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Body, Movement and Dance in

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Body oriented psychotherapy.

The state of the art in empirical
research and evidence-based
practice: A clinical perspective
a
Frank Rhricht
a
Consultant Psychiatrist, Visiting Professor, School of
Social, Community and Health Studies , University of
Hertfordshire , UK
Published online: 14 Jul 2009.

To cite this article: Frank Rhricht (2009) Body oriented psychotherapy. The state of
the art in empirical research and evidence-based practice: A clinical perspective, Body,
Movement and Dance in Psychotherapy: An International Journal for Theory, Research
and Practice, 4:2, 135-156, DOI: 10.1080/17432970902857263

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 Body, Movement and Dance in Psychotherapy
Vol. 4, No. 2, August 2009, 135156

Body oriented psychotherapy. The state of the art in empirical

research and evidence-based practice: A clinical perspective
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Frank Rohricht*

Consultant Psychiatrist, Visiting Professor, School of Social, Community and Health

Studies, University of Hertfordshire, UK
(Received 25 July 2008; final version received 24 December 2008)

The heterogeneous field of body oriented psychotherapy (BOP) provides

a range of unique contributions for the treatment of mental disorders.
Practice based clinical evidence and a few empirical studies point towards
good efficacy of these non-verbal intervention strategies. This is particu-
larly relevant for those disorders with body image aberration and other
body-related psychopathology, but also for mental disorders with limited
treatment response to traditional talking therapies, e.g. somatoform
disorders/medically unexplained syndromes, PTSD, anorexia nervosa or
chronic schizophrenia. However, the evidence base is not yet sufficiently
developed in order to get BOP recognised as suitable mainstream treatment
by national health services and their commissioning bodies. Strong
academic links are urgently required in order to support practitioners
in their efforts to evaluate the clinical work in systematic research. The field
would greatly benefit from the development of international higher
education training in integrated clinical body psychotherapy, enabling
practitioners to obtain a masters degree. From a scientific perspective,
projects on the interface between neuroscience and psychotherapy research
should be conducted in order to understand more fully the therapeutic
processes in BOP, particularly with regard to emotional processing,
movement behaviour and body/self perception. Qualitative research is
needed to further investigate the specific interactive therapeutic relation-
ship, the dynamics of touch in psychotherapy and the additional self-
helping potential of creative/arts therapy components. Provided that these
requirements will be fulfilled, BOP could be established as one of the main
psychotherapeutic modalities in clinical care, alongside other mainstream
schools such as psychodynamic, cognitive-behavioural and systemic.
Keywords: body psychotherapy; body oriented psychological therapy;
movement therapy; evidence base; research

*Email: [email protected]

ISSN 17432979 print/ISSN 17432987 online

2009 Taylor & Francis
DOI: 10.1080/17432970902857263
http://www.informaworld.com
 136 F. Rohricht

There is more wisdom in your body than in your deepest philosophy

(Friedrich Nietzsche, in Thus Spoke Zarathustra, 1885)

Introduction
The heterogeneous field of body oriented psychotherapy (BOP) currently
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presents as rather disorganised from outside. There is a wide range of body

therapies and BOPs on offer (Figure 1). It can appear impossible for a patient
unfamiliar with the field to make an informed choice in order to identify
suitable treatment in this terminological jungle. In contrast, most practitioners
refer to BOP as holistic and creative body-mind work. BOP is regarded as an
established form of psychotherapy and as more effective than talking therapy
for patients with disturbed body experiences. Whilst body psychotherapists
expressed ambivalent views about empirical research in the past, in recent years
a shift towards an emphasis on evidence-based practice emerged. In parallel,
a growing interest in the evaluation of body oriented psychological treatment
for patients with mental health problems can be noted within clinical research.
This paper aims to summarise the current state of the art in the field
of integrated body oriented psychotherapy from an academic perspective. The
author is a BOP practitioner with more than 25 years experience in the field.
The review refers briefly to its underlying shared theoretical foundation,
it describes commonalities between various BOP schools in respect of their
intervention strategies (as outlined in more detail in e.g. Corrigall, Payne, &
Wilkinson, 2006; Marlock & Weiss, 2006; Rohricht, 2000, 2009; Staunton,
2002; Totton, 2003, 2005) and the emerging empirical evidence base as far as
efficacy and effectiveness of different body oriented intervention strategies
for the treatment of mental disorders is concerned. Qualitative aspects of the

Focussing Biodynamic Psychomotricity

psychotherapy
Functional Body mind
Hakomi Relaxation approach
Tai-Chi
Eutonie Analytical
Character Analytic Body psycho-
Vegetotherapy Body oriented therapy
Biosynthesis therapies and
Dance
psychotherapies Movement
Thymopraktik
Rolfing Therapy

Concentrative
Yoga
Movement therapy
Bioenergetics
Body-
Behaviour Shiatsu
Feldenkrais Core-Energetics
therapy

Figure 1. Different body oriented psychotherapy and body therapy schools.

 Body, Movement and Dance in Psychotherapy 137

therapeutic interventions in BOP, aiming to better understand the processes

contributing to change over time, have been researched as well (e.g. Brauniger,
2006; La Torre, 2008; Rohricht, Papadopoulos, Suzuki, & Priebe, 2009;
Schreiber-Willnow & Seidler, 2002, 2005; Seidler & Schreiber-Willnow, 2005)
but are not reported in this review.
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Definition of BOP
The vast literature related to the field of BOP lacks any coherent systematic
definition. Wikipedia refers to umbrella terms such as body psychotherapy
(BPT), body oriented psychotherapy, somatic psychology and body
oriented psychological therapy, and other sources sometimes summarise
those schools, rather misleading, as body therapy. In a recent review of the
evidence base in body psychotherapy, Loew et al. (2006) distinguished clearly
between BPT/BOP and body therapy (BT). The authors emphasised that
BPT/BOP always refers to a therapeutic framework, aiming at enhanced self-
awareness, behaviour modification or insight-oriented psychological problem
solving. General principles, relevant for all psychotherapies, apply to BOP.
Psychotherapy relies on trustful therapeutic relationships and is directed
towards the improvement of a range of identifiable mental and behavioural
disorders regarded as requiring specific treatment (based on theories of normal/
abnormal behaviour), it mostly uses verbal but also non-verbal psychological
techniques, it is a standardised procedure, defined and taught within a
framework of academic institutions, responsible for quality assurance and
supervision.
The European (EABP; www.eabp.org) and the American (USABP;
www.usabp.org) Association of Body Psychotherapy address the question:
What is body psychotherapy on their respective websites. They state that
it is . . . a distinct branch of psychotherapy with a long history . . . involves
a different and explicit theory of mind-body functioning (complex
interaction) . . . The body does not merely mean the soma and that this is
separate from the mind, the psyche. Many other approaches in psychother-
apy touch on this area. Body-Psychotherapy considers this fundamental.
Comparing this definition to those on two other websites in the wider body-
mind field, one can see how little these concepts differ from each other. For
example, the European Forum of Psychomotricity defines the interventions
as follows: Based on a holistic view of the human being, on the unity of body
and mind, psychomotricity integrates the cognitive, emotional, symbolical
and physical interactions in the individuals capacity to be and to act in a
psychosocial context (EFP; www.psychomot.org). Similarly, the Association
of Dance Movement Psychotherapy (DMP) in the UK states: Dance
Movement Therapy is the psychotherapeutic use of movement and dance
through which a person can engage creatively in a process to further their
emotional, cognitive, physical and social integration (ADMT-UK; www.
admt.org.uk). Whilst acknowledging the ongoing controversial debate and
considerable efforts in the field of body-mind therapies/psychotherapies to
 138 F. Rohricht

agree on a unifying language, in this paper BOP is used as umbrella term

despite a more common use of the term body psychotherapy in scientific
literature. This is aiming to widen the perspective in order to include all
available evidence from clinical trials in the wider field of body-mind work.

How does body psychotherapy present on the outside? Some basic facts
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An Internet search using common search engines with body psychotherapy

and body oriented psychotherapy as keywords identifies a vast and diverse
literature: more than 450,000 hits are displayed on Google, the first 757
featured pages all relevant to the search topic. A wide range of practical and
clinical matters are covered. Examples include body work and massage in
sports rehabilitation, severe chronic medical conditions and very specific and
complex mental disorders such as stammering and psychosis. Therapists
delivering (predominantly neo-Reichian) BOP are organised within over-
arching organisations: the US Association of Body Psychotherapy (USABP)
has more than 500 members and publishes a peer reviewed journal, and the
European Association of Body Psychotherapy (EABP) has more than 700
members in 18 countries; there is also the Australian Association of Somatic
Psychotherapy and the South American Association of Body Psychotherapy.
Other BOP schools are also represented within umbrella organisations
nationally. Due to their widespread availability and relevance for clinical
practice, dance and dance movement psycho/therapy as well as (mainly in
German speaking countries) concentrative movement therapy (Schmidt, 2006)
and functional relaxation (Fuchs, 1997; Herholz et al., 2009) are particularly
important.
Professionals regularly present and discuss their work (the 7th International
Congress of BOP took place in 2005 and the 11th European conference in Paris
in 2008). In Britain, the body in psychotherapy has been a major theme in the
UK Council for Psychotherapy conferences, the Association for Dance
Movement Psychotherapy organises annual meetings and the Chiron Centre
for Body Psychotherapy is engaged in a dialogue with Relational
Psychoanalysis and hosted a joint conference in 2007 in Cambridge. In the
USA, four universities offer a masters degree (MA) in Somatic Psychology
and in Europe the EABP accredited European School of Functional
Psychology offers a master degree course in Naples/Italy and Paris/France.
In the UK, master degree courses in Dance Movement Therapy are available
at five universities; other European countries (e.g. Italy and Spain) also offer
a DMP master course.
Within the mainstream psychiatry/psychotherapy literature the picture is
nevertheless rather different. When the same search terms are used in scientific
databases, Medline (1950 to date) reveals 20 documents, PsycINFO (1806 to
date) 189 documents and EMBASE (1974 to date) 17 documents. Furthermore,
BOP is not established as a distinct professional identity. There is no
state accreditation, and only some schools/branches in the wider field of BOP
offer training that is recognised by official registration bodies (e.g. in the
 Body, Movement and Dance in Psychotherapy 139

United Kingdom: Association for Dance Movement Psychotherapy/ADMP,

the London School of Biodynamic Psychotherapy and the Cambridge Body
Psychotherapy Centre). With the exception of the German Lindauer
Psychotherapie-Tage and a few other national psychotherapy symposia,
BOP is rarely represented in mainstream psychiatry/psychotherapy congresses.
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An attempt to systematically describe the field of BOP

Even though these statements point towards a holistic perspective within the
therapeutic intervention strategy, explicitly working with body-oriented, non-
verbal techniques, the definition does not sufficiently discriminate between
BOP and other psychotherapeutic schools. One way of defining the field
of BOP and the differences in comparison with other mainstream psychothera-
pies is to analyse more systematically the contributions made by BOP in the
context of specific mental health problems. Furthermore, it is necessary to
identify the common ground in theory and practice amongst BOP schools.
Given the current lack of evidence base (see paragraph outcome research
underneath), it appears these schools have done little so far to address the
public image of non-scientific and eclectic approaches. This is partly explained
by the jargon used to describe main objectives and methods. The reader is
confronted by an impenetrable vast number of terms introduced to create
distinctions between schools despite a huge overlap in their respective
intervention strategies.
Rohricht (2000) developed a systematic description of the various schools
in the field of BOP, thereby aiming to differentiate on the basis of two defined
axis: (1) insight oriented and/or aiming at behaviour modification (body
psychotherapies) versus functionally oriented, aiming at relaxation or home-
ostasis (body therapies) and (2) main mode of action (perceptive/self-
awareness, affective-cathartic, interactive and/or movement oriented).
Reviewing the primary literature on these BOP schools, particularly with
regard to their theoretical concepts and therapeutic practice, it remains
doubtful as to whether the terminological diversification and the corresponding
differentiation into numerous different schools are really justified.

Theoretical foundation of BOP

The various BOP schools share basic theoretical concepts. Almost all of them
refer to developmental psychology in some way (with emphasis on the
importance of body experiences for early ego-foundation). They also refer to
the basic concept of embodiment (embodied mind theory), affect-regulation
and the phenomenology of body experience (relating to the body as: base line
reference for any psychological processes, precondition for psychopathology,
subject and object of perception, organ of spontaneity/expression and reference
point for feelings) and more recently to findings from (affective) neuroscience.
See overview on theory and practice in various textbooks: Corrigall et al., 2006;
 140 F. Rohricht

Hartley, 2009; Herholz et al., 2009; Marlock & Weiss, 2006; Payne, 2006;
Rohricht, 2000, 2009; Schmidt, 2006; Staunton, 2002; Totton, 2003.
From a research perspective, hypotheses regarding the specific contribution
BOP may offer can be identified (over and above what is currently provided
by other modalities). This approach is focusing on specific non-verbal and
body oriented interventions for particular problems and symptoms (operating
at the centre of emotional processing and motor/expressive behaviour). There
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is a unique interactive therapeutic relationship with a multidimensional

approach aiming to explicitly increase strengths, capabilities and creativity.
Disorder-specific hypotheses include: (1) the immediateness of body experience
is important for reality testing and may hence offer therapeutic benefits
in working with psychosis; (2) body-related perceptions and cognitions form
the basis for ego/self-experience and ego-development (Ego-Consolidation)
and can therefore be utilised therapeutically for the treatment of patients with
personality disorders; (3) the direct impact on emotional processing and related
psychomotor behaviour/movements suggests that BOP can offer unique
interventions in the treatment of affective disorders; and (4) improving body
perception could be a key intervention for the treatment of perceptual
aberration (e.g. distorted body size perception in anorexia nervosa and/or
schizophrenia).

The practice
The model
It is demonstrated . . . that the fundamental premise in body psychotherapy
is that core beliefs are embodied, and that until we begin to experience the pain
held in them directly through our bodies they will continue to run our lives,
even if we mentally understand them (Staunton, 2002, p. 4). According to
its three main roots (reformist movements in creative dance, pedagogy and
psychoanalysis), we can differentiate three main modes of action apart from
relational body-work as follows:
. Concentrative Movement Therapy, Functional Relaxation: explora-
tive and perceptual functional body-mind work, utilising self-aware-
ness techniques, aiming to mobilise and make space for autonomous
inner processes.
. Neo-Reichian psychotherapies: uncovering, energetic and expressive
body-mind work, utilising tension dynamics/grounding and cathartic
processes, aiming to ease/loosen up rigid postures and related pattern
of attitudes, in order to mobilise and make space for repressed
affective contents/emotional processes.
. Dance Therapies and Dance Movement psychotherapies: creative,
explorative body-work utilising movement improvisation, authentic
movement and body dialogues, aiming to strengthen self-potentials
and in order to mobilise and make space for processes related to
underlying conflicts.
 Body, Movement and Dance in Psychotherapy 141

These three main modalities overlap greatly in practice (in integrated BOP)
and an overarching model can be described as follows: centring around the
immediateness of (bodily, emotional and perceptive) experiences and through
processes of focusing the self-experiences, attention and awareness towards the
bodily reality, clients reach a position of basic inter-relational embodiment.
This results via mobilisation of emotional and non/pre-verbal aspects of
underlying conflicts in some kind of critical (and partially cathartic)
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destabilisation. At this point, altering bodily processes are initiated and an

integrative, self-determined reorganisation of reactive and solution focused
behaviours emerge. Totton (2003) furthermore adds an important observation:
Many . . . body psychotherapists work with some kind of somatic memory . . .
and . . . by releasing the restrictions and re-owning the memory . . . a person can
dissolve a corresponding pattern of psychological constraint (p. 19).

What is BOP used for?

In clinical practice in mainstream healthcare settings, body oriented psycho-
logical therapy is used for a wide range of mental health problems despite
its unsatisfactory evidence base. Disorders include: Somatoform disorders,
Anxiety and Depressive disorders, PTSD, Schizophreniform illnesses,
Personality disorders, and Eating disorders. The settings vary including
hospital wards, day hospitals, community and social services settings,
rehabilitation units and schools. Therapy may be in groups (mainly dance,
dance movement and concentrative movement therapy in somatoform and
psychotic disorders), or individual therapy. BOP is considered suitable for all
age groups from young children to the elderly.

How does BOP work?

To date, there is a lack of systematic research investigating the mode of action
of BOP for the treatment of mental health problems or specific disorders.
Clinical observation from case studies and preliminary findings from a few
empirical trials suggest that (other than in the main psychotherapeutic schools)
BOP unfolds its therapeutic effects on different levels. In CBT efficacy
is delivered via cognitive reconstruction of a range of systematic beliefs/
constructs. Psychodynamic psychotherapy is effective via insight oriented
processes. In BOP, therapeutic processes span across these domains and
uniquely modulate emotional processing, affect regulation, movement behav-
iour and bodily self-awareness in order to impact on psychological problems/
processes.

BOP and empirical research (evaluating efficacy and effectiveness)

According to the specific focus of research questions in designing therapy
studies, a distinction between efficacy and effectiveness is made. Differentiating
between efficacy and effectiveness, the methodology of prospectively designed
 142 F. Rohricht

randomised controlled trials (RCTs) is perceived as the gold standard in

evidence-based medicine. This is because of the exclusion of bias and good
internal validity of the tests, suggesting that the interventions are responsible
for treatment effects and not other modulating factors (efficacy). It is well
accepted that the more selective the sample and the more rigorous the manual,
the more difficult it is to generalise findings and translate them into day-to-day
practice (effectiveness, process measures).
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Slade and Priebe (2001) therefore asked: Are randomised controlled trials
the only gold that glitters? They suggested a way forward as follows: Mental
health research needs to span both the natural and social sciences. Evidence
based on RCTs has an important place, but to adapt concepts from only one
body of knowledge is to neglect the contribution that other well-established
methodologies can make.

Setting the scene

Psychotherapy research in general is a relatively young discipline and there
is an ongoing scientific debate about the most applicable, appropriate research
methodologies regarding the evaluation of its efficacy and effectiveness
(e.g. Loewenthal & Winter, 2006). Until about 50 years ago there were
hardly any controlled or comparative outcome trials conducted for
psychotherapy. Eysenck published a first overview of the existing literature
in 1952 and concluded that psychotherapy was not effective. Psychotherapists
across the world contested these findings but it took another 25 years until
Smith et al. (1980) provided their first meta-analysis of results from 485
controlled trials in psychotherapy. To the great relief of the psychotherapeutic
community, their findings suggested that psychotherapy is generally effective.
At the same time, other authors could not find any sufficient evidence
in favour of one particular psychotherapeutic modality, suggesting the
equivalence of all psychotherapies (Luborsky, Singer, & Luborsky, 1975).
The dodo verdict was born: At last the Dodo said, Everybody has won, and
all must have prizes (from Lewis Carrolls Alice in Wonderland). Lipsey and
Wilson (1993) came to a similar conclusion: Based on hundreds of randomised
control trials over the past 40 years, the clear indication is that psychotherapy
is generally effective in alleviating the distress and dysfunction associated with
a wide range of aversive psychological conditions. The main mode of action
identified as the therapeutic mechanism that brings about changes in the
process of treatment was identified as the therapeutic relationship (sometimes
also referred to as alliance). Zinbarg (2000) wrote . . . the well-known Dodo
bird effect from meta-analyses of psychotherapy outcome studies suggests
that common factors such as the establishment of a sound therapeutic alliance
are sufficient for producing at least some degree of improvement (p. 397).
Wampold et al. (1997) published the first meta-analysis that provided
exceptionally strong evidence for treatment specificity. Consecutively, other
meta-analyses showed results in favour of cognitive behaviour
therapies (Chambless & Ollendick, 2001), very few in favour of family or
 Body, Movement and Dance in Psychotherapy 143

psychodynamic psychotherapies. Current lists of Empirically Supported

Therapies (ESTs) are therefore dominated by CBT treatments and these are
currently regarded as the treatment of choice for various mental health
conditions. However, it is important to acknowledge that absence of evidence
does not necessarily mean evidence of absence (of any evidence in other
branches of psychotherapy). Difficulties evaluating other, non-CBT therapies
include the paucity of research initiatives and the thesis that certain treatments,
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especially psychodynamic and experiential ones (such as BOP), cannot be

tested with clinical trials due to the very nature of their intervention strategies.
Summarising the current evidence base against this background it appears that
the dodo bird effect still matters, but that there is also evidence for disorder-
specific efficacy of specific intervention strategies.

Findings from other research areas relevant for the evaluation of BOP
Body image phenomenology
It will be important to develop strategies for the evaluation of BOP in research,
focussing on the complex realities of body experiences. Phenomenological
research identified some disorder specific characteristics with regard to body
image aberration and other body related psychopathological symptoms, the
findings will be described in the following paragraph. Whilst it is important
to acknowledge that BOP operates on the basis of a holistic approach, these
symptoms can be addressed in the context of a disorder specific manualised
intervention strategy and they can therefore be defined as specific outcome
criteria for the evaluation of BOP in empirical research.
For patients suffering from anxiety disorders, studies identified a negative
association between body perception and anxiety levels (Compton, 1969;
Rohricht & Priebe, 1996). A phobic anxiety-depersonalisation syndrome
(Noyes, Hoenk, Kupermann, & Slymen, 1977; Tucker, Harrow, & Quinlan,
1973) has been described, suggesting a degree of somato-psychic dissociation
phenomena. Body image satisfaction was found to be low in anxiety patients
(Lowe & Clement, 1998; Marsella, Shizuru, Brennan, & Kameoka, 1981).
Clinicians refer to a particular syndrome, which may be best described as
a Bermuda-Triangle: Anxiety-tension headache-anger. Hence, therapeutic
strategies for the treatment of anxiety disorders may include elements of
grounding, body-awareness training, boundary articulation and working with
the dynamics of fight-flight impulses.
Patients suffering from depressive disorders often present with a range
of somatisation symptoms (chest pressure, pain, difficulties swallowing, etc).
They also frequently present with motor retardation, lack of drive/energy
and poor motivation. Depressive disorder patients have negative body cathexis,
somatic depersonalisation symptoms and boundary loss correlates with degree
of anxiety symptoms (Rohricht, Beyer, & Priebe, 2002).
Anorexia nervosa is characterised by severe body image aberration,
including overestimation of body sizes, negative body cathexis, hostile attitudes
towards ones own body (sometimes leading to dissociative processes) and
 144 F. Rohricht

control or manipulation of bodily functions (e.g. excessive exercising,

vomiting). The movement analysis of these patients shows reduced and/or
bound free flow of movement, lack of weight emphasis and use of small space
(overview in Lausberg, 2009).
Patients suffering from chronic somatoform disorders have major
difficulties expressing their feelings/emotions (alexithymia), and they use
body language (symptoms) instead of talking about problems. With regard to
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sensory body stimuli, they often experience somatic amplification with stimulus
entrapment. These patients are known to be observing and checking their
bodily functions (control mechanism) and often present with reduced motor
expression (avoidant behaviour), increased muscular tone and tension.
Schizophrenia patients present with a range of qualitatively abnormal
bodily sensation (cenesthesias) and somatic hallucinations (Jenkins &
Rohricht, 2007; Rohricht & Priebe, 2002). They experience a centralised
body schema with underestimation of the periphery and shrinking/enlargement
(size-change) sensations (Rohricht & Priebe, 1997). They describe somatic
depersonalisation and boundary loss (Fisher, 1986). Stereotypical movements
with repetitive self-contact, self-stimulation with clapping hands and tapping
body parts against objects (Du Bois, 1990; Joraschky, 1983) characterise
behavioural aspects of patients with schizophrenia. The overall picture can be
best described as one of disintegration, disembodiment and splitting (Rohricht,
2000; Scharfetter, 1995).

Affective neuroscience
Acknowledging the basic principles of plasticity and synergism, neuroscience
refers to an explicit biological model for psychotherapeutic interventions.
Cozolino (2002) summarises as follows: From the perspective of neuroscience,
psychotherapy can be understood as a specific kind of enriched environment
designed to enhance the growth of neurons and the integration of neural
networks (p. 27). In this paradigm, growth and integration are best achieved
in an effort to further the integration of conceptual knowledge with emotional
and bodily experience. Cozolino (2002) emphasises the importance of thera-
peutic processes that facilitate gaining new information and experiences across
the domains of cognition, emotion, sensation and behaviour. This notion from
neuroscience is very much in keeping with holistic aspects of intervention
strategies in body oriented psychotherapy. More specifically, neuropsychology
describes how movement and emotional experiences are biologically and
experientially associated (a moving experience). The modification of facial
expression (mimic muscles) and gestures modifies subjective mood (Ekman &
Friesen, 1974) and this can be utilised for the treatment of affective symptoms.
The recent fascinating finding of mirror neurons suggests a biological
mechanism for learning through imitation, understanding and empathy,
therapeutically utilised in BOP in the form of mirroring exercises (e.g. in
autism and schizophrenia). Gallese (2005) described mirror neurons as
. . . a common functional mechanism . . . of both (our own) body awareness
and social understanding: embodied simulation. Finally, it is important to
 Body, Movement and Dance in Psychotherapy 145

note that movement planning and behaviour are closely associated with body
schema/body perception and body image (concepts, beliefs) as summarised by
Buytendijk (1971) and Lausberg (2009). This suggests that we need to
specifically target body experiences in order to change behaviour.

Outcome research
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The facts presented here are based on a comprehensive literature search and
monographies on BOP and Body Image (e.g. Fisher, 1986; Geuter, 2002;
Marlock & Weiss, 2006; Rohricht, 2000; and textbooks listed in Section 4.1), as
well as data base searches in MEDLINE (19662008), PsycINFO (18062008)
and EMBASE (19742008) and personal communication. The search focused
on empirical studies, which evaluated the effect of BOP in the treatment of
mental disorders (adults of working age only). Only those studies with defined
BOP intervention strategies according to the above definition (see Section 2)
were considered. The decision to restrict the literature search to these publicly
available sources and not to include the so-called grey literature is based on an
effort to adhere to principles applied elsewhere in mainstream scientific
literature in order to achieve comparably high standards. Therefore, this review
may not capture all outcome studies relevant for the field.
One particular example is the USABP journal, which was included in this
review because if its importance for the field, even though the papers are
difficult to access outside the USA and mainly available as abstracts to the
public. May (2005) published an article on the outcome of body psychother-
apy. He emphasised: Because some of these studies would not meet empirical
criteria in peer-reviewed journals, I called this literature objective. Much of
this literature was available only in back issues of journals with limited
distribution, personal communications, and theses/dissertations (May, 2005,
p. 98). May conducted a systematic and comprehensive literature search and
explicitly excluded Dance/Movement therapies (on the grounds of duplication
of effort).
This was the first published attempt to review outcome studies of body
psychotherapy and it is therefore briefly discussed here in relation to the
findings of this paper. Out of the six retrospective studies May (2005) included
in his review, two surveyed the effects of Radix, an eclectic form of therapy
combining Reichian and Gestalt therapies as well as hypnotherapy. Those two
studies and one study on Energy Stream therapy were not included in
this paper due to their questionable BOP characteristics, a lack of information
regarding clinical characteristics of the samples and because they do not feature
according to the search criteria. Equally, apart from two studies (May, Wexler,
Salkin, & Schoop, 1963; Price, 2005), the nine efficacy studies listed by May
(2005) were not considered in this paper for the following reasons: two studies
focused on non-clinical samples (university students and subjects with career
conflicts), one study was not published, three studies are not accessible and/or
of questionable BOP nature (e.g. Somatic exercises and Gestalt two-chair
exercise, Rubenfeld Synergy) and one study (Peterson & Cameron, 1978) on
 146 F. Rohricht

the combined movement therapy and progressive relaxation in anxiety was

not referenced in his publication. Effectiveness studies quoted by May on
psychomotor therapy, holotropic breathwork, primal therapy and systems
releasing action therapy or those focusing on normal populations or where
the publication is only available on university microfilms were also not
considered for the purpose of this current review for the above named reasons.
In summary, comparing the literature included in this review with the outcome
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studies described by May (2005), many more studies have been identified this
time and there is now a much better evidence base for the efficacy of BOP.
Numerous cohort studies with various methods were conducted between
19601990 in healthy samples and in samples defined as suffering from
neurosis and drug abuse. The findings indicate that these methods are
effective, leading to an increase in body satisfaction, self-perception and
self-esteem. There was also a reduction in muscular tension following the
interventions (e.g. Fisher, 1986; Rohricht, 2000).
Subsequently, studies were carried out in order to specifically evaluate
body-mind approaches in the treatment of mental disorders. There is some
evidence pointing towards the efficacy of dance and dance movement therapy
(and a few others, mainly neo-Reichian body oriented therapies) in depression
and anxiety with improvements in mood, psychological well-being and
subjective quality of life scores after therapy. Stewart et al. (2004) carried
out a study (randomised single-case experimental design) on movement therapy
in a sample of depressed inpatients and they found that the therapy had
a positive effect on mood. However, major methodological shortcomings have
to be acknowledged, such as non-RCT design and mostly retrospective
analysis based on subjective ratings from surveys (Brooks & Stark, 1989;
Dosamantes, 1990; Dosamantes-Alperson & Merill, 1980; Gudat, 1997;
Heimbeck & Suettinger, 2007; Koch, Morlinghaus, & Fuchs, 2007; Kuettel,
1982; Mczkowiak, Holter, & Otten, 2007; Ritter & Low, 1996; Ventling,
2002; Ventling & Gerhard, 2000; Weber, Haltenhof, Combecher, &
Blankenburg, 1994).
Arguably, the most important study concerning the effectiveness of BOP
in routine care (outpatient-setting) was conducted from 2002 to 2005 and
published recently (Koemeda-Lutz, Kaschke, Revenstorf, Schermann, Weiss,
& Soeder, 2006). In this multicentre, naturalistic evaluation study of BOP
(eight different schools including: Hakomi Experiental Psychology, Unitive
Body Psychotherapy, Biodynamic Psychology, Bioenergetic Analysis, Client-
Centred Verbal and Body Psychotherapy, Integrative Body Psychotherapy,
Body-Oriented Psychotherapy, and Biosynthesis), the researchers aimed to
investigate the effectiveness of routine therapy in outpatient settings. Patients
seeking BOP (n 342 participated) were compared to other outpatients (not in
RCT fashion). The assessments were carried out at baseline, after 6 months and
at the end of therapy (over a maximum of 2 years). The instrument used to
estimate treatment responses was the symptom checklist SCL-90-R. This
instrument measures subjectively felt impairment by means of a 90-item self-
report inventory of physical and mental symptoms occurring the preceding
week. Overall, the results suggest good efficacy of BOP for a variety of
 Body, Movement and Dance in Psychotherapy 147

symptoms or problem areas. However, the study design does not allow for
more substantive statements/conclusions.
Combining elements of body psychotherapy with other therapeutic
components, Fernandez et al. (1995) identified a beneficial impact of the
bodily interventions on the pace of recovery in treatment of anorexia nervosa
patients. Konzag et al. (2006) investigated more systematically how inpatients
with eating disorders responded to body oriented psychotherapy (integrative
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group therapy programme over 12 weeks). They included 43 patients in their

cohort-study (15 with Anorexia nervosa and 28 with Bulimia nervosa).
The BOP module combined body oriented perception therapy and so called
communicate movement therapy and was given in addition to CBT and
psychodynamic therapy elements. The main outcome was again measured
using the SCL-90-R symptom scores. As a result, the pre-post comparison
showed a reduction of subjectively perceived problems in most domains,
particularly significant for social insecurity and depression scores. The authors
also investigated how patients rated BOP in comparison with the other non-
BOP modules, which they attended at the same time, and the participants rated
BOP as the most effective module. Body perception scores improved in the
subgroup of bulimia patients only.
Similar findings were described in a controlled trial on movement therapy
for bulimia nervosa patients (Alexandridis, Schule, Ehrig, & Fichter, 2007).
Consistent with results of other studies, the body image disorder in anorexia
nervosa did not respond to BOP (e.g. Sack, Henniger, & Lamprecht, 2002),
whereas the movement behaviour was found to improve in some studies with
regard to reduced free flow of movement, lack of weight emphasis and use
of small space. There was also a more differentiated movement pattern
(Burn, 1987; Lausberg 1998; Lausberg, von Wietersheim, & Feiereis, 1996).
Preliminary evidence following a pilot RCT study in a small sample of patients
who experienced childhood sexual abuse confirmed results from an earlier
study (Mattsson, Wikman, Dahlgren, Mattsson, & Armelius, 1998) and
suggested that body-oriented therapy is efficacious as an adjunct to
psychotherapy in sexual abuse recovery (Price, 2006).
Applying the above mentioned notion of a gold standard for the evaluation
of psychotherapy, the best evidence currently available in the field of BOP is
concentrated on two groups of mental illness: somatoform/psychosomatic
disorders and schizophrenia.
The majority of studies on different psychosomatic disorders (including
irritable bowel syndrome, asthma/COPD and tension headache) have been
looking at the efficacy of a specific form of body psychotherapy named
Functional Relaxation/FR (Fuchs, 1997; Herholz et al., 2009), using various
designs. The study findings indicate a positive impact on somatic symptoms
(Loew et al., 2006). Some studies are of particular interest: Loew et al. (1996,
2001) investigated the effects of FR on airway resistance and forced expiratory
volume (both well validated physical parameters) in patients with acute
asthma. They used a cross-over design in order to compare FR with
sympathomimetic medication (Terbutaline) and a placebo relaxation technique
(isotonic exercises of one hand, called body awareness training for patients).
 148 F. Rohricht

Patients treated with FR showed significant reduction in specific airway

resistance, significantly greater than those treated with the placebo condition.
As expected, only medication resulted in even greater bronchodilatation.
Similar findings were described recently in another RCT, which aimed to
investigate the efficacy of FR as complementary therapy in Asthma (Lahmann
et al., 2009). In another (randomised controlled) study, comparing FR with
unspecific isotonic relaxation in chronic tension headache, the research team
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demonstrated a favourable effect on both the intensity and the duration of pain
(Loew et al., 2000). FR has also been tested as complementary therapy in
Irritable Bowel Syndrome (RCT); the results of the trial suggested a positive
effect of FR on subjective functional impairment scores, if provided in addition
to treatment as usual (Lahmann et al., in press). These results demonstrate how
body oriented psychological therapy does not only impact on psychopatho-
logical symptoms but can also directly modify bodily functions, particularly
those associated with the autonomic nervous system and muscular tension in
skeletal and smooth muscular systems.
Another recent RCT applied robust methodology in order to investigate the
specific effects of another form of BOP named Bioenergetic exercises from
Bioenergetic Analysis in a group of Turkish inpatients with chronic somato-
form disorder. They compared BOP with a control condition of gymnastic
exercises (Nickel et al., 2006). The SCL-90-R measures and records of the
intensity of anger and expression of anger showed significantly greater
improvements in the group receiving the experimental BOP condition.
Symptomatically, patients in the BOP group had significantly lower scores
for depression/anxiety and social insecurity scores after treatment, and the
largest effect was observed regarding specific somatisation symptoms.
Following treatment, patients also had reduced anger levels and reduced
tendency to direct anger inwards. Their spontaneous outward emotional
expression had increased simultaneously. The manualised BOP was carried out
as 60-minute group sessions twice weekly over a period of 6 weeks, and
included a range of bioenergetic exercises: expression/vocal exercises (e.g.
aggression), exercises setting boundaries, and grounding, respiratory and
movement exercises.
Sandel et al. (2005) conducted a RCT with a waiting list control group
crossover design, aiming to treat psychological conditions of women with
breast cancer. In the active treatment group, patients presented post treatment
with substantially improved (breast cancer-specific) quality-of-life measures.
Furthermore, there are three non-RCT studies reporting encouraging effects
of Dance Movement Therapy (DMT, now termed Dance Movement
Psychotherapy/DMP) for breast cancer patients with regard to significant
improvements in subjective quality of life, well-being, partially increased self-
esteem and reduction of anxiety/depression (Dibbell-Hope, 2000; Mannheim &
Weis, 2005; Serlin, Classen, Frances, & Angell, 2000). In a pilot study,
Ho (2005) demonstrated how DMT improved the self-esteem of cancer
patients. Monsen and Monsen (2000) investigated the effects of psychodynamic
body therapy in a controlled trial. They found that the experimental group
improved with regard to subjective pain levels, somatisation, anxiety/depressive
 Body, Movement and Dance in Psychotherapy 149

symptoms and social withdrawal. These results were stable at follow-up a year
after treatment. In a pilot study another group of researchers evaluated the
impact of a body-mind approach (group work, which was derived from DMP
and Authentic Movement) for patients with medically unexplained symptoms.
Payne (in press) described the results of the study, outlining improvements
following therapy and at follow-up regarding general well-being, individually
identified problems/symptoms and overall functioning.
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Concerning patients with schizophrenia, three RCTs demonstrated good

efficacy of BOP for the treatment of social and emotional withdrawal,
psychomotor retardation and self/body perception: psychopathological symp-
toms usually referred to as negative symptoms. May et al. (1963) and Goertzel
et al. (1965) compared a body oriented intervention (Body-ego-technique)
with another form of non-verbal therapy (music therapy) and described an
improvement of psychopathology and body image in both groups. There was
a significant increase in emotional contact and a reduction of restlessness
in the experimental BOP group. A study of movement and drama therapy
versus supportive counselling in chronic schizophrenia patients (RCT) revealed
similar results: significant improvement of social and motor behaviour in the
BOP group and improvements in general psychopathology in both groups
(Nitsun, Stapleton, & Bender, 1974). Rohricht and Priebe (2006) explicitly
aimed to investigate the impact of integrative manualised body oriented
psychotherapy on negative symptoms in chronic schizophrenia in comparison
to supportive counselling. The study results demonstrated substantial reduc-
tion in negative symptoms (assessed with an established rating scale; PANSS)
only in the BOP group after treatment and at 6-month follow-up.
The current evidence base can therefore be summarised as follows: BOP
seems to have generally good effects on subjectively experienced depressive
and anxiety symptoms, somatisation and social insecurity. Patients undergoing
BOP appear to benefit in terms of improved general well-being, reduced motor
tension and enhanced activity levels. There is evidence from one RCT that
bioenergetic analysis may be specifically effective for somatoform disorder
patients, and there is substantial evidence for the efficacy of functional
relaxation on psychosomatic disorders (asthma, tension headache, irritable
bowel syndrome). Patients suffering from severe physical conditions (e.g.
cancer) seem to be responding well to Dance Movement Psychotherapy with
regard to enhanced self-esteem, changes in body perception and improved
coping mechanism. At least three RCTs have demonstrated that schizophrenia
patients with predominant negative symptoms respond to manualised body
oriented psychological intervention strategies, improving their psychomotor
behaviour, social and emotional interaction.

Future perspectives, summary and conclusions

The heterogeneous field of body oriented psychological therapies provides
a range of unique contributions for the treatment of mental disorders.
Practice based clinical evidence and a few empirical studies point towards good
 150 F. Rohricht

efficacy of so called non-verbal intervention strategies (although this is

somehow misleading as all these therapies naturally work with both verbal
and non-verbal interventions), particularly relevant for those disorders with
body image aberration and other body-related psychopathology. Furthermore,
BOP appears to offer promising additional psychotherapeutic tools in areas,
where traditional talking psychotherapies seem to fail so far, e.g. somatoform
disorders/medically unexplained syndromes, PTSD, anorexia nervosa or
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chronic schizophrenia. The best example for the importance of research efforts
in the field is the recent publication of NICE guidelines for schizophrenia
in the UK (http://www.nice.org.uk/guidance/index.jsp?actiondownload&o
42139). Through a robust meta-analytic process, all available evidence base has
been reviewed and body oriented psychotherapy is now recommended amongst
other non-verbal/arts therapies as treatment of choice for chronic schizophre-
nia patients with predominant negative symptoms.
Strong academic links are urgently required in order to support practi-
tioners in their efforts to evaluate the clinical work in systematic research. The
field would greatly benefit from the development of an international higher
education training in integrated clinical body psychotherapy, enabling
practitioners to obtain a masters degree (master of arts or science), comparable
to the US masters degree in somatic psychology. Ideally, this higher training
should be brought together by a group of collaborating leading clinicians
and researchers with representatives from across the spectrum of BOP schools
and be endorsed by the European or US Associations for Body Psychotherapy.
The master degree courses in BOP currently developed at the University of
Hertfordshire/UK are beginning to formulate links with mental health services
in order to provide candidates with clinically relevant work based experience
and could furthermore offer taught clinical doctoral programmes. Hereby, the
clinically relevant critical mass of knowledge and skill base from various
schools could be identified for the formulation of a cohesive theoretical basis
and core intervention strategies comparable to work done within the fields
of cognitive-behavioural, psychodynamic and systemic psychotherapy.
From a scientific perspective, research projects on the interface between
neuroscience and psychotherapy research could be conducted in order to
understand more fully the therapeutic processes at work within BOP, parti-
cularly with regard to emotional processing, movement behaviour and body/
self perception. Qualitative research is also needed to investigate further the
specific interactive therapeutic relationship known as somatic transference
that exists between therapist and client/patient. More research is also needed
with respect to the dynamics of touch in psychotherapy in general and in body
psychotherapy in particular (Smith, Clance, & Imes, 1998; Zur, 2007). Finally,
further research would be beneficial on the fostering of self-helping potentials
above and beyond the effect of the creative/arts and other non-verbal therapy
components that overlap with body oriented psychotherapy. It will be
necessary, in these endeavours, not only to gather knowledge regarding the
active ingredients of BOP, but also to better understand which therapeutic
intervention works best for particular individuals or for specific conditions,
whether any form of combined therapy (different therapies or therapy and
 Body, Movement and Dance in Psychotherapy 151

medication) is indicated or contra-indicated, and which therapists character-

istics are most effective under which circumstances. Provided that these
requirements will be fulfilled, BOP could be established as one of the main
psychotherapeutic modalities in clinical care alongside other mainstream
schools such as psychodynamic, cognitive-behavioural and systemic. However,
since research is not cheap and most body psychotherapy training establish-
ments are still privately funded, the spectre of who pays and how the research
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projects are directed and then analysed remains a very complex issue. One way
forward could come from collaboration between the professional associations
(e.g. ADMP, USABP, EABP) and the university (Masters, PhD) programmes:
one providing the source material, through the practitioners case loads,
and the other providing the time and energy from research students with the
analytic facilities and desire to publish.

Acknowledgements
I would like to thank Dr. Manfred Thielen, Chair of the German Association for Body
Psychotherapy, for his ongoing and passionate support in linking academic research
initiatives with the day to work of practitioners and Priv.-Doz. Dr. Ulf Geuter, who has
been a very important source for information for many years. Nina Papadopoulos and
Professor Helen Payne helped me to formulate and constantly update ideas regarding
the interface between body and movement psychotherapy. Finally, I want to thank all
the colleagues in the field I worked with over the last 25 years, because their experience
and therapeutic wisdom helped me to integrate the rich diversity of body oriented
therapeutic interventions.

Notes on contributors
Frank Rohtricht, MD, MRCPsych, visiting professor at University of Hertfordshire,
Consultant Psychiatrist and Clinical Director East London NHS Foundation Trust and
Body Psychotherapist.
Since 1987 working as body psychotherapist (integrative methods, predominantly
neo-reichian) in various settings. Medical Qualification in Germany 1990; M.D. in 1995
at Free University Berlin, Germany: Body concept and body schema and their
relationship with psychopathological symptoms within acute paranoid schizophrenia.
Specialist training in Psychiatry, Neurology and Psychosomatic Medicine from 1990 to
1997.
Chair of the research section of the German Association for Body Psychotherapy
(part of the European Association of Body Psychotherapy), member of EABP, Patron
of the Association for Dance Movement Psychotherapy UK.
With several publications and through ongoing research activities, he is currently
one of the leading researchers in the international field of Body Image Phenomenology
and Body Psychotherapy in Mental Illness; his book on body-psychotherapy (2000) is
the first text book covering the innovative field of body-oriented psychotherapy in
psychiatry. Subsequently, he developed and evaluated treatment manuals for novel
psychotherapeutic intervention strategies in anorexia nervosa and somatoform
disorders, and for patients suffering from chronic schizophrenia with marked and
dominating negative symptoms. This approach is now recognised by NICE/UK as
treatment of choice for negative symptoms in schizophrenia (NICE schizophrenia
update, March 2009).
 152 F. Rohricht

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