Basic Body Awareness Therapy: embodied identity (BBAT method) [Paperback ed.] 9188809587, 9789188809582

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BASICBODY AWARENESS THERAPY embodied identity

AMANDALUNDVIK GYLLENSTEN, KENT SKOGLUND & INGER WULF

Swedish original title:

BasalKroppskdnnedom . Den levdakroppen Original publisher: Scudentlitteratur AB, Lund Copyright© 20 I 5 Studentlitteracur English translation: Easytranslate 20 I 6 Revision of the English version: Amanda Lundvik Gyllensten, Kent Skoglund and Stephen Garland All rights to the English version reserved. Copyright© 2018 English version Amanda Lundvik Gyllensten, Kent Skoglund and Inger Wulf Cover layout: Sven Hug and th e authors Cover image : The authors Photos : Gyllensten M. Data illustrations: Wulf, Gyllensten and Hug Printed by Vulkan, Stockholm ISBN 978-91-88809-58-2

"Tomeet the world openly, to allow oneself to be permeated by it, to retain one's centre, but to remain in movement and put others into movement, to Let the world reveal itself and to become present through oneself - that is what it means to exist, to Live." (free translation from Jacobsen 1998).

Content

Preface .......

.. ...........

.. .........................

Author presentations ..........

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.. . . .. . ..................

11

Part I Practice .........................................

13

1. A treatment series with Basic Body Awareness Therapy .. ......

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Presentation of patient and physiotherapists .......

.......

15

The story of Anna ..... . .............. ....... ....... 16 Anna and Patrick have their first meeting ............ 17 Second meeting . . .. .. ... .. .. ... ........... .... 22 After eight therapy sessions. . ..................... 28 Anna's continued therapy . . .. ........ .. ... ... ... . 33 Anna in a group ................. ...... ... ..... 36 Seventh time in group therapy ..... .. ..... .. ...... 37 Anna and Patrick have their concluding therapy session .. 40 Anna's reflections after completing the therapy ..... . .. 43 Part II Theory .........

. ................................

2. Basic Body Awareness Therapy - theories . .....

45

............

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Background and development of the method .. . . ... .. ... . 47 Body ego .......

......

. ............

The bodily-anchored identity ........... Patient safety .........

.. ...................

.. .. . ...... .......

... 50

... .. .. 52 ....

... 5 5

International Classification of Functioning, Disability and Health (ICF) .. ... .. .. . ... . . ............. ...... 55 Defin~ions ....... .. ... ..... ........... ... .... 56

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Body Awareness Scale Movement Quality and Experiences (BAS MQ -E) ...... .. ........... ................. . 57 Movement test (BAS M Q) . .. . .... . ....... .. . .... 5 8 The questionnaire (part of BAS-E) ... .. ..... ....... 61 Qualitative interview (part of BAS-E) . .. ........ .. .. 61 The case of Anna - the first examination with BASMQE .... .. .... ........ .... . .... . ...... 62 The case of Anna - BAS M Q-E after therapy ......... 63 Body Awareness Rating Scale Movement Quality and Experience (BARS-MQE) . . ... .. . .. ..... ....... . .... 64 Differences between BAS MQE and BARS-MQE . . . .. 64

3. Body functions .............

.. .. ......

.. . .....

Everyday movements and function .. .......

.....

65 . ...... 65 ... .... 65 .. .....

Balance and posture ......... .. .............. Standing function .. ...................... .... .. 69 Sitting function .. .. .... . ...... ........ ....... . 70 Walking function .. ..... ... .................... 72 Lying function . . . ...... . .. ....... . ......... . . . 73 Breathing ............ ............................ The voice .................................... Coordination/centring of movements . ..... ............. Open and close coordination . .................... Rotation around the balance line . .. . .... .. ........ Walking coordination ...... .... .... .. ........ ... Power and freedom ... . . .. . .... .. .. ............. Rhythm .... .. .... ... . ... ........ . .. .. . ...... Intention and wholeness . ......

. ......

......

.. ....

74 77 78 80 82 83

84 85

... 85

Movement quality ........... ........... .. ....... .. 87 Physical perspective ....... . . ... .. ...... . ...... . 88 Physiological perspective .......... .. ...... . . . .... 88 Psycho-social-cultural perspective .. . .... .. .. .... ... 89 Existential perspective ... ... .... ..... .. .. ..... . . . 90 Movement quality and Tai chi .. .................. 90

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Body awareness and relations ....................... Body awareness and relation to oneself .. ............ Body image . . . ......... Self-awareness ..........

........

... ....

. . 91 91

.. .. ....

... 93

.. .........................

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Significance of brain hemisphere ...................... The importance of verbalising experiences/feelings .....

94 95

Awareness .......................

96

... ..............

To be present and aware .............................

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4. Relationships to others . . .. ... ...................

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Attachment ......................................

99 99

Needs ...... ...... ........... .. ... ........... ... 101 The cycle of needs and the body ......... ...... ... 102 BBAT and the cycle of needs ............ . ....... 103 Touch ... ................. Love and sexuality......

..... ... . .....

....

.. .. ... .. .. . . 104

... . ........

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The encounter between care provider and patient ......... 5. Pedagogical approach ...............

.................

Resource perspective ..... .... . ..................... Guidance ......... ........ .................. The learning process in BBAT. .............

106 108 111

.. ....

111 113 113

Group therapy ... ....... ... .. ... .. ............... 115 Therapeutic factors in group therapy ........ ...... 116 Infusion and maintenance of hope ............ 117 Universality, general applicability ............. 117 Altruism ............ . ..... ....... ....... 117 Interpersonal learning - "to learn from each other" .. 118 Group community, group feeling or group cohesion ................................ 118 Existential factors ...................... .. . 119 BBAT group as a relational exercise .. .. ......... .. 119 Massage ................................ 120 Push-hands .. ........ . ......... .... .... .. 120

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To live in reality and the world ......... . .. . .......... Anna's new perspective ...... ....... ... .. .......

121 121

The "lived body'' and the biographic perspective ..........

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Existentially-oriented viewpoint . ................ 6. Final reflections .................................... Part Ill Movements ..............

7. BBAT movements ..........

... .. 123 125

. ...................

. .......................

. 127

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Sitting movement ... .. ...... . .. . . ... ... .. ....... . . 129 Find your balance in sitting . ................ . ... 129 Standing movement . . ...... . ... . . .. . . . . . . ... ... .. . 131 Find your balance in standing ....... .. ......... . . 131 Raise and lower along the balance line .......... . . . 134 Rotation around the balance line ............. .. .. 135 The wave ............... . ............ . ...... 136 Push-movement ......... .. ................... 138 The open and close coordination ..... . ........... 139 Stop movement ........ . ......... ... ....... . . 141 Lying movements . ....... . ............ . ........... 142 Lying movement being aware of yourself ........... 142 M-sound in a lying position ............ . . . ..... . 144 Gathering of your legs towards each other . . . .. . . ... 145 Stretching movements .. .. ........... . ......... 147 Symmetric stretching movement . .. .. .... . .. . . 147 Alternating stretching movement ......... . ... 148 Gathering movements .. . ...................... 149 Lying gathering into a ball with bent legs .... ... 149 Lying contraction around the centre with the feet on the floor .... .. ................ .. 151 Walking .. . .... References . . . ............

................................. . .. . ....

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.. . .. .......

153 .. .. . .. 155

Preface Large parts of the population of the Western world do not feel well. Despite increased material wealth many people experience stress-, lifestyle-, or life situation-related difficulties. These difficulties can appear in the form of pain, musculoskeletal tensions or as psychosomatic problems. The demand for quick communication places increasing pressure on the individual. Weight problems, eating disorders, and substance abuse are common. Divorce, relationship problems, unemployment or overwork are other reasons for bad health. An uncertain future also causes increased existential worry and may lead to a sense of aimlessness in life. Diagnoses such as depression have increased exponentially. The demands of how one should look and behave to best fit into society's norms and into the social context are great. It is not unusual for the individual to lose contact with the self and with the body. The need for and the interest in biopsychosocial therapy methods is growing, as is the need for literature on this subject. This book is intended for healthcare professionals, but is also for those who are interested in reading more about experiences and theories regarding the connection between body/mind, relationships and the environment. Basic Body Awareness Therapy (BBAT) is both a method of therapy and a humanistic approach. The way to meet people has been shown to be of great importance for the result of any therapy. This book begins with a case study of Anna, illustrating how BBAT can unfold. Usually, theories are illustrated with a case study after the theoretical text, but in this book we have chosen to do it differently: we allow the reader first to share in Anna's therapy with the physiotherapist Patrick. In the theory section, we have chosen to integrate theories significant for function and health. BBAT is described from diverse perspectives

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combining aspects of both body and mind. Theories in the book are based on both quantitative and qualitative scientific studies. Proven experience, so-called "experience-based practice", has also influenced the understanding of BBAT. Inspiration and understanding also comes from physiology, psychology/psychotherapy and Eastern methods - in accordance with the integrative viewpoint of Basic Body Awareness Therapy. The body, awareness, relations, and the conditions of existence in the world are described and placed in relation to the therapy process. The last part of the book describes some basic movements in BBAT. We have selected movements to train awareness, balance, stability and movement coordination. The BBAT method is grounded in both experience and research . There is moderate evidence for the effectiveness of the BBAT method, and more research in the area is needed. Like with other body awareness methods, BBAT cannot be learned only by reading but also needs to be experienced practically. The References at the end of the English version correspond to the references in the Swedish original. Therefore, some of the entries refer to Swedish translations and not to the respective original works.

The authors

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Author presentations Amanda Lundvik Gyllenstenis an associate professor in the Physiotherapy Research Group at the Department of Health Sciences, Lund University, Sweden. She has worked with Basic Body Awareness Therapy within the area of psychiatric rehabilitation/physiotherapy since the 1970's and graduated as a teacher in BBAT in the l 980's. Today, Amanda performs research and teaches mainly within the areas of Basic Body Awareness and Tai chi, and she has published numerous scientific articles in these areas. What interests her is the living body and how people's health can be strengthened through movements and mindfulness. Kent Skoglundis a social worker and Physiotherapist who has worked with Basic Body Awareness Therapy since the beginning of the 1980's. He graduated as a teacher in Basic Body Awareness at the end of the 1980's and since then he has taught BBAT and Tai chi. Kent has had a private practice for 20 years in Vaxholm, north of Stockholm. The treatments are geared mainly to psychosomatics. Kent is generally interested in the natural holistic view of man that is represented in different Eastern philosophies and in existential philosophy. He is also interested in how human personality is reflected in its way of moving. Inger Wulf has been working as a Physiotherapist since the 1980's in Zurich, Switzerland. She came in contact with Basic Body Awareness Therapy in the middle of the 1990's, and started using the method for patients in outpatient care at the Klinik Hirslanden in Zurich. After having gone through BBAT teacher -training in Sweden in the middle of the 1990's, she has worked to spread the BBAT method in Switzerland and internationally. Inger is interested in the person's unique possibility to develop in all dimensions through working with BBAT.

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PARTI PRACTICE

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1. A treatment series with Basic BodyAwareness Therapy Presentation of patient and physiotherapists Anna is a 43-year-old woman who works as a coordinator at a transport company. She tries to combine her working life and her daily life as well as possible despite pains, anxiety, stress, two demanding and rowdy teenagers, and an often-absent husband, John . This has now become overwhelming. Anna is the main person in the story.

Patrick is a 50-year-old physiotherapist who works at a private practice with a focus on lifestyle issues. He has extensive experience in the Basic Body Awareness method and practises Tai chi and Zen meditation. Patrick is one of the main actors in the story. Eva is a 48-year-old physiotherapist who works with BBAT at a medi cal centre where the patients are offered BBAT in a group . This mostly concerns patients with chronic pain conditions and light depressive and anxiety-related disorders. She also uses the Basic Body Awareness meth-

od. Eva has a more peripheral role in the story.

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The story of Anna Anna has now summoned the courage to go to a physiotherapist . She stands at the door sweating, and feels insecure, anxious, and a little dizzy. What will he think about me ... ? Is he going to take me seriously ... ? Maybe I can get a massage . .. ? I wonder if he has time for me . .. ? Anna has butterflies in her stomach . She breathes high up in the chest and notices that her hands are wet and her legs are shaking with anxiety. Think if he shakes my hand, what shall I say... ? Patrick sits at the computer. Who is coming now ... a new patient? Let's see what kind of problem she has. He looks in his notebook, what did she say when she called? Stressed, anxious, upset, and a pain in her neck ... oh well. Patrick stands up straight, becomes aware of his breathing, feels his feet in contact with the floor. How do I stand on my feet? He balances by oscillating a little forwards -backwards, paying attention to what he feels just now. Patrick tries to mentally leave the patient who has just left the therapy room, by drawing attention to himself in the present moment . He performs several BBAT movements to find his balance line, and activates it by bouncing on his heels. Now he feels calm and ready for a new meeting with the next patient .

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Image 1. Patrick bouncing on his heels to find his balance line.

Anna and Patrick have their first meeting Anna opens the door to the waiting room and enters cautiously. She holds her breath. Her heart is pounding and her ears are buzzing. She looks around in the waiting room and goes over and sits on one of the chairs that are there. Where is he? She picks up the newspaper lying on the table. Patrick notes that Anna opens the door cautiously and goes into the room slowly. He also notes that she does not say anything, but sits and waits . Patrick waits for a while to allow Anna to calm down. He takes some tea, drinking several sips. Then he goes slowly into the waiting room and takes Anna's attention. He is careful not to be too intrusive. - Hi, he says with a calm voice. I am Patrick, you must be Anna. He notices that here sits a thinnish tense woma n aged around 45. She appears a bit afraid and anxious. He stretches out his hand and

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notices that she has a weak and uncertain handshake. The hand feels cold and damp. - Hi, Anna answers with a slightly tense voice. My name is Anna and I have an appointment with you now at 10 o'clock. - Good that you came on time. Was it OK to find your way here? We will go into this room. Patrick gestures with his hand to show the way toward the therapy room adjacent to the waiting room . - Yes, I found it easily. Shall I hang my clothes here and take off my shoes? - It would be good if you hang up the clothing here and also if you take off your shoes. He shows her into the room and points to a chair . Please sit here. Patrick sits a bit at an angle, next to Anna on another chair. He turns to Anna . - Did you have any problems in parking? Anna answers that she found a good parking spot close by. - I see in my notes that you feel stressed, are anxious and worried, and you have a pain in your neck . Can you tell me something about it? - Yes, I have had a pain in my neck since last Christmas, and I often feel tense both in the neck and shoulders. Sometimes it feels as if my chest is squeezing. I get no air and it feels horrible. I wonder whether this could be some kind of anxiety, which I have read that many people have. So, I feel restless and unfocused most of the time, Anna says. - Can you say something about in which situations you experience these troubles? - It starts in the mornings when I am on the way to work, she con tinues . It is terribly stressful in traffic and it is very uncomfortable for me to drive, but I need the car at work and to drive the children. And so I always start to think about everything that I am going to do. The boss, who comes and asks whether I have done this or that ... Just the thought makes me tense. And then my husband often travels for his job. Patrick notes this with the husband but doesn't say anything about this just now. 18

- Can you describe your neck and shoulder problems? Do you have pain every day, do you have pain the whole day, is there any time of day when it's better? What do you use to relieve the pain? - I feel tense already when I go off to work. The pain starts in the shoulders and spreads to the neck in the morning and then I drink several cups of coffee to feel better. Sometimes I also have a bad headache. But actually I don't have any coffee breaks - I take a mug sitting at the computer . Sometimes I try to take a cup from the coffee machine and chat with Lotta for a while, and then I feel how tense I am. Sometimes I just get panicky! Ugh! Some days, it's terrible . Patrick notices that Anna is beginning to get upset and is quiet. - Maybe we can talk about your difficulties and panic feelings in a little more detail later when I have seen how you move, he says after a while. You mentioned something about your husband. Are you married or living together? Do you have any children? - Yes, I am married and we have two children, 15 and 18 years old . They both live at home with us. Just now they are hopeless and they scold me all the time. We argue a lot about clothing and times, and they don't always tell me what they are up to . - You said something about your husband often being away at work? - Yes, he is a salesman at Smith's, Anna replies. It is a rather large company and he is the sales manager, so he often leaves early in the morning and comes home late in the evening, or also he can be away for several days .. . Patrick understands that this can be a problem, both that the husband is away so often and that she seems to be the main person responsible for two teenagers, but he chooses not to go into this more deeply for now. Now it is time for Patrick to explain a bit about how he works. - So you have described how you have pain in the shoulders and neck and you feel tense, Patrick says. As you understand, it is important to be able to relax. Actually, I talk more about finding a tension balance. To find a tension balance, it is important to find a balanced posture when sitting and standing . Can you show me how you usually sit when you work?

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Image 2. Ann a's sitting posture before ther apy.

Anna sits up straight on the chair and shows how she usually sits. Patrick notices that Anna is sitting rather far forward on the chair. She is quite tense when she sits, has her back upright, and she pulls up her shoulders a bit and pushes her chin out . Breathing is hardly visible. Her feet do not reach the floor, and only the toes are supported on the floor. - Can you describe in your own words how you are sitting just now, Patrik asks. How is your posture? - Well, as usual, this is how I usually sit. - Is there something in your posture that you are paying attention to right now? - Nah, this is how it usually feels . .. but I feel that I am starting to get a pain in the neck. - I see that you are sitting far forward on the chair, that you are sitting with your toes on the floor, and that you are stretching up and tensing up in the back, he says. To start off, try sitting with both feet on the floor. Feel whether you can relax your shoulders by pulling them up and then dropping them down several times. Anna does what he says, sighs and drops the shoulders . She sits like that for a while .

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- How does it feel now? Patrick asks. - It feels uneasy and I feel like I am slouching .. . but it feels less tense.

Im age 3. Patrick guid es Anna in sitting.

- It can be so simple, Patrick continues. At the same time with this simplicity there are difficulties and that is about your habits . - This is how I always sit, so it would be difficult to change my habits, but it is nice that it feels better just now. - For next time, I would like you to try sitting this way every now and then at your job, and feel how it is to sit like that . - I'll try it, Anna replies. Anna goes away from her meeting with Patrick and feels a little strange. She feels her breathing more; it feels a bit faster but it does not feel like panic . How can it be like this? she thinks. When she comes home, everyone is gone and she is alone. Instead of putting the laundry in the washing machine and cleaning up after breakfast, she sits on the sofa and sits there much longer than usual . She doesn't think about anything special but only sits there. She thinks that it feels quite okay. 21

When Anna has left, Patrick goes into his little kitchen and stands still for a moment while the water boils. He ponders a little about how the meeting felt. He is thinking about how he should proceed with Anna. He suspects that behind the symptoms, there are a lot of problems with self-esteem and relationships . He notices that he feels relaxed and calm but not excited and happy after the meeting. There is a certain feeling that he can't put into words, which concerns him. He takes his teacup and still has Anna in his thoughts.

Second meeting Before the next meeting with Anna, Patrick reflects over the therapy process. Standing in the kitchen, as always he prepares for a new patient by drawing attention to the body and bouncing on the heels to find his own balance line and collect himself. Soon Anna is coming. He feels open before the meeting. He wants to go cautiously and to start by connecting to what was done the last time. He wants among other things to hear Anna say a bit about how she experiences the anxiety that sometimes comes over her. Then he wants to go further by examining Anna's physical resources with the help of several BAS MQ-E movements (see BAS MQ-E, Gyllensten & Mattsson 2011, 2015) . He also wonders what expectations Anna has for the therapy and what she wants out of it . He feels a little uncertain about her resources and ability to change . She seemed a little anxious and fragile last time, but at the same time he thinks she seemed motivated and interested. She could receive the sitting guidance, so there is a possibility for change. Anna feels a bit excited before the meeting with Patrick. She has done her job and practised sitting at work. Now she wants to tell this to Patrick and she in fact feels a little proud and happy. When she now goes in through the door there is another clarity and energy in how she grips the handle and goes into the room . - Hi, Anna says to Patrick, who remains in the kitchen with his 22

teacup. Patrick says hi from the kitchen and goes slowly into the waiting room . He notices that Anna looks a bit happier than last time; this is also visible in her posture, which is a little less tense and upright . - Please come in, Patrick says. Let's go into the therapy room. He sits down in peace and quiet and turns to Anna. How was it, how did you feel after the last time? - Yeah, it's gone well, Anna replies. I have practised a bit at work. I have tried to sit in the way we went through the last time. Not that often, but several times. Sometimes I have been too stressed and busy with other things, but when I remembered it and deliberately sat with my feet on the floor, my neck has felt good. She smiles and looks quite pleased. Patrick asks Anna to move the chair forward and to show how she does it while he watches. Anna takes her time to feel that she has her feet on the floor and sits the way she believes is right . - Is it right? she asks, wondering. - Yes, it looks good. How does it feel? He sees that Anna sits a little reclined but better than the last time. - Try to lean forward a little, he suggests.

Image 4. Ann a perform s the sitting movement : Is it right ?

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- How does it feel now? Patrick asks. - It feels strange - good, but a little awkward . - Where in your body do you feel your breathing just now? - It probably feels most in the chest . - Try to let the breathing be as it is, Patrick says. Today, I thought we would go ahead and do some movements so I can see how you move in daily life. We will do several movements in walking, standing, sitting, and lying. Can you start by walking as usual? Patrick carries out the movement test in BAS MQ-E with Anna. She also fills in a questionnaire pertaining to the test and is interviewed about what she experiences when she makes certain movements. - I see that it is relatively easy for you to move and it seems you like to do it, he says after the test. I also see that you are not completely stable and balanced, that you don't stand completely stable on the floor. It seems that you often tense up and mostly breathe with the chest. You yourself have written that you tense up in answering the questions in the test and this is consistent with what I see when you move . I also noticed that you are sometimes a bit distracted . - Can you see all this? Anna wonders. Do you believe that I can be more relaxed? - Yes, I think so, Patrick says and nods. To change your tension balance can lead to the fact that you will no longer get pain and you will become more sensitive, be more in contact with your feelings and with yourself. - You believe that? It sounds strange, I think. - I think we will begin to pract ise your stability while standing and your ability to stand firmly on the floor. Can you stand as you usually do? Anna stands up and seems a bit unsure how she usually stands . - I think this is how I usually stand, she says after a while . Patrick notes that she again is standing with the weight quite far back on her feet, tensing the legs and lower back, and pushes her chin forward slightly. The shoulders are also a little hunched. How does it feel to stand like that?

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Image 5. Anna's habitual posture. "This is how I believe I usually stand ."

- I don't like to stand at all. It feels tense and annoying, but it is the way I usually stand . Do you think I have a bad posture? - I see that you tense up and it seems that you lean backwards too far. When one does that, compensations occur in the body, and in your case you slide the head forwards, which in turn can cause tension in the neck. We shall see if you can find another balance in the body where you stand more relaxed and balanced. Now we will make some movements. Can you bend your legs slightly and straighten them out again? Patrick demonstrates by bending his legs, sliding down the balance line, and shows Anna how to return to the standing position by pushing with the feet. Anna bends the legs and comes up again. Patrick notes that Anna leans backwards without bending the hips and with too little support from the floor.

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Image 6. Anna slips down along the balance line.

- We will make another movement, Patrick continues. This is called the wave. Follow me, Patrick says. He lifts his arms, draws them closer to the body, then lowers the arms and at the same time bends his knees a little. Anna tries to imitate. Patrick again notices that Anna is making the movements, but the arms and legs are not coordinated. The movement gives a fragmented impression. The breathing is not visible. He thinks that now it is more important to investigate Anna's wishes and ideas about what the goal and content should be for the therapy and how her motivation to train herself would look. - Thanks. You can sit down again. We will talk a little bit about what you want to get out of the therapy. Can you tell me what you think about it; do you have any special requests? - I would like to get rid of the tension in my neck and shoulders. But then it is also my stress and anxiety. My daily life is not working well and I feel like a robot and am never really happy. I feel alone and think that

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Image 7. Anna makes the wave movement.

I have too much responsibility. Sometimes I get panicky when I think that I am always going to be like this! Actually, I don't like being at work at all. I would most of all like to do something else. - Can you describe your anxiety, Patrick asks. - You know, when anxiety comes and grabs me, I panic, Anna explains. It feels like I am going to die. It comes at the most unexpected occasions, when I least of all expect it. I can get nauseous and dizzy and get palpitations. It tightens up in the chest as ifl had an iron belt which was pulled tight, as if I was suffocating. It's quite horrible. -Anxiety is something that many people have, Patrick says. It is unpleasant but not dangerous. Sometimes, it can even help you understand that something is wrong. Anxiety can be of varying power but if one regards and accepts it, then it may fade over time . You can try to accept what you feel and see whether you can get more in touch with the needs or feelings you have. Muscle tension can also be a defence against feelings one doesn't want to know about. There is an alternative approach and an

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opportunity to change the situation by paying attention to everything taking place in the body, and also by making body movements . In this way, one can get a better contact with the body and with oneself. I would like to hear what thoughts you yourself have about making yourself tense and in which situations . Can you give an example of this? - Yes, as I said before, it is often at work I know that I get tense, or when there is too much at home, Anna says. When I lie down in the evening, it is difficult for me to get to sleep and I feel tightness in the chest . Sometimes, it escalates to panic and then I cannot lie still. Once I thought that there was something wrong with my heart . - For the next time, I would like you to notice more concretely what is happening in different situations . What happens, for example, with your neck and your shoulders, what happens with your breathing, in those situations where you find that you tense up or get anxious . Make a note of what you feel. - Yes, I can try to do that, Anna answers.

After eight therapy sessions About three months have passed and Anna comes to her ninth therapy session with Patrick. She has discovered when and how she gets anxiety and gets tense . Her body awareness has increased and she feels and knows when she sits and stands in balance. She has learned to breathe more freely in the situations where she previously tensed up. She has also increased contact with her feelings. She has become sad in a different way in situations where she has noticed that she cannot assert herself or set boundaries. On Patrick's advice, she has kept a diary of her reflections on the movements she began to do at home . She has told Patrick that at one time she seriously considered stopping the therapy. It was when she did the movements a little too much with just breathing and sounds at home. She put that down to the fact that she was sad without knowing why, and then became afraid that the movements would make

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her totally lose control over herself. Patrick has, however, calmed her, saying that it was not unusual for emotions to come out a bit too strongly when the muscles are relaxed, especially in breathing. He has advised her to observe when emotions come. He also recommended her to do a few more of the basic movements when standing or sitting. Patrick believes that the process with Anna is developing in the right direction. Sometimes he wonders whether he is proceeding a little too fast. He has understood that Anna has had a number of strong reactions, and also that her relation to her husband John is problematic. He notices that Anna finds it easier now to find a balanced posture, even though it is still difficult. A movement he often comes back to is when Anna stands and he uses slight pressure on the chest to see how stable Anna is in her balance line.

Image 8. Patrick strengthens Anna's balance through a slight pressure on the chest .

For Anna, it is easier to formulate what she experiences in different situations, both regarding herself and her relationship to other people.

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Patrick thinks that she now needs to continue the process by deepening her contact with the base, by feeling how she directs her weight to the ground and by allowing breathing to be more natural. After having made several initial movements in sitting and standing to deepen the experience of grounding, balance, and breathing, Patrick proposes that Anna sit down on a meditation stool. Anna sits down and Patrick guides her sitting balance. Patrick stands behind Anna and starts by pressing lightly on Anna's shoulders. Anna feels that she can take the pressure and still retain her balance.

Image 9. Patrick tests Anna's balance line through light pressure on the shoulders .

She feels strong and at the same time relaxed. Her breathing suddenly feels freer. It comes and goes without her doing anything . It feels good to get a massage in this way. She feels happy and full of energy. - How does it feel now, Patrick asks. - It feels good, Anna replies. I feel light and strong and full of power in a way that I have not felt before . Now Anna suddenly starts to cry.

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Patrick lets her cry and is there present beside her without saying anything or touching her. - I don't know what happened, Anna says sobbing. Just when I felt so happy I became sad. Strange! - Was there something special you came in contact with or thought about, Patrick wonders . - I am crying but really I am quite angry. I am so damned angry! - Is there some special situation you are thinking about? - I got angry because John is never at home . It is so frustrating that he is always so important and I always take shit there at home . - Good that you both can feel it and say it. Try right now to notice what you feel and to stay a little in the feeling that you have just now. They both sit quietly for a while . - Can we continue, Anna? Patrick says after a while. Anna nods and blows her nose. - I thought that today we should also try a pair exercise taken from Tai chi - it is called "push-hands" and is actually a way to shed some light on how people relate to each other . We place ourselves opposite each other with the right leg in front and put the right hand so that our hands meet at the wrist . We begin to move forward and backward and try to follow each other's rhythm. When we have come into the same rhythm we let the arms form a circular movement which goes count er-clockwise. Keep contact with the feet on the floor and try to let the hands be in contact in the movement . - This is difficult, Anna sighs. It feels like I am losing my balance and my feet don't want to stay on the floor. Patrick notices that Anna is going too far back in the movement. - How good it is that you feel how your balance is, he says. Try not to go so far back, but stay where you are still in balance. Set your limit earlier. In this way, one can create a better place for oneself. Is this going too far back and losing balance something you can recognise from everyday life? Anna is a bit surprised by the question.

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Image 10. Push-hands. Anna loses balance and goes coo far back.

Image 11. Push-hands exercise. Anna keeps within her limits.

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- I don't quite understand what you mean, but it often happens that I pass my limits and become unbalanced. It can be that I feel this way when I'm with John. I have a feeling that I may give in too easily. Patrick thinks that he wants to repeat the exercise another time and ask her the same thing at a later occasion to see if she can connect the exercise with how she works in relation to other people . Anna now allows the movement to get smaller and stays within her balance limits. - Now I feel more stable ...

Anna's continued therapy Another month has gone by and Anna comes for her thirteenth session with Patrick. After an introduction where Anna and Patrick have sat quietly on the meditation stools for five minutes, Anna says that she has got better at setting demands at home and saying no at work. She says that sometimes she has felt anxiety, her heart has pounded, and she has been dizzy. - Is it usual that one can feel like that, or do you think that I should get my heart checked? she asks Patrick. - I think you can wait a bit, Patrick says. If it gets worse, of course you can always check with your doctor, so that you don't need to be afraid that something is wrong with you. But it is not unusual that one can get more anxiety or that the body reacts with vegetative symptoms when one changes one's posture and breathing becomes freer. The old behaviour or attitude has indeed fulfilled a function. Sometimes it can be that one has unconsciously tried to be capable, liked and accepted. Such things can lead to tension and stress in the body. - I have probably done it this way since I was a little child, to be nice and capable and never place demands. I was good enough only when I helped and was capable at home . I experience in retrospect that Mum and Dad didn't care so much . I learned not to place any demands.

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- Can you tell me about a situation where you placed greater demands? - I told John that one evening a week he should come home in good time, fetch our son Philip from soccer practice and prepare the food, so I can be free to do what I want . - How has it worked out? - John wasn't so happy about it and started to talk about his important meetings, but I insisted and now it has worked for two weeks in a row. - How did you experience this? - I felt good but I also got a bad conscience when he had to cancel his meeting. I insisted anyway. Do you think I did the right thing? - It can happen that you get a bad conscience when you do what you need to do instead of caring for others, Patrick replies. Can you cope with it? - I guess I will train myself but it feels unfamiliar ... I am only afraid that John will leave me. - I can understand how this feels, Patrick says with understanding . - Today I would like to go further with the lying-down movements that we have done earlier, Patrick continues. If you can lie down on the floor, we will continue with the contraction round your movement centre. We start with you just lying down and being aware of your breathing and your contact with the floor. During the therapy period, Anna has increased her ability to contract round her centre of movement, coordinate the upper and lower body, and find an interaction with her breathing . She also has started to be freer in making sounds, which she felt was difficult and awkward at the beginning . Patrick also notices that there is a different quality and strength in her voice and thinks that she has come in contact with deeper needs and feelings. - I notice that your movements are freer and that your voice has another quality, he says. How does it feel for you?

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Image 12. Lying contraction movement with legs bent and feet on the floor.

- I have also noticed that my voice has changed , Anna answers. She reflects for a while. There is something else I want to talk about with you. I don't know whether I should say this here, but I have noticed that my sex life with John has improved. - Yes, it may be so, Patrick nods. What do you think about it yourself? - I simply feel more and I am more aware of what happens when we are together. I am no longer so split in my mind and I don't think about anything else but I allow myself to enjoy it more than before. It all works better. Can these movements we do be a part of this? - Absolutely, but there are many factors that work together. Tension balance, breathing, and above all how it's going in your relationship. The most important thing is probably that one has a good relationship and that you respect one another. Another factor is of course that the contraction in the lying movement is a basic coordination pattern also found in the intercourse movement, when it works well. - Mm, yes. I actually feel more respected by John. It's strange, the more I respect and like myself, the more I feel that John also likes and respects me. Me, who was so afraid that he would leave me when I started to say what I wanted .

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Anna in a group Anna has now been in three group sessions. The group consists of six women and two men. It is led by a female physiotherapist whose name is Eva. The group meets ten times during the spring and during that time Anna has a pause in her individual therapy. According to the agreement, she will meet Patrick one time after the group, and end the therapy . At the beginning, Anna was a bit hesitant to take part in the group. Firstly, she felt that separation from Patrick might be difficult, and secondly she thought she might feel insecure being in a group with new people . Gradually, however, Anna has reevaluated the group and she experiences it now as very important . Through the group she can experience that she is not alone in her problems, since several people in the group have similar difficulties. It feels good to do movements together and to hear others saying that they also have pain or difficulties in everyday life. Anna wishes that she could have a bit more space herself in the group and dare to say more about herself. She thinks that she has never really dared to take her place in a social context . Eva notices that the group has started to interact. Some participants come a while before and are talking in the waiting room . There is an accepting and supporting atmosphere during the practice even though there is not a fully-functioning group yet. One of the participants is too dominating and seems not to be accepted by the others. Some participants are a bit quieter than the others. Eva ponders how she shall manage the situation. Today, I will probably spend more time on partner exercises in massage and do some simp le cooperative movements, she thinks. Anna and another participant called Jenny work together with the massage and when Jenny massages a bit too hard, Anna does not dare to say something. In the subsequent conversation, the participants are urged to give each other feedback about how it was to give and receive. Anna still doesn't tell Jenny that it hurt when she did the massage, but

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says that it felt good. At the same time, it didn't really feel good, and she wishes that she had spoken out. In the final round, Eva takes up how difficult it can be to say no to someone, and points out that it is difficult to respect one's own experiences and needs. Anna takes this to heart. At the next group session, Jenny and Anna work together again and this time Anna makes it clear that she wants Jenny to be a bit softer in the massage. Jenny says that it is good that Anna said how she wants it. Afterwards, it feels good to have dared to say something.

Seventh time in group therapy - Today, we will try something new, Eva says. It's called Tai chi and meditation . Meditation and Tai chi are the eastern background to BBAT. We have been sitting down several times on a chair and have paid attention to breathing and posture. This is a form of Zen meditation . Today we will try it a little more. We will sit in the same way we already have done several times, with the feet firmly on the floor. We are also sitting on the pelvis and the sitting bones so we get a naturally relaxed upright posture . Relax your shoulders and let the head be a natural extension of the back. Pay attention to your breathing when it comes and goes in a natural way. We sit like this for several minutes in silence and try to be aware of ourselves. If thoughts come, let these just pass by and return to being aware of yourself Accept what happens without forcing or evaluating yourself The group sits in silence for five minutes. - You can move again, Eva says. Straighten yourselves and maybe yawn a little or do what you feel. - How did it feel? She asks later. - It felt like a long time and I got a sore back, answers one of the male participants in the group. - I thought it was so nice I could have sat forever. It felt so peaceful, a young woman says.

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- It was difficult for me to concentrate, Anna says. My thoughts flew here and there all the time. It was easier when I was alone in therapy with Patrick. - What you are describing shows that one can feel differently, Eva says. It can also vary between times and can change. To sit in this way can be used in one's daily life to practise one's presence of mind. If one sometimes feels fragmented, one can always return to this simple exercise to be aware of oneself for a while in order to pull oneself together. - This is very similar to a mindfulness course I went to one weekend a while ago, says the other male participant. - Yes, it has the same roots, Eva nods. Mindfulness is a version of Zen meditation or Vipassana meditation. - How to breathe, continues the man who had gone through a mindfulness course. I went to a different course where you should try to prolong exhalation. Should we do so here too? - Do you remember which course it was? - It was a basic course in some form of yoga. Maybe it was some kind of meditation perhaps ... I don't remember exactly. - Yes, you do it in some techniques, but here let the breathing be free and natural, Eva says. We usually say that breathing should be released. It's good to hear how you have experienced it. We will talk a little bit about it every time, how each of you feels it, but you don't have to say something. What is interesting is that when someone else says something, then it can be that you discover that this is also the way it felt for you. Therefore, we have conversation rounds now and then at every group session. - Now we will continue to do some gentle movements from Tai chi. Tai chi is an old Chinese movement art used to improve health and mindfulness. According to tradition, it is also a martial art . Here we will concentrate on the health aspects and mindfulness. Eva stands in front of the group and says: - So, look at me. I'll show how it looks. Eva shows a bit of the form softly and with concentration.

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Image 13. Reflecting conversation after the movements.

- We will try. I will show the first movement from the front ... Now I turn and you can just imitate. The arms slide up and then down at the same time as the legs bend. We do it several times. Then we turn to the right. What we are doing is called "brush knee", and then push ... continue several times like this .. . just follow along ...

Image 14. Tai chi. Anna leans too far forward.

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After several movements, Eva turns to the group and asks: How did it feel? - I liked this and I had no back pain at all, says the man who mentioned his bad back earlier. - It was difficult to get the arms and legs to work together, the young woman says. - I recognise this; I have done this before, with Patrick . It feels nice, Anna says. - I don't know. I thought it felt a bit silly, says the man who had been to the mindfulness course . I don't know what this will be good for. I think this isn't for me . It feels a little ridiculous . Eva nods and shows that it is perfectly okay to think that it feels a little ridiculous. She then concludes the group session and says that those who want to try the moves can do them at home.

Anna and Patrick have their concludingtherapy session The group has finished, and Anna is now with Patrick for a conclusion . After having looked a little at how Anna moves and at her sitting and standing posture in a new movement test with BAS MQ-E, Patrick tells Anna what he sees in her movement patterns and movement function. - I notice that you are now more stable and can keep your balance better even on one leg, Patrick says. You can also coordinate your movements better and your breathing has also become coordinated with the movements. - Now I almost never have pain in the neck or shoulders, Anna says. I have noticed that I stand and sit in a more stable way, and that my posture has become much better . Sometimes, I even feel relaxed and move more freely. I seldom panic or have anxiety. When I sometimes get pain, I notice it much earlier and usually I can do something about it with the

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Image 15. Some movements from BAS MQ-E movement tests. Anna stands on one leg.

Image 16. BAS MQ-E . Anna does the wave movement.

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help of the BBAT movements . But I am probably more difficult to deal with. I feel more in contact with my feelings and more aware of myself. In some way, I feel even more secure in contact with others. I think I can better accept changes in myself and outside of myself Even if it hurts, I dare to see things the way they really are. I am no longer afraid of other people . It just feels like I am more alive than before. But there's something I think is strange . How can it be that there has been such a change in me since I started to practise BBAT? The movements we have done have been so simple! Patrick sits quietly for a while . - I believe that a lot has happened in your life, he says. Well, you know, it is the simple things that are so effective. The movements /exercises are just a means for you to be more aware of how you are, both in the movements and in your everyday actions . We have simply been working with fundamental and basic_functions that are the basis for being a balanced and harmonious person. It makes you function better in contact with yourself and in different situations. Naturally, this development will continue. Now you can also take care of yourself and your needs better. It is important for you to be able to feel alive and whole. You have got a tool to self-manage your difficulties . - At work, it is not good, Anna continues . I have a job which is much too stressful. I have learned to speak up better but it still doesn't work so well. I have been thinking about doing something else which I find more fun and less stressful. Patrick nods sympathetically. - It sounds as if you feel that there must be a change and that you have learned to set limits at work. It's good that you have become more aware of it. I also understand that you are considering what you can do to change your situation for the better. How are things at home, then? - Things are tough at home . John doesn't like that I have changed as I have done. He thinks it was better before. It's a bit sad. But I can't be as before - I want to follow what I feel. We actually have an appointment at a family counselling.

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- That sounds good, Patrick agrees. A parallel conversational therapy can often be necessary at the same time as one works with the body. I hear that you have developed a lot. I believe that you will continue to develop. All change is hard work and you are in this process. I believe that you will continue to develop in the future even if we stop our con tact. Anna feels a pang of anxiety - how will she take care of herself with out him? But then that feeling fades away. She looks him in the eye and says: Thanks for your help, Patrick. You and BBAT have meant a lot to me. Anna's voice is now calm and hopeful. Patrick wishes her luck and shakes her hand. It is a solid, warm and distinct hand he gets in his. Anna goes slowly towards the door and takes the door handle clearly and decisively. She opens the door, goes out quietly, and closes the door behind her.

Anna's reflections after completing the therapy When Anna goes out through the door, she feels strong and more aware. She feels ready to face the world. She experiences for a moment the feeling she had when she was about to enter the door for the first time . So small, afraid, alone and worthless, she felt then. Now, she has got more perspective, more self-esteem. She is now changing, and although it is a bit scary, she feels clearly that there is no return to the old life. She sees how she lived a life where she put the needs of others ahead of hers, and did not really take care of herself. She realises that she must prioritise herself to be able to take responsibility for her health, and she under stands that she is hardly unique in her difficulties. Luckily I have been so diligent with my home movements, she thinks. I have learned what I can do myself to be more in balance and feel better . Now I know which movements can help me and I am actually able to take care of myself. I actually don't need Patrick to do this .

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PARTII THEORY

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2. Basic BodyAwareness Therapy - theories Background and development of the method Jacques Dropsy (Dropsy 1975 , 1988) originally formulated the theories regarding Basic Body Awareness Therapy (BBAT). The roots of BBAT go back many centuries to Eastern thought in the form of Zen meditation and Tai chi chuan, but also to Western training methods and philosophies. In Sweden and the Nordic region, the method started at the beginning of the l 970 's. The BBAT development started with Hans Hof travelling from Sweden to Paris to be introduced to Zen meditation . As a priest and professor in philosophy of religion, it was unusual to be introduced to Zen meditation. In Paris, Hof came in contact with the Zen teacher and monk Taisen Deshimaru, as well as Dropsy, who was a student of Deshimaru . Through Hof, Dropsy came to Rattvik in Sweden, where Hof had started the Rattvik Meditation Centre at the beginning of the 1970's. Dropsy taught Zen meditation and Tai chi there . During the 1%O's and l 970 's in France, Dropsy developed a method that he called "Psychotonie". Dropsy was a trained mime artist and obtained a lot of his inspiration from dance and theatre, as well as different training forms such as Alexander technique, Laban dance, and Feldenkrais. Dropsy was also trained in psychotherapy and was inspired by different psychotherapeutic approaches . He taught different group methods, improvisation, and communication. Taking inspiration from different training methods , he developed a number of preliminary

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movements that today constitute the movements used in Basic Body Awareness Therapy. Zen meditation - movement in stillness - and Tai chi - stillness in movement - are marked by relaxed alertness and mindfulness. Dropsy proposed that BBAT worked with an integration of balance, freedom, and awareness (Dropsy 1988). His teaching was characterised by a holistic approach that included the idea that a person exists at the same time in several dimensions - the so-called dimensions of existence: the physical, the physiological, the psychological, and the existential dimension. Dropsy stated that all of these parts in the individual can work in a harmonious and balanced way. The movements would then be harmonious and balanced (Dropsy 1988). These theories remain within BBAT and are reflected in the movements and in the quality of the movements. The threefold contact problem was another of Dropsy's theories. He stated that a problem was reflected simultaneously in the individual's body, in their relation to other people, and in their understanding of reality (Dropsy 1975).

existential

Image 17. The four dimensions of existence, interpreted by Wulf, Gyllensten and Hug.

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Hof also emphasised the importance of a holistic approach. He posed the question : "What does it mean to be a human being?" The answer to this question had, and for a long time has, been character ised by a dualism where body and mind are separate. For Hof, it was the natural response that the human being is a whole, where body / mind form an inseparable unit with a natural interaction. Therefore, it is natural and completely necessary in connection with teaching Zen mediation to also perform physical movements . Through the body, the person also comes in contact with him - or herself. Meditation involves both a way of thinking and a way of relating to one's body to be in the body where the body and mind form a functioning unit (Hof 1985) . Gertrud Roxendal was a physiotherapist with psychiatry as her field of work. She tried to develop psychiatric physiotherapy for her entire working life. Taking inspiration from Dropsy, Roxendal introduced the Body Awareness method to Swedish psychiatric physiotherapy. She received her doctorate with the dissertation BodyAwarenessTherapyand BodyAwarenessScale(l 985). Roxendal had sources of inspiration other than Dropsy . Feldenkrais, Goldberg and Idla also influenced her, among others. Gradually, Body Awareness Therapy was made more concrete and distinct compared with other body awareness methods, and toward the end of the 1980's, the name was changed to "Basic Body Awareness Therapy". Beside the holistic approach, which she shared with Dropsy and Hof, it was also important for Roxendal to put the person into a social and psychological context, where the meeting with other people was the basis for activating and strengthening the person's identity and inherent power/ empowerment (Skoglund 2011). BBAT's development was originally based on clinical practice from the 1970's and onwards, and has now been used clinically for many decades. The physiotherapists who used BBAT with their patients in different illness and health areas discovered that the patients were helped both in getting rid of their symptoms and in changing their behaviour

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in a health-promoting way. From the 1980's, research on BBAT and its effects has increased and contributed to the theoretical development. One of the aims of BBAT is for the person to become more "embodied" - i.e. live more anchored in one's own body. According to the French phenomenological philosopher Merleau-Ponty (1962), the body is both an object, which we have, and an experiencing subject. The person can both have and be one's body simultaneously, as the starting point to create meaning in relation to oneself and others. The body is seen as an inseparable part of the self All body awareness therapy is seen as an inseparable part of the self. All body awareness therapy aims to strengthen and continue an interrupted personal process towards unity and integration. This process has been interrupted within the little child for various reasons, but the development possibilities are always latent (Mehling et al. 2011, Roxendal 1987, 2002). BBAT is mainly a movement therapy. A selection of movements in different starting positions such as sitting, standing, lying and walking, serve as a model for the basic principles in BBAT: balance, freedom, and awareness (Dropsy 1988). BBAT also includes an approach to the body, body movements and body experiences. Through movements and actions, inner needs and feelings are expressed. How people relate to their needs and feelings and how they understand their needs and feelings in relation to themselves and others also imprint the movements and their view of their own identity and self (Gyllensten et al. 2009).

Body ego Roxendal formulated the concept bodyego,which in BBAT involves the way the ego expresses itself through the body (1997). Body ego is the indivisible unit of body and mind. Body ego includes aspects of both the individual's experiences of the body and how the individual expresses themself through movements. According to Roxendal, the BBAT movements aim to restore a disrupted bod y ego. The functions of the body

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ego which one works with in movements and attitudes are: the relation to the ground (anchoring); the relation to the midline; centring; breathing; flow; and relation to one's own body and to others . The guiding principle is the mental presence(Roxendal 1987) . In Sweden, work with the body ego functions has been the hallmark of BBAT. The body ego concept and body ego functions have sometimes been criticised for being dualistic . Roxendal's intention was, however, that the body be the first aspect of the self. Freud (1920) made use of the body ego concept . Later, developmental psychology has instead used other concepts - e.g. the "core self " (Stern 1985) . The movements in BBAT start from a holistic perspective where the whole body is involved in a movement or function. The focus is on floor contact, grounding, the ability to find one's stable balance and to coordinate and centre the movements in an economic and relaxed way. It is also important to understand how power can be created in movement , to feel how breathing can be naturally integrated, and to find a relaxed and harmonious flow of movement . The BBAT method has a clear psychological and existential anchor age, but is based on movements with a focus on presence, to both make and experience the movement. The movements take place in a meeting between to be, to do, and to relate both to oneself and to others . To be present in silence can be very distressing and difficult for many people, because contact with oneself can be difficult to bear. Restlessness, different types of activity, or muscle tension, can be ways to divert attention from not feeling good . Physical activity can also be avoided because one can be afraid of the pulse and heart rate increasing, which can be similar to an anxiety attack. Basic Body Awareness Therapy can be a way to increase tolerance to be present and in contact with the body. In this way, BBAT can also be seen as an exposure therapy (Gyllensten 2012) . Physical activity or exercise can however also be used as a way to avoid experiencing one's anxiety. Breath ing has a central role and is integrated into the movements . The natural and simple in movements and breathing are sought . The 51

goal is to combine maximum efficiency with minimum consumption of power, which involves always having reserves and promoting the quality of movements and the interaction between movement and breathing . Basic Body Awareness Therapy works mainly with processes that affect basic motor functions, i.e. both balance and movements, and with the ability to be present and in contact with oneself and with others. Awareness that I am the one who moves, that the movement expresses "who I am" increases. This contributes to a greater sense of meaning, self-awareness, agency and empowerment. In BBAT, the therapist tries to increase the individual's understanding of one's own needs, body language and resources. Increased body awareness is seen as something positive. It has been claimed that increased body awareness leads to increased symptom fixation or morbid somatosensory amplification (Mehling et al. 2011). These writers point out that body awareness may be defined as an increased ability to recognise one's body sensations and thus a better ability to live more in contact with one's identity, experienced in the body, which is the starting point for making sense in relation to oneself and the environment (Mehling et al. 2011). This means strengthening the experience of empowerment . This may in turn affect one's own reality and ability to act in a larger context . Even pain is accepted and inte grated with the available resources. The salutogeneticperspective,where interest is focused on what keeps the individual in good health despite temptations and problems, is central in BBAT (Roxendal 1987, Antonovsky 1991, Frankl 1986, 1996, Gyllensten 2001, 2012).

The bodily-anchored identity Merleau-Ponty coined the concept embodiment, by which he meant that the person has and at the same time is his own body (Merleau-Ponty 1962) . Gyllensten et al. (201 0) studied how different people experience what is the core idea in the concept body awareness,and in what way this is important for the individual. Researchers have made use of the

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method of grounded theory - a qualitative research method that aims to create models or theories . Gyllensten et al's study resulted in a model that was published in scientific literature . The model has been called the embodied identity . The model is presented briefly in the figure below.

Living in society Living in relation to others

LivingIn the body

Image 18. Embodied identity. "Living in the body" (theme 1) and "Living in relation to others and in society" (theme 2), (Gyllensten et. al 2010).

The significance of the individual's body awareness was investigated through focus-group interviews with healthy people, physiotherapists, psychologists, occupational therapists, priests, shop assistants and farmers, as well as people in psychiatric rehabilitation. The informants were questioned about what kind of experiences they found to be important in order to be aware of and in contact with their bodies . Two important aspects of body awareness (the themes) appeared and were called: Living in the body and Living in relation to others and in society The first theme, Living in the body, showed that the informants felt it important to experience themselves from an inner perspective . Physical balance and stability were connected to the experience of well-being and control. To understand one's own feelings and needs through being in

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contact with one's own body was perceived as the basis for self-confidence and self-reliance. This increased the ability to take care of oneself and one's needs both physically and mentally. Living in relation to others and in society was the other theme. To live in relation to others was expressed as a strong need. To be recognised and valued by other important people should occur by being physically involved, and was of significance for the experience of being alive. How one could be in relation to others was in turn related to how one could be in contact with oneself and one's needs . Having close relationships was perceived as a way to become more clear, visible and satisfied as a person. To live in society was seen as important for feelings of participation and empowerment.

livingin the bodythe innerperspective

Image 19. The content of the theme "Living in the body". Developed from the article by Gyllensten et. al. 2010.

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Patient safety Before therapy is started, it is important that the patient's desires and goals are brought forward . The patient should be informed about what the examinations show and which possible therapy alternatives exist. The patient is the one who has the power to take the decision about the content and design of therapy (Halso - och Sjukvardslagen [Swedish Health and Medical Services Act] 1982 :763). Physiotherapists generally work from a functional perspective based on the Physiotherapyprocess, which involves clinical reasoning throughout the entire therapy process, and where therapy is continuously questioned and assessed (Thornquist 2001). The International Classificationof Functioning, Disabiliryand Health (]CF) is a model from the World Health Organization (WHO) and is one of the bases for the evaluation scale Body Awareness Scale Movement Quality and Experiences (BAS MQ-E) . The function, activity and participation aspects ofICF are used in BAS MQ-E.

International Classification of Functioning, Disability and Health (ICF) The International Classification of Diseases (ICD) was created by the WHO in 1994 to help diagnose different illnesses and for research and comparison work in all Member States. This is revised and updated con tinuously, and it is now on version 10 (WHO 2014). Physiotherapists use the International Classification of Function, Disability and Health (ICF) , which was created in 2001 as a comple ment to the diagnostic system ICD . ICF takes a functional perspective, and looks at disability from both an individual and group perspective. ICF makes it possible to describe a person's functioning,

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functional impairment and health, based on a biopsychosocial model (Socialstyrelsen [Swedish National Board of Health and Welfare] 2014). Both ICF and ICFCY (children and youth version) consist of two parts with two components per part: 1. Function and impairments, which include a. Body functions and body structures, and b. Activities and participation. 2. Contextual factors, which include a. Environmental factors, and b. Personal factors (for now not classified in ICF). ICF is intended to be a statistical tool, a tool in research, a clinical tool for assessing the needs for rehabilitation, habilitation and therapy of various conditions, a social policy tool, and an instrument in education (Socialstyrelsen 2003). Components of functioning and impairments in ICF can be expressed in two ways. On the one hand, they can be used to show problems, i.e. impairments, structural abnormalities, activity limitations or participation restrictions, summarised under the umbrella term impairments. On the other hand, they can indicate unproblematic or neutral aspects of health and health-related conditions, summarised under the umbrella term functioning (Socialstyrelsen 2003, p. 13).

Definitions In the health context, these include: • Body functions: the body's physiological and psychological functions. • Body structures: anatomical parts of the body such as organs, limbs, and their components. • Activity: a person's tasks or actions.

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• Participation: a person's invo lvement in a life situation . • Impairments and structural abnormalities: problems such as a sig-

nificant deviation or loss in body function or body structure . • Activity limitations: difficulties a person can have in performing activities. • Participation restrictions: problems a person can have in involvement in life situations. • Environmental factors : the phy sical, social and attitudinal envi-

ronment in which people live and work - factors outside of the individual. • Personalfactors: the individual background to a person's life, consisting of personal qualities such as gender, race, age, health factors, fitness, lifestyle, habits, upbring ing, coping method, social background, education, profession and previous or current experiences. Body function, activity and participation in ICF are the aspects mainly used in the BAS MQ-E assessment.

BodyAwareness Scale Movement Quality and Experiences (BASMQ-E) In the story about Anna, Patrick used, in an early stage of treatment, the assessment BAS MQ-E . Patrick chose to start with a few movements from the BAS MQ -E assessment before taking the entire test . This method of investigation focuses on both what the therapist sees in the movements (observations), and the subject's own experiences of the body, function and movements. BAS MQ-E contains three parts : • Movement test • Questionnaire about body and body experiences • Experience -based qualitative interview

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The purpose of the combination of the three parts is for both the therapist and patient to receive a broad picture of the patient's condition and situation. BAS MQ-E was constructed by Gyllensten and Mattsson in 2011 and revised in 2015 (Gyllensten & Mattsson 2011, 2015). It is based on the theories of Basic Body Awareness Therapy and the original BAS created by the physiotherapist Gertrud Roxendal in connection with her 1985 dissertation (Roxendal 1985), as well as the developments made by Roxendal in 1993. She further developed the assessments in 1997 to include also the BAS health (BAS-H) and interview scales for body-ego functions, ISK (Roxendal 1997). BAS MQ-E is also influenced by ICE The BAS MQ-E aims to function both clinically and in research.

Movement test (BASMO) The movement test was developed using both clinical expertise and scientific studies. The statistical method factor analysis has been used, aiming to find movement variables that provide as much information as possible in as few variables as possible. Three factors (subscales) emerged, called: • Stability in function • Coordination/breathing • Relating/presence The factor analysis showed that the grouping of the variables correlated with the original theories in Basic Body Awareness that were formulated by Dropsy (1988): balance, freedom and awareness. Roxendal's theories about body awareness build on Dropsy's theories (Gyllensten & Mattsson 2011). The movement test has been tested for inter-raterreliability (coordinated assessment between two different evaluators), and validity in relation to health-related quality of life (SF 36, Sunden et al. 2013 , 58

Image 20. BAS MQ factor Stability in function, interpreted by Wulf, Gyllensten and Hug .

Image 21. BAS MQ factor Coord ination/breathing, interpreted by Wulf, Gyllensten and Hug.

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..

..

...

Image 22 . BAS MQ factor Relating/presenc e, interpreted by Wulf, Gyllensten and Hug.

2016) and psychiatric symptoms (Hedlund et al. 2016). Reliability and validity were found to be adequate. In the movement test, the different functional elements are evaluated from 0 to 4. The number 0 means that the movement is made harmonically, with vitality, stability and ease. The number 4 means that the patient cannot perform movements or does them completely incorrectly. With the help of the movement test, it is possible to evaluate both the quality in different movements, and disability. The test includes everyday functional movements like sitting down, lying down on the floor and getting up, jumping, walking, transferring weight, balancing on one foot , and doing isolated or coordinated movements or simpler BBAT-movements. Selecting the distance to the assessor and relating to one's own mirror image are also included.

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The questionnaire (part of BAS-E) The questionnaire 7he Body and body experiencesis filled out by the patient themself. The focus is on how the body and daily life are working. The scale goes from 0 to 3, where 0 means no symptoms, good functionality and 3 means extreme symptoms - or has not answered the question. The questionnaire also asks if the patient believes that change for the better is possible, and what their present coping strategies are. The questionnaire has been scientifically validated (Hedlund et al. 2016).

Qualitative interview (part of BAS-E) In the Experience-basedinterview, the patient makes five movements from the test, and describes how it feels while he/she makes these movements. What is requested is, for example, the experience of stability and balance in weight transfer, how breathing feels when lying on the floor, or how it feels to be present and pay attention when moving. In this part of the scale no numbers are used. BAS MQ-E thus includes both the physiotherapist's professional observations and the patient's own experiences, which are both estimated with numbers in the questionnaire and are written down verbatim in the qualitative interview. The scale, in consultation with the patient, is used for planning and evaluation of a therapy . It can be used as starting point for a process of change and to communicate aspects of the patient's physical resources and problems to potential cooperating partners in the team (Gyllensten & Mattson 2011).

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The case of Anna - the first examinationwith BAS MO-E In the BAS MQ-E test Patrick made with Anna at the beginning of therapy, Patrick saw in the movement test that Anna had a lot of resources. She was relatively mobile and could perform all the functional tests - for example, sitting down and lying down on the floor and then getting up, and stepping up on a chair. She had difficulties in the subscale Stabiliryin Junction, where Patrick discovered great difficulty, pathology, on the variables "Stability in the balance line." Anna had great difficulties keeping herself within the boundaries in which she could be stable, and also difficulty with stability in stillness at some points. Also, when asked to "stomp" she put her foot down as if to stomp, but there was no stomp . Anna also showed great difficulty being "flexible in the balance line" and "springy in leg movements." In the subscale Coordination/breathing,Patrick saw that coordination and breathing were locked, and the movements were arrhythmic and fragmented. Breathing was not integrated in the movements, and Anna had a slight but continuing muscle tension. In the subscale Relating/presencethere were a lot of resources. Anna could both look at herself in the mirror and be present in the meeting with Patrick in a natural way. In the QuestionnaireAnna said that she felt bad in the body and felt like a robot, and that she had bothersome muscle tensions and chronic pain. She would like to move and exercise, but could only do the bare essentials. She believed, however, that she could come out of her situation (change is possible). In the experience-basedinterview, Anna said that she felt unsteady and out of balance . When she moved, she experienced muscle tension, and she felt that her arms were as tense as logs. She experienced breathing as being locked. She felt that during the movement test, she was present and happy, rather than her usual feeling of being fragmented and unfocused.

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The case of Anna - BASMQ- E after therapy After therapy, Anna changed, and the BAS MQ-E showed the following: • In the movement test, subscale Stability in function, Patrick observed that Anna became more stable in her balance line, both in weight transfers and standing on one foot. Her ability to stomp showed that she had a power and vitality in movement , and her ability to be flexible through the balance line, for example to be springy through the balance line, also improved . This was seen both in walking and in standing spring movements. • On the subscale Coordination/breathing, he observed that breath ing became more integrated with the movements, and Anna no longer locked it when she, for example, balanced on one leg. The ability to coordinate her arms and legs also increased and, for example, the movement "The wave" developed both rhythm and flow. There was still some difficulty with the flow in the rotation movement. • On the subscale Relating/presence there were still many resources, and Anna seemed to have good contact with both herself and with Patrick during the movements . • In the Questionnaire, Anna reckoned that she had only temporary muscle tension and pain, and she thought she could do what she wants in her daily life. She moved/exercised regularly. She also stated that she had several different strategies to feel good and handle her difficulties. • In the experience-based interview, Anna said that she noticed that she was more stable now, and that her posture had become much better. In the coordination movements, she expressed the view that she felt nice and relaxed and much freer to move. She thought that her breathing felt calm and comfortable, and her abilities to concentrate and be present were good.

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BodyAwareness Rating Scale Movement Quality and Experience (BARS-MOE) There is another scale used in connection with the therapy of Basic Body Awareness. It is Norwegian, and created originally through research and development by the physical therapist Ulla-Britt Skatteboe (Skatteboe et al. 1989, Friis et al. 1989, Skatteboe 2000). The scale is also inspired by the theories behind Basic Body Awareness, especially theories about balance, freedom and awareness, as well as the three different movement coordinations (Dropsy 1988, 1998). BARS originally consisted of six subscales that measured (i) body awareness, (ii) emotional awareness, (iii) psychomotor function, (iv) spontaneous actions, (v) verbalisation ability, and (vi) interpersonal function. After a factor analysis, the scale was divided into two subscales: movement dimension and awareness dimension (Skatteboe et al. 1989, Friis et al. 1989, Skatteboe 2000). BARS movement quality has been further developed and validated by Skjaerven et al., and now includes observation of the patient's movement quality and the patient's description of direct experiences (Skjaerven et al. 2013, 2015).

Differences between BASMQ-E and BARS-MOE The difference between the Norwegian BARS-MQE and the Swedish BAS MQ-E is that the Norwegian scale only examines movements from BBAT while the Swedish assessment besides movements from BBAT also includes functional tests inspired by ICF. The experience part of the Swedish assessment in addition includes both qualitative and self-rated experiences perceived by the body, functional ability and movements. It also includes aspects of activity and participation according to ICF. The Norwegian BARS- MQE includes questions about the experience of the body awareness movements.

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3. Body functions Everydaymovements and function The functional capability in everyday movements is dependent on stability in function, coordination and breathing, and the ability to relate to and be aware of both oneself and others in the environment (Gyllensten & Mattsson 2011). This is in accordance with the theories formulated by Dropsy about balance, freedom and awareness as cornerstones of human function (Dropsy 1988, 1998). According to the World Confederation of Physical Therapy (WCPT), maximal movement and functional ability are the physiotherapist's central areas of work, and are of great significance for an individual's health-related quality of life and well-being in physical, psychological, emotional and social perspectives (http:/ /www.wcpt .org/policy /ps-descriptionPT). According to ICF, functionality is dependent on body function, structure, activity and participation. Environmental factors and personal factors are the contextual fields where the individual lives.

Balance and posture The child will, after an important period of crawling and standing on all fours, get up to stand, as the nervous system and muscles gradually mature . Access to the standing position depends in part on the maturity of the organism, and in part on the child imitating its environment . To arrive at this stage takes around one year for the child . To find a good and functional balance in standing, the person is dependent on an optimal relationship between the gravity pulling us down and the

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anti -gravitational forces that provide a balanced straightening . The base in this balanced posture is the feet. To gain access to a dynamic and vibrant balance, one must place body weight on the middle of the feet, i.e. in an area clearly in front of the ankles. Thereafter, there is a dynamic balanced posture built upwards through the balance line. This requires freedom in the knees and hips, and access to balanced bends in the back with a lumbar lordosis, thoracic kyphosis and a cervical lordosis . The bends in the spine thus balance each other. The position of the head is particularly important, and there should be a small extension of the neck. Besides a balanced posture, dynamic balance is dependent on a free breathing where inspiration fills us in an expansion and extension, and exhalation makes us slouch a bit and become a bit shortened . In this way, breathing includes the whole person from head to foot (Dropsy 1975, 1988, Roxendal & Winberg 2002). An ideal posture optimises biomechanical and neuromuscular patterns . These patterns form the basis of the body's longitudinal axis, making breathing easier. A good posture should not involve any effort, should be comfortable, and should be the basis for functional movements. The traditional approach to posture which involves appeals like "straighten up," "pull your shoulders back," and "pull your stomach in" is a simplified view of posture and is, furthermore, incorrect (Elphinston 2006) . With most people, just as with Anna in our story, there are many factors during childhood and adulthood that contribute to the loss of the natural and dynamic balance we had access to as small children . We must search to regain the original coordination (Dropsy 1988). Balance and posture are intimately linked and cannot be separated, several authors say (for example, Trew & Everett 1997). Posture is defined as the body 's position and orientation of the body 's parts in relation to each other. A "good" post ure is considered to be the posture that requires the least energy to maintain and which exposes joints, ligaments and legs to the least strain while at the same time maintaining the body's centre of mass (COM) within the support surface (Thibodeau & 66

Patton 1993). Posturalorientation is defined as the ability to maintain an appropriate relationship between the body's different parts (segments) and between the body and the environment where the task is performed (Horak & Macpherson 1996). Anna tells Patrick that she doesn't like to stand and that it feels exhausting. Her centre of gravity lies too far back, which causes tensions and increased energy consumption, as well as prolongation of pain. In order to be able to perform targeted actions, posture is required to adapt to different situations and actions. In Anna's case, it is essential that she finds the right balance and posture while sitting and working at the computer, in order to avoid unnecessary tension. She also needs to get access to a more economical way of standing and walking in daily life, so that she is able to relax her muscle tension and rely on the body itself to be able to keep itself up. To maintain a balanced sitting and standing posture, a harmony between downward and upward forces is required. The muscular background tension is affected by several factors: resistance from the muscles being extended, i.e. inherent stiffness (Basmajian & Deluca 1985), neural activation of the stretch reflex, and postural activation of anti-gravitational muscles. These however are in a dynamic interaction with the postural swaying which always occurs in standing/sitting in stillness (Shumway-Cook & Wollacott 2010). Posture is also affected by our emotions and by our energy supply. Locking in breathing musculature adds to an increased muscle tension in the diaphragm and parts of the stomach musculature, which also negatively affects the posture pattern. Postural stability is the ability to control COM in relation to the support surface. Postural stability is affected by the environment and the individual 's expectation of what the action requires. The body automatically sets and adjusts stability to counter the demands of the coming action. This is based on previous experiences and knowledge, the so-called "anticipatory postural control" or "feed-forward control" (Shumway-Cook & Wollacott 2010). As regards previous experiences, it is important to be able to sense and interpret impressions in the right

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way. For example, the body is activated differently when one lifts a milk container, depending on whether one believes the container to be full or empty. Postural stability can also be seen from an emotional perspective or a dimension where the experienced balance of life, security and other life experiences play a role. Fear or lack of confidence to be successful affects postural stability. For example, many older people have a fear of falling, wh ich affects stability negatively (Pai et al. 2000). Research shows that postural stability is very important for health-related quality of life and for the balance function in broad terms, as well as for confidence in one's own ability and self-efficacy (Gyllensten 1999, 2009). Situations where one does not feel secure, where self-esteem is fragile, and where the person does not have any clear intention or targeting, can give a feeling or experience that one is unstable or dizzy. This emotional dimension exists in part with Anna when she comes into Patrick's practice for the first time. Postural control refers to the interaction between the individual, the task the individual shall do, as well as the environment (Shumway-Cook & Wollacott 2010). The concept of postural control refers to the individual's ability to control the body's position in the room/space to secure both stability and orientation, as well as the ability to maintain and restore postural control if it is disturbed. It is about the interaction between the individual and the environment. It is believed that the main task of the central nervous system concerning postural control is to ensure that the body's weight projection (COM) is inside the area of support. Balance is also affected by the speed of movement of COM in comparison with the speed of sensorimotor strategies and the ability to pay attention (Shumway-Cook & Wollacott 2010) . The somatosensory aspect of postural control includes propriocep tors in the muscles as well as the Golgi tendon organs. These send important information on the position of the joints and the relationship between the joints in space. The muscle coils signal the muscles' length and change of length. Dermal receptors can give information about the

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body's position and alignment of the centre of mass. To be able to stand in upright balance depends on coordination between the proprioceptive, vestibular and visual sensory systems. The mutual relationship of different body segments, the relationship between the body and the support surface (the somatosensory system) and the relationship between the body and object in the environment (the visual system) are central factors according to Shumway-Cook and Wollacott (2010). The vestibular system gives information about the head's position. The labyrinth in the inner ear detects the acceleration of the head and the relationship to the Earth 's gravity. Sensory integration means that impressions from the different senses are organised and coordinated with each other and thereafter also with the motor system . This integration is essential for well-functioning balance and motor skills. In summary, there are many concepts that describe different aspects of a person's upright position , which is of significance for a well-func tioning stability.

Standing function To relax and let the Earth's gravity act on the body can be seen as an expression for a basic reliance . Here there are parallels to resting confidently as a child in the arms of a safe person. The experience of being carried by the floor or ground thus has parallels to being carried as a child. To be able to have good contact between the sole of the foot and the floor, for example, gives an increased feeling of security, stability and balance that in turn makes the movements freer (Gyllensten 2012). In BBAT this is called grounding. It is seen as one aspect of optimal postural stability and is very important for daily functioning. Grounding exercises/movements are those where the relationship to the floor is noticed and actively emphasised in movements. Grounding can be trained in several starting positions. In BBAT, one practises remaining within stability limits. Stability limits are the areas where the body can

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maintain stability without changing the support surface. This means, for example, that the soles of the foot maintain contact with the floor while the body moves back and forth. To take a step to the side, forward, or backward, or to support with the hands against a wall belongs to the postural protective reactions. In the BBAT movements the person is encouraged to make the movements smaller so that it will be possible to maintain the stability limits without any protective reaction .

Image 23. The balance line.

Sitting function To find inner stability in sitting is based on sitting in such a balance that gravitation and the straightening functions balance each other . Downward gravity activates the upward straightening function. It has been described as "just like a flower that gets water and stands in good earth,

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so can the individual also find a relaxed balance, a relaxed wakefulness" (Hof 1985). When in this way one finds a relaxed balance, the outer muscles can more and more give way, and the deep postural muscles are activated. This in turn releases physiological functions, respiratory flow gets freer, and thereby the balanced posture is further supported. Posture and breathing support and help each other in this way, just as in the standing position . The optimal sitting posture should have the projection of the centre of mass (COM) through the ischial tuberosity and somewhat before th e eleventh thoracic vertebra to avoid the body getting an adverse posture with increased thoracic kyphosis or kyphosised lordosis . An optimal sitting posture is more relaxed than the standing posture but quite unsta ble. How you sit on the chair is important to be able to maintain a good sitting position, according to Trew & Everett (1997) . All people learn to sit in the same way. This has purely biological reasons and depends on the body's maturation, and development of the nervous system, muscles and joints - the basic motor skills (Dropsy 1988, Bader-Johansson 2013). Through constant repetition and exploration, interaction is gradually established between gravity and straight ening functions so that sitting becomes more automatic and without conscious control. Throughout the course of life, for different psychophysical reasons, compensatory posture and movement patterns arise that gradually develop to become more or less unconscious habits. These habits may already be relatively fixed at an early age (Bader-Johansson 2013) . Patrick works with Anna so that she will find a natural, balanced sitting posture. The goal in the therapy is to find a sitting where inner support from the deep muscles is activated. The deep muscles, i.e. mul tifidi and rotators, transversus abdominis and the pelvic floor muscula ture, form a unit that contributes to a basic functional stability (Dropsy 1988, Bader-Johansson 2013, Elph inston 2006) . If there is an unstable sitting posture found in the treatment with BBAT, the person is helped by being instructed to place their feet firmly

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on the floor while at the same time being told to be conscious of the bottom's weight against the chair. In such a way, the feet and pelvis form a triangle that provides increased support from the ground, which in turn can make sitting feel relatively stable. In this starting position, it is possible to activate a basic functional stability. This is something Patrick introduced early on in Anna's therapy .

Walking function The ability to walk makes a person able to widen their field and discover new places; the world opens up. For the child, however, it takes several years to attain a stable and balanced walk. With the adult, the way of walking mirrors both universal laws and individual characteristics. It is easy to recognise a person at a distance by their way of walking (Dropsy 1988, Roxendal & Winberg 2002). Walking is affected both by internal and external factors and it is easy for the functional walking pattern to be disrupted. A disrupted and inefficient pattern of walking can eventually be harmful. A key is to find functional stability walking along the longitudinal axis - in BBAT called the balance line. Contact with postural stability is required for an effective walking movement. This balance line is in no way static and locked, but dynamic, and gives a feeling of a fixed, but at the same time flexible, reference point. The balance line provides good support to the movements of our torso, arms and legs (Dropsy 1988, Elphinston 2006). When the balance line is optimally established, walking becomes easy. The body does not sway here and there in the frontal plane but instead walking involves an effective forward movement in the sagittal plane. The child walks during the two first years with so-called digitigrade walking where the foot as a whole is put on the floor or the toes are placed before the heel. The movement is performed from the hip and the pelvis, and walking looks like rocking. Later, plantigrade walking is developed, where the heel is placed first and weight is rolled forward

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over the foot (Bader-Johansson 2013). In adults, walking takes place from the feet and from pressure from the big toe, and in a rotational movement around the balance line . Walking involves a forward movement as a "falling forward" with a starting point in the standing posture . The alternating free arm and leg movements are only possible thanks to the rotational movement around the balance line or longitudinal axis (Bader-Johanson 2013) . The head's posture is important for facilitating rotation around the longitudinal axis. When walking, we normally do not need to think about how we are doing it. We can raise and lower the rhythm relatively unconsciously. At the spinal cord and brain-stem level, there are so-called rhythm generators that determine the rhythm precisely for rhythmic movements such as walking and breathing (Bader-Johansson 2013, p. 52). Many parts of the brain contribute to control of spinal rhythm generators. Most control comes directly from the formatio reticularis, basal ganglia, cerebellum, and from the cerebral cortex (Kiehn 2006, Brodal 2010, Bader-Johansson 2013) . Walking is a very complex action. The Vietnamese monk Thich Nhat Hanh said that "the real miracle is not to walk either on water or in thin air, but to walk on earth" (Thich Nhat Hanh 1996).

Lyingfunction In lying, there is minimal postural activity. Lying is the position where it is easiest to find relaxation . In lying, gravity acts optimally through all the body's segments that are in contact with the floor (Larson & Gould 1974). To lie down and rest a while naturally provides a good recovery. Rest is really a prerequisite to be able to work. In its interaction with the environment, the child learns to trust its inner needs . To calmly be met and acknowledged is a good prerequisite to feeling secure and thereby having the possibility to give way to gravity and be allowed to rest. To be able to feel in oneself, and sense how things are at the present moment and what one needs or does not want, is a basis for maintenance of

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physical and mental health throughout life. The child establishes early on, already at the age of two to seven months, an important ability to find calm in the body, in dialogue with the environment. Those early months are considered a very important period in the individual's development (Ainsworth 1979, Stern 1985, Fadnes-Leira, 2006). In the basic movements of BBAT, the relationship to the floor is practised - for example the relationship to the ground is consciously noted. The abilities of being carried by the floor and giving in to gravity are also examples of this. Lying is the position that requires the least energy. Often, however, there are muscle tensions and asymmetries, as well as difficulty relaxing and softening against the floor. To be able to lie and notice and accept things as they are is not always easy. A lying position can create anxiety because the muscles naturally are the least active here, and they no longer act as a psychological defence. This can impede contact with inner needs/feelings or conflicts (Bunkan 1997). This may mean that the person becomes restless or anxious. With many patients, it is then good to start training in sitting and standing because it can be distressing to lie and give in to one's muscle tensions . With Anna, there is an obvious muscle tension in lying, and she cannot give in to gravity, relax, and allow herself to be carried by the floor.

Breathing Breathing is life, and to breathe with the lower part of the stomach-ab domen promotes health and helps to oxygenate every cell in the body (Demoise 2010) . Free breathing allows freedom, effectiveness and harmony in the movements and contact with inner needs and desires (Dropsy 1975). When one has exhaled air with carbon dioxide, the respiratory centre in the medulla provides an impulse to inhale again. The impulse is passed through nerve pathways to the diaphragm and the intercostal muscles are activated . When the diaphragm is lowered by inhalation,

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the lungs stretch out and the chest and the abdomen expand. A soft widening of the back and shoulders also occurs. The organs in the abdomen and pelvis become compressed in the inhalation phase and their circulation is stimulated. Only if the volitional skeletal musculature in the torso, arms and legs is in balance and relaxed, can the inhalation wave travel out in the periphery . During exhalation, the diaphragm is raised passively back up into the chest like a dome and the intercostal musculature is activated. The lungs are compressed and abdominal organs go back to their original position as air streams out . Under optimal conditions, the whole breathing cycle occurs by itself without control. In a state of calm and inner harmony, after exhalation there will be a small breathing pause (Holler -Zangenfeind 2007). Dropsy said that the rhythmic interplay between exhalation and inhalation is like a continuing ebb and flow, a rhythmic series of contractions and relaxations (Dropsy 1975). Breathing can also be controlled by our conscious will. We can breathe quickly or slowly if we wish. Even unconscious factors affect breathing. These factors can be suppressed feelings or efforts to adapt one's behaviour, as well as stress or anxiety. This creates tensions in the respiratory musculature. To hold one's breath or breathe just a little decreases vitality and in that way also leads to a diminished experience of needs and feelings, which become less intrusive. In this way, tensions in the respiratory muscles and contro l of breathing work as a part of a psychological defence. The diminished emotions of the individual become an adaptation to a difficult situation and sometimes a necessity to survive mentally or physically (Reich 1945, Lowen 1975, Gyllensten 2011). This pattern is unconscious in adults, but begins early in childhood, often as a part of the attachment period, upbringing and the socialisation process. When breathing is inhibited, symptoms such as experiences of a hold in the diaphragm, shortness of breath, discomfort from the stomach or the heart, and decreased vitality can occur (Bunkan 1987, 1997, Gyllensten 2011) . Breathing is part of both the autonomous and the volitional nervous system (Dropsy 1975). Breathing 75

affects also the organism's fundamental metabolism . There are examples of humans under certain conditions who can adapt the relationship between breathing and metabolism so that they can live naked in Himalayan snow (Dropsy 1975) . Usually it is not so dramatic, but one can affect the sensation of ice cold feet by releasing the breathing and there by improve blood circulation . BBAT encourages the individual to simply notice the breathing and accept what is experienced at the present moment . Through acceptance and gentle movements, however, there is the long-term goal to obtain a freer and more harmonic breathing and to come in contact with oneself Initially, the significance of allowing the breathing to be untam pered is emphasised - allowing the breathing to spontaneously adapt itself to different situations and circumstances . Autonomous breathing is very effective and shou ld be left in peace as much as possible. This is the starting point in BBAT and is one of the basic aspects in working with the awareness of the breathing . In BBAT, one also works with conscientiously integrating breathing with movements. The aim is to change the habit/behaviour of holding one's breath and tensing up when doing something like moving or performing activities. By integrating movement and breathing, the breathing is also deepened and gently released from tensions. Releasing the breathing in BBAT is also done with the help of sounds . There are many therapies that stress the importance of a long exhalation. This is a means to activate the parasympathetic system, achieve rest and relaxation and to come in contact with oneself. The long exhalation is emphasised within some Zen traditions. Waiting for the inhalation is another important aspect of this meditative technique. Hof emphasised the long exhalation which bottoms in the lower abdomen; this is also an optimal way to saturate oneself (Hof 1985) . Some writers state that it is enough to be aware of the pelvic floor in exhalation. This will activate the deep abdominal muscle - transversus abdominis - that in turn interacts with the deep postural muscles - multifidi and rota tors. This prov ides a natural inner functional stability, activated by the

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breathing (Lam 2006a) . This is an example of the connection between deep breathing and basic postural stability.

The voice The voice is intimately associated with breathing and is developed in parallel with breathing when the body grows. Each voice is unique. The voice is communication with the outside world. Small children inform their parents if they feel well or not with the help of the voice. The voice is affected on many occasions - for example, when someone is unsure or tense. You can most often directly decide whether a person is in harmony with him-/herself, or whether something is amiss, just by hearing the person talk (Dropsy 1988, Holler -Zangenfeind 2007). In BBAT, breathing is deepened and extended with the help of sounds. The sounds used are the m-, ah-, oh- and e-sounds. The aim is to deepen the breathing and softly prolong the exhalation . Sounds have different aims, where the m-sound is connected with deepening and releasing one's own breathing. The m-sound is one of the earliest sounds a child uses in, for exa~ple, babbling. In BBAT, the m-sound can be seen as a natural sound, both to create calm and to get more in contact with the self. The sounds "oh", "ah" and "e" are often used when working with action and intention. The ah-sound is considered to be more open, the oh-sound is considered to be more immersive, while the e-sound stands for gathering around the upright balance line (Dropsy 1988). The voice exercises lead to practising one's communication not only outwardly to others but also with inner sensations, like inner vibrations and resonance . The exercises affect not only the vocal cords, but like other BBAT-movements, the whole person. When working with the voice, one works with the whole self This also applies here as in other BBAT-movements, using the power in the right way, economically and effort-savingly. If one is blocked in posture, breathing or energy flow, the voice will be unconditionally affected. It is very difficult to get 77

a deep, relaxed and mellow voice when one is not in physical balance. Body awareness and balance in muscular and breathing activation are important for the voice to develop optimally. Breathing is not just a function of the person; it expresses the person that we are. We have our breathing and we are our breathing (Dropsy 1975, Holler-Zangenfeind 2007) . A tone begins with an intention . Exhaled air and muscle tone put in motion the vibration of the vocal cords. These are led further over the skeleton and the surrounding body structures - the so-called bodily spaces - vibrate with it. When the tone's fine vibrations cause the body room to ring, we speak about a resonance room. Resonance and vibrations are prevented from spreading through the body by postural deviations, muscle tensions, overstrained vocal cords (e.g. hoarseness), controlled breathing and fear to show one's feelings. To be able to develop one's unique voice resources one must work economically with the whole body. It also requires to accept all experiences which one carries within oneself The voice expresses the person one is, irrespective whether one is aware of it or not (Holler-Zangenfeind 2007). In Anna's case, her voice developed from the first time she came to Patrick. At the beginning, she was afraid and uncertain and had a thin and tense voice. When she left Patrick, her voice had developed a deeper and more relaxed tone .

Coordination/centring

of movements

Freedom in the motor function is dependent on breathing, balanced posture and movements being integrated, as well as the ability of the torso to coordinate the movements effectively. This takes place via the contact through the centre of movement. 7he centre of movement is localised in the middle of the torso, between the breastbone and navel at the front of the body as well as across the inside of the torso to the area around the thoracolumbar joint on the dorsal side. In this area, the

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great muscle groups meet from the thorax and pelvis/hip region. The diaphragm cupola is also here. In Basic Body Awareness Therapy, the centre for movement is located in the solar plexus area. The movement centre has great significance both for well-functioning coordination and for the use of power and freedom in the movements. When the movement is centred, it becomes fluid, circular or spiral-formed - that is, three-dimensional. The experience from the movement is that it feels free and easy (Skjaerven et al. 2008). Coordination is dependent on the balance between the centre and the periphery. Proximal stability is stability and strength in the central areas of the torso, both at the front and the back. The more developed stability is in this area, the more refined the motor function in the distal parts of the body is - e.g. arms, hands, legs and feet. The large respiratory diaphragm muscle attaches in several places in the central area. Muscle tensions in the back, in the diaphragm or in the abdominal muscles can lead to the area around the centre of movement becoming hard and tense . The movement pattern can then become fragmented, stiff and less coordinated. The body can feel locked, tense and restrained. If the movements are centred and not fragmented, they are experienced and expressed as a uniform wave movement where minimal power is needed and the whole body is interconnected. The experience of interconnection and feeling like a coherent entity will often be improved when centring increases in therapy work (Gyllensten 2012 p. 193) . Also, stability along the longitudinal axis or the balance line is important for the movement to be coordinated and centred. Centring and breathing integration are expressed in the individual's movement quality, where the interconnection and coordination of the whole body is visible. According to BBAT theory (Dropsy 1988) there are three original torso coordinations: opening and closing (flexion/extension of the torso), rotation around the balance line, and turning /counterturning (walking coordination).

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Open and close coordination

Image 24. Open and close coordination in standing .

The centred coordination pattern opening and closing is very closely connected to emotional life and to basic autonomous functions . Laughter and crying are examples of emotions when one closes around the centre . Even in fear, one may close the torso and possibly find it difficult to open oneself again. In happiness, one relaxes and opens oneself up in deep inhalation (Reich 1968). A lack of contact with this coordination may also be a sign of less contact with oneself and one's emotions. This may then give symptoms/ problems in the form of one not experiencing one's own needs and not being able to take care of oneself in a good way or assert oneself in relations at home or at work. Contact with emotions decreases when there are tensions in the breathing muscles. Not only the feelings that one

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doesn't dare/want to feel, but all feelings decrease in strength and may make emotional life feel flat and dull. Anna in our story has lost herself. She feels stressed, pressured, and filled with anxiety. She has difficulty in resting and recovering her strength, and at the same time feels that she is not good enough, and that life is dull. To live one's life from day to day as a robot cannot continue in the long run. Her relationship with work colleagues, her children and her husband have been affected negatively. Anna has lived her life placing greater value on the needs of others than on her own needs . This pattern may have existed since childhood . Anna was not centred and in contact with herself at the beginning of therapy. In BBAT, we also practise finding one's centre in lying. This starting position often has the advantage of reducing muscular tensions, if anxiety is not too high. Here, one can look for more gentle, centred, and energy-saving movements with flow and rhythm. One example is gentle stretching -relax movements, where one can practise stretching from the centre without using too much effort. In this movement, one can also practise sensing when one reaches the limit for what can be done while maintaining contact with the whole body with ease and elasticity. The participant then stops stretching and relaxes, being aware of how the body springs back to its original length. This is one aspect of centred movements in lying. This practice promotes flow, elasticity and presence.

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Rotationaround the balance line

Image 25. Rotation around the balance line in standing.

The other movement coordination is rotation along the longitudinal axis, where the individual rotates around the stable balance line, relaxed and free with minimal effort. This is also an overall coordination from the soles of the feet on the floor up to the vertex of the head. The movement starts around the centre and spreads toward the periphery where, for example, the arms swing from side to side.

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Walking coordination

I Image 26. Walking coordination .

Walking involves turning and counterturning around the balance line, and is one of the three basic coordination patterns . Walking is a whole movement where no part of the body attracts attention, but it becomes a homogeneous perception: "the whole of me walks" (Dropsy 1988). Every disruption in a part of the body causes compensatory disruptions in the rest of the body. The legs and the feet form a basic foundation and the left foot and the right foot alterna te contact with the ground. The legs and the feet create "wheels" under us, which gently and dynamically roll forward . In this way, the legs and feet can gently meet the foundation and adapt themselves to different changes. The different joints of the feet and legs contribute to a freedom and flexibility that can spread to the hips and pelvis. A well-integrated walking is at the same time both silent and elastic, without jerks. The movements of the arms and 83

legs are an extension of the torso's movement . Important "motors" in this coordination pattern are the oblique abdominal muscles and chest muscles, which converge in our centre level with the solar plexus area at the front of the torso, and level with the lower thoracic vertebrae and the upper lumbar vertebrae in the back of the torso (Dropsy 1988).

Powerand freedom In Eastern philosophies, the centre is placed in the lower abdomen and called hara or tan tian. This area lies three finger-widths below the navel and just as far into the body. In Tai chi and in other martial arts, this area is considered to be the powerhouse of the body. In Tai chi, one says that power comes from the feet - the basis - and is accumulated in the centre - tan tian - to be spread out into the periphery. Here it is also important that breathing and movement coordinate. In inhalation, one is filled with energy and in exhalation one gives out energy. One opens and closes. This can be applied to all movements in Tai chi irrespective of which form one practises (Lam 2006a, 20066) . Also in BBAT, the power centre area is used as an integrated part of the movement centre, especially if the movement has an intention of using one's power more optimally. When one practises a push movement such as pushing something forward, it is emphasised that the impetus comes from the floor, then moves on through the hip, pelvis and movement centre and out in the arms. The arms can then be relatively relaxed and one pushes with help of shoving from the floor using stronger muscles in the legs and pelvis.

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Rhythm Rhythm is another aspect of centring. A well-coordinated and harmonic movement can be seen as the result of a rhythmic exchange between tension and relaxation . After accomplished work, the relaxation phase decreases the risk of fatigue. This applies to computer work as well as chopping down a tree. A rhythmic movement requires that breathing be fully free and responds with a reflexive adaptation . The exchange between power and freedom gives rhythm to the movement. Using one's power in a meaningful way is one of the goals with the BBAT movements. When this is accomplished, movements are characterised by a subjective experience of ease, the body functions as a whole, and the movement can provide pleasure .

Intention and wholeness Both intention and wholeness are important for the quality of movement . When doing the BBAT movements, one uses the intention and images to create a meaning, often from an imagined function or con text . This may involve imagining that one is "pushing something away", resulting in legs that are stretched out, or that "the waves of the sea'' lift the arms up when the legs are anchored to the ground . Attention is th us not focused on the local muscle work that is performed, but on the task of the movement. In BBAT, this way of performing movemen ts is inspired by movement science and Tai chi. In Tai chi, each movement has a meaning in a martial art situation. In BBAT, however, it is usually not martial arts but other images that are used. A number of scientific stud ies on effective movement have concluded that if one pays attention to "external factors" (meaningful actions), one has behavioural advantages compared with focusing attention on more "internal muscles" (for example on one's own legs and the specific muscles performing this work) .

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To direct attention on the goal, e.g. a football goal or the green for a golf ball, gives a much better precision and ability compared with paying attention to what the body's different parts are doing (Lohse, Wulf & Lewthwaite 2012, Wulf 2007). This holds true for both athletes and pat ients with different prob lems (Laufer et al. 2007). Studies have also shown that this applies to how motor learning takes place. When one learns a new ability/movement, it takes time and a lot of practice before the movement is linked in the synapses and established in a long-term motor memory, a so-called established central motor program . When one starts to learn a new ability/movement, so-called peripher al programming is used. This phase in learning demands strong attention and full concentration to coordinate the different parts of the body. This is very energy-consuming, and the result will be that the movement will be slow, careful and tentative . This phase is characterised by excessive effort and concentration. It is experienced as being very difficult to control the muscles both to perform the task and to control the stability of the torso. The body becomes rigid and stiff. Usually one also holds one's breath when making the movement and first frees the breathing when the movement is finished. This results in getting tired quickly, and endurance is put to the test. How long it takes for a movement to become established in a central program depends on several factors. These can be, among others, age, natural aptitude, physique, motivation, ability to do similar movements, and how often and how long one practises. This also includes the ability to create an intended image of the desired ability/movement. Gradually, a transition phase follows where the individual sometimes manages to make the movement flawless and sometimes slips back to the beginner stage. However, control transfers later from being conscious cortical-based, to being activated unconsciously from the brainstem, basal ganglia and cerebellum. The action /movements are shifted from the short -term to the long-term memory. When a motor program is established, the movements are anticipatory, i.e. done pro actively instead of reactively. This is much faster and requires much less energy. A sensory component sensitive to just that information for the

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movement/action is also formed . This makes one recognise adequate sensory signals at a subliminal level and one can integrate the compensations directly in the movement sequence . Motor skills are thus intentional and directed toward fulfilling a goal (Trew & Everett 1997). In BBAT, the intention and goal are defined through the different images and aphorisms used. That the movement has an intention and a goal characterises the quality in the movement and gives the movement clarity (Skjac:rvenet al. 2008). The inner movements experienced as sensations and feelings are also important in BBAT (Dropsy 1975, 1988, Roxendal & Winberg 2002, Gyllensten 2001, 2012). The expression "an eye inward and an eye out ward" used in BBAT means to be in contact with both oneself and the outer contextual goals/world. It is the individual as a whole who expresses him- or herself in movements and actions.

Movement quality Movement and movement functions are, according to the physical ther apists' professional world organisation (World Confederation of Physical Therapy, WCPT), two of physiotherapy's most important areas. This is also in line with the theories of BBAT, where the focus is to work with movement function and movement quality. Movement quality deals with the general impression of a movement, a movement that involves the whole person from "head to toe". It also deals with mimicry, and gestures that express a person's inner life. The living body expresses, in each action, all aspects of the living person . Movement quality is about how flexible and adaptab le the individual's movements and actions are. The movement should at the same time be targeted and aesthetic (Skjac:rven1999, Skjac:rvenet al. 2003, Skjac:rven et al. 2008). In the assessment instrument and movement test "Body Awareness Scale Movement Quality and Experience" (BAS MQ-E), a person's 87

movement quality is assessed in a standardised test. In this assessment, different functions with respect to both resources and problems are studied . Movement quality is viewed as a resource and rated with the value 0 or 1. A score of zero indicates that the movement is done with vitality, stability and ease (Gyllensten & Mattsson 2011, 2015). Skja::rven et al. have explored different aspects of movements and movement quality in connection to BBAT. Their focus was on movement quality and its relation to various factors tied to the four different existence dimensions or perspectives: physical, physiological, psychological/relational and existential (Skja::rven 1999, Skja::rven et al. 2003, Skja::rvenet al. 2008) .

Physicalperspective The physical perspective deals with biomechanical and spatial aspects that is tracks and forms of movement made possible by the skeleton's formation and the function of the muscles . Finding an optimal track and a tension -balanced muscle-use makes the movements less strained. The interaction between centre and periphery are of the greatest importance. Three basic coordinations are part of this perspective . The physical perspective involves more mechanical aspects of the movement . Postural stability and balance are important prerequisites for movement quality on this level.

Physiologicalperspective The physiological perspective deals with the movement's timing or rhythmic aspects. Here one finds the movement's buoyancy, flow, elasticity and resilience. These qualities are dependent on muscular tension balance and a free breathing. They are expressed as a wave movement that optimally can spread throughou t the entire body. The interplay 88

between free breathing and an optimal muscular tension level suited to the actions provides a feeling of being dynamically alive. The free breathing gives a flow to the movements. This also gives natural pauses in movements and actions like an ocean wave that heaves, ebbs, and then heaves again. This rhythm should be adapted to the different situations in daily life to make it possible to continue an activity without getting exhausted. A harmonic movement starts from the central zone in the torso and spreads out in the periphery, and in this way forms a harmonic unit. To be centred in the movements and have access to a free breathing that is integrated with movements, are important prerequisites in this perspective.

Psycho-social-culturalperspective The psycho -social-cultural perspective is about the interaction of movements or actions with the inner life - feelings, thoughts, will - and the expression of inner life in the world. This movement quality or movement expression is dependent on attention and intention. Attention is directed both toward the inner life and toward the outer world, provid ing a special quality to the actions. There is a great difference between an aimless action and an action characterised by a clear intention. Actions with attention adapted to different situations will make presence in the movement possible. In this perspective it is important to expand consciousness to include a larger or smaller part of the outside world, so in an effective way one can adapt and interact with others in different situations. Internal emotional life also creates nuances to movement expression. Inner life and the outer expression in movements or actions should hang together to show clarity in what one wants. An important prerequisite in this perspective is presence - both an inner attention to own feelings, thoughts, and needs, as well as an attention to the outer circumstances.

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Existential perspective The existential perspective deals with a person's abilities to be conscious ly aware and self-reflect. This awareness enables the person to make conscious choices in action and to reflect over these choices. This ability is connected to the feeling of identity: the "I am". Based on the feeling "I am", the person can consider and review the inner as well as the outer circumstances, and act in an adequate way and not in an instinctive, automated way. The person will become freer and more inclined to act consciously and effectively. Rooted in oneself, one can thus act in a safe and calm way in the world. This is also reflected in the movements that reveal this increased calm and clarity. Self-reflective ability and a mindfulness in the present moment are the requirements in this perspective.

Movement quality and Tai chi In the Chinese movement art Tai chi, movement quality is most conspic uous. There are many styles and forms in Tai chi, but all share common principles . According to Chinese philosophy, the different movements in Tai chi express the harmony that exists in nature and the concept of yin and yang. This concept mirrors the balance between expansion /con traction, male/female, act/recover, breathe out /breathe in. Sometimes one aspect dominates, sometimes another, but together there is always a balance between the two in an ongoing movement . The common prin ciples that exist in Tai chi are summarised in body control, movement control, and inner control (Lam 20066). Body control includes balance, body alignment, the ability to keep the body upright in different posit ions, and the ability to make weight transfers in a controlled and balanced manner. Movement control involves movements being slow, gentle and con tinuous . Here, movements are done with the feeling of slight resistance. 90

One says also that Tai chi is like "swimming in the air". In such a way, it resembles the physiological level in Basic Body Awareness Therapy. The feeling of moving against a very slight resistance makes all the movements feel coherent, as if moving in water. Inner control involves an inner relaxation as well as a mental inner peace. The Chinese relaxation concept involves an inner relaxation, an inner expansion, an inner opening. Inner peace involves letting the senses become quiet but at the same time being fully aware of what happens in the present. Tai chi as a movement principle involves having an aware and conscious attitude toward other people and the outside world, and adapting to different situations. This is expressed most clearly in the martial art "push-hands", or as it is sometimes called "sensing hands". In Tai chi as a martial art, the basic principle is to yield, absorb and redirect power, and not go against the incoming force so that a con flict arises. In this way, there will be a gentle martial art coming from within (Lam 20066) .

Body awareness and relations Body awareness and relation to oneself Research has shown that there is an interaction between increased body awareness and better ability to be in contact with oneself, others and the environment (Gyllensten et al. 2010). Therefore, it is important to train one's body awareness regularly (Mehling et al. 2011) . A num ber of researchers see body awareness as the basic and primary part of self-awareness (Neisser 1997). Body awareness is continually updated through constant incoming sensory information and information from the motor system on our ability to use our body (Trew & Everett 1997) . The therapist's own body experience is a prerequisite for the therapeutic process that is required 91

in work with other people. Patrick in our story practises his own body awareness, which leads to a better understanding of Anna. When Anna gradually obtains increased body awareness, she gradually increases contact with her own body, bodily signals and her own emotional life. She will gradually develop an increased contact with her sensory perceptions, both proprioceptive and interoceptive (sensory input from the body's internal organs). To develop contact with the body signals is, according to some authors, the central aspect in many different body awareness therapies (Mehling et al. 2011). The more aware one becomes of the body's signals and what these mean, the easier it is to control, modify, or adapt to one's needs and life situation. By practising mindfulness and presence, the ability to be aware increases. This will also entail changes in the nervous system. In the peripheral nervous system this can be an increased contact with the soles of the feet, for example, and in the central nervous system, an increased awareness of emotions and / or cognitive processes, for example. An increased body awareness means coming in contact with oneself and experiencing oneself from the inner perspective, which means a strengthening of one's identity (Gyllensten et al. 2010). For the individual, the body experience is something central for the self-image and the experience of being alive. In BBAT, the ability to be aware of the body is trained from the beginning, for example while lying and paying attention to the body-parts that are in contact with the floor. Many people experience differences between the right and left side of the body in the lying scan of the body in contact with the floor. Patients are encouraged to let the experience from the practice just be as it is, accepting it, not evaluating or trying to change anything. To practice feeling the body as a whole as it is, is focused regardless of asymmetries.

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Body image The three-dimensional body image that we are conscious of is determined by the body's physical form, posture and the physiological boundaries of innervated skin. The same type of information is decisive for spatial orientation. It means that control and subjective experience of balance is tied to the cortical network for the body image, for spatial orientation, and for what we call internal models. Body image informa tion is continuously supplied to the network, which designs movements (Fadnes & Leira 2006) . Body image can be seen as the conception of one's own body perceived from inside through muscular perception. It is like a moving, never-ending perception of the changes that constantly take place in our organism, and never stops until we die. Body image therefore forms an image of our whole existence. The image of the body is an image of the self (Dropsy 1975).

Self-awareness Hedlund (2014) stated that the most basic levels in self-awareness emanate from a sensormotor, corporeal level. This innate ability to integrate sensory input, so-called multi-sensory integration, has been found to be of great importance (Postmes et al. 2013, Hedlund 2014). Multi-senso ry integration means that the child can integrate impressions from, for example, vision, proprioception, and interoception . This occurs as early as the first years of life. This ability is also linked to the ability to differentiate impressions. The perception of self-boundaries is developed both through proprioception and sensations from the skin, which provides a surface to the outside world. Vestibular sensory integration contributes to the development of self-awareness and provides information about balance and environment. If there is a deficiency in the multi-sensory integration, a confusion, a perceptual incoherence,may arise. Perceptual

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incoherence must be compensated so that pathological distortions of the self-awareness and different medical conditions do not arise (Hed lund 2014, p. 21). The concept of body ownership, the feeling that the body belongs to one's self, and agency, the feeling of being the source of one's own activities, are important dimensions that also have significance for self-awareness. These processes normally occur automatically at a pre-reflective level and are important for control and the experience of having a defined self. Self-awareness is thus rooted in body awareness.

Significance of brain hemisphere The brain hemispheres work differently. The right hemisphere has the focus on how just this moment looks, tastes, smells and feels (Taylor 2006, p. 36) . The functions associated with proprioceptive and sensory awareness, connection, and the experience of feelings in the present are located here (Yokoyama et al. 1987) . The experience of wholeness, and artistic activities such as music, poetry, image creation and symbols, are mainly localised to the right hemisphere (McGilchrist 2009, Gainotti & Silveri 1996, Taylor 2006). The left hemisphere functions differently from the right and pro cesses information in a network connected to logical thought such as order, structure, language, accomplishment, and reflection. An analysis of the different parts of the brain shows that movement is initiated in the left hemisphere. The experience of the self as separate from others and unique is also located in the left hemisphere . Neurological networks have been established which react automatically to sensory impressions . These networks allow the person to process great amounts of information without spending much time on individual details. The left hemisphere recognises patterns and can use previous experiences to predict what will happen . This part of the brain analyses and critically evaluates what I like or do not like. The left hemisphere understands how letters function and how these are put together into sounds which create 94

concepts. Non-verbal communication is, however, interpreted mainly in the right hemisphere, which is concentrated on the big picture and supplements the left hemisphere's understanding of what is said (Taylor 2006). The individual often interprets the non -verbal message as more true than the verbal, and thereby non -verbal signals are considered to be the most important communication between peop le throughout life. A balance between the brain's different characterist ics may be needed for good health. If a person is emotional and artistic, it is possibly the logical and analytic aspects of personality that need to be stimulated. With others, it may be the experience of the body as a whole and con tact with emotions that need to be focused on in order for a good balance to develop .

The importance of verbalising experiences/ feelings Anna in the story has, after BBAT, found it easier to formulate what she experiences in different situations, both concerning herself and con cerning her relationships with other people. To verbalise what has been experienced is usually done at the end of a therapy session. It is a way of developing awareness of the body experience and can be seen as a way to integrate the brain's different functions as well as to further stimulate the experience of the individual as a whole . The body experience has been clarified through words and thereby become accessible for cognitive reflection. Body awareness and body sensations may thereby be better processed, understood and integrated into the self-image.

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Awareness Awareness is a gradual process, like a dimmer, where one can be more or less aware or present in what one experiences or does. When we become conscious, the brain creates neural patterns, like a map . Sometimes the pattern becomes blurred and the map becomes ambiguous. The con scious experience of the body is the basis for the creation of awareness (Damasio 2011). One can imagine a person who has poor contact with one's feet, e.g. Anna who sits with only the toes on the floor. When she consciously places the whole foot on the floor, the area in the brain that represents her feet is activated. The activation of this area increases awareness of the feet. The more often she raises awareness of the feet, the clearer the map becomes . Awareness of the body as a part of the self or awareness of the self through bodily experiences is central in this process. Practising awareness or min dfulness leads to structural changes in the brain. This is called neuroplasticity(Siegel 201 O). Research has shown neuroplasticity to be a normal function of the brain, fundamental for learning and the development of the individual . New experiences and environments lead to growth of new neurones or new synaptic connec tions. This can take place with older individuals as well as young. Social interactions, physical activity and stress will affect the brain (Hogberg & Linander 2013, May 2011). In an 8-week study of Mindfulness -Based Stress Reduction (MBSR), participants made the awareness exercise noticing the body parts while lying, and performed soft stretching in contact with the breathing, and sitting meditation. The results revealed an increase in the ability to concentrate and an increase in the grey mat ter in the hippocampus and parts of the brain connected to learning, memory, affect regulation and the sense of being connected as a whole human being (Holzel et al. 2011) .

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To be present and aware Mindfulness is a concept that originates from Zen tradition and has a history of several millennia. Human beings have always been forced to focus on what happens at the moment for survival. Nowadays, threats come as much from inside ourselves in the form of experienced demands, which lead to stress, as they do from the outside. The importance of being mindful of what happens within us is as great as being aware of dangers from the surroundings. It is important that we become conscious of our inner needs and desires to be able to choose what is good for us. fu children we can be very present in what we do, almost engulfed. Conscious presence is developed gradually, and at the age of three we get an experience of "I am me". This ability is strengthened gradually but all the time is fragile and unstable, like a flashing light (Dropsy 1988). This inner light can illuminate greater or lesser parts of the whole of us, not only balance and breathing but also inner life in the form of thoughts, feelings, sensations. These inner sensations that we become aware of will be the objects one can think about and reflect on . Sometimes it can happen that one becomes intensely aware of just this inner light as a subjective experience of "I am", and that the awareness of the different objects fades (Dropsy 1988) . This can happen in med itation but naturally also in certain moments in daily life. Sometimes one can get a feeling of total affinity with what is going on just now. To be able to draw attention to one's inside and become aware of the body, thoughts, experiences and sensations in a non-judgemental way is central to Basic Body Awareness Therapy. The choice of what to pay attention to is one of the brain's most important tasks (Nilsonne 2009). There are separate but interacting systems to direct attention. These are stimulus -driven or controlled attention, automatic or voluntary attention (Nilsonne 2009). Stimulus-driven attention is controlled by the environment - something happens and this catches the attention. Controlled attention has a predetermined

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focus where one tries to remain. These two types of attention are managed in different places in the brain (Nilsonne 2009). Not to be trapped by one's own experiences is also called cognitive decentring. The words de.fusionor metacognitionare also used to describe the mechanism which focuses on increased awareness of inner thoughts or experiences. This leads to a better ability to not act automatically in connection with negative experiences, and is considered an important aspect of the positive effect of practising mindfulness (Mattsson 2013).

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4. Relationships to others Attachment Humans become what they are both through genetic constitution and through relationships to the world. The human being is in constant interaction with the environment. This already starts in the womb. Man is dependent on relationships to meet both physical and mental needs (Gyllensten & Olsson 2013). The little child needs someone who is there who connects to it, and understands its needs of warmth, nourishment and loving care. The child has an innate ability to bond with his caregiver. The caregiver must also have the ability to create an emotional bond with the child. The parent must be able to attach to the child and sense the child's emotional and physical needs. The adult needs to be emotionally available and both interpret and provide adequate responses for the needs of the child at the right time as well as continuously over time . What creates inner security and structure in the little child is the emotional bond between parent and child : that is, the attachment between parent and child (Bowlby 1977, Ainsworth 1979) . This attachment is significant for both cognitive and emotional development. The little newborn child has many resources. There is already a biological innate ability to attach to the parent. The basic affects are also innate. Even the fight-flight system is innate. At the age of one year, the brain's pre-frontal structures and the ability to control and understand the basic affects, i.e. the social structure, start to develop. This development is dependent on the quality of the attachment. The adult 's ability to recognise and respond to the child's emotional needs is thus decisive for the child's development of inner security, positive self-esteem, and ego-strength 99

(Gyllensten & Olsson 2013, p. 14). The attachment is the basis for supporting the child's physical and mental control processes and also for the development and understanding of oneself and other people. One can say that the child's own self-experience comes from outside through the parent's way of holding the child, looking at the child, nurturing it, and reflecting its needs, sensations and feelings. Later, the child's attitude to her-/himself is a reflection of the attitude the parent has had to the child. How the parent has taken in and touched the child is then reflected in how the child lives in its own body and owns its own feelings. Through the relationship with the parent, the perception of subjective self gradually grows and the individual emerges in relation to her-/himself. The relationship to the body and self will then become the starting point for the individual's subjective reality and for the relationships to the environment (Gyllensten & Olsson 2013, p. 12). The attachment and later the child's ability to tolerate his/her own feelings are dependent on the parent's ability to handle emotional challenges. When the parent is able to be there, as a secure basis for the child, the child learns that there is protection, and that feelings can be expressed openly, even negative feelings. This creates a basis for providing security, hope and rest in the child. It becomes meaningful for the child to communicate, energy is released to explore, and physical and mental development becomes possible. If the child does not receive this basic security from the parent, an insecure attachment pattern is created. This can be of different kinds depending on the parent's difficulties. If the parent feels anxious and distances themself from the child's need for closeness and comfort, an attachment pattern of insecurity and avoidance is formed. If the attachment is activated by the parent's worry and not by the child's needs, an insecure ambivalent attachment pattern emerges. A threatening or abusive parent creates an insecure disorganised attachment pattern where the child splits her-/himself into different parts. A child needs people who are emotionally present to be able to think about her-/himself and about others . If there is a secure attachment, the child learns to tolerate others' and its own feelings. The observing 100

self - that is the ability to perceive and reflect over one's own feelings and actions - is also called the ability to mentalise (Fonagy et al. 2003). It involves to consider and reflect over thoughts, body sensations and experiences with an empathetic understanding of oneself. It means that one can live in somebody else's inner world and be compassionate and empathetic - that is to see oneself from the outside and others from the inside (Gyllensten & Olson 2013, p. 17). The ability to mentalise is established early in the interplay between parents and child. It is created through the parents' reading and responding to the child's intentions and their letting the child be motivated by his/her own inner state. This leads to the child getting a viable feeling of self. The small child in the early phase of attachment has no concept of words or thoughts. The experiences are non -conscious and non -verbal. Self-development thus takes place on a corporeal level. Knowledge of the importance of the non -verbal as the basis for self-development is one of the cornerstones in the BBAT method. As BBAT therapists, we meet the patient on a non -verbal level via movements . In this way, we connect to the child's early non-verbal development (Stern 1985).

Needs Needs are important motivators for the individual's development and behaviour. Needs shift all the time from basic survival needs such as food, water, and sleep, to the ability to create meaning and beauty. The psychologist Maslow formulated theories regarding a person's development following the needs. Development depends on the needs being satisfied. He divided needs into four different levels: physical needs, psychosocial needs, needs of self-realisation, and existential needs. He argued that one must first satisfy the physical survival needs and the basic needs of community and affinity before one can be free to realise an optimally meaningful existence (Maslow 1943). Failure to satisfy the basic needs leads to significant negative consequences. Gyllensten & 101

Olson (2013) have further developed Maslow's ideas, and suggest that one can divide the needs according to the following principles: security, worth and meaning. Security includes the physical body. It is largely operated autonomously, through all the biological processes going on in humans to sustain life, such as breathing, the heartbeat, blood circulation, and nutrition. Our body would not survive if there weren't some "I" who takes responsibility to listen to it and to what it needs. This "I" must make sure that the primary needs of water, food, rest, etc., are met. Primary needs also include the need for loving physical and mental touching (Gyllensten & Olsson 2013). Worth refers to getting one's needs of connection, attachment, affinity and community met. The human being needs to be accepted by, and be important and meaningful to, other people. People want to feel that they are needed. It is a basic need to experience themselves as meaningful to other people, but also to experience that other people mean something to them. People have a need for confirmation that they have something genuinely human in common with others, not only by what they do, but also by their existence (Gyllensten & Olsson 2013).

The cycle of needs and the body Arising needs are shown in physical sensations and affects experienced in the body. Gradually there arises an image or fantasy of, for example, a plate with food on, or an inviting bed. This leads to feelings of longing or avoidance in their primary form. Feeling a desire to move closer to what one fantasises about is a positive feeling. A negative feeling is one you want to avoid. It is a danger or threat. This is how in the healthy individual thoughts arise about satisfying the need to eat or to take a snooze. When sufficient energy motivates the individual (the need is sufficiently strong) then they act on it by eating , taking a nap, or running away, and in this way the need has been met. The growing need must reach consciousness for the individual to be able to satisfy it and 102

achieve rest and homeostasis (equilibrium) again (Gyllensten & Olsson 2015). If the need is more complex, the feeling must be understood so we can act in an appropriate manner. All needs, including those that are about worth and meaning, function in the same manner, from scratching the nose to complex human activities such as the creation of art. If the individual has a history, starting from childhood, of being listened to and positively responded to, then they have a readiness to listen to physical and mental sensations and to pay attention to the different sensations that arise and signal new needs. This is, however, not always so easy. For different reasons, the individual may not dare to listen to one's own needs and feelings. The conflict is often that one has an unconscious notion about not being worthy of getting one's needs met. It is, however, important not to blame but to understand chat as a child one has done the best to survive physically and mentally, despite not having been optimally taken care of by one's caregiver. It is important to pay attention to the body signals, vitality affects, and feelings.

BBATand the cycle of needs BBAT as a therapy method focuses on the first part of the cycle of needs - needs being expressed non-verbally, without words, in the form of perceptions or physical sensations. These physical expressions must be noticed, tolerated and accepted. They are expressions of the life within the person and can be helpful in understanding what they need to feel well. Patrick suspects that Anna's needs of affinity and community were not met when she was a child. To be accepted, important and meaningful to other people is not naturally integrated in her. She has not been loved simply for existing, but she managed by being clever and by delimiting the undesirable pares of herself. She enacts this behaviour in her current family life with John and the children, and also at her work. She has compensated by being capable, reading the needs of others, exerting herself, tensing up and delimiting the feelings that

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she perceived early-on to be threatening. She does this by locking her breath. Now this pattern results in her not feeling well, either physically or mentally . She feels anxious and like a wandering zombie, without contact with herself The muscles have hardened, and breathing has become shallow and fast. Muscle tensions have resulted in pains, and Anna feels trapped. Eventually, when she becomes aware of this, Anna develops her ability to understand her sensations and reflect over her life and her needs. Together with the BBAT therapist she develops new strategies to take care of herself

Touch Massage or touching may be a part of BBAT. Massage has often been criticised as a means to promote passivity and to attach patients to a therapeutic relationship where the therapist is the expert and the patient plays a passive and dependent part. Touch is however something very basic for the human being and an effective and early non -verbal communication of emotions between child and caregiver (Field 2001). People who have experienced loving and tender touch find it easier to communicate in a tender and caring way to others (Fromme et al. 1989, Uvnas Moberg 2009) . Touch is important for health. Several studies show the positive effects of touch on blood pressure, cortisol levels, well-being, anxiety, and basic security. With the small child, touch is necessary for the development of the brain's synapses and for physical, mental and intellectual development (Andersen & Guerrero 2008, Gerhart 2007, Montagu 1986). In one study, the brain size of neglected children, eight months to six years old, was compared with the brain size of children who grew up with good care. The brains of the neglected children were smaller in size and less developed (Perry 2002). The loving touch also helps children to regulate blood pressure, heart rate and growth hormone production, and helps them to build a well-functioning immune system (Gerhart 2007) .

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Loving touch of the primary care provider is decisive for a positive attachment . This attachment then becomes a meaningful template for the ability to bond in relationships with other people. Physical touch is important in intimate relationships between adults. The hormone oxytocin is released and associated with the "peace and quiet" system (Uvnas Moberg 2009). Studies have shown that women who receive physical touch from their partner before a stressful situation have lower cortisol levels and lower heart rate than women who receive only social support or no support at all (Ditzens et al. 2007). Some patients do not experience massage and touch as being positive. This may originate in a negative experience of touch from when they were small. If as a child, you have learned that touch is associated with pain, punishment or abuse, then touch may not be positive when reaching adulthood (Andersen 2008, Fromme et al. 1989). Having difficulty with or avoiding touch in relationships is a sign of basic mistrust and constitutes a problem leading to difficulties in relationships with other people and love partners (Downey, Khouri & Feldman 1997). It often interlinks with a basic uncertainty of one's own value and an expectation of being rejected. Being negative to touch can also be an expression of a mental illness where the individual experiences anxiety when touched due to difficulties feeling the limits of one's own body. Touch then constitutes a risk of feeling invaded . To try touching in safe conditions together with an experienced ther apist has clinically been shown to be very valuable. In BBAT, massage takes place in silence and with conscious awareness of the experience, and after the patient has given their consent. Giving feedback and setting limits is encouraged if the experience becomes overwhelming or unpleasant . In this way, the patient is the one who has control, which can reduce fear and discomfort. Massage in BBAT is in this way an exposure exercise for patients who have touch-avoidance. For patients where touch is something positive, it sets healing pro cesses in motion, which accelerates the effect of the therapy. The massage lasts around five to ten minutes, takes place with clothes on, and 105

is an integrated part of the movement therapy. The risk of the patient becoming passive is minimised because the stated aim is that the patient shall be involved in the experience. Often the massage part in BBAT therapy is experienced as something very positive and nice, and which strengthens the alliance with the health professional as well as the ability to interact with other people.

Love and sexuality Love and sexuality are seldom discussed in physiotherapy. Illness, stress and worry can negatively affect living with a partner, and this impacts on the joy of living and quality of life. When one is in the mid-life as Anna is, with pain and stress and a conflict with her husband about taking too much responsibility for their children, one easily loses access to feel sexual excitability. When breathing is locked, one feels less worry and anxiety, but one can also lose contact with positive feelings such as interest, love and happiness. This has happened with Anna and contributed to Anna and John drifting apart in their relationship . To have a good relationship with one's partner is important. To be able to love someone else, it is important to love oneself as the person one is and accept one's deficiencies and shortcomings. With therapy from Patrick, Anna is beginning to learn to know herself better and experience her own needs. She has more and more begun to understand, accept and even like herself as she is. According to the WHO, a healthy sexuality is part of good health. Sexual well-being increases quality of life. Prerequisites for a good sexuality develop in childhood. Sexuality is life-long learning, self-learned by most of us. Sex is not just procreation; it is a love-filled relationship, sensuality, access to emotions, and sexual arousal . Problems in relation to oneself and the partner, anxiety, inhibitions and inner restrictions often impede sexual arousal. Children have often been hindered in their

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first sexual experiences, rather than supported. Also, performance anxiety, medication, illness, hormone changes and age-related changes can affect sexual enjoyment. Anna dares to mention to Patrick that the BBAT movements increased her access to her sexuality. She notes that she has an increased desire. After BBAT, Anna now likes herself and her body better, which is a new feeling for her. She feels more valuable and can thereby better appreciate a loving touch . She feels worthy of a loving touch . Anna can see that she dares to be more active when she has bodily contact with John. This has a positive impact on how she functions with him in different ways. Anna's tensions in the breathing and the stomach may have been an expression of a prohibited or taboo attitude to pleasure and sexual well-being. This is often tied to a feeling of lack of freedom in the stomach . A reaction when one is excited is that one tenses up and holds the breath. It is a reaction that impedes enjoyment. Through increased awareness and freedom in breathing, one becomes more vivid. This enriches sexual enjoyment and allows orgasm. Expressions such as "it makes me feel warm in the heart" and "it feels all the way down to the stomach" reflect a feeling of desire that depends on the stomach being free (Dropsy 1975, p. 89). With the help of movements and an increased freedom in breathing, Anna now has better contact with her own sensuality and sexuality. Sexuality is connected to several existential dimensions, where physical, physiological , psychological and existential factors cooperate to make the experience of love more complete.

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The encounter between care provider and patient How the care provider encounters the patient for the first time will characterise the therapeutic relationship (Stenmar & Nordholm 1994). When Patrick encounters Anna, he sees in her a person who is a human being just like himself. He sees her not as a patient with a diagnosis that he will act upon; that would mean seeing her as an object. If this will be a real encounter, a meeting between two human beings, he must see her as an individual. Real forces of interaction can then arise, and development becomes possible (Buber 2001). Sometimes we must encounter others as an object, but we should never forget that behind the object there is also a human being even if this being cannot speak or communicate in any other way (Buber & Sallstrom 2008). To encounter Anna in the right way involves meeting her at a level that she understands and can assimilate. If Anna herself has not begun to reflect over the connection between symptoms and life situation, Patrick should then hold off until Anna herself does the reflection and understands the connection. He can however lead her toward a greater understanding by asking questions. Through this, a development can take place within Anna so that she starts to reflect more about herself and come more in contact with herself. If the therapist asks experience-related questions, he/she helps the patient come into contact with his/her existential self, his/her own being and his/her biography. This also allows an increased confidence in one's own body and increased body awareness. To accept chronic pain, for example, and to integrate the painful body in the identity, are often goals for therapy (Afrell 2014, Roxendal & Winberg 2002). In psychotherapy research, it has been found that about 50% of the therapy effect depend on patient factors. That is, the patient's own resources, ability to bond, motivation, capacity for change, and trust.

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About 10% depend on the method used. The therapist's experience and attitude to the method is responsible for about 10% . General factors and the relationship to the therapist count for about 30% of the effect, irrespective of which therapy method is used. General factors refer to how the patient experiences how they have been listened to, how respected they feel, whether or not the therapist seems to be trustworthy, knowledgeable and interested in them, and whether the patient experiences that there is a hope and cooperation between them and the therapist about the problem (Luborsky 1994, Lambert 1999).

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s. Pedagogical approach Resource perspective A basic principle in the therapeutic approach in BBAT is encountering the patient where they are in their development just now. The resource perspective guides the strategy of the therapy, and involves paying attention to when the patient can maintain their optimal grounding, balance, centring and mental presence. The physiotherapist works a lot with the movements the patient can do best. If the movements become too difficult, the patient cannot maintain the basic functions of stability, centring or presence. The physiotherapist then takes a step back and keeps to what is simple, what the patient manages to do. It is important that the physiotherapist does not become too ambitious by giving the patient too many and too difficult movements. Patrick starts with a simple sitting movement and this is sufficiently challenging for Anna. In summary, we want to emphasise the importance of simplicity, respecting the responsiveness of the patient and watching out for being too performance -oriented as a therapist. To meet Anna at the right level involves meeting her in a way she understands and can face up to. In BBAT, the therapist can however lead their patient toward a greater understanding by asking simple questions. For example: "In which situation have you noticed that you tense up?" or "How does it feel just now?" Through these questions, Anna starts to reflect more about herself and gradually also recognises the connection to her own life. It is important for the therapist to be genuinely interested, to see, listen to, respect and acknowledge the patient. This holds true both for individual therapy and therapy in a BBAT group.

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Together, Anna and Patrick explore different possibilities and new movement behaviours. The principle is to work with movements for the whole body, so that all the different parts of the body fuse together to a uniform movement where Anna can be as grounded, balanced and centred as possible. Breathing and movement are invited to become more integrated through use of the m-sound. When Anna makes the "wave movement", for example, Patrick asks her to sound the consonant "mmmm" when she bends the legs and lowers the arms . The goal is for Anna to become more aware and present both in her own experience and in her movement. One starts as simply as possible. After some time when the patient is able to do the simple thing in a balanced way, the complexity of the movement is increased, so that it corresponds to everyday life's functional needs . Simplicity, making the movement small and energy-saving, is maintained . To be in silence is also practised in sitting and lying presence . Patrick adjusts and develops the movements continually so that Anna is able to remain in contact with her balanced stability, able to integrate breathing and movement, and be present in her body /experience. The patient may need to be "exposed", i.e. to be challenged to remain in a movement perceived as unpleasant, if their behavioural pattern is to escape everything that is unpleasant. It is then important that the patient themself is involved in and accepts being exposed to discomfort, so that they can explore other possibilities rather than limit themself In the movement /exercises, it is important for the patient to receive acknowledgement and confirmation from the therapist. When Patrick invites Anna to make the "wave movement", he looks at whether or not she manages to give the weight to the floor (cooperate with gravity) and at the same time maintain stability in the balance line, and whether or not she coordinates her arms and legs. He acknowledges what he sees in the movement and gives feedback without evaluating, asking Anna to notice how it feels to do the "wave" in this way.

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Guidance Patrick helps Anna find her own resources through guidance . Guidance can be given in several ways. The first is usually that the therapist will show the movements that he wants Anna to do by using his own body. He also uses words, metaphors or touch to make Anna aware of how she uses her body. Guidance can also be used to find a new movement path or coordination. Moreover, he wants to strengthen her contact with her grounding, line of balance and centring. That Patrick himself is able to be present, grounded, balanced and centred during the therapy with Anna is a basic prerequisite. It is important that he is present in the moment and acknowledges and confirms her resources and difficulties in an accepting manner, without evaluating her performance. Patrick's own experience of BBAT is one of the most important instruments in the therapy. It is also important that he himself continues to practise the BBAT movements because BBAT, like meditation and physical activity, is "perishable". In BBAT, the physiotherapist instructs the patient by moving together with them. The non-verbal communication used and the movement together activate mirror neurones . Like a small child, Anna copies. Patrick explains by using words, imagery and /or metaphors .

The learning process in BBAT The learning process in BBAT or "The movement learning cycle" is a concept published scientifically by Skj~rven et al. (2010). The authors developed and described the importance of the patient becoming involved in their own learning process and how the physiotherapist can motivate the patient to become involved. Skj~rven et al. emphasised the importance of the therapist's own movement awareness, and that the therapist themself has gone through

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a learning process. This is essential to be able to see, understand and lead the patient in a process toward increased movement quality. It is also crucial to create a trusting and accepting encounter that is patient-focused so that the patient feels involved in their own process. Other important factors are that the therapist actually sees the patient's resources, and not just symptoms or illness, notes changes and development, and gives feedback to the patient, even if the change is slow. Positive feedback motivates the patient to go further. The therapist's role is to support and motivate, as well as to lead the process further . The learning process follows a strategy that can be described as a cyclical pattern. Cyclical models for practical learning have also been described by Kolb (1984) and Dropsy (1987). The therapist is a coach and leads the process forward by helping the patient discover, explore and integrate movements in their awareness. To help the patient explore the movements is essentially different from correcting movements from the outside. To teach by being in movement emphasises that the experience of the movement is integrated in the person. The learning process goes in different cycles all the time - increased contact gives increased experience and gradually increased integration of both movements and, in the figurative sense, the meaning of life. Anna feels that she has gained better balance and can handle the impact from others and feel strong and relaxed. An example is when Patrick gives her massage through pressure on the shoulders when she sits in a meditation position. She can integrate the different parts of the body to a more balanced and functional posture, where the breathing can also be integrated and thereby become freer. Patrick goes further by exploring Anna's wishes and ideas about the therapy's goal and her motivation to practise by herself Anna needs help from him to be able to verbalise, formulate, and see the meaning of her therapy. This is however a gradual process and Anna slowly finds it easier to find a balanced posture and formulate what she experiences . In her group therapy with BBAT, the cyclical learning process starts again by creating contact in a new way, in part through other movements 114

and together with other people. In the meeting with Jenny, Anna gets to explore and make experiences of not being able to set limits, but then later to be able to speak out when it doesn't feel good, and to experience the feeling of satisfaction which emanates from being able to set limits. In summary, the learning process starts with a first contact with oneself in the movements. It is the therapist's task to lead and guide the patient further toward an in-depth explorationthrough the movements . This in-depth exploration leads to knowledge and experiencesand here it is important that the therapist confirms the progress so that the patient can tie this to the in-depth experience of him- or herself Increased interest and increased motivation from the patient leads to increased practice, and thereby an integration of different parts of the body to a harmonic unit/whole . This also leads to increased contact with feelings and needs. Gradually doing the movements/exercises, and the experience of oneself, appears as a basis to see one's own role in relation to daily life; exercising receives a meaning in relation to daily life. Here, increased awareness leads to increased reflectionand ability to verbalise different experiences and phenomena. This may in turn increase the ability to find new strategies in life (Skja::rvenet al. 2010) .

Grouptherapy When Anna has been to treatment with Patrick a couple of times, he tells her about the possibility that she can start in a BBAT-group . He explains the importance of working in a group and meeting others . In a group, Anna can maintain the functions she attained in her individual therapy . Anna is doubtful, since in other connections she has noted that she loses herself when mingling with others. She can also feel threatened and it can cause anxiety when she cannot assert herself in a group setting, and she finds it difficult to say no and set limits in situations with other people. Patrick emphasises that in a group, it is just this that she can practise: being herself and maintaining her

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stability and centring even though she is with others. He sees it as a further step in her development . He emphasises that in the group, one works from one's own possibilities and goals. Most of the time in the group is dedicated to movements/ exercises where each and every member works according to their own abilities . At the end, there is a possibil ity to verbalise experiences from the day and tell the others something about what was experienced dur ing the session . By listening to others' experiences, it is possible to understand oneself better. Many group participants find it positive to hear that one is not alone in one's problems and difficulties, Patrick explained . It can also be good to hear how others have handled their own difficulties and how they use BBAT movements in daily life. According to many patients, this infuses hope, leading to a feeling that change is possible, he says. Anna decided to rise to the challenge of being in the group, but this is not always the case for every patient. Sometimes longer individual therapy is needed to strengthen self-esteem before joining a group . Exposure to contact with oneself and one's body can be sufficiently provocative , and there fore an individual evaluation of the advantages and disadvantages of group therapy is required .

Therapeutic factors in group therapy The American author and professor in psychiatry, Yalom, has in his work and in his research on group processes found several factors of importance for development and growth of the group and the individual (Yalom 1985). Even if the therapy process is endlessly complex, Yalom believes that there are therapeutic factors which can be separated and which are valid for different groups. Below follows a description of several of these factors, relevant in BBAT.

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Infusion and maintenance of hope

An important feature of all therapy is that it creates and maintains a hope of change and improvement. It is important that the therapist conveys an optimistic approach and believes in what he or she is doing, the possibility for change, and what is conveyed . In this way, pessimism can be turned into cautious optimism. This is an important therapeutic factor. Perhaps there are participants in a group who can pass on earlier results of therapy, and demonstrate change and improvement. This infuses hope and is a strong motivating factor for other participants to take part in the group. Universality, general applicability

It is a usual feeling with patients that they are alone in their problems and thoughts. The patient is perhaps socially isolated and doesn't have someone with whom they can ventilate their problems. Therefore, it is important early on in therapy to resolve this feeling of loneliness by stimulating an open dialogue where the different participants share each other's problems or difficulties. This may be important to relieve and reduce the feeling of shame and worthlessness. Altruism

"The best way to help a man is to let him help you", Yalom writes in his book on group psychotherapy (1995, p. 13). We as human beings need to feel that we are needed and useful to others. It can be just as beneficial to give something away as to receive. Being concerned with others for a moment makes one forget oneself. To be concerned with others and listen to them with respect is healing both for the listened to and the listener. This is an important aspect in group therapy and provides a new perspective on life. For many people, it is just as important what fellow patients in a group are concerned about, as what the therapist does. A

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therapist is paid to be involved, while a fellow patient's involvement is spontaneous and real. Interpersonal

learning

- "to learn from each other"

According to Yalom, this is the most important therapeutic factor in group therapy. It is important for the human being to be part of groups and social relationships . A group functions often as a social microcosm: in a group you practise to meet people in other real social relationships. Someone who is withdrawn and quiet becomes quieter in a group, and the one who is active and dominant becomes all the more active in a group. When roles in a group become clarified and conscious, the therapist and other participants in the group can help the individual become aware and change their manner to function in the group and in other social interactions. The individual can grow, mature and develop. If one manages to change a behaviour or understand symptoms and actions in a small group, it becomes easier to change behaviour when a person finds herself/himself in a larger group or other settings. Interpersonal learning in a group takes place in a "here and now", and awareness of roles must take place in an atmosphere of acceptance and security. Interpersonal learning can take place at different levels through body movements, posture, reflections, asking questions, expressing feelings, taking different approaches : everything which involves being a human being. Yalom also describes how the patient 's therapeutic goals are changed over time from relief of symptoms to awareness of how one functions in interpersonal relationships, and how one can grow in relation to others. Group community, group feeling or group cohesion

We know through research that the relationship between patient and therapist is very important in individual therapy. In a group, the relationship between patient and therapist is also important, but so is the relationship to other group members, or to the group as a whole. 118

It is essential to be accepted in the group and share its values. A good group solidarity or group feeling requires a positive relationship to the group, so that the group members feel satisfied and there is a sense of a common realm. The members support and accept each other. The more important the group is for the individual, the more one gives of oneself in the group. This is a therapeutic factor in itself, but perhaps even more important is that this factor is a necessary prerequisite for the other therapeutic factors to work in the group. To be accepted in a group is a strong experience and leads to growth and development. Existential factors

The fact that one works in a "here and now" perspective opens one up for awareness of oneself at different levels: physical, emotional and existential. The group becomes a model, a microcosm which shows how one functions in daily life. It opens one up for reflection on our condition as people or human beings. Yalom states that despite different positive factors, such as installation of hope, altruism etc., we nonetheless strug gle with the basic preconditions for existence - the knowledge that we shall die, that we are basically alone, that we are free and in this way also responsible for our life, and that we must reflect on the meaning of life.

BBATgroup as a relational exercise Massage and push-hands is a way to practise being in a closer relation ship. People meeting each other in pair exercises mirrors in a clear man ner how one relates in daily life. Often it takes place in an unconscious manner, but through becoming aware of one's behaviour , it is possible to choose some other approach - that is to change something in what one usually does. The group is a working model for training how one functions in daily life - setting limits, for example.

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Massage

When Anna was massaged by Jenny in the group, in the beginning she did not tell her that it was too hard and forceful and didn't feel good. On a later occasion, when she managed to say to Jenny that she wanted the massage to be lighter and less forceful, she became very satisfied and gained increased trust in herself She had managed to set limits . The group is an excellent and safe place to experiment with changing one's behaviour. This requires that the group leader can create an accepting and permissive group situation (Dropsy 1975). One works from the resource perspecti ve and with the individuals included in the group. It may be that someone can do only very simple movements. However, performing very simple movements often can lead to a deep experience of oneself, and "Less is more" (Dropsy 1975) . Push-hands

Push-hands is a BBAT exercise that can be done in a group. It originates in Tai chi. Push-hands is done together with a partner . This gentle exercise is originally a martial art. The ultimate aim is to learn to cooperate with others. Anna has practised push-hands with Patrick and has had interesting experiences of how she, in the movement, relates to another person . In push-hands, a person moves back and forth, transferring weight in a standing position, and the whole time there is contact with another person through hands/arms. During this exercise, one learns to listen to and feel each other's movement energies. There can be too much power or too little power that the partner uses in the movement. As in Tai chi, it holds true to use as little power as possible, but still to maintain one's balance, stability and grounding. An aim is also to develop a sensitivity and responsiveness to the partner. When the partner moves toward someone, one listens and feels the incoming power, yields, absorbs and redirects the movement/power. This means that one practises recognising one's partner's power/energy, while also being 120

aware of one's own energy or tension level. To be able to give way (but not give up), it is important to be in contact with one's own stability, grounding and tension level, both physically and mentally. When Anna made the exercise with Patrick, she noticed that she tensed up, went too far back with her weight, and easily lost her balance. Anna could not, at this stage, connect this to what she was used to doing in daily life. When she and Patrick continued to try push-hands , there was an aim that she gradually should become aware of her behaviour to not keep within her limits during the exercise. This was also true when she encountered different situations/relationships in her daily life. With Patrick, she could learn in a purely physical way that she should stay within the limits where she could maintain her stability. Maintaining physical stability can be a way to increase the feeling of empowerment and trust in one's own ability (Gyllensten et al. 2009). Anna also discovered in this process the parallel between movement behaviour and behaviour with other people.

To live in reality and the world Anna's new perspective With the help of the BBAT Anna came progressively more in contact with herself from her inner perspective. Her experience after therapy was that she felt more physically anchored/grounded, which increased her self-esteem. Anna's perspective on everyday life was widened, she felt more alive and involved in daily life, and more closely connected to herself and life. At the same time, she dared to be more aware of her own reality and to acknowledge her anxiety. Anna could, at the end ofBBAT, better express her needs and dare to think about the future. What Anna experienced and felt in the moment was accepted as right. Here, Patrick was not an expert, but his role was to acknowledge 121

Anna in what she felt. Anna needed to become more alive and to come out from her robotic existence. She needed to discover and to trust that she had freedom to choose a way. To develop and to emerge from her pain/anxiety spiral, she needed to do something in her life. Once she experienced and became aware of this, she felt that she couldn't go back to how it was before.

The "lived body" and the biographic perspective To experience a connection in one's own life strengthens the experience of identity and can make the symptoms understandable in one's own life processes, according to Chamaz (1995) . She stresses that it is important to have continuity and predictability in how one understands oneself and the body sensations. In a chronic illness, a biographic breakdown or rupture takes place and the individual no longer recognises oneself and one's own body signals. To accept oneself with the difficulties one has is the basis for acceptance, which is necessary to reclaim one's body and one's biography, and necessary to regain one's identity (Chamaz 1995). Bullington et al. (2005) described how individuals with chronic pain experience pain, their lives and meaningfulness, during rehabilitation with dance/music therapy. Initially, the relationship between the painful body, the ego and the world was chaotic and disintegrated. As the treatment progressed, the patients began to understand the significance of pain in life, and were able to articulate that they no longer identified with the pain but could relate to and reflect over it. Gradually, a sense of order grew and the patients could see the connection between the pain and life (Bullington et al. 2005). An increase of body awareness is then a step to be able to interpret what the body is expressing, and gradually to learn other strategies to deal with stresses, difficulties, or conflicts (Afrell 2014). The "lived body" both expresses and mirrors who you are. The 122

body and body experiences are the basis for the individual's experience of phenomena and conditions in the world. The experience of the body is the experience of myself (Merleau -Ponty 1962).

Existentially-oriented viewpoint The approach in BBAT is inspired by existential philosophy, which describes the ability to make informed choices in your life. It is not always obviously easy or even always possible to make one's own choices. Group and organisational levels as well as environmental factors can affect and hinder a person's possibility to do this . To choose to live with awareness that one has a basic ability to make conscious choices may lead to coming in contact with one's own anxiety. According to existential philosophy, anxiety is an unavoidable part of a person's existence (van Deurzen 1998). Existential therapy never tries to eliminate anxiety. To cure the ability to experience anxiety is to cure life itself (van Deurzen 1998). To see life and reality as it is can mean discovering anxiety. When anxiety is exposed, the next step is to try to endure it and thereafter find new creative paths. If life starts to be handled more actively, there arises a feeling of power and vitality. Anxiety can be viewed as a signal that one does not take care of one's needs (Gyllensten & Olsson 2013). To live authentically is a way to hand le one's anxiety. A non-authen tic life is characterised by a feeling of having gone astray. One becomes confused and locked, and desperately tries to find a direction in life. What are my goals? Here, the task of the therapist is to help the indiv idual find their wishes and purposes (van Deurzen 1998). An authentic life does not involve following the path of least resistance. It means going in the direction that one's conscience offers, to be in tune with one's own goals and own needs, naturally within the framework of the situation, as well as in accordance with one's values. There is, however, no guarantee that an authentic life automatically makes one happy. To be authentic can sometimes be associated with anxiety and pain. 123

In Existentialpsychology,Jacobsen discusses lifestyle, vitality and authenticity Qacobsen 1998). To open oneself to anxiety paves the way for the courage to face life and the feeling of being alive, to open oneself for one 's own inner existence. Vitality is an important part of the phenomenon of courage to face life, the feeling that life has its own worth. Viability gives a human being the possibility to live based on one's goals, meaning and intention. Do I manage my life in the right way? Do I regret something in my life? Or do I live right in accordance with myself? Do I live an authentically free and self-determined life chat is not formed primarily by the values and norms of the time? Existentially-oriented therapy has the cask to re-establish the connection between the human being and the world . Just as it is important to develop our sensibility for what is nearby, our own body, our own mood, our closest relationships, it is also important to develop our openness for what is distant. This can be the life conditions of people in other countries, how we exploit and use our natural resources, or the unity of the ecological system.

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6. Final reflections The Swedish National Board of Health and Welfare published the National Guidelines for Treatment of Depression and Anxiety (2016 version). The guidelines list several physically-anchored therapeutic treatments that can be used in therapy for anxiety and depression . Physical exercise and Basic Body Awareness Therapy are mentioned as treatments that can be beneficial. The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) points to inadequate evidence concerning both physiotherapeutic and psychological therapy both separately and in combination for treatment of generalised long -lasting pain . Instead, a multimodal rehabilitation is recommended, with focus on increasing quality of life and functional ability. Therapy shall bring together physiotherapy, physical activity and training according to principles of behavioural medicine. This takes a starting point in the fact that behaviour and life-style factors have an effect on body symptoms, the emergence of diseases, and above all the maintenance of and development of disease (SBU 2010) . Anna in our case report is a woman. Here there is a clear gender issue. In many countries, the incidence of generalised long-lasting pain in the female population is twice that of men (Afrell 2014). Also, the incidence of anxiety and depression is higher in women than in men (SBU 2012). Patients with pain/anxiety symptoms often look for a physiother apist because the difficulties are experienced in the body. The BBAT therapist is not a psychotherapist but works with helping the patient to come more in contact with "the living body" and understand the symptoms as a communication /indication that something is not right in life.

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PART Ill MOVEMENTS

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7. BBAT movements The movements in BBAT are characterised by them always being done in mindfulness . They aim to build up the inner musculature and improve stability in the body, as well as to develop a more functional movement pattern. Freedom , flow, ease and intention are some important compo nents in all BBAT movements . The physiotherapist always starts with the movement and the body positions the patient manages best. The movements presented here are examples of how a session can be. This part of the book is designed to show what a physiotherapist does when instructing a patient . Physiotherapists who lead movements, however, use their own words based on their own experiences.

Sitting movement Find your balance in sitting In order to find a balanced sitting position, you should start with sitting on the front part of a chair with a horizontal seat. Sit only on the pelvis - on the sitting bones - and let the thighs be free to move. Place the feet a little bit apart from each other so that the legs have a relatively open angle that feels comfortable . Move the legs back and forth, and stop where you have a straight natural line between your hips, knees, and feet. The whole footpad should be in contact with the base. If the knees fall too far to the side, you lose contact with the inside of the foot and if the knees fall toward each other, you lose contact with the outside of the foot. You then lose something of your root or base. Let the feet be right under the knees to facilitate an upright posture. 129

Sit like that for a while and pay attention to your posture from the feet to the head as a whole . Are you leaning forward or backward? Do you have the same weight on both legs? Do you feel tense or relaxed? In order to find your posture, you should start to pay attention to the pelvis. The pelvis and the feet form the base in sitting . When sitting on the front part of the sitting bones, the pelvis rotates forward a bit so that one gets a small but still relaxed curve in the lower back. To find just this optimal angle you can make a small rolling movement on the sitting bones so that you first collapse a bit and pay attention to how it feels. Thereafter, you roll forward a bit until you notice that you actively stretch up. Do this several times, and it will gradually become easier to find the relaxed and awakened upright balance. For the head to find its natural extension of the body's balance line, it is good to look ahead in a relaxed manner. Now you can try to stretch the whole of you toward the ceiling a bit, and then gently give way so that you feel support from the chair. In this safe base and anchoring you can move like a tree that easily sways in the wind; first swing slightly forward and backward and then a bit sideways, to gradually stop in a balanced posture. Notice the natural fl.ow of the breathing and the respiratory movement. What moves when you breathe? Free breathing can be felt differently from time to time . Breathing is like a shadow that follows all shifts in us. Try to consciously relax in the stomach and downwards toward the pelvis as well as on the backside to get access to breathing which includes the whole of you from the feet to the head . In order to further give support to the upright posture, you can make an m-sound when you breathe out. You can now return to noticing the whole of you in your sitting position. You have found your sitting balance, which releases your breathing, and where your breathing and posture support each other. You can observe and reflect upon different parts of yourself Perhaps you note that you now and then get lost in your thoughts and become fragmented in your attention . Then you can quietly and with stillness return to 130

noticing your posture and your breathing.

Image 28 (30). Find the balance in sitting.

Standing movement Find your balance in standing Start by standing in the way that you usually stand, in order to recognise yourself and your standing pattern. How do you experience your general posture? Are you standing in balance? Do you feel steady? Are you tense or relaxed? In order to find a relaxed balanced posture you can start by noticing the feet and the position of the feet. How far are they from each other? Are they somewhat angled out or parallel? Are you standing with equal weight on each foot? Do you put most of your weight on the

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heels, on the front of the foot, or somewhere in the middle? Start finding your balance by keeping a roughly hip-width distance between the feet, with them angled in a way that feels most comfortable. Do some pendulum movements backward and forward, and notice how the pressure under the feet changes . Notice how it feels in the whole of you when you have your weight on the heels, and when you have your weight on the front of the foot. Stop when you have the weight in the middle of the foot, which clearly is in front of the ankles. Oscillate a little from side to side and then stop with equal weight on both feet. Pay attention to how it feels. For most people, this centre of gravity is somewhat more forward than that to which we are accustomed. Then go on and note the position of the knees. Are they bent backwards or forwards or are they free and easy? Tense the legs by pushing them a bit backwards. Notice how it feels in the legs and in the whole of you . Give way in the knees; soften a bit so that you can easily move them forward and backward . Sink down a bit so that the legs are slightly bent . Notice how it feels. Stretch the legs a bit until they come to a more nat ural position where they can easily be brought both forwards and backwards. When the knees are in this free position, the legs can function as springs and easily adapt to different situations and contribute to both flexibility and elasticity. Freedom and flexibility in the ankles and knees also contributes to freedom and balance in the hip joints. Be aware of the hips by first bringing the pelvis a bit forward, stretch the hip joints, and note what happens with your trunk. Then bring the pelvis back and find a middle position . Bring the pelvis further back so that the upper body is moved forward and the hip joints are bent. Find again a middle position for the hips and pelvis. Bend the legs a little and note that the hips are also a little bent. Then move your attention to the trunk and start by having a general sense of the whole. Are the back and chest tense or relaxed? How is your posture in the trunk? Upright or hunched? How do you hold your head in relation to the trunk? Find the balance from below by noticing the lumbar spine or sway. In standing, it is natural to have a little sway but it

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should be relaxed. Make a little movement with the pelvis, forward and backward, to feel whether or not the sway-back will become too tense and whether or not you collapse somewhat. Find a balanced middle position with a small but soft sway-back . Notice the chest and thoracic spine. Here, we also look for a balanced posture around the balance line. Start by noticing your exhalation and feel for the chest softening and sinking down a bit. Notice the head's position. Make a small stretch of the neck to balance yourself and to find a feeling of ease and alertness. After having found a balanced posture, draw attention to your breathing. Placing one hand on the stomach and one hand on the chest might help . Where can you feel the movement? Notice it without interfering and accept what you note.

Image 29 (31). Find your balance in standing.

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Raiseand lower along the balance line Now you have balanced yourself to find a functional standing. Continue with some more active movements. Active standing can give a feeling of being part of a process, an attentive and forward attitude. Place the centre of gravity of the feet gradually more forward so that it will be easy to lift the heels from the ground and bounce a few times on the heels to establish a contact with your balance line. When you have balanced yourself as well as possible, you can bend the legs a bit. To stay in your balance line you need to bend gently at the ankles, knees and hips. Don't go further down than being able to keep your balance line stable. Be sure that the knees move in the same direction as the feet, in order to contribute to an obvious grounding and anchoring in the base. When we bend a bit in the legs, it is also important that the pelvis is allowed to move in a somewhat back-rotated movement, so that the sway-back is slightly softened. Keep the gentle relaxation in the chest and freedom in the neck. Then go back to the starting position by pushing with the feet towards the ground. When you come back to the starting position with straight and relaxed legs, the lumbar spine resumes a small sway-back by the pelvis rotating a bit forward. Let the arms and chest be free and soft. The gaze can be lowered a bit and rest at a point on the ground several metres in front of you. Make this movement several times. Let the breathing be integrated in the movement in the way that feels most natural. Extend the movement by gently coming to the front of the foot and let the heels leave the Boor somewhat. Continue by calmly sliding up and down along your balance line, allowing breathing to be integrated so that movement and breathing find a common rhythm and so that the movement feels like a flow through the whole of you .

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Image 30. Raising and lowering along the balance line while retaining stability.

Rotation around the balance line With access to a good ground /base and a good relation to the balance line, you can now try to find one of the basic coordination patterns, a symmetric rotation around the balance line. In this movement, the whole body is rotated in the same direction around the balance line as in a discus throw. Start from the balanced standing position and start a rotation engaging the whole of you from head to foot . All the parts are moved at the same time, not as a compact block but more as a spiral, at the same time free and coordinated. Try to find an optimal path for the movement - a simple rotation without using a lot of power. Let your gaze rest on the Boor or close your eyes for a while. Make the movement with the least possible effort, and try to find a free rhythm and a free fl.ow that are integrated with breathing.

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When you have worked with this movement for a while and found its form and flow, you can look up and around at the same time as you turn. Pay attention to what is around you. Keep your own stability, stay within your limits, and at the same time interact with the outside world.

Image 31. Rotation around the balance line in standing.

The wave This movement starts from the balanced posture and the standing raise-lower movement along your balance line. At the same time, you add an arm movement, so that you move completely as a unit . Start by gently bending your legs, keeping your balance line so that the trunk is bent neither forward nor backward, and bend a bit in the hips as if you are about to sit on a high stool. Do this several times. Then, at the same time as you straighten your legs, allow the arms to follow in a forward and upward movement until they are just under

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shoulder height. At the same time as you bend your legs, let the elbows lower a bit so that they come closer to the trunk. Press down the hands in front of the body as if to apply a little force toward the Boor. Repeat the simultaneous leg and arm movement until they act as one unit without stop and in a soft and continuous Bow. Let breathing be integrated in the movement so that you breathe in on the upward movement and breathe out on the downward movement. Here you can also add a clear and obvious intention going down, pretending that you are pressing a ball under water, and on the upward movement you recover, filling yourself with energy. This whole movement coordinates with the breathing. Adding an m-sound to your exhalation helps you activate your exhalation muscles and close a little at the front . When breathing in, the whole of you expands as one unit.

Image 32 . The wave: dynamic coordination with the arms and legs, integrated with breaching.

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Push-movement Here, we take a walking stance. The front foot points toward an intended target, with the back foot at a 45-degree angle in relation to the front foot. Stand with the feet at a certain breadth so that you get a good support from the base where you feel stable. This is a basic starting position in different self-defence methods , and in all these you work with somewhat bent legs to get space to move forward and backward . Soften a little in the sway-back to become more grounded and stable in your posture . Set yourself in a walking stance with your legs bent a little . Make some weight transfers forwards and backwards in order to find the range of movement where you feel stable and upright, without bending the trunk backwards or forwards. Keep the knees slightly bent the whole time. The feet remain on the floor the whole time in order to keep in contact with your base. To be able to push, you need a target and a clear intention. Open your eyes and turn your gaze toward this target. At the same time, the trunk is rotated slightly. Put your hands in front of the solar plexus area. Direct your intention to the target. With support from your back leg, transfer your weight forward, and from the centre of yourself, press the arms and hands slightly forward and upward . When you go back, the arms are pulled back to the solar plexus area. The movement of the arms thus makes an elliptical movement . Here it is important to maintain contact with the centre and keep your limits so that your stability and balance are kept through the whole movement. Breathing is also integrated with the movement . When you go forward and push, then you breathe out and direct your attention toward the target . When you go back, you recover by breathing in. By adding an m-sound to the exhalation and the forward movement, you also activate your central power in your abdominal muscles. In this way, you take your power partly from the ground through your feet/legs, partly from your central and abdominal muscles, and allow your power to be spread out in your arms .

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Image 33. Push-movement: to push forward and recover, with integrated breathing.

The open and close coordination In this movement, you start like in the previous standing movements from the standing balanced posture. Here you use in a clear way a coordination pattern that emphasises opening and closing around your centre. Open and close coordination is closely connected with breathing and emotional life. The origin of this movement is in the breathing movement, where you soften and close somewhat on exhalation, and on your inhalation you expand somewhat while at the same time stretching yourself a bit. Make this movement clearer so that on your exhalation you allow yourself to give way a little or soften in your balance line around your centre. The head is bending backwards a little. Hips, knees and ankles are bending at the same time. You close at the front, you open at the

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back, and the sway-back is softened . This movement can gradually become more enjoyable and may readily be followed by a resounding sigh wit h the sound "ah", to devote yourself to the movement. The movement consists of two parts that create a functional whole. So after devoting yourself to your exhalation, you straighten up on your inhalation and return to the starting position with a certain control in your upright position . Continue to play with the movement with little or no force. Find the interaction between breathing and movement, and be careful with softening in the balance line. Gradually, this movement becomes a harmonic wave movement with an exchange between open ing and closing around the centre. Note that you remain in your balance line for the entire time.

Image 34. Open and close coordinat ion in standing.

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Stop movement In the previous movement, you devoted yourself and let yourself soften in the balance line by giving way to gravity and allowing the movement to take place. In this movement, you will now try to use the same path you have already trod, but now through an active contraction of your front as if to protect yourself against a threat. Through actively contracting the body's front, the upper and lower parts of you are closing like in a bite. The "upper jaw" movement or chest movement is spread out in the arms, which come up in front of the body in a circle-shaped movement . The elbows go outwards and the fingers are directed toward each other and form a protection in front of you. The "lower jaw" or pelvic movement is spread down into the legs. In this way, the whole body or the whole of you is involved.

Image 35. Stop movement: a centred movement where arms

andlegs are coordinated

through the trunk.

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Also in this movement, it is important that breathing and voice are integrated. In the active gathering on the body's front, you breathe out and push out a "ho" or "hoo" and after a while, a "stop" or "no" to create a boundary toward the outside world. The gaze is clearly directed forward toward an intended target. The contraction marks a boundary and a "no". Then return to the starting position. This is a harmonisation of giving out and recovering energy. The recovery takes place on your inhalation.

Lying movements Lyingmovement being aware of yourself Lie on your back on a blanket on the floor. Try to lie down without putting something else underneath you, but if it feels too uncomfortable then try a rug or other mat, preferably not too soft. You can also place a pillow under the neck if you need to. If it hurts in the lumbar spine, then you can place a pillow under your knees as relief for the back. Let the arms lie at a comfortable distance from the body, and let the legs be relaxed so that the feet rotate out slightly. How does it feel to lie on the floor? To be aware of this, let your thoughts come to rest, and direct your attention to yourself. Is there something that attracts your attention? Does it hurt anywhere ? Does it feel comfortable or uncomfortable? Just notice how it feels. Accept the way it is just now. Start directing your attention to different parts of yourself. Note the heels' contact with the floor. Does it feel hard or soft? Is there a difference between the right and left heel? Rest for a while in this experience. Continue to notice the calves' contact with the floor. The calves can sometimes be of slightly different sizes; how is it for you? Is there a difference between the right and left calf? Which parts of the back of

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the thighs do you feel against the floor? Even if you do not feel the entire thigh or the knee, then perhaps you still become aware of them by paying attention to these parts. How does the pelvis lie on the floor? Which different parts of your back do you feel against the floor? Which parts don't you feel? Try to only "notice but not change" if you do not want to change. Which parts of the arms do you feel? Are you letting the arms rest? How is your head positioned? Do you let it lie on the floor? Please turn the head a little from side to side to yield slightly in the neck. Make a small nodding movement and notice any tensions in the neck. Does the head lie in the body's midline or does it lean in some direction? We continue to your front and start with the face. In the face we often have a lot of tensions; how does it feel for you? Pay attention to the forehead, eyes, and jaws. Is the tongue pressed toward the palate or the teeth? Try to soften in the face and notice the "new" feeling . Continue by noting the throat and chest. Note the stomach's different parts. Does it feel tense or relaxed in your groin? How do you feel in your thighs? Make note again of the feet. When you have gone through the whole of you, direct attention to the general feeling of the way it is just now. Lie like that for a while to "digest" the feeling.

Image 36. Lying movement , awareness of the body.

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M-sound in a lying position Stay lying on your back. Focus on your breathing without changing anything- only notice how it is. Is it easy to breathe or is your breathing restricted somewhere? Does your breathing feel thin and shallow or does it feel deep? Where can you feel that it moves when you breathe? Put your hands on your stomach in the soft area between the navel and the breastbone. Let the elbows rest against the floor. How are your hands? Are they tense or soft and open? Let the finger-tips be directed towards each other and feel whether or not the hands can gently rest on the stomach . Notice what takes place under your hands without changing anything. Is there a movement or not? Can you sense whether the eventual movement spreads somewhere or not? Try to allow breathing to take care of itself, to find its freedom. Free breathing can be fast or slow, regular or irregular. It is very easy to disrupt or to control the breathing. Sometimes this becomes a habit which one hardly notices. How is it for you just now? By not controlling, you can allow breathing to regain its freedom.

Image 37 . M-sound in the lying position.

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Adding an m-sound to your exhalation can deepen awareness of your breathing. Continue like that for a while and let the sound contribute to an increased flow. To add an m-sound on exhalation can also be like starting a "central motor", with a small increase in abdominal muscle activity. This movement may lead to a feeling that you are a unit, a unit that closes during exhalation and opens during inhalation. How does it feel for you?

Gathering of your legs towards each other Start by focusing on your legs or the lower part of you. You will now try to perform a more active movement. How do you feel in your legs just now? How do the feet lie? Are they outwardly rotated or do they point up to the ceiling? Try to actively turn the feet somewhat toward each other, relax, and let the feet turn out again. Do this several times and try to use very little force. Perhaps you note that it is the entire legs that are turned toward each other and then fall apart a bit. Move the legs closer toward each other so that the insides of the legs are in contact with each other. Press the legs lightly against each other and then relax so that the legs again fall apart. Do this several times . From where does power come to do this movement? Gradually, perhaps, you feel that the power comes from the legs but also from the stomach, your centre, and in this way it is really the whole of you that is involved in this movement. It is a gathering action from the whole . Between each gathering action, you relax and open yourself Gradually you find a rhythmic movement. Try to play with the pace, being somewhat faster with less power, and somewhat slower but with more power. Do you notice your breathing in this movement? Do you hold your breath? Or is your breathing involved and if so, how? Try to breathe out on your gathering movement and breathe in when you relax. In such a way,you get a rhythm between activity and recovery. If you can find

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a balance between these aspects of breathing, you will be able to keep going for a long time with what you are doing. Try to add an m-sound to this leg movement . Pay attention to what takes place in the gathering of the legs. Maybe it will become a more unified gathering with a little activity from the whole of you - a gathering from your centre that is spread in different directions but where your intention is in the gathering of the legs.

- _J Image 38. Lying leg-gathering, where the legs are gathered toward each ocher, and then softly returned co the initial position.

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Stretching movements Lie for a while on your back and digest the previous movement. Let your awareness rest in the whole of you . Open your senses and try to take in what you feel in you just now. Try to be aware of "what is" just now. Let the arms slide up along the floor to about shoulder height. How does it feel in the shoulders and chest? Stay a while in this position to allow your shoulders and chest to adapt and soften. To pay attention to and to loosen your arms, shoulders, chest, start with a small turning of the arms in an inward rotation and then in an outward rotation. Does it feel the same in the right and left shoulder? Let the arms very lightly slide out along the floor in a small stretch as a way to open yourself, then again elastically spring back. Do it several times while noting the feelings and sensations. Symmetric stretching movement

Move the arms up closer to the head if your shoulders allow you to. Move the legs closer to your midline. Stretch the arms and legs cautiously in opposite directions so that the whole of you is extended. Relax and let the whole of you spring back. Do it this way several times. Use only a little power. Let the stretching take place inside of you so that you stretch front and back equally. Pay attention to your breathing . If you hold your breath, then the movement is blocked. Take your arms down cautiously, put your hands on your stomach, and rest while paying attention to what you feel in you just now.

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Image 39. Symmetric stretching movement, where the whole body is screeched and then springs back co the initial position.

Alternating stretching movement

After a period of attentive rest, you again allow the arms to come down on the floor. Bring the arms up gently so that they come closer to the head. Bring the legs somewhat closer to your midline. Lie for a while in this position and let the body adapt to this position. Stretch the whole right side, the leg, the trunk and the arm gently and cautiously. Use only a little force and stretch so that it feels as comfortable as possible. Relax by gently giving in. Stretch the left side in the same way. Then stretch alternately the right and the left sides. Continue little by little with increased flow and a small increase in pace so that it becomes like a dance involving the whole you . Try to maintain an intact and stable midline. The movement can at the same time be both united and free. Take the arms down gently and place the hands on the centre of your stomach and rest while being attentive to how it feels right now.

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Im age 40. Alternating stretches through the right side and the left side of the body.

Gathering movements Lying gathering into a ball with bent legs

Bend the legs so that the feet can rest on the floor. Keep the feet at a hip -width distance from each other, where you get as stable a position as possible,Start by resting a while with bent legs. Let the lumbar spine relax and sink down a bit toward the floor. Continue by pulling the legs

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Image 4 1. Lying gath ering into a ball with the legs pull ed towards th e chest. Lightly pull yourself together on the from, and then spring back to the starting position.

up closer toward the stomach and chest. Put your hands around your knees in a collected position. Fold your hands or hold one hand on each knee . Rest in this position for a while to get used to it. Give way to unnecessary tensions in arms, shoulders and in the neck . Pay attention to your breathing and let small breathing movements spread. On an exhalation, clarify the breathing movement by using the arms and hands to help pull the legs cautiously against the stomach and chest . When you feel a slight resistance let go of the pressure and let the legs move away

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from the trunk elastically. Release the arms and make room for inhalation. Do this movement several times in order to find interaction between the movement and breathing. Add an m-sound to your exhalation to clarify your breathing and also to little by little get help to start the "central motor" where you, with help of your abdominal muscles, make a slight contraction on the front at the same time as the back is rounded and softened. The neck is also integrated in the movement and the head is bent slightly backwards. On your inhalation, you return again to the starting position. Starting from your centre, this becomes an active gathering movement on exhalation and an opening movement on inhalation. Lying contraction around the centre with the feet on the floor

Bend the legs, placing the feet on the floor at a comfortable distance from each other. If you like, rest your hands at your centre, between the navel and the breastbone. Be aware of your breathing. After a period of relaxed rest you may notice how you expand somewhat on inhalation and deflate somewhat on exhalation. This is your breathing at rest. Add your m-sound to your exhalation. Although you use just a little power, you can sense the light natural contraction around your centre. This may now become a more active action where you close on exhalation and open up on inhalation. This coordination around your centre becomes a full united movement where the whole of you takes part. You contract on the front, the back is rounded, and the head is bent somewhat backwards but always in contact with the floor. On inhalation you straighten out again. You can play with this closing movement from your centre. Try very small movements and switch to more powerful movements. The more power you put into the movement, the more power will be expressed through your voice. Don't do so much that you can't find a relaxed flow and a natural rhythm. End by stretchingout the legs, placing the hands on the stomach

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and rest while paying attention to the whole of you and your breathing, which now returns to tidal breathing.

Image 42. Lying contraction around the centre with the legs bent and feet on the floor.

After having done the gathering movements in a lying position, stretch the legs out again and place the hands on the stomach. Return to rest and note how it feels in the whole of you. Pay attention to your breathing again . Here there may be an impulse to yawn and impulses for spontaneous stretching movements. Let them through. These spontaneous stretches are very natural movements and stimulate the body,

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waking it up precisely as you want dog does after having rested.

to

do in the mornings or as a cat or

WalkinS? Stand up and balance yourself. Notice your standing posture from feet to head. How is your posture just now? Decide to start walking, not because you need to have a goal for your walking - just walk. Choose a pleasant tempo and pay attention to how you walk. Try to be aware of yourself and the way you walk. Note how the feet meet the ground. Let the feet gently roll from the heel and forward . By winding down with the big toe in walking, you also get a natural forward pushing power. Mobility in the feet helps you to find the flexibility in the legs and softness in the knees and hips. Pay attention to your knees so that they are not overstretched in some part of the walking phase. This softness and flexibility in the feet and legs may make you feel like you are rolling forward. Pay attention to your hips, pelvis and lumbar spine. The movement here is dependent on an upright and balanced posture. Keep the upright posture and at the same time try to soften somewhat in these parts. How does the movement change when you notice different parts of you? Do you get more tense, or can you yield somewhat? How do you move your arms? Do they move automatically or do you pull them forward and back? The movement of the arms is dependent on freedom in the chest and openness in the chest and shoulder muscles. How is it for you? How are the arms and legs coordinated in relation to each other? How do you hold your head? Note if the head forms a natural extension of your balance line, and note whether or not it is kept locked or there is a natural movement in your head when you walk. Return to the experience of the whole of you. Be aware of your breathing. Let breathing and walking coordinate to a harmonic unit.

Youcando thisbestby simplyallowing it to happen. 153

Image 43. Walking: to walk at a comfortable pace .

154

References Afrell, M (2014). Att leva med en kropp som vdrker - samtal med fysioterapeut. (Living with a body in pain - dialogues with the Physical Therapist) Avhandling, Medicinska fakulteten, Linkopings Uni-

versitet. Ainsworth, MS (1979). The mother-infant attachment. American Psychologist. Vol 34 (10): p. 932-937. Andersen, PA & Guerrero, LK (2008). Haptic behavior in social interaction III. In Grunwald M. (ed.) Human haptic perception . Basics and applications. Basel: Birkhauser Verlag, p. 155-164. Antonovsky, A (1991). Ha/sans mysterium. Stockholm: Natur och Kultur. ( Unraveling the Mystery of Health, l 987, Jossey-Bass Inc. Publishers) Asberg, M, Skold, C, Wahlberg, K, Nygren, A (2006). Mindfulness Meditation - nygammal metod for att lindra stress. Lakartidningen. Vol 42 (103): p. 3174-3177. Bader-Johansson, C (2013). Rorelse och interaktion: Om grundmotorik, stress och sjdlvreglering. (Movement and Interaction: About basic motor function, stressand self regulation) Lund: Studentlitteratur. Basmajian, J, De Luca, C (1985). Muscles alive: their functions revealed by electromyography. 5th ed. Baltimore: Williams & Wilkins. Biguet, G, Keskinen-Rosenqvist, R, Berg, AL (red.) (2012). Att forsta kroppens budskap - sjukgymnastiska perspektiv (To understand the message of the body - physical therapy perspectives) Lund: Studen-

tlitteratur. Bowlby, J (1976). The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory.An expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 155

1976. The British Journal of Psychiatry.Vol 130: p. 201-210 . Broda!, P (2010) . The central nervous system - Structure and Function. 4th edition. New York: Oxford University Press. Buber, M (2001) . Jag och Du. (Me and You) Ludvika : Dualis forlag. Buber, M, Sallstrom, P (2008) . Distance and relation. Ludvika: Dualis forlag. Bullington, J, Sjostrom-Flanagan, C, Nordemar, K, Nordemar, R (2005). From pain through chaos towards new meaning: two case studies. TheArts in Psychotherapy . Vol 32 : p. 261-274. Bunkan, B (1987) . Muskelspi:inningar:undersiikning och behandling. Stockholm: Liber. Bunkan, B (1997). Kropp, respirasjonog kroppsbilde.Oslo : Universitetsforlaget. Chamaz, K (1995) . The body identity and self: adapting to impairment. The SociologicalQuarterly.Vol 36(4): p. 857- 880 . Damasio, A (201 O). Self comesto mind: Constructingthe ConsciousBrain. Pantheon. Demoise, C (2010) . Tai chi as spiritual practice. Demoise, USA. van Deurzen, E ( 1997). EverydayMysteriesExistential dimensions of Psychotherapy.Routledge. Ditzen, B (2004). Effectsof romanticpartner interactiononpsychologi.cal and endocrinestressprotectionin women. Cuvillier Forlag, Gottingen . Downey, G, Khouri, H, Feldman, SI (1997). Rochester symposium in developmental psychopathology. In Cicchetti, D and Toth, T (eds.) Early interpersonaltrauma and later adjustment: The educational roleof rejectionsensitivity. Rochester NY: Rochester University Press, p. 85-114. Dropsy, J (1975) . Leva in sin kropp (To live in one'sbody). Lund: Aldus. Dropsy, J (1988). Den harmoniska kroppen. (The Body in harmony). Stockholm: Natur och Kultur . Dropsy, J (1999) . Human expression - the coordination of mind and body. In Skjaerven LH (ed.) Bevegelseskvalitet,kunst og helse.Bergen: H0jskolen in Bergen, p.11-24 .

156

Elphinston, J (2006). Total stabilitetstraning. Stockholm: SISU. Fadnes, B, Leira, K (2006) . Balansekoden. Om samspillet mellom kroppslig og mental balanse. Oslo: Universitetsforlaget . Field, T (2001). Touch. Cambridge: The MIT Press. Fonagy, P, Gergely, G, Target, M, Jurist, E (eds.) (2003) . Affect regulation, mentalization and the development of the self London : Karnae Books. Frankl, V (1986). Livet maste ha en mening.(Life must be meaningful) Stockholm : Natur och Ku!tur. Friis, S, Skatteboe UB., Hope, MK, Vaglum, P (1989). Body awareness group therapy for patients with personality disorders. 2. Evaluation of the Body Awareness Rating Scale. Psychother Psychosom. Vol 51: p. 18-24 . Fromme, DK, Jaynes, WE, Taylor, DK, Hanold, G, Daniell, J, Round three, R, Fromme, ML (1989). Nonverbal behavior and attitudes towards touch. journal of Nonverbal Behavior . Vol 13: p. 3-14. Gainotti, G, Silveri, MC (1996) . Cognitive and anatomical locus of lesion in a patient with a category-specific semantic impairment for living beings. Cognitive Neuropsychology. Vol 13: p. 357-390 . Gerhart, S (2007) . Karlekens roll: Hur kanslomdssig narhet farmar spadbarnets hjarna . (The role of love, How emotional attachment shapes the brain of the infant.) Stockho lm: Karneval Forlag. Grossman, P, Niemann, L, Schmidt, S, Walach, H (2004). Mindful ness-based stress reduction and health benefits: a meta-analysis. journal of Psychosomatic Research. Vol 57 : p. 35-43. Gyllensten, AL (2001) . Basic Body Awareness Therapy. Dissertation, Medicinska faku!teten, Lunds Universitet, Sweden. Gyllensten, AL, Hansson, L, Ekdahl, C (2003). Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. journal of Bodywork and Movement Therapies. Vol 7 (3): p. 173-183. Gyllensten, AL, Ekdahl, C, Hansson, L (2009) . Long-term effectiveness of Basic Body Awareness Therapy in psychiatric outpatient care: 157

a randomized controlled study. Advancesin Physiotherapy . Vol 11: p. 2- 12. To link to this Article : DOI: 10.1080 / 14038190802242061 Gyllensten, AL, Skar, L, Miller, M, Gard, G (2010) . Embodied identity - A deeper understanding of body awareness. Physiotherapy Theoryand Practice.Vol 26 (7): p. 439-446 . Gyllensten, AL (2011). Andningen i ett psykosomatiskt perspektiv The Breathing in a PsychosomaticPerspective.In : Olseni, L,Wollmer, P (red.) Sjukgymnastik vid nedsatt lungfunktion. (PhysicalTherapyfor decreased function of the lungs)Lund : Studentlitteratur, p. 165- 167. Gyllensten, AL (2013). Basal Kroppskdnnedom.(BasicBody Awareness Therapy). In : Biguet, G, Keskinen Rosenquist, R, Berg AL (red.). Att forsta kroppens budskap . sjukgymnastiska perspektiv (To understand the messageof the body-physical therapyperspectives) Lund : Studentlitteratur, p. 189-205 . Gyllensten, AL, Mattsson, M (2011, revised 2015) . Manual Body AwarenessScale-Movement Quality and Experience. BAS Rorelsekvalitet och Kroppsupplevelse . Lund: Trialis. Gyllensten, B, Olsson, G (2013) . Det terapeutiskamotet. Om relationens signifikans i psykoterapi och vardagsliv. ( The therapeuticencounter: the significanceof the relation in psychotherapyand everyday Life) Lund: Trialis. Harris, T, Lagerstrom, A (2008). Konsten att leva innerligt. (The Art of a Heart-felt Life)Falun: Wahlstrom & Widstrand . Hedlund, L, Gyllensten, AL (2010). The experiences of basic body awareness therapy in patients with schizophrenia . journal of Bodywork & Movement Therapies.Vol 14: p. 245 -254. Hedlund, L (2014) . Basal kroppskannedom och psykomotorisk funktion hos personer med allvarlig psykisk sjukdom (Basic Body awarenesstherapy and psychomotorfunction in persons with severe mental illness).Dissertation. Department of Health Sciences, Faculty of Medicine . Lund University, Sweden. Hedlund, L, Gyllensten, AL, Waldegren, T, Hansson, L (2016). Assessing movement quality in persons with severe mental illness. 158

Reliability and validity of the Body Awareness Scale Movement Quality and Experience. PhysiotherapyTheoryand PracticeVol 32 (4): p. 296-306. Hof, H (1985). Eli mer mdnniska. (To becomemore human.) Uppsala: Bokfi:irlagetAsak. Horak, F, Macpherson, J (1996). Posturalorientation and equilibrium. In: Shepard, J, Rowell, L (eds.) Handbook of Physiology, section 12. Exercise: regulation and integration of multiple systems. New York: Oxford University Press, p. 255-292. Hi:iller-Zangenfeind, M (2004). Stimme von Kopf bis Fuss. Innsbruck: Studienverlag. Jacobsen, B (1998). Existensenspsykologi.(ExistentialPsychology)Stockholm: Natur och Kultur, p. 217-219, 248. Kabat-Zinn,] (2008). Full Catastrophe Living. New York:Random House . Kiehn, 0 (2006). Locomotor circuits in the mammalian spinal cord. Annual Review of Neuroscience . Vol 29: p. 279 -306 . Kolb, DA (1984). Material from ExperientialLearning, experienceas the sourceof learning and development. http:/ /www.learningfromexperience .com/images/uploads/process -of-experiential-learning. pdf. Accessed 2006-05-31. Lam, P (2006a). Tai Chi for beginnersand the 24 Forms. Balmain, N.S.W: Limelight Press. Lam, P (2006b) . TeachingTai Chi effectively.Narwee, Australia: Tai Chi Productions. Lambert, MJ, Bergin, AE (1994). The effectiveness of psychotherapy. In: Garfield, SL, Bergin, AE (eds.) Handbook of Psychotherapy and Behaviouralchange(fourth edition). New York: Wiley. Larsson, CB, Gould, M (1974). Orthopedic nursing 8th ed. St. Louis: CV Mosby. Laufer, Y, Rotem -Lehrer, N, Ronen , Z, Khayutin, G, Rosenberg, I (2007). Effect of attention focus on acquisition and retention of postural control following ankle sprain. Archivesof PhysicalMedi-

cine and Rehabilitation.Vol 88: p. 105-109. 159

Lohse, KR, Wulf, G, Lewthwaite, R (2012). Attentional focus affects movement efficiency. In: Hodges, NJ, Williams AM (eds.) Skill acquisition in sport: Research, theory &practice (2nd ed .). London:

Roucledge, p . 40 -58. Lowen, A (1975) . Bioenergetics. The revolutionary therapy that uses the language of the body to heal the problems of the mind. New York: McCann and Geoghedan Inc . Luborsky, L (1994) . Therapeutic alliance as predictor of therapy out comes. Factors explaining the predictive success. In Horvath, AO, Greenberg, LS (eds). The working alliance, theory, research and practice. New York: Wiley and Sons Inc.

Lundberg, D, Axelsson, S, Bovie, J, Eckerlund, I (2006) . Metoderfo'rbehandling av Ungvarig smarta. En systematisk litteraturdversikt. SBU (Swedish Co uncil of Health Technology Assessments), 1 nr. 77 (Methods for treatment of prolonged pain. A systematic literature review. Maslow, AH (1943) . A theory of human motivation. Psychological Review. Vol 50 (4): p. 370-396. Mattson, J (2013) . Den kansliga revolutionen . Nu tar mindfulness nas-

ta step. (The sensitive evolution, next step in mindfulness) Mod ern Psykologi. Vol 5: p. 49-53. McGilchrist, I (2009). The master and his emissary. The divided brain and the making of the modern world. London: Yale Universiry Press. Mehling, W, Wrubel, J, Daubenmier, C, Kerr C, Silow T, Gop isetry, V, Steward, A (2011). Body Awareness: a phenomenological inquiry into the common ground of mind -body therapies . Philosophy, Ethics, and Humanities in Medicine . Vol 6:6. Merleau-Ponry, M (1962) . The phenomenology of perception. London: Roucledge. Moncagu, A (1986). Touching: The human significance of the skin (3rd ed). New York: Harper & Row. Nhat Hanh, T (1996). Mandeltradet i din tradgard: Uppmarksamhetens under. Lund: Attusa forlag. (Miracle of Mindfulness, 1976, Beacon Press, USA)

160

Nilsonne, A (2009) . Mindfulness in the brain. Stockholm : Natur och Kultur . Pai Y-C, Maki, BE, Iqbal, K, Mcllroy, WE, Perry, SD (2000) . Thresh olds for step initiation induced by support-surface translation: a dynamic center -of-mass model provides much better prediction than a static model.journa l of Biomechanics.Vol 33 : p. 387 -392. Perry, BD (2002). Childhood experience an d the expression of genetic potintial : What childhood neglect tells us about nature and nur ture . Brain and Mind. Vol 3: p . 79-100 . Postmes, LS, Herman N, Goedhart, S, van der Stel, J, Heering, HD, de Haan, L (2013) . Schizophrenia : a self-disorder due to perceptual incoherence . SchizophreniaResearch.Vol 152 (1): p. 41-50 . Reich, W (1968) . Thefunction of the orgasm.New York: Farrar, Straus and Giroux . Roxendal, G, Winberg, A (2002). Levandemanniska. BasalKroppskanne-

domfor rorelseochvila. (The living being.Basicbodyawarenesstherapyfor movementand rest).Stockholm : Natur och Kultur . Roxendal, G (1985). Body Awareness Therapyand the Body Awareness Scale,therapyand evaluation in psychiatricphysiotherapy.Disserta tion: Gothenburg University. Roxendal, G (1987). Tre BAS skalor:Body AwarenessScale (BAS), BAS

halsa,Intervjuskalafor Kroppsjaget(ISK).(The threeBodyAwareness Scales, the BAS, BAS-Health and Interview Scalefor the Body ego (ISK)) Lund: Studenditteratur. Siegel, D (2010). Das achtsameGehirn. Freiburg : Arbor Verlag, p. 53-54 . SBU, Statens beredning for medicinsk urvardering (2010). Rehabilitering vid ldngvarigsmarta. En systematisklitteraturoversikt.Partiell uppdateringochfordjupning av SB U rapport1771I +2. Stockholm : SBU-rapport nr. 198 . ISBN 978 -91-85413-34 -8. Shumway -Cook, A, Woollaco tt , M (2012). Motor Control. Translating researchinto clinicalpractice.4th ed. Wolters Kluwer/ Lippincott Williams & Wilkins .

161

Skatteboe, UB, Friis, S, Hope, MK , Vaglum, P (1989). Body Awareness Group Therapy for Patients with Personality disorders. I. Description of the therapeutic method. Psychotherapy and Psycho-

somatics.Vol 51: p . 11- 17. Skatteboe, UB (2000) . Basalkroppskjennskapog bevegelsesharmoni . Vidareutvecklingav undersokelsesmetoden Body AwarenessRating Scale, BARS bevegelsesharmoni. Oslo: Oslo University College , Faculty of Health Sciences. Skj~rven, LH ( 1999) . A vt£resegselv- merjullt og helt - En tillnt£mning til Bevegelseskvalitet.(To be oneself more fully). Hovedfagsoppgave, Hogskolen i Bergen . Skj~rven, LH, Kristoffersen , K, Gard, G (2008). An eye for movement quality: A phenomenological study of movement quality reflecting a group of physiotherapists' understanding of the phenome non. PhysiotherapyTheoryand Practicevol 24 (1): p . 13-27 . Skj~rven, LH, Kristoffersen, K, Gard, G (2010) . How can movement quality be promoted in clinical practice? A phenomenological study of Physical Therapist experts. Physical Therapyvol 90: p. 1479-1492. Skj~rven, LH, Sundal, MA, Gard, G, Strand, LI (2013) . Body AwarenessRating Scale, BARS, a physiotherapeuticassessmenttool. Bergen : Hogskolen in Bergen. Skj~rven, LH, Gard, G, Sundal, M, Strand , L (2015) . Reliability and validity of the Body Awareness Rating Scale (BARS): an observational assessment tool of movement quality . Europeanjournal of Physiotherapyvol 17: p.19-28 . Skoglund, K (2011). Institutetfor Basal Kroppskdnnedom(IBK) http :// www.ibk.nu /vad-ar -bk/h ur-startade-det -som-idag-kallar- Basalkroppskannedom Socialstyrelsen (National Board of Health and Welfare, Sweden) (2014) .

Klassifikation av funktionstillstdnd, funktionshinder och hdlsa. http: // www.socialstyrelsen. se/ klassificeringochkoder /koderfunk tio nstillstandicf 162

Stenmar, L, Nordholm, LA (1994). Swedish physical therapists' beliefs on what makes therapy work. Physical Therapy. Vol 74 (11): p. 1034-1039. Stern, D (1985). Interpersonal World of the Infant: A View from Psychoanalysis and Development. New York: Karnac Books. Sunden, A, Ekdahl, C, Magnusson, PS, Johnsson, B, Gyllensten AL (2013) . Physical function and self-efficacy- Important aspects of health-related quality oflife in individuals with hip osteoarthritis . European journal of Physiotherapy. Vol 15 (3): p. 151-159 . (DOI: 10.3109 /21679169 .2013.830331) Sunden A, Ekdahl, C, Horstman, V, Gyllensten, AL (2016). Analyzing movements. Development and evaluation of the Body Awareness Scale Movement Quality (BAS MQ) . Physiotherapy Research InternationalVol 21 (2): p. 70-76. Taylor, JB (2006) . Min Stroke. (My stroke) Malmo: Bra Bocker. Thibodeau, G, Patton, K (1993). Anatomy and physiology 2n d ed. St Louis: CV Mosby. Thornquist, E (2001) . Diagnostics in Physiotherapy. Process, patterns and perspectives. Part I. Advances in Physiotherapy. Vol 3: p. 140150. Tomkins, S. (1962). Affect, imagery, consciousness. Oxford, England: Springer. Trew, M, Everett, T (1997). Human movement. An introductory text. 3rd ed. London: Churchill and Livingstone. Uvnas-Moberg, K (2009). Narhetens hormon . Oxytocinets roll i relationer. (The hormones of closeness. The role of Oxytocin in relationships). Stockholm: Natur och Kultur. World Confederation of Physical Therapy: http:/ /www.wcpt.org/whatis-physical-therapy Accessed 14th January 2014 . Wulf, G (2007). Attention and motor skill learning. Champaign, IL: Human Kinetics. Yalom, I (1995). The theory and practice of group psychotherapy. New York: Basic Books. 163