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Issue: 05 March 2008

The technique of body awareness is helping patients with some of the most intractable problems. Daloni Carlisle looks at the growing popularity of this therapy

What do you do for the patient on whom everyone else has given up? It's a question that Hilary Haynes, lead physiotherapist at St Andrews hospital in Northamptonshire, used to ask herself. Then she found basic body awareness therapy, or BBAT.

Not new but different

Not surprisingly, then, the number of practitioners in the UK is also growing. Perhaps the leader among them is Anne Parker, superintendent physiotherapist at the Royal Edinburgh hospital.

'I came into contact with it by chance,' she says. She had been searching for some time for an evidence base for physiotherapy in mental health and finding very little. One day she did an internet search on two words in her native Norwegian: psychiatry and physiotherapy. 'It was like saying “open sesame”,' she says. 'There was loads of information.' And most of it was about BBAT.

Through a series of coincidences she came into contact with Professor Skjærven and organised the first UK BBAT courses. 'It's a very comprehensive therapy,' she says. 'It's not something you can learn at the drop of a hat. You have to learn it over time. It's the personal input that takes a lot of time, but it is very rewarding. I have never felt so healthy.'

She is hugely enthusiastic but tempers her comments. 'It sounds like I am advocating it for everybody,' she says, 'I am not. For some patients it is much easier to go the way of ordinary exercises because that's how people live. But in specific instances it can be used to retrain people or show them a way back to their own healthy selves. That's how I see it.'

She is anxious not to appear critical either. 'It is something entirely new in physiotherapy. I am not saying people are not looking at the whole person because I think most physiotherapists want to help in that aspect.

'But it is perhaps working with a person's experience and their own resources, and working with yourself alongside so that you are attuned to that person. Then it's something that is different.'

Another BBAT practitioner is Phillipa Beattie, now trained to level three of BBAT's four levels of competency. She works in Vale of Leven hospital overlooking Loch Lomond. She is using BBAT with a broad spectrum of patients, not just those with mental health problems, and finds it very useful for patients who have a psychological basis to their physical problem (see panel: Listen to your body).

'I say, “hang on a minute, what is the block here and how can you overcome it?” What I am really trying to do is help people to understand their own body.'

For Ms Beattie, BBAT's big difference is its lack of goals. 'This is not goal oriented and not goal driven,' she says. 'This is opening a door and saying: “The world is your oyster. Go out and explore”. It is trying to get patients to be non-judgemental and non-anticipatory about what they will find.'

BBAT certainly seems to have touched the people who use it very deeply. All talk about the impact it has had on their practice and all are advocates for its wider adoption. 

'Initially I thought it was a bit pink and fluffy, and I am not that sort of a person. I am bossy and like telling people what to do,' admits Ms Haynes. 'But I have changed the way I practise as a result of learning and experiencing BBAT. I am much more likely to wait and offer suggestions rather than correct people. I am able to allow silences, and hold back and give time.'FL

FURTHER INFO

If you want to know more about BBAT contact Anne Parker, email anne.parker@lpct.scot.nhs.uk or Liv Skjaerven, email liv.helvik.skjerven@hib.no

What is Basic Body Awareness Therapy?

BBAT is an evidence-based physiotherapy method aiming to mobilise a person's resources for health. It does this by guiding them to be present in the here-and-now, while experiencing simple everyday movements in lying, sitting, standing and walking. Touch, massage, relational exercises and use of the voice are also included, while integrating balance, free breathing and awareness is central to this process.

By increasing body awareness and improving quality of movement it is possible

to use one's body more efficiently, have more contact with oneself and one's feelings, set boundaries, have more confidence relating to others and cope more easily with the demands of everyday life.

This approach is not only suitable for people with physical and/or psychological problems, but also for stress management, health promotion and personal development. It can be used in individual or group therapy. The perspective is holistic, considering physical, physiological, psychological and existential aspects of human existence.

Listen to your body

Sarah (not her real name) has been using BBAT since 2004. She has a chronic fatigue syndrome and says: 'I wanted not so much rehabilitation as a method to keep up my current ability.' She had no energy to exercise and her muscles were wasting away. She was referred to Phillipa Beattie who taught her to understand and listen to her own body.

Sarah explains: 'I did a lot of work on my core stability, sitting on the edge of a chair and doing some movements to find my core.' She also learnt gentle t'ai chi exercises to keep up her arm strength. 'It's made me a lot more aware of myself and given me a sense of when I am going to faint. That makes it easier to deal with and I don't panic about it now.

'I keep up the exercises and I am  able to do things like get a cup out of a cupboard above my head. I am more confident in understanding my own illness and my own body.'

Her client group at the private psychiatric hospital includes young people with learning disabilities, challenging behaviour, attention deficit hyperactivity disorder and dyspraxia. 'These are very, very difficult and disturbed young people,' she says. 'They have had appalling social histories, family breakdown, trouble with the police and they are totally unmanageable. We only get them when everybody else has given up.'

Ms Haynes works as part of a multi-disciplinary team in a programme designed to give the young people a structured environment and help them develop the skills that are so badly missing - social skills and self-help skills such as getting dressed in the morning.

As a physio she concentrates on developing their physical skills. 'Many of them are very clumsy and have poor body posture,' she says. 'They have poor body awareness and do not know where their hands are in relation to the rest of their body, for example.'

But she found she had very little in the way of an evidence-based, structured approach to offer - that is, until she read a small article in Frontline about BBAT, a physiotherapy technique that is widely used in Scandinavia but relatively unknown here.

'The article said how wonderful it was for patients with chronic schizophrenia, and I thought it had to be worth a try,' says Ms Haynes. She enrolled on a course in the UK and hasn't looked back since. She is now enrolled on a masters course at Bergen University College in Norway.

BBAT, she says, helps give people a basic awareness of their body and how they use it, and can change that awareness to help them gain control of themselves and their lives. 'We are usually running on autopilot,' she explains. 'Our mind is somewhere else - deadlines, children, work. By focusing on your body and your breathing you have to be in the present, here and now. That's very calming for people with depression, anxiety and ADHD.'

BBAT, she says, is a structured, evidence-based approach that incorporates assessment alongside intervention. Becoming a practitioner involves a comprehensive course of study that requires students to practise BBAT themselves and also to teach the techniques to the next group of students. 'With BBAT you start from where the patient is,' explains Ms Haynes. 'You try to lead them and get them to a better way of moving, concentrating on the quality of movement and trying to look at the body as a whole rather than the shoulder or the knee.'

Doing this might involve massage, t'ai chi movements, using the voice or simply experiencing everyday movements such as standing, sitting or lying down. For example, Ms Haynes is working with one very disturbed young man who asked to have two carers holding his arms to stop him lashing out at passers-by. She is doing push-pull partner exercises with him. 'I get him to think we can do this hard or soft, we can cooperate. It gives him the idea he has control over his own arms.'

Another young woman has such severe and long-standing depression and is so accustomed to sitting with her neck hunched that she can no longer hold her head up. Some days all she can manage is to allow Ms Haynes to massage her shoulders as she huddles beneath her duvet.

Admittedly, Ms Haynes's client group is an unusual one, even for BBAT. Most practitioners are using the therapy with people with mental health problems  however, including schizophrenia, depression and eating disorders. It is also used with people who have long-lasting pain and/or have been sexually abused, and these are the areas where it is most used in Scandinavia and other parts of mainland Europe.

Ms Haynes is under the tutelage of associate professor and physiotherapist Liv Skjærven, who set up the University College Bergen masters course in basic body awareness management in 2003. She did this partly to develop the evidence base but also to ensure that the technique had a rigorous quality assurance behind it. She has also worked with physios across Europe and the US, running workshops and seminars.

Professor Skjærven explains: 'What I saw coming to my courses in the UK were physiotherapists who were highly qualified in t'ai chi or yoga but were worried that this was not officially a therapeutic modality. In BBAT we have an assessment tool that makes us able to evaluate the use of these techniques.'

The evidence base is strong and growing, she maintains. There are a few randomised controlled trials that have found it to be beneficial, and a multitude of case studies. Its attraction is not just the evidence base, however. 'I think a lot of physios like it because it offers personal growth too. People use it to develop themselves,' says Professor Skjærven.