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THE USE OF BODY PSYCHOTHERAPY AT GERMAN CLINICS FOR PSYCHOSOMATICS A REPRESENTATIVE CROSS SECTION SURVEY

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1 FROM THE DEPARTMENT OF PSYCHOSOMATIC MEDICINE PROF. DR. THOMAS LOEW OF THE FACULTY OF MEDICINE AT THE UNIVERSITY OF REGENSBURG THE USE OF BODY PSYCHOTHERAPY AT GERMAN CLINICS FOR PSYCHOSOMATICS A REPRESENTATIVE CROSS SECTION SURVEY Inaugural dissertation for obtaining the doctoral degree in medicine at the University of Regensburg Margarete Braunete presented in 2014 by the Faculty of Medicine in Regensburg

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3 FROM THE DEPARTMENT OF PSYCHOSOMATIC MEDICINE PROF. DR. THOMAS LOEW OF THE FACULTY OF MEDICINE OF THE UNIVERSITY OF REGENSBURG THE USE OF BODY PSYCHOTHERAPY IN GERMAN CLINICS FOR PSYCHOSOMATICS A REPRESENTATIVE CROSS SECTION SURVEY Inaugural dissertation presented by Margarete Gisela Braun to the medical faculty of the University of Regensburg

4 Dean: Prof. Dr. Dr. Torsten E. Reichert 1st reporter: Prof. Dr. Thomas Loew 2nd reporter: Prof. Dr. Karin Tritt Oral exam day: May 18th

5 Contents Introduction ... 6 Question ... 6 Definition of body psychotherapy ... 7 Development of body psychotherapy from 1920 to today ... 8 Summary presentation of the most frequently mentioned methods of body therapy and body psychotherapy Autogenic training Functional relaxation Concentrative movement therapy Breathing therapy Dance therapy Feldenkrais PMR Acupuncture massage according to Penzel Communicative movement therapy Integrative movement therapy Eutonia Alexander Technique Biodynamics Structural body therapy Shiatsu Psychotherapy according to Albert and Diane Pesso Pesso Boyden System Psychomotor Bioenergetic analysis Music therapy and rhythm therapy (TaKeTiNa) Methods Results and discussion Descriptive statistics of the respondents: Distribution of body-oriented procedures in Germany of the therapy methods Therapy offer of the clinics in comparison

6 Body Procedures as a Form of Psychotherapy How Much KT is performed? Coding of the therapeutic measures Contraindications for body psychotherapy procedures Which professional groups carry out the body psychotherapy procedures? General conditions of the training courses with certificate of the respective professional society Comparison of the supplementary training courses for body psychotherapists Occupancy of the training facilities Overview of the framework conditions for certification in different body (psycho) therapy methods: Autogenic training Functional relaxation Concentrative movement therapy Breathing therapy Dance therapy Feldenkrais Progressive muscle relaxation Acupuncture massage according to Penzel Communicative movement therapy Integrative movement therapy Eutonia Alexander Technique Biodynamics Structural Body Therapy Shiatsu Psychotherapy according to Albert Pesso Bioenergetic Analysis Summary of Results Deutsch Summary Bibliography Appendix Acknowledgment Affidavit

7 CV Cover letter to the chief physicians questionnaire

8 Introduction Question How important is body psychotherapy in German psychosomatic clinics? In view of the growing popularity of this direction of therapy in the outpatient and inpatient areas (Marlock, 2007), it is interesting to obtain concrete figures on the therapy actually carried out in the German psychosomatic clinics, also in order to understand a future development of this sub-segment of psychosomatic medicine to be able to. Accordingly, the survey deals with the following questions: - Which body psychotherapy procedures are actually used? - What percentage of patients in a psychosomatic clinic receive body psychotherapy? What therapeutic value does body psychotherapy have? - How do the practitioners rate the effectiveness of body psychotherapy? For which diseases do you think body therapy is particularly suitable, where do you see contraindications? - How can the body psychotherapy procedures be recorded in the accounting system of the clinics? - From which professional groups are the body psychotherapists recruited? - What qualifications do the performing therapists have? Do you value certificates from professional associations? - What conditions are attached to the certificates of the professional associations? To what extent do these certificates create a basis for comparing therapists and therapy methods with one another? In order to create a basis for the considerations presented here and the research results presented below, the term body therapy should first be defined and the history of this therapeutic approach briefly 6

9 can be reproduced. Since the term body psychotherapy covers a very broad field, the most widespread methods in Germany are briefly explained. Definition of body psychotherapy Body psychotherapy, or body-oriented psychotherapy or somatic psychotherapy, describes a therapeutic approach in which access to the patient is sought not only through cognitive methods such as anamnesis, depth psychological analysis or behavioral analysis, but also through the patient's body , its movements and changes in state. The body psychotherapeutic model of thought assumes that the body itself stores and processes information so that mental suffering manifests itself in the form of physical phenomena. This information can only be read physically and - partly through cognitive awareness - changed. The pioneer of body therapy, Wilhelm Reich, describes physical tension alias body armor as an expression of mental blockages or character armor [s] (Reich, 1970). Body psychotherapy offers two approaches to changing this body memory: on the one hand in the form of movement, on the other hand in the form of mindfulness, which is understood to be the conscious tracing of one's own physical sensations. See (Müller-Braunschweig, 2010). In both cases, the body offers access to the patient's unconscious, which is further analyzed and processed in a consecutive talk with the therapist. The term body therapy can be distinguished from the term body psychotherapy. The main difference between the two therapeutic approaches is that the effect of body therapy is based solely on physical action and sensory functions, without directly affecting the psyche by means of verbal intervention or psychological analysis. (Geuter, 2000) (Handwo rterbuch der angewandte Psychologie, 1993) Changes in psychological well-being are definitely desired effects in body therapy, but the approach here is often more a preventive psycho-hygiene than psychotherapy. However, this differentiation has not yet fully established itself in practice. Although 7

10 there are procedures such as the Alexander Technique or the Feldenkrais Method, which in their self-image are firmly assigned to body therapy, but in fact even these procedures are often used in a mixture with talk therapy and the line cannot be clearly drawn. In the questionnaire used here, the different procedures were deliberately not classified or assigned in order not to restrict or influence the respondent's answer options. Therefore, the term body psychotherapy or body-oriented psychotherapy is not intended to exclude body therapy methods in the following, as long as this is not explicitly mentioned. Development of body psychotherapy from 1920 to today At the turn of the century, the idea of ​​including touch and movement, i.e. physical experiences and actions, in the psychotherapeutic process was a novelty in Europe. Where Freud promised and propagated a unified path to psychoanalysis with psychoanalysis, jealously attacked alternatives and banished everything physical from the therapeutic process, several approaches developed in parallel, which today make up the roots of body psychotherapy. (Müller-Braunschweig, 2010) However, there never was a unified alternative movement. Instead, individual therapists developed their own theories and methods, the students of which, while influencing each other, created their own concepts, all of which wanted to be regarded as independent procedures. This is how the colorful bouquet of therapy schools emerged, generation after generation of therapists, which we summarize today as body-oriented psychotherapy. Petzold referred to this phenomenon as method inflation (Marlock, 2007). Accordingly, the history of body psychotherapy up to the turn of the millennium reads like a summary of countless biographies. A detailed description of these developments can be found in particular in Geuter (Geuter, 2000). Basically, body psychotherapy developed from three different directions: gymnastics, the self-healing powers of which Elsa Gindler was the first to discover and use in her seminar for harmonious physical training, and also from expressive dance, which Mary Wigman first publicly practiced in 1914 8

11 and was put on a psychotherapeutic-theoretical foundation by Rudolf von Laban, and finally from psychoanalysis, to which Wilhelm Reich in particular added a physical level with the development of vegetotherapy. Reich thus caused a split from classical psychoanalysis, which is still reflected today in the split between psychotherapists and body psychotherapists. Even before Reich, Sàndor Ferenci designed an active technique with facial expressions, gestures and physical contact, but in contrast to Reich, intimidated by the vehement rejection by the Freudians, turned away from these theses again. Ferenci's thoughts were only rediscovered in the 1940s and became the basis of humanistic body therapy. (Loew, Tritt, Lahmann, & Röhricht, 2006) In view of the increasing popularity of the body-oriented procedures that have emerged since the 1920s, Gustav Heyer asked the VI. Congress of General Medical Psychotherapy to include a treatment of the soul from the body in psychotherapy. (Marlock, 2007) A real integration of body psychotherapy into classical psychotherapy did not take place in the following years either, although aspects related to body psychotherapy were also integrated into psychotherapist training in the compulsorily standardized psychoanalysis of the NS period. (Geuter, 2004) Largely independent of this, the body-oriented procedures became more widespread, particularly in Europe, the USA, Canada, Australia and Brazil. In the West, a center for body psychotherapy emerged in London in the 1970s with David Boadella and Gerda Boyesen, the founders of biosynthesis and biodynamics. In the USA, dance therapy established itself with the establishment of the American Dance Therapy Association (Marlock, 2007), while in East Germany, Anita Wilda-Kiesel introduced communicative movement therapy in the form of specialist physiotherapist training for functional disorders and neuroses. (Geuter, 2004) However, it would be premature to assume that body psychotherapy was firmly anchored in the therapy landscape at this point in time. As recently as 1985, the Protestant hospital in Halle was about to close because the body psychotherapy introduced by Hans Joachim Maaz was offended. Maaz is one of the leading figures in analytical body psychotherapy today. (Geuter, 2004) and (Krüger, 2002) A survey carried out by Andritzky in 1999 came to the result that 14.4% of outpatient psychotherapists and 11.5% of outpatient doctors 9

12 used body-oriented procedures. (Andritzky, 1999) As the present survey shows, the procedures have meanwhile also gained a firm foothold in the inpatient area. The increasing demand for body psychotherapists must of course be met. In the old tradition, this is done in the schools of the individual procedures. A new development is emerging in the academic field: at the University of Marburg it is possible to study a master’s degree in motology with a focus on body psychotherapy from the 2010/2011 winter semester. In addition to the corresponding theoretical background in education and psychology, this course also includes self-experience in various body psychotherapy methods such as concentrative relaxation, hakomi or dance therapy. (Philipps-Universität Marburg - Chair of Motology, o.j.) The therapists trained here are no longer representatives of a specific school, but body psychotherapists in a broader sense. A trend towards consolidation and standardization can also be seen in the basic concepts of the individual schools: Younger methods try to combine aspects of different older methods, as is the case, for example, with Integrative Therapy by Hilarion Petzold or the Structural Body Therapy by Grassmann and Derschetta tried, or incorporate Far Eastern ideas from Buddhism and Taosimus into their concept, like Ron Kurtz with his Hakomi. (Geuter, 2004) A bundled, united appearance offers a clear advantage over the fragmentation of the past few years, both in dialogue with other disciplines and in the struggle for scientific and social recognition. Accordingly, some of the already established methods have come together at the European level in the EABP and in the United States in the USABP. (Marlock, 2007). In order to be recognized by the EABP, the procedure must prove to be valid, i.e. provide evidence of its diagnosis and treatment concept and its understanding of the effect. (EABP - Scientific Validity of Body Psychotherapy, o.j.) In this way, the methods should be made comparable and the term body psychotherapy should lose the odor of arbitrariness that was attached to it due to the many independently working therapy schools. The basic concept of body-oriented psychotherapy procedures has recently received confirmation, particularly from neurology, which has new evidence for the 10th

13 provided a direct connection between body and psyche and their possibilities of influencing one another. (Röhricht 2000) These findings, as well as knowledge from infant research and developmental psychology, are increasingly being integrated into the model of body psychotherapy, examples being Alfred Pesso's psychomotor therapy and analytical body psychotherapy. (Marlock, 2007) There is so far only a few stringent scientific evidence for the effectiveness of body-oriented psychotherapy procedures. On the one hand, this is certainly due to the rather subjectively perceptible change that defines almost every form of psychotherapy. On the other hand, until a few years ago there was probably no need to provide such evidence. With the advance of evidence-based medicine in everyday clinical practice, however, this has changed, so that attempts are also being made in psychiatry and psychosomatics to meet the requirement of scientific verifiability that has become established in other disciplines. (Marlock, 2007) For functional relaxation, for example, randomized prospective intervention studies are already available that show their effect on the vegetative nervous system in bronchial asthma. (Loew et al. 1994, Loew et al. 1996, Loew et al. 2000, Loew et al) A detailed list and description of the studies on body psychotherapy are provided by Löw, Tritt, Lahmann and Röhricht with their overview of empirically evaluated body psychotherapy procedures (2006) . So today body psychotherapy is at a point of change. The path leads away from the multitude of independent methods towards a more uniform picture, on both a conceptual and an organizational level. At the same time, it faces the challenge of defending its rightful place in the psychotherapeutic canon through scientific validation. 11

14 Summary of the most frequently mentioned methods of body therapy and body psychotherapy Body psychotherapy as such does not actually exist. (Marlock, 2007). As already indicated in the previous chapter, a colorful bouquet of body (psycho) therapy methods has developed since the 1920s. According to Geuter, they all have one thing in common: the revolt of subjective nature against reification. (Geuter, 2000) Furthermore, they can be divided into three large groups: Such procedures, the concept of which is primarily relaxation and the tracing of physical sensations, which should make a psychological reorganization possible, called by Geuter as exploratory and functional body work, on the other hand those procedures which are commonly referred to as neo-eichian and which aim at uncovering the unconscious by loosening the Reichian body defenses and uncovering and releasing blocked instincts. A third concept can be found in particular in analytical body therapy: Here, the relationships between bodies, their actions and reactions to one another are to be examined and used therapeutically. (Boadella in Röhricht, 2011) In the following, the most frequently used procedures in Germany will be briefly explained, with particular emphasis on the specific methodology, the psychological approach, if any, and their particular indications and target groups. The order in which the procedures are listed depends on the frequency with which the procedure in question was mentioned in this survey. 12

15 Autogenic training The autogenic training according to Johannes Heinrich Schultz is one of the best-known relaxation methods in Germany, as this study also confirms. The patient or practitioner of autogenic training learns to use autosuggestion to build up a relaxed basic state of his own. The learning process of autogenic training is divided into three sections: The basic level should have an effect on the vegetative nervous system, i.e. in particular the blood flow to the skin and organs, pulse and breathing, but also a deep relaxation of the skeletal muscles and generalized inner calm. In the intermediate level, the patient learns to influence behavior and emotions through simple, positively formulated phrases, corresponding to repetitive self-conditioning that also affects the time after training, e.g. with the sentence I stay calm, which should also result in a certain imperturbability in everyday life. (Brenner, 2004) The upper level is dedicated to dealing with the subconscious and is only learned after having mastered the other levels. This is where visual exercises are used for the first time, such as creating figures, colors or people in front of the inner eye. There are a number of different exercise sets for the advanced level. (Hoffmann, 2012) At the end of each exercise unit, the practitioner consciously withdraws from the state of relaxation. Autogenic training can be learned with a trainer, but also with an audio book course or textbook. The practitioner's independence is an essential core of autogenic training. The exercises should be carried out three times a day, if possible, and can be performed in a lying or sitting position. A practice unit (e.g. basic level) takes about 15 minutes. (Brenner, 2004) In principle, autogenic training is suitable as a supportive measure for the majority of psychiatric and psychosomatic illnesses. In the meantime, numerous studies in the sense of evidence-based medicine have also proven the effectiveness in the most diverse areas of therapy, but also salutogenesis and prevention. A meta-analysis by Stetter and Kupper of 60 studies showed positive 13

16 Effects of AT both with initially somatic complaints such as tension headaches, hypertension, coronary heart disease, asthma or Raynaud's as well as with primarily psychosomatic problems such as somatoform pain syndromes, anxiety disorders, depression and sleep disorders, although the boundaries are difficult to draw here. (Stetter & Kupper, 2002) In the area of ​​salutogenesis, Vidas et al. Showed, for example, that AT has a positive effect on the subjective success and duration of breastfeeding in newborns. (Vidas, Folnegović-Smalc, Catipović, & Kisić, 2011) A new development is neurobiological research into the effects and effectiveness of relaxation processes in the human brain. Several studies have demonstrated using fmrt recordings how the reaction of patients to pain stimuli differs significantly depending on whether or not they were in a state of relaxation brought about by AT. (Naglatzki et al., 2012), (Schlamann, Naglatzki, de Greiff, Forsting, & Gizewski, 2010) The German Society for Medical Hypnosis and Autogenic Training describes this method as the longest established psychotherapeutic. (DGÄHAT, o.j.) In fact, Schultz developed this method around the 1920s, based on his experience in the field of hypnosis. He presented autogenic training for the first time in book form. Functional relaxation Functional relaxation is a method of << noticing what has gone unnoticed in the human body. >> (The method of functional relaxation, oj) FE uses proprioception to gain a refined feeling for one's own body and self . There are no fixed exercises. The patients are encouraged (in groups or individually) to make small movements (e.g. twisting the wrist), which they perform while exhaling. This is followed by a break in which to feel the movement and the feelings it triggers. 14th

17 In doing so, she focuses her self-perception on five physical reference systems: floor (external support), movement system (internal support), skin (protection and boundary), body cavities (internal space) and breathing (self-rhythm). (Joraschky, Loew, & Röhricht, 2006) In this way, unconscious memories and feelings stored in the early phases of development should be made tangible and a therapeutic processing process should be initiated. The experiences made here are always analyzed with the therapist and discussed in relation to the patient's biography. (Joraschky 2006) Accordingly, functional relaxation is clearly one of the deep psychologically analytically oriented body psychotherapy procedures. According to the working group for FE, the areas of application of the method primarily include psychosomatic disorders (functional disorders and organ disorders), but also personality disorders, neuroses and somatopsychic disorders (such as cancer). Functional relaxation can also be used to help resolve learning blocks in children. Efficacy in the therapy of bronchial asthma (Loew, Siegfried, Martus, Tritt, & Hahn, 1996), (Loew et al., 2001), the irritable colon (Loew, Heinrich, Arnim, 1994) and chronic headache (Loew, Sohn, Martus, Tritt, & Rechlin, 2000) could be proven in studies. Functional relaxation was developed by Marianne Fuchs in the 1940s. She had previously worked as a gymnastics teacher. When her own son fell ill with asthma, she invented a method of influencing his breathing rhythm and ultimately also his autonomic nervous system with touch and sound. Together with Viktor von Weizsäcker, she further developed these techniques for functional relaxation. (Fuchs, 1984) Concentrative movement therapy Together with the patient, the CBT therapist tries to identify the psychological causes of his physical complaints by perceiving his body language

18 the reason to go because the human body is the best image of the soul. (Universitätsklinikum Heidelberg, undated) Becker describes concentrative movement therapy as the body-oriented counterpart to the verbal free association of classical psychoanalysis. Instead of word associations, she works with spontaneously improvised movements, scenic representations and symbolizations using objects such as cloths, stones or balls. (Becker, 2010) As in functional relaxation, the therapy sessions do not follow a rigid process, but are characterized by the interplay of movement and psychotherapeutic conversation. The impressions triggered by the movement improvisation are processed with the therapist in a psychoanalytically oriented manner. (German Working Group for Concentrative Movement Therapy DAKBT e.v, o.j.) Indications for KBT can be found in psychosomatic disorders, eating disorders as well as phobias, psychoses and (severe) trauma. The KPT is particularly suitable for a patient group with a tendency to over-intellectualization or alexithymia. (Becker, 2010, p. 132) A positive effect of the concentrative movement therapy could be proven regarding the body image and the general well-being. Summaries of the empirical evidence on KBT can be found in Seidler (Seidler, 2001) and Loew (Loew et al., 2006). Helmut Stolze gave concentrative movement therapy its first name (then provisional at the time) in 1958, thus distinguishing it from Gindler's work (communicative movement therapy), from which it had developed. A short time later, Christine Gräff began using this method in German clinics as well. A group around Ursula Kost founded the German Working Group for Concentrative Movement Therapy, which created a theoretical foundation for the method and laid down the guidelines for further training. (Stolze & Gräff, 2006) 16

19 Respiratory therapy The term respiratory therapy or respiratory work extends over a wide field, even if one ignores the pulmonological definition of respiratory work. The manipulation of the breath and its effect on the sensation have always been the subject of therapeutic teachings, for example in the Asian Chi Gong, the breathing exercises of yoga or in the shamanic rites of Africa. (Ehrmann, 2004) A large number of different respiratory therapy schools have emerged recently, such as rebirthing according to Orr, holotropic breathing according to Grof or the method of experiential breathing according to Ilse Middendorf, to name just a few of the better-known representatives. Some of these procedures differ fundamentally both in their therapeutic approaches and in the specific methodology. (Ehrmann, 2004) There is also the breathing therapy of the work and research community for breathing work and education AFA, to which the following descriptions refer. Mehling defined breathing work on the basis of interviews with those performing it as training in the body's self-awareness that is focused on the breath, which leads to a precortical understanding of physical and mental processes. These processes can then, but do not have to, be processed verbally in a therapy session. (Mehling, 1999) According to this study, the respiratory therapists at the AFA see their work primarily as preventive health care, while around 50% of them use it to accompany psychotherapy. (ibid) The therapy sessions take place either in a group setting, where the group is stimulated by the therapist using movement exercises to sharpen proprioception and mindfulness, or as individual therapy, in which the patient lying on a couch is touched, such as small stretches in the joints, gentle shaking or Stroke in the rhythm of breathing, stand in the foreground. (Bischof, 2008) A verbal processing of the feelings that arise can be added. (Cf. Karoline von Steinaecker in (Müller-Braunschweig, 2010). Respiratory therapy is accordingly often used in the field of psychosomatic disorders (pain syndromes, functional breathing difficulties, burnout) but also in the support of pregnant women and in preparation for the birth (Bischof, 2008) (Meyer, 2001) 17

20 Mehling et al. found in a first randomized controlled study on 36 patients with chronic back pain a significant improvement in symptoms through respiratory therapy, which roughly corresponded to the change through the physiotherapy tested as a comparative method. (Mehling, Hamel, Acree, Byl, & Hecht, 2005) In a pilot study of patients with bronchial asthma, the anxiety-relieving effect of breathing therapy was demonstrated, while the somatic complaints of asthmatics did not improve. (Steinaecker, Welke, Bühring, & Stange, 2007) Loew et al. in teachers who suffered from burn-out syndrome. (Loew, Götz, Hornung, & Tritt, 2009) Dance therapy Dance therapy offers its patients the opportunity to discover hidden feelings or conflicts in dance and to communicate them non-verbally where their linguistic ability to express themselves reaches its limits. Improvised dance becomes a form of expression here, but also a means of creative processing: You may improvise sadness. () Improvising brings the feeling up. () Only when you create, when you concentrate, does something happen in you. (Quote from Trudi Schoop in Moscovici, 1989) In addition to the free improvisation and dance design described here, dance therapy uses the teaching of concrete dance techniques that give the patient a firm hold and expand his own movement repertoire, but also specific methods such as mirroring patient movements and gestures . Different movement analysis tools such as Laban's movement analysis (LMA), the Movement Psychodiagnostic Inventory (MPI) and the Kestenberg movement profile (KMP) are used as diagnostic tools. (Willke, 1991) In the schools of the professional association of dance therapists in Germany, a meeting is also part of the review of the processes initiated during therapy. (BDT - The Trial, n.d.) 18

21 According to the BTD, the indications for dance therapy include the most common clinical pictures in psychiatry and psychosomatics as well as somatopsychic disorders in oncological, rheumatological or neurological diseases. (BTD - Indications for Dance Therapy, oj) The courage with which dance therapists, in contrast to most body psychotherapy schools, also focus on severe psychiatric illnesses such as severe psychoses, can probably be explained by the history of their origins: the Dance therapy pioneers in the USA, Trudi Schoop and Marian Chase, started working with this particular group of patients at psychiatric clinics. In the 1960s, American dance therapists brought these ideas to Germany, where, as is so often the case in body psychotherapy, a multitude of different schools and concepts developed. In order to put a stop to this fragmentation and to create better traceability of the therapy quality and methodology, the professional association of dance therapists in Germany was founded in 1995, which also certifies suitable training centers. (Willke, 2007) The effectiveness of dance therapy is the subject of a relatively large number of studies. A good overview of the current study situation is provided by Koch, Bräuninger et al. (Koch & Bräuninger, 2005). Some notable examples are a meta-analysis of 23 studies with a control group that show the effectiveness of dance therapy, particularly in reducing anxiety symptoms (Ritter & Low, 1996), a study by Mannheim et al., Which shows a significant improvement in quality of life in oncological rehabilitation (Mannheim & Weis, 2005) and a study by Koch et al., which demonstrates effectiveness in patients with depression after a single intervention (here in the form of circular dances). (Koch, Morlinghaus, & Fuchs, 2007) Feldenkrais This method, named after its inventor Moshé Feldenkrais, is less a therapy concept than a learning concept of so-called organic learning. 19th

22 The method is used in two different forms: On the one hand, as awareness through movement, a group lesson in which the students perform everyday movements at the instruction of the teacher and thus acquire improved body awareness and new movement patterns for their everyday lives. (Feldenkrais & Wurm, 1996) The second form of concept is functional integration, in which the student lies individually on a couch in front of the teacher. Here the teacher leads movements on the patient's body with gentle pressure or pushing, reacts to any resistance and blockages in the pupil's movement system and teaches him new areas of movement and paths through non-verbal communication. (What is Feldenkrais?, N.d.) Since non-verbal communication is in the foreground in individual lessons, Feldenkrais pedagogy is not used as a form of psychotherapeutic intervention. It is therefore more likely to be used in preventive health care, in chronic pain and tension, in improving the quality of life in geriatrics or in physical rehabilitation after accidents or in the case of disabilities. (Feldenkrais Association, o.j.) Several studies have already been carried out to prove the effectiveness of the concept. An overview of the study situation can be found in Busch (Busch, 2011) and Ernst et al. (Ernst, 2005): Five out of six studies showed a positive effect of Feldenkrais teaching on multiple sclerosis, shoulder and neck pain and chronic back pain, but the authors point to numerous weaknesses in the study design. Recent studies show a significant improvement in the sense of balance and mobility in seniors through organic learning. (Ullmann, 2010) (Connors & Galea, 2009). PMR The progressive muscle relaxation according to Edmund Jacobson is a relaxation procedure, which initially aims at the active relaxation of the skeletal voluntary muscles. This muscular relaxation should then also be transferred to the autonomic nervous system and lead to an overall more relaxed state of mind. (Brenner, 2004) Jacobson assumes that most of the so-called 20

23 civilization diseases are triggered by stress and the associated harmful tension in the body. In the PMR, the patient learns step by step to perceive this tension, to identify it and finally to release it. Ultimately, the trained patient should be able to bring about the state of relaxation out of every everyday situation. (Jacobson & Wirth, 2006) This method can be learned from a trained therapist or on your own. Jacobson himself has published instructions for learning his technique on your own, and there are numerous other teaching media in the form of audio books, videos or written instructions. The PMR can be billed to all health insurers via the Association of Statutory Health Insurance Physicians, some insurers organize courses for their customers or offer audio courses for download on their homepage. In the additional training in psychotherapy / psychoanalysis, training in PMR can also be taken into account.The reason for this extraordinary recognition of the procedure is probably also the large number of scientific publications that prove the effectiveness of PMR in many areas, for example in combating chronic pain (Lauche et al., 2013) or anxiety and depressive symptoms (Isa, Moy, Razack, Zainuddin, & Zainal, 2013). Acupuncture massage according to Penzel The acupuncture massage according to Penzel was developed in the 1970s by Willy Penzel on the basis of the meridian theory of traditional medicine, influenced by neural therapy according to Hunecke and by chirotherapy. In contrast to classic acupuncture, no needles are inserted into the patient's body with acupuncture massage, but the course of the meridians is traced with an iron rod and, if necessary, the acupuncture points are stimulated directly using a massage or vibration device. Stroking with the therapy stick is supposed to recharge energy-empty meridians with energy and thus for a 21

24 Restoring the balance of energy flow in the body. (Chavanne, 1996) Indications for the acupuncture massage according to Penzel lie in particular in diseases of the movement system such as chronic back pain, joint problems and spinal deformities, but can also be used to support organic diseases. (ibid) Accordingly, AMP is used in psychosomatic facilities more for symptomatic pain relief in somatoform pain syndromes and less in connection with psychotherapy. Franke et al. in a comparative study found a significant advantage of AMP over traditional massage therapy with regard to pain reduction in patients with chronic back pain (15% reduction with AMP vs. 10% reduction). (Franke, Gebauer, Franke, & Brockow, 2004) Communicative Movement Therapy Anita Wilda-Kiesel, defines the Communicative Movement Therapy she developed as a specific method of physiotherapy in complex psychotherapy, especially as a supplement to conversation psychotherapy. (Anita Wilda Kiesel, 1998) Movement in the group should offer the patient a framework for experience with his own personality and with the other group participants. In a playful, symbolic way, the patient can test his old behavior in interaction with the others and try out new behavior. In contrast to concentrative movement therapy, communicative movement therapy aims less at body awareness and relaxation than at communication and integration in the group. (Communicative movement therapy, n.d.) 22

25 These playful exercises consist of movements in space, for example walking in a circle of flanks, partner exercises such as leading and being led or playing ball. During the exercise, the therapist asks questions that are intended to encourage the patient to reflect, which are initially only answered in silence, but later discussed in the group. Although the exercises in Communicative Movement Therapy are often similar to those of physiotherapy, the practitioner is much more a psychotherapist than a physiotherapist, because it is not about correcting incorrect movement sequences or assessing and improving the physical performance of the patient, but about the social aspect, the inherent in the exercises. The movement therapist is in close contact with the team of treating doctors and psychologists throughout the therapy. (ibid) Since 1971, communicative movement therapy has been the main component of training to become a specialist physiotherapist for functional disorders and mental illnesses and is therefore an integral part of in-patient psychiatric hospital operations. (Geyer, 2011.) In the reunified Germany there is no such thing as a specialist physiotherapist, so that the therapists have now organized themselves in the Academy for Communicative Movement Therapy. (Communicative movement therapy, o.j.) Integrative movement therapy Integrative movement therapy is the body therapeutic part of integrative therapy according to Petzold. The founder himself describes his psychotherapeutic approach as follows: Integrative therapy is a holistic psychotherapeutic procedure that includes psychotherapy, body therapy, sociotherapy, supervision and work with creative media on the basis of these basic principles anchored in integrative therapy. Important goals of integrative body and movement therapy are to promote awareness, i.e. the 23rd

26 body awareness, as well as the change of personality structures via the change of physical processes such as breathing and motor skills and conflict-centered, uncovering work. (von Haren, Werner, 1998) The therapy can take place both as an individual session and in a group setting. According to the Society for Integrative Movement Therapy, it is in principle suitable for all age groups and illnesses. It can be used for health promotion as well as for curative education or psychotherapeutic application, with correspondingly changed priorities in the therapeutic process. Depending on the requirements of the patient's situation, the session can be designed to be either exercise-centered and functional, experience-centered and stimulating, or conflict-centered and revealing. (German Society for Integrative Body and Movement Therapy e.v., o.j.) Eutonia With the help of eutonia according to Gerda Alexander, the student or patient should learn to achieve a balanced state of tension physically (and subsequently also psychologically). This is achieved on a physical level by stretching shortened muscles and toning slack muscles, by relaxing the blood vessels and tissues, and by improving blood flow to the periphery. The therapeutic process is based on two basic techniques: the perfusion, which can be traced back to an improved circulation in the tissue triggered by the therapist's touch and which should be felt by the patient as both warmth and cold, and the contact technique, in which through a concentration on the sense of touch when touching objects a noticeable transfer of energy can be experienced. The application of this contact technique in the everyday life of the patient should help him to work with improved muscular blood flow and thus to suffer from less wear and tear and overexertion syndromes. Other parts of a eutony session can include stretching exercises, balance exercises, posture exercises, etc., as well as the specific improvement of the patient's work situation, for example by adjusting chair sizes and work equipment. When the body tensions applied in childhood are released, patients may experience 24

27 memories and repressed feelings arise, which are discussed and processed with the therapist. Gerda Alexander therefore sees eutonia treatment as a suitable support for psychoanalysis. Eutonia is also indicated for psychosomatic disorders, stuttering, but also in rehabilitation after brain trauma, for symptoms of paralysis and visual disturbances. (Winckel, 1964) Although, according to Gerda Alexander, there are already indications of the physical changes due to eutonia treatment via skin resistance measurements and electromyographic measurements, and with the research of mirror neurons and the C-tactile efferents, new explanatory models for Gerda Alexander's observations are open (Milz, 2004) , unfortunately there are currently no studies on their specific effectiveness on the well-being of the patient. Alexander Technique The Alexander Technique is an educational teaching method that aims to enable the learner to identify harmful habits, discard them and replace them with new courses of action and movement. The aim is to enable the most harmonious, effortless interplay of the so-called primary control, consisting of body, neck and trunk and their relationship to one another. The tools that Frederick Matthias Alexander developed for this purpose are, on the one hand, inhibition, a pause in front of an active reaction or action, which makes it possible to stop the bad habitual reaction that has been trained over the years, and, on the other hand, concentration on the individual steps of an action , called means whereby in contrast to an inflexible goal fixation (end-gaining). (Gelb, 1996) The German Alexander Technique Association sees indications for the Alexander Technique in particular in reducing stress, in personal development, in the case of musculoskeletal disorders and tension pains and in support of psychosomatic disorders. The method is also particularly popular among actors, musicians, speakers and other professional groups who depend on the effect and function of their body and voice. 25th

28 The Alexander Technique is taught both in individual lessons and in group settings. In particular, movements from everyday life of the student (walking, sitting in front of a screen, writing, etc.) are picked out. The teacher draws the student's attention to harmful habits with subtle touches and shows alternative paths of movement. (ATVD - Alexander-Technik-Verband Deutschland, o.j.) Two randomized controlled studies prove a positive effect of the Alexander-Technik on patients with chronic back pain. It must be mentioned, however, that in one case no improvement compared to conventional heat treatment could be demonstrated (Schuth, 2012), while in the second study the cost-benefit ratio for physiotherapy was calculated more favorably than with the Alexander Technique, although the latter a larger positive effect could be recorded. (Hollinghurst et al., 2008) Biodynamics The clinical psychologist Gerda Boyesen developed the method of biodynamic psychotherapy on the basis of three therapeutic approaches: She draws her image of man and her understanding of the human psyche both from Freud's psychoanalysis (for example with the subdivision of the person into it , I and superego) as well as from the Reichian model of the libido flow as central life energy. In practice, the third building block is borrowed from physiotherapy, especially from Bülow-Hansen's massage technique. (Boyesen, Boyesen, & Wailand, undated) According to Gerda Boyesen, intestinal peristalsis has two different functions: on the one hand, the material digestion of food, and on the other hand, the psychological processing of fear, stress and conflicts. If a person is unable to come to terms with a conflict, especially in his childhood, the blocked flow of energy leads to hardening or hypotonia in his muscles, connective tissue and bones. Through a precise massage and loosening of these hardenings, the tensions manifested there are released. The energy released in this process is now digested in the intestine by what is known as psychoperistalsis, which is 26

29 the therapist can follow up in the form of bowel noises using a stethoscope in the sense of bio-feedback. (Boyesen, 1987) Accordingly, in the bioenergetic therapy sessions, the focus is on massages, and pictures, breathing techniques and conversations are also used. This work mostly takes place in individual therapies, but group settings are also possible. (Freudl, o.j.) Structural body therapy Structural integration was created on the basis of Ida Rolfs Rolfing, influenced by osteopathy, yoga, the Feldenkrais method and the Alexander technique. In its holistic model of thought, structural body therapy also assumes that trauma manifests itself on a physical level. In contrast to the main focus of many other body therapy methods, the focus here is not so much on the muscles as on the fasciae and connective tissue as support, protection and form-giver of the human body. With structural integration, adhesions, scarring and shortening of the fascia should be eliminated by means of manual pressure, body movements and a conscious change in posture. The patient's body is straightened up again through these changes, protective and bad postures are given up and the body moves in a harmonious relationship to gravity instead of fighting against it. (Grassmann, 2004) The therapy takes place in ten thematically consecutive sessions in which different body parts are at the center of the action. The therapy can make the patient aware of the causal trauma that may have led to scarring and poor posture. You will be carefully worked through with the therapist through physical exercises and conversation. This part of the therapy was named Traumasomatics and is the content of a specific therapist training within the training in structural integration. (Grassmann, 2004), (Pohlenz-Michel & Grassmann, 2006) 27

30 Shiatsu Shiatsu is the Japanese word for finger pressure and describes a massage technique based on the meridian system of traditional Chinese medicine, which is based on the energy channels that, according to TCM, run through the human body. (Definition of Shiatsu, n.d.) According to Rademacher, the basics of TCM are also valid for Shiatsu. (Rademacher, 2009) In Shiatsu, the therapist massages the patient with the help of his or her body weight, i.e. more in the sense of leaning towards the patient than with pure guided muscle strength. (Shiatsu Germany, n.d.) Although Shiatsu sees itself more as a method of health promotion and less as a form of psychotherapy in the western modern sense, value is also placed on targeted conversation in the therapy session. The therapist diagnoses a psychological and somatic imbalance in the patient's body and habitus and classifies them in the dual system of yin and yang, which is the basis of the thought model of TCM. The massages are not aimed exclusively at physical well-being, but also at emotional and mental processes. (Rademacher, 2009) Indications for Shiatsu massage accordingly range from stress syndromes, chronic and acute illnesses to accompanying therapy for cancer, but there are also explicit therapy concepts for mental illnesses such as anxiety disorders. (ibid) Psychotherapy according to Albert and Diane Pesso Pesso Boyden System Psychomotor "Pesso therapy (internationally known as Pesso Boyden System Psychomotor, PBSP) essentially consists of the systematic construction of healing synthetic memories on both a cognitive and physical-emotional level." (Fischer-Bartelmann, n.d.) 28

31 According to Albert Pesso, every person has an optimal self, which, however, does not fully develop due to various defects or trauma in the life story. Such a deficiency in the basic human needs e.g. Similar to the regression in classical psychoanalysis, (lack of love of the mother) can be consciously relived. In a further, actually healing step, the deficiency can be remedied by a new scene according to the patient's wishes, an artificial, compensatory memory is created that complements the patient's life story. To raise awareness, Pesso uses a scenic representation of the child's conflict-prone situation, which he calls structures, instead of verbal processing. (Pesso, 1999) The protagonist and at the same time director and screenwriter of such scenic representations is the patient himself, the fellow patients in his group act according to his ideas. They symbolize negative, but also ideal parts of the patient's ego, his parents and caregivers, but never the whole real person. (Moser in Pesso, 1986) The Pesso couple basically saw their method as a supplement to classic conversation psychotherapy. A completed psychotherapy training is a prerequisite for learning the method. Its indications lie in working with patients with developmental deficits, injuries or trauma and gaps in the system of the family of origin. Albert Pesso's psychotherapy has also been tried and tested in patients with psychoses and borderline disorders. (Pesso, 1986) Bioenergetic Analysis The bioenergetic analysis was developed on the basis of the character analysis of Wilhelm Reich by his student Alexander Lowen and his colleague John Pierrakos. It integrates Freud's classical psychoanalysis with Reich's character analysis. (Ehrensperger in Müller-Braunschweig, 2010) Instead of looking for the subconscious exclusively in verbal form, the patient's body is first analyzed: his posture, in which Reich's body armor manifests itself, his mobility, breathing, and the blockages 29

32 of these, which indicate a blockage of the flow of energy. According to Lowen, this flow of energy is the origin of what then comes to light in a visible form as emotions, behavior and posture. (Lowen & Bavendamm, 1998) Lowen described five character structures according to which certain characteristics of the patients are to be classified. These character descriptions are assigned to one another physical features (in the sense of posture etc.) on the one hand and basic psychological structures on the other. After the therapist has analyzed his patient accordingly and diagnosed his or her basic problems, therapy follows both verbally and with the help of physical interventions. These often take place in stressful positions that symbolize the patient's everyday stressful situations.The patient either moves upright in the room, sits or stretches on the so-called breathing stool, but can also lie on a mattress, etc. (Ehrensperger in Müller-Braunschweig, 2010) The bioenergetic analysis is indicated for all mental illnesses, especially in a patient group that tends to show strong resistance to the therapeutic process, such as borderline patients, because here it is possible to switch to the physical level, if during the conversation the patient's resistance hampers the progress of the therapy too much. According to studies, the bioenergetic analysis achieves above-average results, especially with neuroses and psychosomatic disorders, while others found an improvement in symptoms that was independent of the diagnosis. (Ventling & Gerhard, 2000). A more recent randomized controlled study on Turkish immigrants with somatoform disorders was also able to demonstrate a clear reduction in symptoms through the psychoenergetic analysis. (Nickel et al., 2006) 30

33 Music Therapy and Rhythm Therapy (TaKeTiNa) Music therapy and rhythm therapy are also often offered as a complementary program to classical talk therapy at many German clinics. These forms of therapy also follow the approach of reaching the patient's psyche in ways other than verbal. Accordingly, there are some great similarities to body psychotherapy (for example breathing exercises in singing and breathing therapy), which is why the two directions should also be briefly presented here, although they are not the subject of the present survey. In music therapy, which nowadays is practiced almost exclusively in the form of active music therapy, the patient can express himself using various instruments, mostly in the form of improvised play. The joint improvisation in a group in particular offers a lot of opportunities to play out social processes and conflicts. Instruments that are easy to play are usually used (e.g. drums, xylophone, etc.), so that no previous musical knowledge is necessary to participate in therapy. (Deutsche Musiktherapeutische Gesellschaft, o.j.) TaKeTiNa, rhythm therapy and rhythm pedagogy after Reinhard Flatischler, was named after one of the syllable sequences, (Ta Ke Ti Na), which are intoned as spoken chants in group lessons. (Flatischler, no year) In addition to chants, various percussion instruments are used in rhythm therapy. Even an embryo experiences rhythm as a defining element of its feelings, in the form of the mother's continuous heartbeat and in her movements. Accordingly, the rhythm in TaKeTiNa is seen as an effective instrument with which the psyche of a person can be influenced in the long term. Rhythm structures should give the patient back a feeling for ego structures, the interaction in the chants and drum concerts bring the rhythm of the individual into harmony with the rhythm of the others or reveal differences. Great attention is also paid to the personal experience of the body in walking, clapping, etc. Conflicts and feelings stored in the body consciousness, comparable to the Reichian body armor, come in the 31

34 rhythm exercises emerged. This shows the close relationship to body psychotherapy. Frank Riehm, head therapist at the Specialist Clinic for Psychosomatics in Heiligenfeld, even goes so far as to compare the movements and vibrations during the rhythm exercises with a massage, which, similar to the concept of many body psychotherapists, can relieve tension in the body and mind . (Rihm, o.j.) Both for music therapy and for TaKeTiNa rhythm therapy, there are specialist societies in Germany that supervise and certify the training of trainers and therapists and endeavor to conduct scientific research into therapy methods. Music therapy can be studied at several universities in Germany as a bachelor's and master's degree. 32

35 Methods The questionnaire shown in the appendix was sent to the chief physicians of 236 psychosomatic clinics in February 2010. After an initial collection of responses over a period of four months, the same questionnaire was sent a second time in May 2011 with the aim of increasing the response rate even further. In the case of hospitals that returned the questionnaire a second time, the most recent answer sheet was scored. Since this was only a very small group (3 clinics), the questionnaires that were answered several times could not be used to gain any relevant knowledge about the course of the issues addressed in the questionnaire over time. Also part of the survey carried out at this time was a survey on the subject of quality assurance certificates at German psychosomatic clinics, the possibility of accommodating accompanying persons and therapy offers in foreign languages. The subject of the present work is only the first part of the survey on the subject of body psychotherapy. In a second part of the thesis, the framework conditions of the certifying training pathways to become a body therapist or body psychotherapist were examined. For this purpose, the websites of the relevant specialist societies and their information brochures were used for the eighteen therapy methods mentioned in the questionnaire, and the representatives of the specialist societies were contacted by telephone and by. The answered questionnaires were evaluated with SPSS, the figures and tables were created with SPSS and Microsoft Excel. 33

36 Results and discussion Descriptive statistics of the respondents: Of the 236 clinics (N = 217) and rehabilitation clinics (N = 27) in Germany that were contacted, 90 clinics answered the questionnaire (38%). Private clinics and clinics with a predominantly psychiatric focus were not taken into account. The clinics surveyed included a total of 48 clinics with a family therapeutic approach (mother-child clinics, father-child clinics, child and adolescent psychosomatic medicine). Of these specific institutions, only 8% answered the questionnaire. The 13 specialist clinics for withdrawal and therapy for addiction disorders must also be counted among the special facilities. Of them, 23% took part in the survey. The response rate among the rehabilitation clinics was 13%. If one only looks at the 159 psychosomatic clinics without further specialization, the overall response rate is 48%. Spread of body-oriented procedures in Germany 88 clinics (98%) use body psychotherapy in the treatment of their patients. In the questionnaire and also in the cover letter, it is clear that the questionnaire is also aimed at those clinics that do not use body psychotherapy. For example, it is explicitly pointed out that the questionnaire contains three other topics in addition to body psychotherapy. The question as to whether the high percentage could also have been due to the fact that only those clinics answered the questionnaire in which body psychotherapy is carried out can therefore be denied. From this it can be concluded that this high percentage is quite representative and that KPT has found its way into a large number of German psychosomatic clinics. 34

37 Number of clinics In the vast majority of clinics (92%) more than one method is used. Most clinics offer three (27%) or four (20%) different therapy methods in parallel. The range is wide, however, ranging from just one procedure (9%) to nine different procedures within a clinic (1%). The following graphic shows exactly how many clinics have a certain number of therapy methods in their therapeutic repertoire Number of different procedures at a clinic Figure 1: How many different methods are offered in the individual clinics? 35

38