Content uploaded by Margit Koemeda-Lutz
Author content
All content in this area was uploaded by Margit Koemeda-Lutz on Apr 07, 2014
Content may be subject to copyright.
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
113
Evaluation of the Effectiveness of
Body Psychotherapy in Outpatient
Settings (EEBP):
A Multi-Centre Study in Germany & Switzerland
Margit Koemeda-Lutz, Martin Kaschke, Dirk Revenstorf,
Thomas Scherrmann, Halko Weiss and Ulrich Soeder
Editor’s note: This study, done my members of the European Association for Body Psychotherapy (EABP), including Hakomi Therapists, is
the first major empirical research done that demonstrates the efficacy of body-psychotherapy methods. It was first published in German in the
Psychother Psych Med Psychosom 2006 (56) 480-487, is translated here into English by the EAPB, and is used with permission.
The references remain in European format, as opposed to APA style.
Martin Kaschke, Dipl.Psych., Dipl.Biol.; Hakomi-therapist; university studies and professional training at Heidelberg. Works as a
psychotherapist in a psychiatric and psychotherapeutic day clinic: Tagesklinik für Psychiatrie und Psychotherapie, Erbach, Odenwald. EWAK
coordinator in Germany. Doctoral thesis on disorder-specific applications of body psychotherapy (work in progress).
Margit Koemeda-Lutz, Dr.rer.soc., Dipl.Psych., graduated from Konstanz University, major in psychology. 1978-1985: worked with a
neuropsychological research group at the university of Konstanz. 1981-2000: founding and executive member of the annual psychotherapy
conference “Breitensteiner Psychotherapiewochen”. 1994-2001: served in the executive committee of the Swiss Society for Bioenergetic
Analysis and Therapy, SGBAT. Licensed psychotherapist SPV in free practice at Zürich and Ermatingen. Faculty member SGBAT and IIBA.
Coordinating trainer in Switzerland. Serves presently in the scientific committee of the Schweizer Charta für Psychotherapie. 2004-2007:
editor of “Bioenergetic Analysis – The Clinical Journal of the IIBA”. www.sgbat.ch und www.koemeda.ch
Dirk Revenstorf, Prof. em. Dr. rer. soc., Dipl.-Psych., graduated from Hamburg University, major in psychology; personality and
psychotherapy research at the Max-Planck-Institut for psychiatry at München and at the university of Konstanz. Professor for clinical
psychology at the university of Tübingen and at the Universidad de las Americas Puebla (Mexico). From 1984 chair of the Milton Erickson
Society (Germany). Psychotherapy training in: Behaviour Therapy, Gestalt, Hypnotherapy, Body psychotherapy; Study focusses: theory of
personality; methodology of research; psychotherapy research, behaviour therapy, hypnosis, couple therapy, psychotherapy training.
www.meg-tuebingen.de
Thomas Scherrmann, Dr. rer. soc., psychologist, psychotherapist, doctoral thesis on “Coping Processes in Families of Schizophrenic
Patients”. Director of research projects and trainings for family members dismayed by endogenous psychosis. Research on mindfulness as a
basic principle and effective factor in psychotherapy. Contract partner of the German health insurance system for behaviour therapy and
clinical hypnosis; certified Hakomi therapist; licensed psychotherapist and Shiatsu therapist in free practice in Tübingen; independent
researcher.
Ulrich Soeder, Dipl.-Psych., graduated from Heidelberg University, major in psychology, Hakomi-therapist. 1996 to 2002 member of a
research group at the Technical University of Dresden with the following focusses: epidemiology, research on mental health care systems;
prevention of back pain and evaluation of programmes 1996 – 2002; from 2002 body psychotherapist in free practice, trainer and coach;
www.secondview-consulting.com.
Halko Weiss, Ph. D., Dipl.Psych., graduated from Hamburg University, major in psychology. Psychologist, psychotherapist; founding
member and senior trainer of the Hakomi Institute, Inc., in Boulder, Colorado. International Director of the Hakomi Institute of Europe, e.V.,
at Heidelberg. Psychotherapist in free practice and in several institutions; trainer for industrial leaders; trainer for body psychotherapy in
Europe, North America, New Zealand and Australia. www.hakomiinstitute.com und www.hakomi.de
Address for correspondence: Dr. Margit Koemeda, Fruthwilerstraße 70, CH 8272 Ermatingen. e-mail: koemeda@bluewin.ch For more
detailed information about this study, additional results and graphs please see our online publication (in German): www.thieme.de/ppmp or
www.thieme-connect.de.
ABSTRACT: The following are results from a multi-site process and outcome study of body psychotherapies. The design is
naturalistic and evaluates the effectiveness of body psychotherapy treatments in outpatient settings. Three German and 5 Swiss
member institutes from the European Association for Body Psychotherapy (EABP: 38 members) participated. The Swiss
institutes were also members of the Schweizer Charta für Psychotherapie. Well established questionnaires (e.g. BAI, BDI, SCL-
90-R, IIP-D) were administered at three points of measurement (at intake, after 6 months and at the end of therapy (after two years
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
114
at maximum). Follow-up data were collected at 1 year after termination of therapy (n = 42). Patients who sought body
psychotherapeutic treatment (n = 342 participated in the study) did not differ from other outpatient psychotherapeutic patients
regarding sociodemographic data, level of impairment and psychopathology. After six months of therapy (n = 253) patients
showed significant improvement with small to moderate effect sizes. At the end of therapy or after two years of treatment at
maximum (n = 160) a large effect was attained on all scales. These are lasting results according to follow-up data (n = 42). This
naturalistic prospective field study provides evidence for the effectiveness of the evaluated body psychotherapy methods and to
classify as phase IV- (“routine application”) and level I-evidence.
Key words: Psychotherapy research, body psychotherapy, effectiveness, outcome, naturalistic design.
Introduction
Up until recently, there has been little quantitative research
on body psychotherapies, although professionals trained in
this modality considerably contribute to in- and out-patient
psychiatric and psychotherapeutic health care [22, 23, 31].
Meanwhile several models exist for systematizing and
historically locating body psychotherapeutic approaches
[e.g. 39-46]. A recently published handbook [33] illustrates
how body psychotherapies developed in relation to
psychodynamic approaches and elaborates several aspects
of body psychotherapeutic theory and treatment techniques.
The European Association for Body Psychotherapy
publishes definitions of shared basic concepts on its
Website [47], which continue to be refined via an ongoing
process of communication among the proponents of its
member institutes.
Some of the basic body psychotherapeutic assumptions
include the following (note that this is only a selection):
1) The body is an indispensable component of human
existence and should therefore be explicitly
addressed in psychotherapeutic treatments
2) Psychic and somatic processes evolve in a parallel
manner over time. These processes interact and
can be observed, examined and influenced from
different system levels.
3) From a developmental point of view an extended
phase of non-verbal communication precedes
verbal communication – ontogenetically as well
as phylogenetically.
4) In adult life information processing and
communication mediated by cognition or speech
only constitute a subset of all processes involved.
5) Memories as well as unconscious material can to
some extent be triggered and moved to
consciousness by affective, motor or sensory
stimulation.
6) Vitality and health consist not only of a clear mind,
but are also based on well-balanced and well-
regulated physiological and emotional
functioning.
7) Body psychotherapy techniques are characterized
by incorporating a) nonverbal interventions, b)
behavioural interactions c) physical contact d)
diagnostics that also consider non-verbal (i.e.
visual) information and e) psychosomatically
defined goals in therapy.
Earlier studies on body psychotherapies were based on
retrospectively collected data [32, 34, 38]. This study
prospectively examined the effectiveness of body
psychotherapeutic treatment in outpatient settings in
Germany and Switzerland using a naturalistic design.
According to the rules of research in medical or natural
sciences [48, 49], this study can be assigned to phase IV,
i.e. an evaluation of “routine applications” in practice.
Following Rudolf [50] it can be attributed to the phase of
“applied psychotherapy research” and claims in this
context of naturalistic field studies an evidence rating of
level I [51]. Data about symptoms and patients’ well-being
were collected at several points in time (at intake, after 6
months of therapy, at the end of therapy (after 2 years of
therapy at maximum) and at a 1-year follow-up). This
research was initiated in January 1998 by the Hakomi
Institute of Europe. First results were presented at the 7
th
European Convention for Body psychotherapy at
Travemünde, Germany [33]. Eventually the study
expanded to multiple sites (Dresden, Heidelberg, Tübingen,
Zürich). Preliminary results were published in 2003 [36,
37]. In 2005 the study was awarded the USABP research
prize. Only patients who had body psychotherapeutic
treatment in outpatient settings were included in the study.
Therapists from the following schools participated (in order
of joining the project; names of foundation presidents
(international and national), and references concerning
theoretical concepts and treatment techniques in brackets):
Hakomi Experiential Psychology (Ron Kurtz, Halko
Weiss; [54]); Unitive Psychology (Jacob Stattmann, Gustl
Marlock; [55]); Biodynamic Psychology (Gerda Boyesen;
[56]) – in Germany – and Bioenergetic Analysis SGBAT
(Alexander Lowen; Thomas Ehrensperger; [57, 58]);
Client-Centred Verbal and Body Psychotherapy GFK
(Christiane Geiser; Ernst Juchli; [59]); Institute for
Integrative Body Psychotherapy IBP (Jack Lee Rosenberg;
Markus Fischer; [60]); Swiss Institute for Body-Oriented
Psychotherapy SIKOP (George Downing; [61]);
International Institute for Biosynthesis IIBS (David
Boadella; [62]) – in Switzerland.
The following questions guided our study, which
completed its data collection by the end of 2005:
1) What kind of patients seek and request outpatient
body psychotherapy?
2) How much do patients improve on the following
variables: psychopathological and psychosomatic
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
115
symptoms, interpersonal problems, and
expectations of self efficacy during treatment?
3) Can these results be maintained for a one-year
period following the termination of treatment?
4) To what extent do patients’ and their therapists’
perspectives on the psychotherapy correspond?
Methods
Sample and Procedure
Eight institutes of the European Association for Body
Psychotherapy [47] participated in this study. The Swiss
institutes (N = 5) were also members of the Swiss Charter
for Psychotherapy [63]. The selection of institutes was not
systematic. The EABP represents 12 professional societies
in Switzerland [64] and 16 in Germany [65]. Each institute
taking part in the study designated one research coordinator
who was in charge of organizing data collection. All
certified members of the participating institutes who had
completed a full training and worked in outpatient settings
were invited to take part in the study. The participating
therapists agreed to apply the method taught in their
institutes. They were asked to attempt to recruit every
patient who took up treatment within a previously defined
period of time and document demographic data, symptoms
and preliminary diagnoses including patients who would
not participate. All patients were informed about the study
and given the information that their participation was
voluntary. Participants read, signed and gave their
informed consent to therapists. For reasons of anonymity
this written consent remained with the therapists.
Anonymity was ensured by using a self-generated code
consisting of 6 letters.
Data collection occurred at intake, after 6 months, and at
the end of therapy (at the latest 24 months after intake).
There was also a follow-up one year after the end of
therapy.
The participating institutes entered the study at different
points in time. Therefore data collection was extended over
several years (1998-2005).
Questionnaires
For data collection well-established and standardized
questionnaires were used, in order to increase
comparability with other studies [68, 69]. From a body
psychotherapeutic point of view these instruments can be
regarded as non-specific.
Demographic information was gathered according to the
"Deutsche Standarddemographie" (German standard
demography) [70]. Therapists carried out diagnostic
assessments according to ICD-10 [71] within the first three
sessions. Symptoms of psychopathology were measured
using the "Beck Angst Inventar" (Beck Anxiety Inventory,
BAI: [72]), “Beck Depressions Inventar” (Beck Depression
Inventory, BDI: [73]) and the “Symptom Check List”
(SCL-90-R [74, 75]). Physical discomfort was measured
using the "Beschwerdenliste" (List of Psychosomatic
Complaints, BL: [76, 77]) and interpersonal problems
measured by applying the „Inventar zur Erfassung
interpersonaler Probleme” (Inventory of Interpersonal
Problems, IIP-D: [78, 79]). In addition, the general
"Selbstwirksamkeitserwartung" (expected self-efficacy,
SWE: [80, 81]) was measured. Patients were also asked to
judge global life changes that occurred since they began
therapy in important domains (work, leisure time, family
life, domestic duties, somatic well-being). Patients had
approximately one hour to fill in all questionnaires.
Therapists gave information about the formal state of the
therapy and also judged global changes in the above-
mentioned areas of their patients´ lives.
The average changes over time were analysed using
multifactorial analyses of variance (factor „institute“ =
membership of therapists; repeated measurement factor
„duration of therapy“ = different points of measurement).
In addition effect sizes according to McGaw und Glass [82]
were computed. According to Cohen [83] they were
categorized as small (0.2 – 0.5), medium (0.5 – 0.8) and
large (> 0.8).
Results
A description of the characteristics of patients treated with
body psychotherapy will be followed by a description of
the process and outcome results of their therapies.
Altogether 124 therapists (between 8 and 22 per institute,
on average 16) and 342 patients (between 17 und 58 per
institute, on average 43) participated. Therapists had 1 – 14
patients, on average 3, included in the study. The
participating therapists had the following basic professions:
In Switzerland 25% were medical doctors, 54%
psychologists and 21% had other basic professions. In
Germany 13% were medical doctors, 21% psychologists
and 43% had other basic professions; in Germany 23% of
the data on therapists’ basic professions were missing.
Outpatient Body Psychotherapists’ Clients
At intake 342 clients with an age range between 18 and 64
years (median 37 years) were examined. 73% of the clients
were female. 36% were married, 52% single and 12%
divorced. 60% had a partnership and 43% had children, on
average 2. The highest educational level was for 31%
graduation from high school („Abitur“). 28% had
graduated from a college or university. 41% had no more
than ten years of school (“mittlere Reife”) or had
completed vocational training. 59% of the clients in this
study had had previous psychotherapeutic treatment.
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
116
Treatment costs were totally reimbursed by insurance
companies for 33% of the clients, partially for 29% of the
clients, 28% had no reimbursement at all, 10% did not
answer this question. Demographic data of the participating
patients tended to vary within the ranges known from other
studies of outpatient psychotherapy [23, 32, 34, 84, 85].
Diagnostic assessments were carried out by therapists at
intake according to ICD-10 criteria [71]. In 79% of the
cases patients were only assigned to one primary diagnostic
category, while 21% therapists diagnosed comorbidities.
Primary diagnoses were combined into larger categories.
These catagories were 41.2% neurotic stress and
somatoformic disorders (F4), 28.9% affective disorders
(F3) and 12.9% personality and behavioural disorders (F6).
F5, F1 and F2 ranked only with 8.2%, 1.5% and 0.3%
respectively. Z-Codes were assigned in 7.3% of the cases.
According to the questionnaires used in this study, patients
were described as follows: 40.6% (self efficacy) and 88%
(psychosomatic complaints) revealed clinically significant
impairments at intake. In all measures taken, the
participating patients significantly differed from normal
controls (4.26 < t < 29.55; p < 0.0001). Figure 1 shows the
SCL-90-profile at intake and figure 2 shows the IIP-D-
profile.
Figure 1: Subscale means and global severity index (SCL-90-R) of body psychotherapy patients at intake, after 6 months and at
the end of therapy (after 2 years at maximum) as compared to normal controls and hospitalized psychiatric patients at intake.
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
117
Figure 2: Subscale means IIP-D of body psychotherapy patients at intake, after 6 months and at the end of therapy (after 2 years
at maximum).
Process description
Although follow-up data is continuing to be collected and
analyzed, (s. [89]), the data reported in this article was
collected through the end of 2005. Data from 253 cases
after 6 months of therapy was analyzed, as was data from
160 cases at termination of treatment (or after 2 years of
therapy at maximum). In addition data from 42 cases at a 1
year follow-up was analyzed. During the last quarter of
2005 all participating therapists were once again contacted
and asked about the process of all therapies involved in the
research. Fifty-eight percent of the participating therapists
answered. This covered 199 out of 342 patients. Forty-three
percent of these cases had ended their therapy in a way that
was mutually agreed upon by both patient and therapist.
Twenty-six percent had ended their treatment prematurely
from the therapists’ point of view (for a variety of external
reasons: change of residence, financial shortcomings, death
or internal reasons: lack of motivation to continue therapy).
In 54.9% of therapies which ended in a mutually agreed
upon termination, treatment had lasted less than 2 years.
For the remaining cases measurement after two years was
intermittent.
Since not all questionnaires were completed, there are
varying numbers of cases for varying questionnaires.
Completed therapies (n = 84) lasted 24 months on average
(sd=14.8) and took 52.8 sessions (sd= 42.7; median =
42.5). Eleven percent out of these patients received
medication in addition to psychotherapeutic treatment.
Prematurely terminated therapies (n = 53) lasted 10 months
on average (sd=7.7; median = 8) and took 26.3 sessions
(sd=21.2; median = 21). Twenty-four percent of these
patients had received medication. Therapies not terminated
before December 2005 (n = 62) had lasted 6 - 7 years
(1.6%), 4 – 5 years (8.2%), 3 – 4 years (14.8%) or 2 – 3
years (75.4%). No intake measurements were carried out
later than December 2003. These ongoing treatments had
taken 105 sessions on average until December 2005
(SD=59.2; median = 89.5). Twenty-eight percent of these
patients received psychotropic medication.
A comparison of intake data from the four subsamples
(complete data sets at intake, after 6 months of therapy, at
termination (or 2 years of therapy at maximum) and
follow-up) resulted in no statistically significant bias by
selection (drop-outs). Chi
2
-tests were carried out for level
of education and sex (0.01 < Chi
2
< 2.28; 0.32 < p < 0.94;
exception: complete data sets at follow-up were received
from patients with a higher level of education: (Chi
2
=
15.91; p = 0.0004)). Two-tailed t-tests were carried out for
age and all questionnaires (0.29 < t < 1.9; 0.06 < p < 0.78).
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
118
Group Changes
Treatment modality had no
significant influence on
therapy processes (0.32 <
F
Inst
(7; 140) < 2.37; 0.06 < p
< 0.94; 0.26 < F
Inst*Zeit
(14;
280) < 1.89; 0.14 < p <
0.95; exception: IIP-D:
F
Inst*Zeit
(14; 280) = 1.89; p =
0.03; Unitive Psychology
therapists proved to
demonstrate a maximum
level of change in their
patients: mean at intake =
1.83; mean at termination
(or after 2 years) = 0.93).
However, the influence of
therapy duration was highly
significant in all cases
(17.07 < F
Zeit
< 72.28; p <
0.0001; s. fig. 3).
Analyses of variance were used to analyze the comparison of measures at termination and follow-up (treatments that lasted
longer than 6 months were included) and proved that therapy results were stable. The data revealed that even some mild
improvements could be observed (0 < F
Zeit
< 2.88; 0.1 < p < 0.97; BL: F
Zeit
= 2.88; p < 0.01).
Changes of Impairment with Increasing Duration of Therapy
Figure 3: Manovas: Comparison of means at intake, after 6 months and at the end of therapy (after 2 years at maximum); 17.07 <
F
Therapiedauer
2;143) < 72.57; p < 0.001; IIP: Inventory fort he Inquiry of Interpersonal Problems – Global Score, SCL-GSI:
Symptom Check List – Global Severity Index, BAI: Beck Anxiety Inventory, BDI: Beck Depression Inventory, BL: List of
Psychosomatic Complaints and SWE: Selbstwirksamkeitserwartung (Expectation of Self Efficacy). (+) For reasons of perspicuity
SCL-90-R-GSI scores were multiplied by 10 and IIP-D-global scores by 8.
Within the first 6 months of therapy an average of 21
sessions (SD = 9.04) were utilized. 253 cases were
included in this analysis. Anxiety (BAI), depression (BDI),
overall impairment by symptoms (SCL-90), somatic
complaints (BL) and interpersonal problems (IIP-D)
significantly decreased during this period of time.
Concomitantly, the expected self efficacy (SWE) increased
significantly (see fig. 3; *** = p < 0.0001).
For the comparison of measures at intake and at the
termination of treatment (2 years after intake at most) 160
cases were included. An average of 58 sessions was
utilized during this period of time.
Improvement in all scales was more pronounced than after
6 months of therapy. Again anxiety, depression, overall
symptoms, somatic complaints and interpersonal problems
decreased significantly. The expected self efficacy,
likewise, increased significantly (see fig. 3; *** = p <
0.0001).
Effect sizes for changes between intake and 6 months, as
well as between intake and termination (2 years at
maximum) are presented in figure 4. Within the first 6
months of therapy small to medium changes occurred in all
measures. Before the end of therapy (after 2 years of
therapy at maximum) the effect sizes for all scales (except
expected self efficacy: d = 0.41) were large and ranged
between 0.80 und 0.96.
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
119
Effect Sizes after 6 Months of Therapy and after 2 Years at Maximum
Figure 4: Effect sizes after 6 months and after 2 years of therapy at maximum (as compared to intake): small (0.2 – 0.5), medium
(0.5 – 0.8) and large (> 0.8). IIP-Ges: Inventory for the Inquiry of Interpersonal Problems – Global Index, SCL-GSI: Symptom
Check List – Global Severity Index, BAI: Beck Anxiety Inventory, BDI: Beck-Depression-Inventory, BL: Beschwerdenliste (List
of Psychosomatic Complaints) and SWE: Selbstwirksamkeitserwartung (Expectation of Self Efficacy).
Individual Changes
In addition to group changes, individual changes
concerning BAI, BDI, BL, IIP-D and SCL-90 scores will
be reported here. These analyses include, according to each
point of measurement, data from 253, 160 and. 42 patients
respectively.
Frequencies of clinically relevant symptoms of anxiety
(BAI > 11) decreased from 70% at intake to 53% after 6
months to 41% at termination (or after 2 years) and 38% at
follow-up. Frequencies of clinically relevant symptoms of
depression (BDI > 18) decreased from 35% at intake to
17% after 6 months to 5.8% at termination (or after 2
years) and amounted to 19% at follow-up. Mildly increased
scores (11 < BDI < 17) at intake decreased from 34% to
17% after 2 years and to 14% at follow-up. Seventy-seven
percent of all patients scored within the normal range (BDI
< 10) at the end of their therapy (or after 2 years of
treatment), 68% at follow-up. At intake 88% had
psychosomatic complaints deviating from average scores of
healthy subjects (mean=14.3, sd=10.8), 23% after 6
months; 34% at the end of or after 2 years of therapy and
46% at our follow-up survey. Concerning interpersonal
problems 29% at intake, 23% after 6 months, 10% at
termination (or after 2 years) and 8% at follow-up had
deviant scores (stanines > 7).
Cut-off scores as well as critical differences have been
published for the SCL-90-R scale. Therefore, statistically
and clinically relevant changes can be differentiated for
single cases [90, 91]. Following Franke [75], a GSI-raw
score of 0.3 for psychotherapy patients was assessed as a
critical difference. Gender specific cut-off scores are 0.57
for men and 0.77 for women. Within 2 years 41% of the
patients improved to the degree that their amount of
symptomatic impairment compared to that of normal
controls. More than half of all patients (57%) achieved
some statistically significant improvement.
Concerning the list of psychosomatic complaints as well as
the anxiety inventory, patients who were still in treatment
after two years tended to have been more severely impaired
at intake (p = 0.06).
Global Measures of Impairment – A
Comparison of Perspectives
In four domains (1. profession and education, 2. leisure
time and social activities, 3. family life and domestic
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
120
duties, and 4. somatic well-being) ratings of therapists and
patients were collected at all four points of measurement
(scales ranged from 0 = none to 8 = maximum
impairment). In addition ratings of perceived changes were
collected after 6 months and after 2 years of therapy (1 =
much better to 7 = much worse). Both groups consistently
stated across all domains a continuous decrease of
impairment with increasing duration of treatment (main
factor duration of therapy: 2.16 < F
time
(2; 104) < 147.65;
0.0001 < p < 0.12). On average patients and therapists both
were in concordance regarding the perceived changes.
Interestingly, the therapists’ assessment of impairment was
significantly more negative than the patients’ at intake and
still after 6 months of treatment (main factor perspective:
0.96 < F
perspective
(1; 105) < 13.98; 0.0003 < p < 0.33). After
2 years this trend was inverted (interaction duration of
therapy * perspective: 6.52 < F
(2; 104) < 15.93; 0.0001 <
p < 0.01). Pairwise correlations of patients’ and therapists’
ratings range (at intake, after 6 months and after 2 years)
between r = 0.37 and r = 0.45 (p < 0.0001) for profession
and education, between r = 0.33 and r = 0.54 (p < 0.0001)
for leisure time and social activities, between r = 0.13 (p =
0.01 at intake) und r = 0.46 (p < 0.0001) for family life and
domestic duties and between r = 0.32 and r = 0.41 (p <
0.0001) for somatic well-being. Correlations for perceived
changes are r = 0.50 after 6 months of treatment and r =
0.47 (p < 0.0001) at the end of therapy (or after 2 years).
Discussion
The present study documents representative aspects of the
contribution of body psychotherapists to outpatient
psychiatric-psychotherapeutic care in Germany and
Switzerland. It also contributes to quality assessment and
management in this field. It examines body
psychotherapies in the natural environment of outpatient
settings.
Many studies of the efficacy of outpatient psychotherapy
have been conducted in university settings. The advantages
of high internal validity achieved by previously defined
treatment protocols, selected samples and highly elaborated
evaluation procedures are opposed by low ecological
validity [52, 53]. Therefore, comparatively little is known
about the effectiveness of psychotherapy outside inpatient
or university settings (phase IV [48, 49], „application-
oriented psychotherapy research“ [50], level-I-field-
research studies [51]). This study attempts to help fill this
gap.
Prospective data are reported here for the first time, as
opposed to other studies evaluating body psychotherapy
that only used retrospectively collected data [32, 34, 38].
So far, body psychotherapy schools have kept their
distance from academic research. However, the increasing
pressure on all treatment modalities to prove their
effectiveness in recent years has made possible an outcome
study like the present one.
A multi-site focused study of the efficacy of (body)
psychotherapy under natural conditions demands high
organisational capability, as well as patience and endurance
from all participants. When standardized measurements of
efficacy are not an integral part of therapy, the extra
amount of time spent on the evaluation is considerable.
Since participation in the study was voluntary, it became
obvious that therapists were reluctant to have their practical
work scientifically evaluated. Furthermore, motivation was
a problem, since the therapists volunteered and their work
on this research project was not remunerated. With this in
the background, data collection, which started in January
1998, proceeded rather slowly. Considerable decreases in
case numbers from intake to termination of therapy
presumably are due to this lack of evaluation follow-
through not only from patients but also from the
participating therapists.
The idea to include a "waiting-list" control group (as
originally intended) was dropped, partly for practical
reasons (body psychotherapists are rarely in a position to
make waiting lists) and partly for ethical reasons (people
seeking therapy should be offered treatment as quickly as
possible with referrals to colleagues if necessary). Also,
several evaluation studies of other modalities currently
exist, so that the research results can be compared to them.
Diagnoses and symptom profiles of outpatient body
psychotherapy patients at intake are typical of and
comparable to outpatient psychotherapy clients in general;
their educational level is higher than that of the normal
population [92]. A considerable percentage of the patients
examined exhibits comorbidities. Apart from a relatively
high number of Z-codes (7.3%), a similar profile of
diagnoses was found in the present study (F4 > F3 > F6) as
in two other studies that examined patients in outpatient
settings and included different modalities [80, 26].
Furthermore this was true for a recently published meta-
analysis carried out at the university of Dresden which
included over 150’000 patients [93, 94], according to
which F4-diagnoses held by far the highest, F3-diagnoses
the second highest rank of psychopathological disorders in
Europe. A more detailed analysis of the diagnostic data in
relation to outcome measures will be carried out by
Kaschke [89].
The relative frequency of Z-code assignments for the
classification of problems presented could be related to the
requirement that the reported diagnoses were to be made
within the first 3 sessions. Patients possibly speak more
easily about external factors influencing their lives, at the
beginning of therapy. Another reason might be that a
significant percentage of the cases were not reimbursed by
health insurance companies and, therefore, a diagnosis
"proving illness" was not necessary. Nevertheless, the
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
121
symptom profiles still exhibited a high proportion of
clinically relevant impairment at the beginning of therapy.
Statistical analysis demonstrates that with increasing
duration of treatment, the effectiveness of outpatient body
psychotherapy increases. Statistically significant treatment
effects are not only found on a group level, but clinically
relevant reduction of impairment and complaints can also
be demonstrated on an individual level. Within the first 6
months of treatment, significant improvement was
achieved and became markedly stronger toward the end of
therapy. Apart from a reduction of symptoms in mental,
somatic, and interpersonal areas, the increase of expected
self-efficacy was remarkable. Self-efficacy is considered to
be an important resource in handling stress and emotional
problems. It is also regarded as a stable personality
dimension [80]. The within group effect for the expected
self-efficacy at the end of therapy was markedly lower than
the within group effect for the total score of the symptom
checklist (d(SWE) = 0.41 vs. d(SCL) = 0.96). Nevertheless,
it is of high practical value, since it represents a change on
a personality dimension. This suggests that body
psychotherapy not only reduces symptoms but also gives
impetus for positive personality development. The results
for interpersonal problems demonstrate that positive
changes in interpersonal areas begin to occur during the
course of therapy.
Most outcome measures from the end of therapy remained
stable until the 1-year-follow-up measurement.
Results from the comparison of perspectives concerning
global impairment in several areas of patients’ lives
demonstrate that patients’ and therapists’ assessments
correspond but are not totally congruent. A comparison of
means may reflect a somewhat overprotective attitude on
the therapists’ side at intake (they tend to overestimate the
severity of patients’ impairment as compared to patients).
Toward the end of therapy the therapists’ stance changes
and could be interpreted as cajoling patients into autonomy
(therapists may underestimate the severity of impairment in
contrast to their patients). Correlation coefficients show
that individual therapist-patient couples’ ratings are far
from being totally consistent. This may be one of the
sources from which psychotherapies generate their
necessary dynamics.
Internally consistent treatment concepts and techniques for
the examined treatment modalities do exist [54-62], but
they lack carefully detailed disorder-based treatment
routines. Therefore, consistent with our naturalistic design,
we had to base our assignment of therapists to the different
body psychotherapeutic modalities on their membership in
the above-mentioned institutes and on their self-
declarations as to which modality they applied. There were
no significant differences in effectiveness between the
eight body psychotherapeutic modalities. This corresponds
to the results of meta-analyses comparing different
modalities [3, 4], in which the specific applied methods
only explain a very small amount of outcome variance.
Only in the domain of interpersonal problems was there a
high proportion of patients with higher than average scores
at intake requesting therapy from Unitive Psychology-
therapists, who in the process of therapy achieved a greater
than average decrease in these scores.
Statistical analyses revealed that fully documented cases (4
measurements) did not differ from partially documented
cases (3 or less measurements) according to their scores in
all questionnaires at intake. Cases in which we have
measurements after 6 months of therapy may be considered
representative for the total sample of clients examined at
intake. Those who stayed in treatment up to 2 years,
exhibited slightly higher anxiety scores and psychosomatic
complaints at intake. Follow-up data also come from a
subsample which may be considered representative for the
total sample examined at intake (with the exception that
they had a significantly higher education). A higher
percentage of patients, whose therapy lasted longer than 2
years (28%), and of those whose treatment prematurely
ended (24%), received medication in addition to
psychotherapeutic treatment – as compared to patients
whose treatment ended in a mutually agreed upon
termination, on average after 2 years (11%).
Not all examined patients attained clinically relevant scores
on all measured variables at intake. Therefore the category
“unchanged” also includes subjects who were not impaired
to a clinically relevant degree at intake. Out of the follow-
up group of examined patients, 62% did not exhibit raised
symptoms of anxiety, 81% had no clinically relevant scores
of depression, 54% did not differ from healthy controls
concerning psychosomatic complaints, 92% exhibited no
interpersonal problems and 41% had no psychopathological
symptoms at follow-up, which was 1 year after their
therapy had ended.
Prospect
More collaboration between professional researchers and
practicing psychotherapists is desirable, and the dialogue
among the different therapeutic modalities should be
substantially increased. For body psychotherapy schools,
this study demonstrates that a comparative evaluation using
standardized instruments of therapy research need not be
feared. Prospectively, the important task of formulating
specific therapeutic goals and developing suitable
measuring instruments remains important. If these were
developed, the indices for efficacy discussed here could be
supplemented by indices that are specific to body
psychotherapy. In addition, disorder-specific interventions
could be operationally defined and their efficacy could then
be investigated. The results from this study demonstrate
that body psychotherapeutic approaches can claim an equal
stature in mental health care.
Koemeda-Lutz, Kaschke, Revenstorf, Scherrmann, Weiss, & Soeder
_____________________________________________________________________________________
Hakomi Forum – Issue 19-20-21, Summer 2008
122
Conclusion
Patients who seek body psychotherapy treatment match
clients of other outpatient facilities as to demographic
variables, symptoms, complaints and severity of
impairment.
The efficacy of body psychotherapy treatments could be
demonstrated in several domains (anxiety, depression,
other psychopathological symptoms, interpersonal
problems and psychosomatic complaints). Significant
improvement occurred after six months. The longer the
treatment, the more the improvement. The effect sizes for
treatments that lasted up to 2 years were > .80.
References
01
Lambert M J & Bergin A E. The effectiveness of
psychotherapy. Pp 143-189 in: Bergin A E, Garfield S L
(eds). Handbook of Psychotherapy and Behaviour Change,
4
th
edition. New York: Wiley, 1994
02
Tschuschke V, Kächele H, Hölzer M. Gibt es
unterschiedlich effektive Formen von Psychotherapie? In:
Psychotherapeut 1994; 39: 281-297
03
Wampold B E. The great Psychotherapy Debate. Models,
Methods, and Findings. New Jersey: Mahwah, 2001
04
Lambert M J. Alle haben gewonnen; also bekommen alle
einen Preis. Aber es hat noch Patz für Verbesserungen, wenn
die Therapeuten auf mögliche Behandlungsfehler
aufmerksam gemacht werden. Vortrag, 1. Gemeinsamer
Kongress der Schweizer Psy-Verbände, Bern, 3.7.2004
05
Berns U. Psychotherapieausbildung im Licht empirischer
Psychotherapieforschung. Psychotherapeut 2006; 51 (1): 26-
34
06
Margraf J, Lieb R & Habegger D. Ursachenforschung im
Nationalen Forschungsschwerpunkt Sesam. A Jour 2006; 33
(März): 14-16
07
Kriz J. Von den Grenzen zu den Passungen.
Psychotherapeutenjournal 2005; 1: 12-20
08
Orlinsky D E & Howard K I. Process and outcome in
psychotherapy. Pp. 311-381 in: Garfield S L & Bergin A E
(eds). Handbook of Psychotherapy and Behaviour Change.
New York, Chichester, Brisbane: Wiley & Sons, 1986
09
Strupp H H. The Vanderbilt Psychotherapy Studies:
Synopsis. J Consult Clin Psychol 1993; 61: 431-433
10
Henningsen P, Rudolf G. Zur Bedeutung der Evidence-Based
Medicine für die Psychotherapeutische Medizin. PPmP
Psychother Psychosom med Psychol 2000; 50: 366-375
11
Grawe K. Psychologische Therapie. Göttingen: Hogrefe,
2000
12
Grawe K. (Wie) Kann Psychotherapie durch empirische
Validierung wirksamer werden? Psychotherapeutenjournal
2005; 1: 4-11
13
Tschuschke V. Die Psychotherapie in Zeiten evidenzbasierter
Medizin. Fehlentwicklungen und Korrekturvorschläge.
Psychotherapeutenjournal 2005; 2: 106-115
14
Zurhorst G. Eminenz-basierte, Evidenz-basierte oder
Ökologisch-basierte Psychotherapie?
Psychotherapeutenjournal 2003; 2: 97-104
15
Laireiter A R, Vogel H. Qualitätssicherung in der
Psychotherapie. S. 18-46 in: Laireiter A R, Vogel H (Hrsg).
Qualitätssicherung in der Psychotherapie und
psychosozialen Versorgung. Ein Werkstattbuch. Tübingen:
DGVT-Verlag, 1998
16
Grawe K, Donati R, Bernauer F. Psychotherapie im Wandel.
Von der Konfession zur Profession. Göttingen: Hogrefe,
1994
17
Sanderson W C, Woody S. Manuals for empirically validated
treatments. The Clinical Psychologist 1995; 48: 7-11
18
Chambless D L, Sanderson W C, Shoham V et al. An update
on empirically validated treatments. The Clinical Psycholgist
1996; 49: 5-18
19
Strauß B M, Kächele H. The writing on the wall – comments
on the current discussion about empirically validated
treatments in Germany. Psychother Res 1998; 8 (2): 158-170
20
Cierpka M, Orlinsky D, Kächele H, Buchheim P. Studien
über Psychotherapeutinnen und Psychotherapeuten.
Psychotherapeut 1997; 42: 269-281
21
Willutzki U, Botermans J-F, SPR Collaborative Research
Network. Ausbildung in Psychotherapie in Deutschland und
der Schweiz und ihre Bedeutung für die therapeutische
Kompetenz. Psychotherapeut 1997; 42: 282-289
22
Schweizer M, Budowski M. Versorgungsdokumentation.
Gesamtbericht. Neuchâtel: Schweizer Charta für
Psychotherapie, 2001
23
Schweizer M, Buchmann R, Schlegel M, Schulthess P.
Struktur und Leistung der Psychotherapieversorgung in der
Schweiz. Erhebung der Schweizer Charta für Psychotherapie.
Psychother Forum 2002; 10 (3): 127-146
24
Von Weizsäcker V. Körpergeschehen und Neurose.
Stuttgart: Klett, 1947
25
Von Uexküll T. Psychosomatische Medizin. Hrsg: Adler R
H, Herrmann J M, Köhle K et al. München, Wien: Urban
und Schwarzenberg, 1979
26
Hahn P (Hrsg). Psychosomatik, Kindlers Psychologie des 20.
Jahrhunderts. Zürich: Kindler, 1979
27
Janet P. Principles of Psychotherapy. New York: Freeport,
1924
28
Ferenczi S. Bausteine zur Psychoanalyse. Bern: Huber, Bd.
1-4, 1984.
29
Groddeck G. Verdrängen und Heilen. Aufsätze zur
Psychoanalyse und zur Psychosomatischen Medizin. Berlin:
Fischer, 1988
30
Marlock G, Weiss H (Hrsg). Handbuch der
Körperpsychotherapie. Stuttgart: Schattauer Verlag, 2006
31
Seidler K-P, Schreiber-Willnow D, Hamacher-Erbguth A,
Pfäfflin M. Die Praxis der Konzentrativen
Bewegungstherapie. Psychotherapeut 2002; 47: 223-228
32
Gudat U. Bioenergetische Analyse als ambulante
Psychotherapie – Anwendungsbereiche und Wirkungen.
Psychother Forum 1997; 5: 28-37
33
Soeder U, Kaschke M, Scherrmann T et al. The outcome of
Body psychotherapy – an evaluation study. 7
th
European
Congress of Body Psychotherapy, Travemünde, 1999
34
Ventling C, Gerhard U. Zur Wirksamkeit bioenergetischer
Psychotherapien und Stabilität des Therapieresultats. Eine
retrospektive Untersuchung. Psychotherapeut 2000; 45: 230-
236
35
Müller-Hofer B. Klientenzentrierte Körperpsychotherapie
(GFK-Methode) Ergebnisse einer Praxisevaluation.
Universität Salzburg: Dissertation, 2002
