**6. The scope of physiotherapy in mental health**

**4.1. Mental health in physiotherapy**

182 Clinical Physical Therapy

**4.2. Physiotherapy in mental health care**

**5. Definition of physiotherapy in mental health**

Not all physiotherapists realize that mental health is all the business of physiotherapy. However, it is well illustrated in the following quotation: 'no health without mental health'. As health care providers, physiotherapists are also involved in the prevention and promotion of health, including mental health. It is their responsibility to inform individuals adequately about mental health, eliminate misconceptions about mental illness and refer them when nec‐

Consciously or unconsciously, colleagues will be confronted in their practice with indi‐ viduals with frail mental health, chronic musculoskeletal disorders, chronic pain and psy‐ chosomatic disorders. In their stories, components of mental health are interwoven, and the patients deserve an appropriate physiotherapy intervention. In addition to these conditions, more severe physical diseases such as cardiovascular diseases, Parkinson's disease, rheuma‐ toid arthritis, hypertension, Diabetes mellitus, metabolic syndrome, asthma, asthma/chronic obstructive pulmonary disorder (COPD), cerebrovascular diseases (stroke), obesity, epilepsy, cancer and other diseases are frequently accompanied with a 'rollercoaster' of emotions, feel‐ ings of anxiety and pain. After all, individuals with mental disorders have numerous physical health complaints (cardiovascular diseases, metabolic syndrome, obesity, osteoporosis, etc.) due to medication, sedentary behaviour or inactivity and consult primary health services.

In summary, it all adds up for the health care providers to optimize access to physiotherapy for people with mental illness, give them the most appropriate treatment [9] and give addi‐ tional thought to the mental health dimension of their patients' physical conditions [10].

In some countries, physiotherapists have a long tradition of using physiotherapy in mental health and developed specific approaches for common and severe disorders aimed at improv‐ ing the quality of daily life. It is time to bring all the knowledge together to consolidate it and centralize the interventions with a view to offer appropriate care to a specific vulnerable but growing group in society. For these persons, specific interview, assessment and therapeutic skills are necessary. The interview is based on the principles of the bio‐psychosocial and moti‐ vational interview [11]. The story, including the context, life events and chronic stressors in relation to the health of each patient, is mapped. The assessment focuses on lifestyle in rela‐ tion to the health, mood and anxiety features, illness behaviour and psychological well‐being.

The IOPTMH developed a definition that generally describes the field of physiotherapy in mental health that is recognizable among most colleagues across the world. Physiotherapy in mental health is a specialty within physiotherapy. It is implemented in different health and mental health settings: psychiatry and psychosomatic medicine. It is Person‐centered and pro‐ vided for children, adolescents, adults and older people with common (mild, moderate) and

essary to specialized professionals in mental health and psychiatry.

Depending upon the problem, the story of the patient, and the results of the observation/eval‐ uation, the patient's treatment goals will be established, and the physiotherapist can choose a more health‐related approach or psychotherapeutic physiotherapy (see **Figure 1**). *The physical health‐related approach* aims to improve the global physical health of patients with psychiatric disorders. Physical activity can help to reduce cardiovascular disease and premature mortal‐ ity in people with psychological problems. *The psychosocial‐related approach* emphasizes the acquisition of mental and physical proficiencies related to the body in motion and support of personal development to enhance people's ability to function independently in society. *The psychotherapeutic‐related approach uses the body in movement* as a gateway to ameliorate the social affective functioning of an individual. When using this approach, the physiotherapist creates a setting that favours the initiation and development of a process in the patient by employing specific working methods that aim to help patients to access their inner workings.

**Figure 1.** The scope of physiotherapy in mental health.

In physiotherapy in mental health, a rationale for applying psychological models (e.g. cog‐ nitive behavioural therapy, acceptance and commitment therapy, etc.) is offered as a tool to strengthen physiotherapy interventions in the treatment of a wide variety of disorders in children, adolescents, adults and the elderly. The cognitive behavioural physiotherapy treatment approach consists of the identification of current and specific problems related to the moving human being. The physiotherapy goals are based on the SMART principles (Specific, measurable, acceptable/attainable, realistic/relevant and time bound). The treat‐ ment is I think it is patient‐centered and the ultimate physiotherapy goal is to change unhealthy habits and promoting an active lifestyle and healthy posture. The focus lays on self‐management and relapse prevention. Different modalities (see **Figure 2**) such as cogni‐ tive techniques (cognitive restructuring, problem solving and cognitive functional training), behavioural (relaxation, pacing and graded exercise therapy and behavioural activation), supportive, educational and other techniques such as (bio‐) feedback, movement and body awareness and relapse prevention for children and adults are integrated into this treatment [14]. The acceptance and commitment physiotherapy approach is supporting the patient to clarify his/her values and helping them to take the necessary steps towards living a meaning‐ ful life despite the discomfort [15].

**Figure 2.** Cognitive behavioural techniques in physiotherapy.

#### **6.1. 'Physical health‐related' approach**

The physical health‐related approach aims to improve the global physical health of the person with mental health problems. Studies have shown that people with mental health problems are more susceptible to inactivity and are at risk of a sedentary lifestyle. In addition, the use of psy‐ chotropic drugs can result in the development of metabolic syndrome, obesity, osteoporosis and cardiovascular disease. The physical health‐related approach is consistent with the recent recommendations of the World Health Organization (WHO) about the relationship between individuals' 'physical inactivity' and poor health and a serious threat to their quality of life [16].

Clinical practice has highlighted the importance of tailoring physical activity to each person's individual abilities to influence the quality of life. The challenge is to motivate people to stay active throughout their daily life. People who do not continue to exercise lose their independence and do not maximize their potential in life. The American College of Sport Sciences [17, 18] offers guidelines. It is the task of the physiotherapist to integrate and adapt these guidelines to fit the context of a person with mental health problems [19–22].

#### **6.2. Psychosocial‐related and psychophysiological approaches**

In physiotherapy in mental health, a rationale for applying psychological models (e.g. cog‐ nitive behavioural therapy, acceptance and commitment therapy, etc.) is offered as a tool to strengthen physiotherapy interventions in the treatment of a wide variety of disorders in children, adolescents, adults and the elderly. The cognitive behavioural physiotherapy treatment approach consists of the identification of current and specific problems related to the moving human being. The physiotherapy goals are based on the SMART principles (Specific, measurable, acceptable/attainable, realistic/relevant and time bound). The treat‐ ment is I think it is patient‐centered and the ultimate physiotherapy goal is to change unhealthy habits and promoting an active lifestyle and healthy posture. The focus lays on self‐management and relapse prevention. Different modalities (see **Figure 2**) such as cogni‐ tive techniques (cognitive restructuring, problem solving and cognitive functional training), behavioural (relaxation, pacing and graded exercise therapy and behavioural activation), supportive, educational and other techniques such as (bio‐) feedback, movement and body awareness and relapse prevention for children and adults are integrated into this treatment [14]. The acceptance and commitment physiotherapy approach is supporting the patient to clarify his/her values and helping them to take the necessary steps towards living a meaning‐

The physical health‐related approach aims to improve the global physical health of the person with mental health problems. Studies have shown that people with mental health problems are more susceptible to inactivity and are at risk of a sedentary lifestyle. In addition, the use of psy‐ chotropic drugs can result in the development of metabolic syndrome, obesity, osteoporosis

Cognive techniques

Supporve educaonal techniques

CBT

Behavioral techniques

**Relaxation skills:** mindfulness based

**Behavioral activation:** graded physical acvity, enjoyment, reduce avoidance

**)feedback:** awareness of physiology using objecve devices; movement and body awareness

> **prevention:** self-monitoring, discussing triggers, coping skills

**Pacing:** changing physical acvity structure, breaking up the acvity in

stress reducon

smaller chunks

**(Bio-**

**Relapse** 

Other techniques

ful life despite the discomfort [15].

**Problem solving:** defining problems planning responses, trying out soluons,

training.

184 Clinical Physical Therapy

evaluaon of succes

**Cognitive restructuring:** direct challenge to alter irraonal thoughts and/or reducing fear of physical acvity; cognive funconal

**6.1. 'Physical health‐related' approach**

**Figure 2.** Cognitive behavioural techniques in physiotherapy.

**Psychoeducation:** provision of informaon,

**Support:** movaonal interviewing, encouragement, connued monitoring

eology and treatment

The psychosocial‐related approach emphasizes the acquisition of mental and physical skills related to the 'moving body' and support of people's ability to function independently in society and to improve their quality of life. The activities aim at learning, acquiring and training psychomotor, sensomotor, perceptual, cognitive, social and emotional proficiencies. Other elementary proficiencies are stressed, such as relaxation education, relaxation skills, stress management, breathing techniques, psychomotor and sensory skills and also cognitive, expression and social skills. Through exercises, patients acquire a broader perspective and can experience their own abilities. Moreover, the learning of the basic rules of communica‐ tion is integrated [23]. The psychophysiological approach involves the use of physical activ‐ ity to influence mental health problems such as in the treatment of depression and anxiety disorders [24–34]. In the literature, the benefits of physical activity for mental health are well accepted. Physical activity has a positive influence on mental well‐being, self‐esteem, mood and executive functioning. Through these effects, a downward spiral that leads to dejection can be stopped. Well‐balanced and regularly executed endurance activities (walking, biking, jogging and swimming) power training (fitness training) and mindfulness‐derived exercises) augment physical and mental resilience; improve the quality of sleep; enhance self‐confi‐ dence, energy, endurance and relaxation; and, in general, decrease physical complaints.

#### **6.3. Psychotherapeutic‐oriented physiotherapy approach**

The psychotherapeutic‐oriented physiotherapy approach uses the motor domain as a gateway to ameliorate social affective functioning. This approach puts less emphasis on the acquisition of skills but more on the awareness of psychosocial functioning and facilitating a process of change. Using movement activities, the physiotherapist creates a setting that favours the initiation and development of a process aimed at helping patients to gain greater insight into their own func‐ tioning. During these activities, patients are invited to venture outside their comfort zone, think outside the box, experience new things, become more in touch with their inner self and cope with numerous emotions (depressive feelings, fear, guilt, anger, stress, feelings of unease, estrange‐ ment and dissatisfaction) and negative thoughts (intrusion, obsession, morbid preoccupations and worrying). Moreover, they are confronted with their behaviour (i.e. impulses and lack of abilities) or cognitive symptoms (i.e. derealisation and lack of concentration). Through psycho‐ motor therapy, an alternative perspective on experiences can be proposed. Experiencing the pos‐ sibility that an alternative may exist triggers new emotions and experiences, and a discrepancy between reality and the patient's perception of reality emerges. Consequently, it is important to note that it is not the physical activity itself but the patient's experiences and inner percep‐ tion that play the central role. The careful guidance and encouragement of the physiotherapist and the opportunity to experience feelings in a safe environment allow the patient to develop behaviour, which would not have developed otherwise. Although the underlying problems are not necessarily resolved, the therapist tries to improve problem management of the patient. The patient shares his behaviour, feelings, and thoughts with the therapist initially and, eventually, with his peers. More emphasis is placed on experiences and how reactions to these experiences function as a dynamic source of power [23].
