
and the therapeutic relationship to
investigate if we found any
differences and similarities in the
experiences of the patients, this
strategy was found to be adequate.
This practice of a strategic choice is
common in qualitative research
(Jensen et al. 1999, Shepard et al.
1993).
The procedure of making video
recordings from the group sessions
served the purpose of actualizing the
memory of the treatment sessions.
With the ‘outpatient group’, there
could be up to a week between the
Basic BAT group and the interview.
In the ‘inpatient group’, the
interview was carried out within a
couple of hours. As the treatment
period is much longer with patients
suffering from schizophrenia, the
time span for data collection was
different for the two groups (see
Fig. 2) adjusting to the clinical
reality. Patients with schizophrenia
have a much longer treatment
period than patients in general
psychiatric outpatient care. To
obtain a rich, manifold description
of the phenomena of interest was the
objective. Still the quality of the
interviews varies a lot. It was
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Gyllensten et al.
generally much more difficult to get
the patients with schizophrenia in
the ‘inpatient group’ to speak freely.
This resulted in more questions
being asked and the answers being
shorter. This was especially true for
the first interview, but changed in
interviews two and three. We have
judged the value of the material as
adequate and interesting, mirroring
one of the difficulties of this group
of patients.
The analyses of the patients’
process in Basic BAT revealed that a
sense of improved balance and
stable posture was central. This is in
line with theories of Basic BAT
(Dropsy 1988, 1999, Roxendal
1995). The patients in this study thus
supported the theories of Basic
BAT, emphasizing the impact of
balance, grounding and center line
as important aspects in treatment.
The importance of balance has also
been focused in other areas of
physiotherapy. Balance and postural
control was one of the most
important factors in identifying
patients with musculoskeletal
disorders in need of
multidisciplinary rehabilitation
(Grahn et al. 1996). Balance was
improved and falls reduced in older
subjects by the use of T’ai-chi
exercises (Wolf et al. 1997). Since
Basic BAT and T’ai-chi are closely
related, the impact of this kind of
treatment on balance and postural
control seems to be strong.
‘Personal involvement’ appeared
to be vital to the ability to practice
Basic BAT alone. To continue
practice alone is viewed as an
important factor in physiotherapy
practice in the area, since it is
believed to be related to outcome. In
psychotherapy research,
involvement is considered to be the
best predictor of outcome (Gomes-
Schwartz 1978). To be able to
understand or create meaning also
seemed to be important to be able to
involve oneself. This is in line with
research from psychotherapy where
180
factors like motivation are shown to
have a great influence on outcome
(Lambert & Bergin 1994). The
ability to involve oneself more in
treatment, found in this study, also
seemed to be related to the duration
of treatment. The patients who had
a longer treatment period of Basic
BAT also seemed to be more
involved. Perhaps this is related to
the fact that to continue treatment
one has to be motivated and
involved. To fully understand these
phenomena more research is needed.
In the ‘inpatient group’ the patients
had not specifically chosen to
participate in Basic BAT, since this
was part of the curriculum in which
they were expected to participate.
This was obvious at the first
interview, when some of the patients
expressed a difficulty in
understanding the meaning of the
exercises. This had an impact on
motivation and involvement in the
therapy.
‘Awareness and handling of body
signals’ was the most frequently
stated gain from the movement
exercises in the ‘outpatient group’.
As informant 11 put it (see Results,
the category of ‘Deepened
awareness and interpretation of
signals’), this increase of awareness
and contact motivates you from the
inside to take care of yourself in a
better way. The patients seemed to
be able to develop the qualities of
improved contact with the body and
the self. Generally, the patients in
the ‘outpatient group’ expressed
many positive benefits from their
participation in the Basic BAT
group. The experiences seemed to
involve not only the body, but also
more emotional aspects and self-
confidence. The aim of Basic BAT
treatment according to the theories
is to help the patients to feel from
the inside what is a good balance,
and to find ease and freedom when
moving. This is done by encouraging
the patients to develop their own
proprioceptivity, sensitivity and

awareness. To discover that they
themselves possess the tool to feel
good within their body, strengthens
the experience of self-confidence and
trust in the body, according to the
same theories (Roxendal 1985,
Mattsson 1998, Dropsy 1999). The
results from this study indicate that
these aspects of the Basic BAT
theory seem to be most relevant for
the patients treated in outpatient
care.
To the patients with
schizophrenia in the ‘inpatient
group’, who had much more basic
problems with identity, the
experience of, or wish for, contact
with and control of the body was
more central. The aspect of control
of the body is not emphasized in the
theories of Basic BAT. This opens
the field for some interesting
hypotheses about the importance of
body and movement control in
schizophrenia rehabilitation.
Concerning the working alliance,
the theme of ‘Characteristics of the
PT’ contains factors that can be seen
as an expression of type 1 signs of
the working alliance, denoting the
characteristics of the therapist
(Luborsky 1994). This can be due to
the interview guide using questions
about these factors. The factors do
however also feel very relevant in
physiotherapy treatment. They are
very much like the categories
reported by expert PTs interviewed
about what they believed to be
important in the interaction with
their patients (Gyllensten et al. 1999,
2000).
The theme of ‘Treatment-related
factors’ can be seen as an
expression of type 2 signs of the
working alliance, according to
Luborsky (1994). These signs convey
a sense of cooperation, working
together in a joint effort in dealing
with the patient’s problem, and
indicate the quality of the working
alliance. Also in physiotherapy goal
orientation, cooperation and
thought about making progress are
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Basic body awareness
signs of a positive physiotherapy
process and a positive working
alliance.
Three of the six patients in the
‘inpatient group’ (half of the patient
group) felt that they had a good
working alliance with the PT. Of the
remaining patients, one (informant
4) did not develop a good
therapeutic relationship with her
PT. She did not make any positive
remarks about the relationship or
interaction, although she
experienced that she had mastered
the movements. With another
patient (informant 3), there seem to
have been great difficulties
establishing a good working
alliance, not only for the PT. This
patient generally had problems to
remain in rehabilitation at the
cognitive long-term rehabilitation
unit. Because of intense psychotic
suicidal impulses, she was
transferred to another ward and was
more heavily medicated. Yet
another patient (informant 2)
expressed a negative opinion of the
PT’s ability to help, but had a
positive experience of the relation
with the PT in general. According to
research in psychotherapy, the
ability of patients with the diagnosis
of schizophrenia to develop a good
therapeutic relationship and
working alliance seems to be
problematic. Less than half of the
patients with schizophrenia in a
randomized, controlled study of
treatment effects of psychotherapy,
formed a good working alliance
(Stanton et al. 1984, Gunderson et al.
1984). A Swedish study of the
therapeutic alliance in a group of
long-term mentally ill patients
treated at a unit based on cognitive
therapy revealed the patients’
ratings of the therapeutic alliance in
the initial phase to be good in 38.5%
and fair in 57.7% of the cases
(Svensson & Hansson 1999).
In the ‘outpatient group’ four of
the five patients had a positive
working alliance with their PT. The
181
patients in this group had less
problems with relationships and
they had themselves chosen to
participate in the Basic BAT group.
This made them more motivated
and the forming of the working
alliance less problematic.
The most problematic aspects to
form a positive working alliance
seemed to be related to the theme
‘Therapeutic relationship’ and the
feeling of lack of trust in the PT or
doubts about whether the PT
thought that they could make any
progress in the treatment. Here is a
link to the experiences in Basic BAT
where the patients who reported a
positive therapeutic relationship also
reported that they used the Basic
BAT exercises on a daily basis at
home. Interestingly, these patients
were found in both patient groups.
This result is in line with the results
from psychotherapy research, where
the patient’s qualities of openness
and trust are seen as essential for the
ability to develop a relationship that
is favorable to the learning process
(Strupp 1973). This finding
generates a new research hypothesis
of the relationship between the
therapeutic relationship especially
trust and outcome in Basic BAT
treatment.
The concept of the working
alliance may serve as tools in the
identification and differentiation of
factors that help or hinder the
development of a good cooperation
between patient and PT. Among the
different definitions of the working
alliance, the definition by Horvath
and Greenberg (1994) seems to be
best suited for the area of
physiotherapy. They emphasize the
interaction between the technical
and relational aspects in addition to
the collaborative relation between
patient and therapist. In
physiotherapy, where treatment
involves working with body-related
skills, as well as touch and not only
verbal interventions, this seems to be
the most applicable. The theories of

Luborsky (1994) about the different
types of the working alliance also
seem to be relevant in the area of
physiotherapy.
Conclusion
The study points to the importance
of the ability to involve oneself and
find the personal meaning with the
Basic BAT exercises. Improvement
of balance and posture was the most
commonly reported therapeutic
effect. The patients in the
‘outpatient group’ also expressed
that they had developed an
awareness that led to an ability to
understand and handle signals or
sensations from the body in a more
positive way. The patients in the
‘inpatient group’ had gained or
wanted to gain a better control of
the body and movements. The
therapeutic relationship and
trust in the PT was a critical aspect
for the ability to develop a positive
working alliance. The concept of the
working alliance seemed to be useful
also in physiotherapy practice to
describe and analyze factors that
promote or hinder the development
of a good cooperation in treatment.
This study added some knowledge
about the experience of the patients
which generated some new
hypotheses to be tested in further
research.
ACKNOWLEDGEMENTS
The authors thank Vårdalstiftelsen,
Sweden, the Medical Faculty at Lund
University, Sweden and the County of
Scania, as well as the Department of
Physical Therapy, University of Lund,
Sweden for financial aid. We thank
Göran Nordström, the head of the
Division of Psychiatry, Lund University
Hospital, for making the necessary
resources available. We are also grateful
to and wish to thank all the patients who
shared their experiences and thoughts
J O U R NAL O F B O DY W O R K AN D MOVE ME N T T H E R A PIE S JULY 2 0 0 3
Gyllensten et al.
with us, and the expert physical
therapists involved in the study.
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