Atlas›Domain IV · Body-oriented psychotherapy›Guide 081
Guide IV-081

Body-oriented psychological therapy for schizophrenia

Frank Röhricht2000
A 32 · L 37 · M 3113 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Frank Röhricht's manualised group body-oriented psychological therapy (BPT; called body psychotherapy in the NESS reports) for chronic schizophrenia with predominant negative symptoms, as delivered in the UK NESS trial: 20 group sessions of 90 minutes, twice weekly on non-consecutive days over 10 weeks. The NESS manual is an updated version of the one used in the 2006 exploratory trial (Röhricht & Priebe 2006: single site, one body psychotherapist, supportive counselling as control, same 20 × 90-minute format). The trial papers cite the manual as Röhricht (2000) (Savill et al. 2017) or as Röhricht & Papadopoulos (2010), Body oriented psychological therapy for chronic schizophrenia (Martin et al. 2016). The HTA report states that Röhricht holds a pending copyright on the schizophrenia manual, and the manual is unpublished; Röhricht's own 2009 review mentions developing disorder-specific manuals for chronic schizophrenia with marked negative symptoms but does not describe their contents. What is documented: the format, therapist training and supervision, the aims of the manual, the five session sections with the example activities named in the HTA methods chapter, the session guide sheet and the adherence scale (NESS HTA report 2016; Savill et al. 2017). Not documented in published sources: exercise-level steps and wording, any phases across the 20 sessions, the content of the HTA appendices (session sheet, adherence-scale items), and any touch or consent procedure. These remain [synthesis] or [uncertain]. The 2006 RCT design is taken from the HTA background. [source: Priebe et al. 2016 HTA, methods and scientific summary; Savill et al. 2017; Martin et al. 2016; Röhricht 2009, p. 150]

What it is. BPT is a manualised outpatient group programme, not a separate school of therapy. It brings together the three roots that Röhricht sees in body-oriented psychotherapy:

  • perceptive, self-awareness work (Concentrative Movement Therapy and Functional Relaxation);
  • neo-Reichian work with grounding and tension;
  • dance movement therapy (improvisation and "body dialogues").

These non-verbal methods are combined with insight-oriented verbal reflection. In the NESS trial it was delivered by accredited dance movement psychotherapists. [source: Röhricht 2009; Martin et al. 2016; Priebe et al. 2016 HTA]

How change is thought to happen. Röhricht describes body experience in chronic schizophrenia as "one of disintegration, disembodiment and splitting". Its features include:

  • abnormal bodily sensations;
  • a body schema that is centralised, with the periphery underestimated;
  • somatic depersonalisation and loss of boundaries;
  • stereotyped self-touch.

He argues that the immediacy of body experience supports reality testing. The NESS report states the manual's aims: reconstructing "a coherent ego structure through grounding and bodily awareness", strengthening self-referential processes so that social interaction feels safer, widening emotional responsiveness, improving "boundary demarcation" between self and others, and reducing emotional withdrawal through expressive, responsive and communicative behaviour. It proposes three routes of change: a non-verbal route into emotional interaction for people whom negative symptoms make hard to reach through talking; the link between movement and emotion, which a group may strengthen because members observe and imitate each other's expressive movement; and improved body perception and body image. Röhricht and the trial authors present these as hypotheses. Note that the NESS trial did not show BPT to be better than Pilates on negative symptoms. [source: Priebe et al. 2016 HTA, background and methods; Röhricht 2009; Martin et al. 2016]

2. Framework

Format (NESS version). [source: Priebe et al. 2016 HTA; Priebe et al. 2013 protocol; Martin et al. 2016]

  • 20 group sessions, 90 minutes each, twice a week on non-consecutive days, over 10 weeks.
  • Group size: at most 10 in NESS. The protocol planned about 8, and Martin et al. used up to 8.
  • Venue: community sites, for outpatients.
  • Staffing: one lead therapist and one co-facilitator. In NESS the co-facilitator was a volunteer. In Martin et al. it was a trained dance movement therapy or psychology student.

Who delivers it. [source: Priebe et al. 2016 HTA; Martin et al. 2016]

  • NESS used therapists accredited by the Association of Dance Movement Psychotherapy (ADMP), with an extra 2-day training in the manual. Martin et al. used a 3-day workshop with Röhricht and Papadopoulos.
  • Supervision: at least three 90-minute sessions per group with a senior therapist, in person or by video.
  • No therapist ran more than two groups.
  • In Martin et al., the therapists had no other role in the patients' care.

Who it is for (trial criteria). [source: Priebe et al. 2016 HTA]

  • Age 18–65.
  • ICD-10 schizophrenia (F20.0–F20.9), with symptoms for at least 6 months.
  • PANSS negative subscale score of 18 or more.
  • No change in the type of antipsychotic for 6 weeks.
  • Community outpatient, able to consent.
  • Excluded: a physical condition that prevents taking part in a group, or not enough command of the group's language.

These are research criteria. Treat them as a starting point for clinical selection. [synthesis]

Session structure: five fixed parts, repeated every session. The aims and example activities below are those the HTA methods chapter gives for each part; it gives no timings and no full exercise instructions. [source: Priebe et al. 2016 HTA, methods and scientific summary; Savill et al. 2017; Martin et al. 2016]

  • Opening circle. Establishes the group as a therapeutic space, supports basic communication and draws attention to the body. Each person describes their current feelings and energy level. Example activities named: breathing exercises, structured communication, self-massage.
  • Warm-up. Standing in a circle, the group moves different body parts, exploring the personal kinesphere (the space within reach), general space and physical sensations. Aims: self-awareness, emotional engagement and reality testing.
  • Structured tasks. Aimed at body-image disturbances such as boundary loss and desomatisation. Example activities: mirroring, body sculpturing with ropes or art materials (and body-image sculptures in pairs), and partner or group tasks that explore the difference between self and other.
  • Creative section. Movement as a source of expression and pleasure: dancing, making music or collage, play with various objects, and group sculptures with reflection on perceptions and emotions.
  • Closing circle. Disengaging from the session and reflecting on the events, thoughts or feelings it raised; each person refocuses on themselves through body-oriented exercises.

Martin et al. say the exercises use individual, pair and group work. Savill et al. (2017) describe facilitating "verbal and pre-verbal communication" between participants as the thread running through all five parts. [source: Martin et al. 2016; Savill et al. 2017]

The published sources do not give a time for each part. One way to divide 90 minutes is opening 10, warm-up 15–20, structured tasks 25, creative movement 20–25, closing 10–15. [uncertain] [synthesis]

Phases across the 20 sessions. Neither the HTA report (methods chapter and scientific summary) nor Savill et al. (2017) describes phases across the course, session-by-session themes or criteria for moving between phases; both describe the same five-part structure for every session. After each session the NESS therapist completed a session guide sheet to review that session and plan the next one (HTA Appendix 1; its content was not available), so planning ran session to session inside the fixed frame. Whether the manual itself sets phases is [uncertain]. [source: Priebe et al. 2016 HTA, methods]

Röhricht's general model of change in body-oriented psychotherapy has four steps [source: Röhricht 2009]:

  1. Focus on immediate bodily, emotional and perceptual experience.
  2. Mobilise the non-verbal side of underlying conflicts. He calls this a "partially cathartic" destabilisation.
  3. Change bodily processes.
  4. Self-determined reorganisation of behaviour.

The schizophrenia trial descriptions include no cathartic component, so do not import step 2 into this programme. [synthesis]

A workable progression [synthesis]:

  • Sessions 1–6 (orientation and safety). Learn the ritual. Mostly individual work in the circle: grounding, awareness of body parts, simple shared rhythms. Pair work only as short, side-by-side mirroring.
  • Sessions 7–14 (pair work). Face-to-face mirroring with turn-taking. Body-image sculptures with a partner. Verbal reflection becomes longer.
  • Sessions 15–20 (group expression and consolidation). Group sculptures and creative movement on themes the group raises. Then a planned ending: review, plus a personal body-based practice to take away.

Move to a later stage when most members [synthesis]:

  • attend reasonably regularly;
  • can stay with an exercise for several minutes without marked distress or disorganisation;
  • can say at least one sentence about what they noticed;
  • accept pair proximity.

If they cannot, stay with or go back to the earlier format, because the fixed five-part structure is kept either way. In the trial analyses, attending 5 or more sessions was counted as "compliance". That is a research threshold, not a clinical criterion. [source: Priebe et al. 2016 HTA]

3. Guiding principles

Each principle is followed by its practical meaning.

  • Start from immediate body experience. Ask "what do you notice now in your body" before asking about meaning or history. [source: Röhricht 2009]
  • Combine non-verbal and verbal work. Every movement task ends with a short verbal reflection. Röhricht calls the label "non-verbal" "somehow misleading". [source: Röhricht 2009; Martin et al. 2016 citing Röhricht 2009]
  • Rebuild a coherent self and clear body boundaries. Choose tasks that clarify where the body is, where it ends, and what belongs to "me", including tasks that explore the difference between self and other. Choose them over tasks that loosen or dissolve. [source: Priebe et al. 2016 HTA, methods ("boundary demarcation"); Martin et al. 2016]
  • Use grounding and body awareness as the foundation. Begin and end with contact with the floor and with simple attention to the body. [source: Priebe et al. 2016 HTA, methods (manual aims; opening and closing circles)]
  • Link movement with emotion. Invite people to notice how a movement or posture changes their mood or energy, and to name it. [source: Priebe et al. 2016 HTA; Röhricht 2009 citing Ekman & Friesen]
  • Build expressive, responsive and communicative behaviour. Prefer tasks where people send, receive and answer movement signals. This works against withdrawal and blunted expression. [source: Martin et al. 2016; Priebe et al. 2016 HTA]
  • Use the group's emotional interaction as an active ingredient. Encourage members to notice and respond to each other, not only to the therapist. [source: Priebe et al. 2016 HTA]
  • Focus on strengths and creativity. Notice and name what people can do and invent. Explicitly building "strengths, capabilities and creativity" is part of the approach. [source: Röhricht 2009]
  • Keep the structure predictable. The same five-part ritual every session. Change the content, not the frame. [source: Martin et al. 2016; Priebe et al. 2016 HTA]
  • Grade the social demand. Move from individual to pair to group work, both within a session and across the course. [source: Martin et al. 2016 for the three formats; ordering is synthesis]
  • Support reality testing. Bring the person back to concrete, checkable sensations, such as weight, the floor, temperature, or the size of a gesture. [source: Röhricht 2009]
  • Build a trusting relationship. The approach rests on a trustful therapeutic relationship, built through reliability, warmth and transparency about every exercise. [source: Röhricht 2009]
  • No catharsis or regression in this population. Do not use breath intensification, cathartic discharge (hitting, screaming), stress positions or regressive age-play. None of these is reported in the programme. [synthesis]
  • Respect autonomy. Joining in is always optional. Watching from a chair counts as taking part. Every exercise offers a smaller or seated version. [synthesis; consistent with "self-determined reorganisation" in Röhricht 2009]
  • Keep the group separate from the care team. Ideally, group therapists hold no other clinical role with members, but there are clear routes for sharing risk information. [source: Martin et al. 2016; the risk route is synthesis]
  • Work within your competence. The programme was delivered by accredited dance movement psychotherapists with manual training and supervision. Clinicians from other professions should get equivalent training and supervision. [source: Priebe et al. 2016 HTA; the recommendation is synthesis]

4. Intervention inventory

How complete this is. The published sources (HTA methods chapter and scientific summary, Savill et al. 2017, Martin et al. 2016) name these elements of the programme:

  • the five session parts;
  • breathing exercises, structured communication and self-massage (opening circle);
  • warm-up of body parts exploring the personal kinesphere, general space and physical sensations;
  • mirroring;
  • body sculpturing with ropes or art materials, and body-image sculptures in pairs;
  • partner and group tasks exploring the difference between self and other;
  • group sculptures;
  • creative movement and dance, making music or collage, play with various objects;
  • reflection on perceptions and emotions;
  • grounding and bodily awareness;
  • individual, pair and group formats.

The manual and the NESS session sheet are unpublished, so any further exercises in the manual, and how each named activity is run, are not known. [uncertain]

For each element below, the Purpose line is sourced. The detailed Steps, durations and wording are the author's synthesis, built to fit the stated aims, unless a line is tagged otherwise. [source: Priebe et al. 2016 HTA; Martin et al. 2016; Röhricht 2009; Underwood 2016]

Touch and consent (applies to every item). The NESS HTA methods chapter and Savill et al. (2017) describe no therapist touch in BPT; the only contact activity they name is self-massage in the opening circle. They give no consent procedure for touch, and the manual was not seen. [uncertain] By default, run every exercise without therapist touch. Where partner exercises involve contact, take these steps [synthesis]:

  1. Explain. Describe the exact contact first: who touches, where (only hands, forearms, upper back or shoulders), and for how long.
  2. Ask. Ask each person individually.
  3. Offer a no-touch version. Always offer one, for example copying at a distance, verbal instruction, or using an object such as a scarf or ball.
  4. Agree a stop signal. Agree a word and a gesture, such as a raised hand, that ends contact at once.
  5. Check in. Check during the exercise and again afterwards.
  6. Write it down. Record consent.

Also [synthesis]:

  • Never touch near the chest, buttocks, groin or face.
  • Never use sexual or genital touch.
  • Be extra cautious with members who have persecutory ideas about being touched or influenced, a trauma history, or sexual disinhibition.

Touch-based work needs specific training and supervision. Check what your licence, employer and jurisdiction allow. [synthesis]

Not part of this programme. Breath intensification, cathartic discharge (hitting, kicking, screaming), stress positions and deep-tissue work are not reported in the schizophrenia programme. Do not add them. [synthesis]

Physical screening before the group starts [synthesis]. Ask about:

  • cardiovascular or respiratory illness;
  • epilepsy;
  • pregnancy;
  • recent injury or surgery;
  • falls risk, including orthostatic dizziness on antipsychotics;
  • marked extrapyramidal side effects.

Adapt movements so they can be done seated or with support. The trials excluded only people whose physical condition prevented group participation. [source: Priebe et al. 2016 HTA for the exclusion]

4.0 Preparation: individual orientation meeting (not described in the sources) [synthesis]

  • Purpose: Lower the anxiety of a first group, explain the frame, screen for risk and physical limits, and agree consent rules. This is especially useful when amotivation is high. [synthesis]
  • Steps:
    1. Meet for 20–30 minutes.
    2. Explain the 20 sessions and the five-part structure.
    3. Say that the group involves movement in normal clothing, that no special skills are needed, and that sitting out is allowed.
    4. Explain the default of no touch.
    5. Ask about physical limitations, medication side effects, and current symptoms that involve the body (for example somatic hallucinations, or feeling controlled or penetrated).
    6. Agree how the group therapist will contact the care coordinator if there are concerns.
    7. Give the dates in writing and offer reminder texts.
  • Example language (illustrative): "It's a movement group, but it isn't exercise class and it isn't about being good at dancing. We'll notice how our bodies feel, try some simple movements together, and talk a little about it. You can always choose to watch."
  • Watch for: Fears about the body that could become part of a delusion, a history of sexual trauma, and hostility toward groups. These mean you should plan adaptations before session 1.

4.1 Opening circle: check-in on feelings and energy

  • Purpose: Establishes the group as a therapeutic space, supports basic communication and draws attention to the body. Each person describes their current feelings and energy level. This brings attention to the present, gives the therapist a quick reading of each member's state, and is a first, low-demand step in expression. [source: Priebe et al. 2016 HTA, methods and scientific summary]
  • Steps [synthesis]:
    1. Chairs in a circle. Therapist and co-facilitator sit opposite each other.
    2. Briefly restate the frame: duration, opting out, the stop signal.
    3. Go round the circle. Each person names a feeling and an energy level. Offer scaffolds:
      • a 0–10 number;
      • a weather image;
      • pointing to where the energy is in the body;
      • a small gesture that shows it.
    4. The therapist reflects back briefly and does not explore in depth.
    5. Note anyone who seems markedly more unwell, low or suspicious than last time, so you can check in with them privately.
    6. Takes about 5–10 minutes.
  • Example language (illustrative): "Let's go round. In a word or a number from 0 to 10, how is your energy today? If words are hard, show us with your hands." / "Thank you. Low energy is welcome here; we'll start from where you are."
  • Watch for: Long silences and members who say "nothing" or "don't know". Accept a number or a gesture instead. It is working when, over time, people give more differentiated answers, add a body location, or comment on each other's check-in.

4.1a Opening-circle body focus: breathing, self-massage and structured communication

  • Purpose: The HTA methods chapter names breathing exercises, structured communication and self-massage as example opening-circle activities that draw attention to the body and support basic communication. [source: Priebe et al. 2016 HTA, methods] Which breathing exercise, which areas are massaged and what form the structured communication takes were not described. [uncertain]
  • Steps [synthesis]:
    1. Seated in the circle, feet flat, eyes open.
    2. Breathing: simply notice the natural breath for a moment, a hand on the belly or lower ribs if wished. Do not ask members to change, hold, slow or speed the breath.
    3. Self-massage, own hands only: tap, rub or knead hands, forearms, shoulders, back of the neck and thighs briefly, firmly enough to feel the surface of the body. Anyone may do only the hands or skip it. No one touches anyone else.
    4. Structured communication: a round with a fixed form, for example say your name and pass a ball to someone who thanks you and says theirs, or make one gesture that the next person repeats before adding their own.
    5. Close by asking what changed in the body (warmer, more awake, calmer, nothing).
  • Example language (illustrative): "Just notice your breath for a moment; there's no need to change it." / "Use your own hands to wake up your arms: tap from the shoulder down to the fingertips." / "Say your name and roll the ball to someone."
  • Watch for: Breath focus raising anxiety or odd sensations: shorten it, look around the room, move to self-massage or the feet. Self-massage that becomes repetitive or stereotyped (Röhricht describes stereotyped self-touch in chronic schizophrenia) or rough: slow it and give a clear end. Any member touching another: stop and restate the rule. It is working when members join the round without prompting and report warmth, alertness or calm. [source: Röhricht 2009 for stereotyped self-touch; the rest is synthesis]

4.2 Warm-up in the circle, part by part

  • Purpose: Standing in a circle, the group moves different body parts, exploring the personal kinesphere (the space within reach), general space and physical sensations, to build self-awareness, emotional engagement and reality testing. This activates the body, brings attention to its whole extent (including the periphery, which Röhricht describes as underestimated in schizophrenia), and builds shared rhythm. [source: Priebe et al. 2016 HTA, methods; Röhricht 2009 for the periphery]
  • Steps [synthesis]:
    1. Everyone stands in a circle (seated version allowed) with feet hip-width apart.
    2. The therapist leads and names each part as it moves: shake out the hands; circle the wrists; shrug and roll the shoulders; turn the head gently side to side; circle the hips; bend and straighten the knees; lift the heels, press the soles into the floor, wiggle the toes.
    3. Keep each part short and easy, and move on while members are still engaged.
    4. Go from periphery to centre and back.
    5. Later in the course, invite members in turn to lead one movement for the circle to copy.
    6. Close by standing still for a moment, breathing normally, without deep or forced breathing, and noticing the warmed areas.
    7. Takes about 10–15 minutes.
  • Example language (illustrative): "Let's wake up the hands — shake them as if shaking off water. Now notice: where do your hands end? Feel your fingertips." / "Who would like to show us a movement for the shoulders? We'll all copy you."
  • Watch for:
    • Dizziness or unsteadiness from antipsychotics: offer a chair or support.
    • Rigidity or tremor: reduce range.
    • Embarrassment: keep eyes on the therapist, not on each other.
    It is working when posture becomes more upright, movement range and tempo increase, and people volunteer to lead.

4.3 Grounding and bodily awareness

  • Purpose: The NESS report states the manual's aim of reconstructing "a coherent ego structure through grounding and bodily awareness". The closing circle includes refocusing on oneself through body-oriented exercises. Grounding also draws on the neo-Reichian root of Röhricht's integrative approach. [source: Priebe et al. 2016 HTA, methods and scientific summary; Röhricht 2009] The exact grounding exercises in the manual were not described. [uncertain]
  • Steps [synthesis]:
    1. Standing (or seated, with feet flat), knees soft.
    2. Ask people to feel the weight going down through their feet. Shift the weight slowly left and right, then forward and back, 5–6 times each, and find the middle.
    3. Press the feet into the floor, then release. Notice the floor pushing back.
    4. Seated version: press the thighs into the chair and the back against the backrest.
    5. Attention tour (1–2 minutes): feet, legs, pelvis, back, shoulders, hands, face. Name only temperature, pressure and contact, not meaning.
    6. Optional: stand with the back to a wall and feel the contact.
    7. Close by naming one sensation aloud.
    8. Keep the whole sequence to 3–8 minutes. Keep eyes open, with no breath manipulation and no long silent inward focus.
  • Example language (illustrative): "Feel your feet on the floor. The floor is holding you up. Let your weight sink a little — now find the middle." / "Name one thing you can feel right now — warm, cold, heavy, light."
  • Watch for:
    • Long inward focus can increase dissociation or bring up odd sensations. Keep it short and concrete, with eyes open.
    • If someone reports a strange or intrusive sensation, bring their attention back to external contact points (feet, chair, wall) and to looking around the room. Do not interpret it.
    It is working when people can name sensations more readily, stand more steadily, and say they feel "more here" or calmer.

4.4 Body-boundary and sensory-awareness tasks

  • Purpose: Structured tasks target body-image disturbances, named in the HTA report as boundary loss and desomatisation, through partner or group tasks that explore the difference between self and other; the warm-up adds exploration of the personal kinesphere. This strengthens the experience of one's own body as bounded and self-owned ("boundary demarcation"). [source: Priebe et al. 2016 HTA, methods; Martin et al. 2016; Röhricht 2009] The specific boundary exercises in the manual were not described. [uncertain]
  • Steps [synthesis]:
    1. Self-contact tracing. Each person runs their own hands along the outline of their arms, shoulders and legs, with moderate firm pressure, 2–3 times. Then they say where the skin is and where "outside" starts. This uses self-touch only.
    2. Personal space. Standing, each person explores the space around them with their arms (front, sides, behind, above, below). Then they mark it as a "bubble" and notice its size.
    3. Distance in pairs (later sessions). One partner walks slowly toward the other. The other raises a hand, or says "stop", when the distance feels right. Then they swap.
    4. Use props for edges if helpful, such as a rope circle on the floor or a mat.
    5. Close with a brief verbal reflection.
  • Example language (illustrative): "Trace your arm from shoulder to fingertips. This is the edge of you." / "You choose the distance. Say stop when it feels right, and your partner stops."
  • Watch for:
    • Talk of being permeable, controlled or invaded. Shift to concrete edges and to choice and control ("you decide"), and do not debate the belief.
    • In pair distance work, a partner who doesn't stop when asked. Intervene immediately.
    It is working when people set distances clearly, hold their ground, and describe their own body edges more confidently.

4.5 Mirroring in pairs

  • Purpose: A structured task in which partners mirror each other's movements. It trains attention to another person, non-verbal attunement, responsiveness and turn-taking, which target the loss of intercorporeality and the expressive deficits seen in negative symptoms. Röhricht notes that mirroring is used therapeutically in body-oriented psychotherapy, including in schizophrenia, and links it to mirror-neuron research. [source: Priebe et al. 2016 HTA; Röhricht 2009; Martin et al. 2016]
  • Steps [synthesis]:
    1. Pairs stand facing each other about 1.5–2 m apart. Early sessions can work side by side, or have the whole circle mirror the therapist.
    2. Partner A leads with slow, simple movements of the arms and upper body. Partner B copies as if in a mirror.
    3. After about 1–2 minutes, the therapist calls "swap".
    4. Progressions:
      • more speed or range;
      • adding facial expression (smile, frown, surprise), which links to the movement–emotion and affect-expression aims;
      • "follow-the-follower", where neither leads, for 1–2 minutes.
    5. No touch.
    6. Each pair gives brief feedback: what was easier, leading or following, and what did they notice in their partner.
  • Example language (illustrative): "A, move slowly enough that B can stay with you. B, be A's mirror." / "What was it like to be followed? To follow?" / "Try showing a feeling with your face and arms — your partner mirrors it."
  • Watch for:
    • Paranoid discomfort with eye contact: allow looking at hands or shoulders.
    • Ideas of being copied or mocked: explain the game first and keep roles clear.
    • Pairs who drift into chaotic or very fast movement: slow the tempo.
    It is working when there is more synchrony, longer engagement, more facial animation, spontaneous laughter or comments, and members asking to lead.

4.6 Body-image sculpture with a partner

  • Purpose: The HTA methods chapter lists "body sculpturing with ropes or art materials" among the structured tasks for body-image disturbance, and the scientific summary names body-image sculptures in pairs. The task makes a person's implicit body image or self-image visible and shareable, which supports self-perception and reality testing, links posture to feeling, and gives practice in describing oneself to another person. [source: Priebe et al. 2016 HTA; Röhricht 2009] How the manual sets it up (a rope or art-material outline, partners shaping each other, or both) was not described. [uncertain] A material version [synthesis]: each person lays a rope on the floor, or draws on large paper, to show the outline and size of their body as it feels today; then stands or lies beside it, compares it with a partner's view of their actual size, and says what is different.
  • Steps [synthesis; no-touch default]:
    1. Each person chooses a theme, for example "how I feel in my body today", "how I am when I have energy", or "how I'd like to stand".
    2. The "sculptor" shapes the "clay" partner by demonstration or verbal instruction only. For example, "lift your right arm halfway" or "lower your head a little". The partner copies.
    3. Hands-on shaping happens only with the full consent steps above, and only at the hands, forearms and shoulders.
    4. The sculptor steps back and looks at their sculpture for 20–30 seconds. Then they say what they see and how it fits or differs from how they feel.
    5. The "clay" partner says what it felt like to hold the posture: what mood or energy it brought.
    6. Optional: the sculptor makes a second sculpture of a wished-for state and notices the difference.
    7. Swap roles.
    8. De-role: each person shakes out and returns to their own stance.
    9. Takes about 15–20 minutes.
  • Example language (illustrative): "Show your partner, without touching, how you're standing in your body today. They'll copy you so you can see it from outside." / "Looking at it now, what do you notice? Is it bigger or smaller than you expected?" / "Holding that shape, what feeling comes with it?"
  • Watch for:
    • Distorted size perceptions ("I'm tiny"/"I'm huge") shown openly. Use concrete comparison ("let's see where your hand actually reaches") rather than argument.
    • Distress at seeing a low-mood posture held up. Move to the wished-for posture and to grounding.
    • Discomfort with being shaped. Keep it verbal.
    It is working when descriptions become richer, the person can say how the posture changes mood, and the person tries an alternative stance.

4.7 Group sculpture

  • Purpose: Part of the creative-movement segment. Members together form a group sculpture and then reflect on the perceptions and emotions it brings up. It builds group belonging, encourages people to take an expressive role, and makes interpersonal positions (close or distant, central or peripheral) visible. [source: Priebe et al. 2016 HTA; Martin et al. 2016]
  • Steps [synthesis]:
    1. Choose a theme with the group: "our group today", "a machine", "a park", "energy", or a feeling that came up in the check-in.
    2. One at a time, members step into the space and take a still shape that connects to the shapes already there. Connection can be by proximity, gaze or matching angle. Physical contact only by mutual consent.
    3. When everyone (or everyone who wishes) is in, hold the shape briefly, only as long as it stays comfortable.
    4. Each person names one word for what they feel in their own position.
    5. Variations:
      • add one small repeating movement and one sound or word each, to make a "moving sculpture";
      • let one person step out, look at the whole, and comment;
      • rebuild it as the group would like it to be.
    6. Dissolve slowly. Everyone returns to their own space and grounds briefly.
  • Example language (illustrative): "Step in when you're ready and find a shape that fits with what's already here." / "From where you're standing, one word — what's it like in your place?" / "If we changed one thing, what would it be?"
  • Watch for:
    • Members who always stay at the edge: invite them as the "observer", or let them place the first shape.
    • Ideas of reference ("they're standing like that to show me something"): name the instruction clearly.
    • Unconsented physical contact.
    It is working when members join spontaneously, choose more central positions, and comment on each other's places.

4.8 Creative movement improvisation and movement dialogue

  • Purpose: The creative section uses movement and dance as sources of expression and pleasure. It draws on the dance movement therapy root (improvisation, "body dialogues") to bring out spontaneity, expressive range and interpersonal response, and to connect movement with emotion. [source: Priebe et al. 2016 HTA, methods; Röhricht 2009; Martin et al. 2016] Which improvisation structures the manual uses was not described. [uncertain] Unstructured authentic-movement work with eyes closed is not reported for this population, so avoid it. [synthesis]
  • Steps [synthesis]:
    1. Give a clear structure with a beginning, middle and end, plus optional music with a steady beat.
    2. Qualities. Explore contrasting qualities in turn, about 1 minute each: heavy and light, fast and slow, big and small, strong and soft, jagged and smooth.
    3. Dialogue. In pairs, A makes a movement "statement" and B answers with a movement. Do 3–5 exchanges, then swap. Progress to a whole-group "conversation" round the circle.
    4. Feeling to movement. A member names a feeling (from the check-in or from the reflection). Everyone finds a movement for it. Then find its opposite.
    5. Return to a neutral stance and do a brief grounding.
    6. Takes about 15–20 minutes.
  • Example language (illustrative): "Let's move as if we're very heavy... now as light as a feather. Which one is closer to you today?" / "A, say something with a movement. B, answer it." / "Someone said 'tired' earlier — let's all find tired in our bodies. Now its opposite."
  • Watch for:
    • Overstimulation: rising agitation, disorganised or bizarre movement, laughter that doesn't fit. Slow the music, return to the circle and the feet.
    • Very restricted movement: accept a hand-only version and praise any variation.
    It is working when people use a wider range of qualities, respond to partners rather than repeating one pattern, and link a movement to a feeling word without prompting.

4.8a Creative play: making music, collage and objects

  • Purpose: The HTA methods chapter lists making music or collage and play with various objects, alongside dancing, as sources of expression and pleasure in the creative section. These suit members for whom whole-body movement is hard, and pleasure itself targets anhedonia. [source: Priebe et al. 2016 HTA, methods] Which instruments, materials or objects were used was not described. [uncertain]
  • Steps [synthesis]:
    1. Music: simple percussion (hand drums, shakers) or body percussion (clapping, stamping). The therapist holds a steady pulse; each member in turn offers a short rhythm that the group echoes; then a round where each person plays "how I feel now" and the group answers.
    2. Collage: paper, magazine pictures, glue sticks (no sharp scissors if risk is a concern). A theme from the session, such as "my body today" or "what gives me energy"; each person shows theirs and says one word about it.
    3. Objects: pass a ball across the circle with eye contact and name; move a scarf in pairs, one leading; hold a large elastic band or rope as a group and feel each other's pull and give.
    4. Return to the circle and a brief grounding before the closing circle.
  • Example language (illustrative): "Let's find one beat together... now you lead, and we'll follow." / "Pick pictures that show how your body feels today, no need to explain them." / "Feel the pull of the band: who is pulling, who is giving?"
  • Watch for: Overstimulation from noise: lower the volume, shorten turns. Collage images about weight or body shape: no comments on bodies, keep to the member's own word. It is working when members play spontaneously, laugh, take a turn to lead, or say they enjoyed it.

4.9 Verbal reflection on perceptions and emotions

  • Purpose: Non-verbal tasks are joined to insight-oriented verbal reflection on perceptions and emotions. This consolidates what was experienced, practises putting feelings into words, and supports reality testing. [source: Priebe et al. 2016 HTA; Martin et al. 2016 citing Röhricht 2009]
  • Steps [synthesis]:
    1. After each structured or creative task, gather in a standing or seated circle for 3–5 minutes.
    2. Ask in this order:
      • sensation: what did you notice in your body;
      • feeling: what mood or emotion came with it;
      • relation: what did you notice about your partner or the group;
      • meaning or everyday link, optional: where else do you feel like that.
    3. Accept single words, gestures or numbers.
    4. Reflect back strengths.
    5. Do not interpret psychotic content. Acknowledge the experience and return to shared, concrete observations.
  • Example language (illustrative): "What did you notice in your body? ... And what feeling went with that?" / "You said your arms felt 'more yours' — when else do you get that?" / "That sounds like a strong sensation. Right now, can you feel your feet on the floor?"
  • Watch for:
    • The same few members dominating: use rounds.
    • Abstract or delusional elaboration: gently bring it back to sensation.
    It is working when there is a richer emotional vocabulary, more spontaneous comments, and people linking session experiences to daily life.

4.10 Closing circle: group reflection and refocusing on oneself

  • Purpose: The group reflects on the session, and each person refocuses on themselves through body-oriented exercises. This contains the session, brings arousal back to baseline, and marks a clear end before people return to the community. [source: Priebe et al. 2016 HTA]
  • Steps [synthesis]:
    1. Return to the circle.
    2. Each member says one thing they take away (a word, a movement, or one thing they liked).
    3. Refocus with a short body-oriented sequence:
      • feet on the floor and weight in the chair or legs;
      • self-contact tracing of the arms;
      • one shared closing movement that the group keeps for the whole course (for example, a stretch up and a release down).
    4. Repeat the energy rating from the opening.
    5. Remind people of the next session date.
    6. The therapist stays 5–10 minutes afterwards for anyone who seems unsettled.
    7. In the last 2–3 sessions, use the closing to prepare for the ending: review the course, and agree a short personal grounding practice to keep using.
  • Example language (illustrative): "Let's finish by coming back to ourselves — feet down, feel the chair. Trace your arms, shoulders to hands." / "Your energy was 3 at the start; what is it now?" / "What's one thing you'll take with you today?"
  • Watch for:
    • Anyone leaving more agitated, frightened or low than they arrived. Check with them privately and follow the risk route (Section 5).
    It is working when post-session energy or calm ratings are stable or better, people leave without distress, and they return.

Co-facilitator role (format element, not a technique). The co-facilitator joins in all exercises and models participation. They partner members who have no pair, sit beside anyone who is struggling, and step out with someone who needs a break. Afterwards they debrief with the lead therapist. The trials included a co-facilitator but did not give the role in detail. [source: Priebe et al. 2016 HTA; Martin et al. 2016; role detail is synthesis]

5. Handling problems

The published trial reports give only attendance figures and the lack of serious adverse events. They give no protocol for dealing with problems. Everything below is [synthesis] unless a source is cited.

What the trials report [source: Priebe et al. 2016 HTA; Martin et al. 2016]:

  • NESS: median attendance was 11 of 20 sessions (IQR 5–17). 75.7% of participants attended 5 or more sessions.
  • NESS: no serious adverse events related to the intervention.
  • Martin et al.: 30.9% dropped out, mostly because of lack of motivation.

Low motivation and non-attendance (expect this; it is part of what negative symptoms are).

  • Before the course: an individual orientation meeting (4.0) and reminder texts or calls the day before each session.
  • Ask the care coordinator to help with travel.
  • Keep a consistent day, time and venue.
  • After a missed session, send a warm, low-pressure contact ("we missed you; the next group is Thursday"). Never shame people for missing sessions.
  • Let people rejoin at any point. The fixed five-part structure makes it easy to pick up again.
  • After two misses in a row, meet briefly one-to-one about the barriers: sedation, transport, anxiety, voices.

Minimal engagement in session (standing still, blank face, "don't know").

  • Lower the demand: a seated version, hand-only movement, or the observer role.
  • Respond to tiny changes ("I saw your foot keep the beat").
  • Offer forced choices instead of open questions ("heavier or lighter?").
  • Have the co-facilitator partner them.
  • Don't press for verbal disclosure. Movement on its own counts.

Overwhelm, overstimulation or rising psychotic symptoms during a task.

  • Stop or slow the exercise.
  • Return the person (or the group) to grounding: feet, chair, eyes open, look around and name three objects in the room.
  • Lower the volume or turn the music off.
  • Offer a break in a quiet corner with the co-facilitator.
  • Afterwards, check what happened. Share any new or worsening symptoms with the care team that day.
  • If one type of task keeps triggering symptoms (for example, inward focus or face-to-face pair work), drop or adapt it for that person.

Distressing bodily experiences (somatic hallucinations, feeling controlled, feeling unreal or "not my body").

  • Do not explore or interpret the content inside the group.
  • Acknowledge it ("that sounds really unpleasant").
  • Shift attention to external contact and concrete edges (4.3, 4.4).
  • Make sure the person has full control over distance and contact.
  • Review it individually and with the care team.

Röhricht's account of cenesthesias and boundary loss explains why these experiences may come up. [source: Röhricht 2009 for the phenomenology; the response is synthesis]

Suspicion or paranoid ideas about partners, mirroring or touch.

  • Explain every exercise in advance, including exactly who does what.
  • Allow the person to choose their partner or work with the co-facilitator.
  • Don't require eye contact.
  • Keep everything no-touch.
  • If they read the exercise as being mocked, re-state its purpose plainly and offer to swap roles so they lead.

Resistance: "this is childish" or "what's the point".

  • Validate the feeling.
  • Explain the rationale in everyday terms: noticing your body and expressing yourself can make it easier to feel and show emotions and to be with people.
  • Invite them to treat it as an experiment for three sessions.
  • Give them an adult role, such as leading the warm-up or being the observer in the group sculpture.

Ruptures (feeling exposed, laughed at, or pushed too far).

  • Name the moment and take responsibility ("I think I asked too much just then").
  • Ask what would help, and adjust.
  • If needed, repair individually after the session.
  • Within the group, protect members from teasing by stating the norms: no comments on bodies, any participation is valid.

Group conflict, intrusive or disinhibited behaviour, unconsented contact.

  • Stop the exercise.
  • Restate the rules on boundaries and consent.
  • Separate the pair.
  • Speak to the person individually.
  • Exclude someone only after repeated breaches. Agree this with the care team.
  • Sexualised behaviour: end the contact exercise immediately, document it, and review with supervision.

Medication side effects and physical limits (sedation, extrapyramidal rigidity or tremor, akathisia, weight-related discomfort, orthostatic dizziness).

  • Use seated and slower versions and shorter repetitions.
  • Never comment on body size or shape.
  • Liaise with the prescriber if side effects limit participation.

NESS measured extrapyramidal symptoms with the Simpson-Angus Scale. [source: Priebe et al. 2016 HTA, for the measure only]

Body shame, trauma history, gender and culture.

  • Ask before the course about comfort with mixed-gender pairs, music and movement.
  • Allow the person to choose a partner.
  • Avoid exercises that draw attention to the chest or hips.
  • Offer clothing-neutral movements.
  • If trauma memories surface, use grounding and the window of tolerance. Refer for trauma-focused work separately; this group is not the place for processing trauma.

Suicidality, self-harm or acute relapse.

  • Follow your service's standard risk-assessment and escalation procedure the same day.
  • Agree the communication route with the care coordinator before the group starts (4.0).
  • A person in acute relapse may pause and rejoin later.
  • Do not run cathartic or high-arousal work.

Ending and loss of the group.

  • Signal the ending from about session 15.
  • Use the final closing circles for review.
  • Give each member a short personal grounding practice to keep using.
  • Link them to ongoing activity, such as community arts, movement or exercise groups, through the care team.

Therapist competence and drift.

  • Keep the five-part structure every session.
  • Use supervision and fidelity checks. NESS provided at least three 90-minute supervision sessions per group (four in two cases). After every session the therapist completed a session guide sheet to review and plan, and independent body psychotherapists rated four sessions per group (one per quartile, excluding the first and last, only with at least three attendees) on a 10-item adherence scale scoring each core component 0–2 (total 0–20). The scale covers session content and therapist competence and is published as online supplement DS1 to the British Journal of Psychiatry trial paper; its items are not reproduced here [uncertain]. A clinician can adopt the same habits: a short post-session review sheet and occasional peer-observed sessions. [source: Priebe et al. 2016 HTA, methods; the adoption is synthesis]
  • Bring to supervision any urge to add expressive, cathartic or touch-based techniques from other training.

Doubts about effect.

  • Tell clients honestly that this is a supportive, experiential group, not a replacement for medication or psychosocial care.
  • Review each person's goals at sessions 10 and 20.

The NESS trial did not find BPT better than Pilates on negative symptoms. It found only small differences in expressive deficits and movement-disorder scores. [source: Priebe et al. 2016 HTA; Underwood 2016]

Sources

Online sources

Further online sources

Cited works [uncertain: known through the sources above]

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