Journal of Contemporary Psychotherapy, Vol. 34, No. 4, Winter 2004 ( C© 2004)

Contemporary Psychotherapy: MovingBeyond a Therapeutic Dialogue

James C. Overholser, Ph.D.

Psychotherapy was developed as a means of using words to heal emotional pain.Although a therapeutic dialogue can be helpful to many clients, some people needa more action-based intervention. Psychotherapy may be enhanced by adaptingseveral therapeutic procedures that have been found effective in physical therapy.Where physical therapy can help clients learn to manage chronic physical pain,psychotherapy can help clients learn to manage chronic emotional pain. Bothphysical therapy and psychotherapy can help to facilitate awareness, flexibility,strength and endurance in order to maximize the client’s functional ability.

KEY WORDS: psychotherapy; endurance; strength; flexibility.

Psychotherapy began as a procedure for using words to heal physical symp-toms that were caused by emotional pain. Therapy can help expose clients toemotional conflicts that were not resolved in the past (Alexander, 1954b). Morethan 50 years ago, Franz Alexander (1948) described the notion of a ”CorrectiveEmotional Experience” as central to psychotherapy. For Alexander (1954a), theprimary tool of therapy involved using transference and regression to help clientsconfront and change their dependent attitudes and relive their early interpersonalconflicts through the relationship with the therapist. Analysis of the transferencerelationship can help clients learn to confront repressed emotional memories andunresolved developmental conflicts from the past. However, most contemporarytherapy settings cannot afford the frequency (i.e., more than once a week) and du-ration (i.e., longer than six months) of therapy sessions that are needed to developa strong transference relationship. Thus, when working in a short-term therapysetting, it can be difficult to develop and work through a transference relation-ship of adequate intensity. Nonetheless, therapy can help to re-create and re-enact

Address all correspondence to James C. Overholser, Ph.D., Department of Psychology, Case WesternReserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7123; e-mail: overholser@case.edu.

365

0022-0116/04/1200-0365/0 C© 2004 Springer Science+Business Media, Inc.

366 Overholser

difficult emotional situations in order to facilitate a corrective experience in session(Kipper, 1986).

Many forms of contemporary psychotherapy go beyond an exclusive re-liance on a traditional therapeutic dialogue and include action-based interventions.Alexander (1950) felt that the therapist must exert a steady pressure on clients toapply the therapy dialogue to their life experiences outside of the analytic hour.Often, these therapeutic activities help to bring action and emotion into the treat-ment. Also, therapeutic exercises can help clients to develop awareness, strength,endurance, and flexibility in their coping skills. The development of new and moreeffective coping skills can help clients learn to confront and manage difficult situ-ations (Overholser, 1996). Often, practice and repetition are needed before clientscan develop new coping skills into effective and useful habits.

The present manuscript draws an analogy between psychotherapy and theprocedures used in physical therapy. In the field of physical therapy, therapeuticexercises are used to increase strength, coordination, endurance, and flexibility(Kisner & Colby, 1985; Schramm, 1997). Physical therapy can provide assistanceto clients who are struggling with organic pain or physical impairments. Therapeu-tic exercise programs often include strategies designed to increase both strengthand endurance (Mangine, Heckmann, & Eldridge, 1989; Spielholz, 1990). In a sim-ilar manner, psychotherapy can sometimes be viewed as a rehabilitative processwhereby clients learn to manage their emotional pain by engaging in therapeuticexercises that promote awareness, flexibility, strength, and endurance for copingwith difficult situations.

Clients may feel discouraged to learn that treatment involves a challengingand painful process, and that immediate pain relief rarely occurs. In this regard,psychotherapy and physical therapy seem quite different from massage therapy.When an individual suffers from assorted injuries and pains that limit mobility,physical therapy can be painful but works to strengthen the muscles and improvethe client’s ability to function. Physical therapy ends after a limited number ofsessions that focus on assessment and therapeutic exercises (Schramm, 1997).In contrast, massage does not hurt, but feels soothing. Despite recent evidenceof the beneficial effects of massage therapy (Moyer, Rounds, & Hannum, 2004),massage may help clients feel better without necessarily getting better. Researchhas shown that the beneficial effects from therapeutic massage only last as longas the treatment is continued (Hasson, Arnetz, Jelveus, & Edelstam, 2004). Forsome people, there may be no end to “a weekly massage” because the achesand pains return each week. Some forms of psychotherapy may be aligned withphysical therapy, as opposed to the procedures of massage. Psychotherapy can helpto improve the client’s capacity to deal with both internal and external conflicts(Alexander, 1948). It can be useful to help clients identify specific skills they coulddevelop that would reduce their feelings of distress and improve their ability tofunction.

Moving Beyond Dialogue 367

A primary goal of psychotherapy is change. However, most people are guidedby the principle of economy of effort, whereby certain patterns are repeated un-til they become automatic, effortless, and stable over time (Alexander, 1948).Clients should perform psychotherapy exercises between sessions, because im-portant changes can be made during the interval between sessions (Alexander &French, 1946). Therapeutic exercises involve specific activities that clients can beasked to complete during a therapy session or practiced between sessions. Often,these exercises are designed to develop new skills, strengths, or abilities in theclient (Overholser, 2002). In many situations, numerous repetitions are neededbefore clients can be expected to develop a new skill or cultivate a new habit.Therapeutic exercises can bring action and emotion into a psychotherapy session,moving away from an exclusive reliance on talking as therapy.

THERAPY TO MANAGE PERSISTENT PAIN

Most forms of pain include a combination of physiological arousal and psy-chological processing (Meilman, 1984a). Physical therapy often focuses on helpingclients learn to reduce or tolerate physical pain. Physical therapists draw an impor-tant distinction between acute and chronic pain (Meilman, 1984b). Many peopleexperience occasional bouts of acute physical pain, which is time-limited and oftenresponds to periods of rest. However, in the treatment of chronic pain, there may beno expectation of healing. Instead, therapy focuses on confronting any disabilityand impaired lifestyle due to the pain. When working to reduce chronic physicalpain, it is useful to emphasize the client’s responsibility for health and change(Meilman, 1984c). Unfortunately, many patients choose to restrict their lifestyleas a means of limiting their pain (Meilman, 1984d), and devote their energiestoward complaining or convincing others that their pain is legitimate (Meilman,1984e). Also, patients need to appreciate that pain can be maintained through sec-ondary gains (Meilman, 1984f). Ultimately, the goal of physical therapy centerson restoring the individual’s ability to function (Gloth & Matesi, 2001), withoutnecessarily attempting to reduce the feelings of pain (Schramm, 1997). The ther-apist often monitors the client’s functional abilities, documents limitations, tracksimprovements, and facilitates adaptive changes. Simply discussing the pain maynot help it go away.

Psychological therapy often tries to address emotional pain, including sad-ness, guilt, shame, and anxiety. An important distinction can be seen when workingwith acute versus chronic emotional pain. Many people experience periods of acuteemotional pain, such as the grief that follows the death of a loved one. Alexan-der (1951) believed that supportive therapy could be used to help clients dealwith the temporary impairment that was caused by acute emotional stress, suchas divorce or bereavement. However, chronic emotional pain and the concomitant

368 Overholser

lifestyle problems can be much harder to treat. When clients suffer from chronicconditions, therapy can help them to confront any unresolved conflict and pro-mote changes in current psychosocial functioning. In some cases, imagery can beused to help painful memories become less aversive (Fidaleo, Proano, & Fried-berg, 1999). Therapy can focus on strategies for increasing activity, reducingpassivity, and discontinuing avoidance coping when clients are diagnosed withchronic depression (Jehle & McCullough, 2002) or generalized anxiety disorder(Overholser & Nasser, 2000). Simply discussing the negative emotional reac-tions will not be effective in promoting positive change. However, an activity-based intervention may challenge clients to learn new ways of functioning moreeffectively.

THERAPY TO ENCOURAGE AWARENESS

Therapy often helps clients learn about their body, mind, and biopsychosocialinteractions. In physical therapy, patients can learn about basic anatomy, muscles,and tissue damage (Richardson, 2002). Clients can become more aware of theirown bodily functioning, various sensations, and motoric limitations. Brief educa-tional segments can help clients learn about the structure, function, and pathologyof their body (Twomey & Taylor, 1994), and can improve compliance with otheraspects of treatment (Richardson, 2002). Treatment effects are unlikely to last un-less the client understands the importance of a regular exercise program (Schramm,1997).

In psychotherapy, clients can learn about the mind, cognitive processes, andemotional regulation. Clients can become aware of their own cognitions, and theymay begin to appreciate the interplay between perceptions, interpretations, eval-uations, attributions, expectations, and emotions. Alexander (1950) believed thatsuccessful therapy involved gradually improving the client’s ability to recognizeand express repressed emotions and memories. Even basic psycho-educationalsessions can help to inform clients about emotional problems, maladaptive copingstrategies, and resources available for recovery.

As part of therapy, assessment measures can be used to gather informationabout current symptoms, problems, abilities and limitations. Both self-report mea-sures and performance-based tests can be used to gather information that mayhelp to guide the treatment plan. In addition, self-monitoring forms can be used tocollect daily information and to increase the client’s awareness of recurrent prob-lems and triggering events. For example, an adult male with panic, anxiety anddepression was seen for outpatient psychotherapy (see DiFilippo & Overholser,1999). Simple self-monitoring forms helped the client learn to identify situationsthat tended to elicit his feelings of sadness or anxiety.

Psychotherapy can help clients to better understand self and others (Zinker,1977). Pure logical approaches are often not enough to help clients make lasting

Moving Beyond Dialogue 369

changes (Ellis, 1979). Instead, clients need to experience their cognitive and affec-tive reactions with a higher level of awareness (Bohart, 1993). It can be importantfor clients to experience their negative emotions in order to access the cognitive andsomatic changes that accompany bouts of anxiety (Overholser & Nasser, 2000).Therapy can help clients learn to fully experience their emotions, become moreaware of any underlying thoughts and feelings, and promote the potential for pos-itive growth (Mahrer, Boulet, & Robson, 1998). In some situations, role-playedinteractions can be used to improve a client’s awareness of their impact during in-terpersonal conflict, and can confront their misguided interpretations of the socialevents (Casey, 1973).

THERAPY TO EXPAND FLEXIBILITY

In physical therapy, patients can use therapeutic exercises to become morelimber, flexible, and capable of a wider range of motion (American College ofSports Medicine, 1991). Motoric flexibility depends on the range of motion inthe joint, and the ability of the muscle to stretch (Zachazewski, 1989). Stretchingexercises are used at the start of therapy to enhance flexibility (Farrell, Drye, &Koury, 1994) so clients are ready to begin more challenging activities.

In psychological therapy, clients can learn to experiment with new ways ofinteracting with self and others. Flexibility requires an ability to shift thoughts andactions as needed to adapt to a specific situation. Cognitive flexibility, creativityand divergent thinking are essential elements in problem-solving, allowing clientsthe ability to generate a wide variety of coping options. Flexibility can involvea cognitive shift in perspective from nihilistic pessimism to realistic optimism.Clients can learn to become more spontaneous and flexible in their reactions to avariety of situations.

Behavioral flexibility is important in most social relationships, whether deal-ing with a disgruntled co-worker or interacting with an irritable spouse. In manysituations, clients need to be secure and confident enough to experiment with newways of dealing with self and others. Before clients can learn new coping strategies,they need to reduce their habitual reactions, and discontinue any rigid, maladaptiveways of relating to others (Overholser, 1996). Then, with the help of the therapist,clients can expand their range of movement to extend beyond their normal comfortzone.

THERAPY TO ENHANCE STRENGTH

Most forms of therapy try to improve the client’s strength. In physical therapy,strength is defined as the maximum degree of force or power that can be generatedby a group of muscles (American College of Sports Medicine, 1991). It takes time,

370 Overholser

persistence, and regular exercise in order to improve one’s strength. As part of therehabilitative process, certain exercises should be performed at home even afterthe physical therapy has been discontinued (Farrell et al., 1994).

In psychotherapy, strength can be defined in terms of ego strength or copingskills. Regular exercise of self-control may be capable of strengthening a client’scapacity for difficult but adaptive, voluntary actions (Baumeister, Muraven, &Tice, 2000). For example, prolonged exposure can facilitate therapeutic change inclients suffering from anxiety disorders. However, clients should not be pushedbeyond their ability to cope with physical or emotional discomfort.

Physical therapy sometimes relies on the overload principle, whereby musclestrength is increased via exercises that exceed the capacity of the muscle (Kisner& Colby, 1985). Actually, the exercises should not overload the patient, but theyshould require more activity and energy than normally displayed by the patient(Howell, 1988). In psychotherapy, clients are sometimes asked to participate inprolonged exposure sessions. Therapeutic exposure activities can help clients ac-cess the “hot cognitions” that underlie their pathological view of self or others.

In physical therapy, exercises often follow the principle of progression,whereby a series of exercises can help clients to gradually progress from weak-ness to normal working conditions (Colson, 1975). Specific basic skills must beacquired before moving on to more difficult tasks (Farrell et al., 1994). Likewise, inpsychotherapy, clients are expected to move from weakness to strength in a grad-ual progression. The notion of gradual change underlies the hierarchy of situationsthat guides systematic desensitization. A gradual hierarchy of challenging situa-tions can facilitate client cooperation and persistence. Clients can be repeatedlyexposed to specific emotional conflicts, reduced to a tolerable level of intensity,until the client is able to respond in a more adaptive manner (Alexander, 1948).Also, role-played interactions can follow a logical progression across interrelatedscenes (Kipper, 1986). It can be useful to inform clients that therapeutic exerciseswill proceed at a level for which the client is ready. Although this does not alwaysmean they will be easy for the client to perform, it does convey an attitude ofconfidence in the client’s ability to manage a challenging situation.

Physical therapy often relies on the principle of rhythm, whereby exercisesflow smoothly and do not inflict sudden strain on the muscle (Colson, 1975). Inpsychotherapy, activities can be explained and client expectations can be clarifiedin order to help prepare clients before situational challenges are incorporated intosessions. Role-played simulations can be used to monitor the client’s reactions dur-ing analogue stressful situations. Assertiveness training provides examples whereclients need to be strong in order to stand up for their own rights as well as therights of others. Again, a gradual progression across sessions can facilitate growthwithout causing excessive pain or distress. When using role-played interactionsor in vivo exposure, the therapist can guide the activities to flow from the client’snew strengths and abilities.

Moving Beyond Dialogue 371

THERAPY TO INCREASE ENDURANCE

Some clients experience frequent bouts of emotional distress because of theirinability to tolerate feelings of physical, emotional, or social discomfort. Low frus-tration tolerance can be seen as a central component of many emotional disorders(Ellis, 2001). An important goal of therapy involves enhancing the client’s abil-ity to tolerate feelings of discomfort. In physical therapy, endurance refers to theability to resist fatigue and continue with the activity (Mangine et al., 1989). Inpsychological therapy, endurance can include a similar form of stamina, but canbe expanded to include emotional and attitudinal fortitude.

For many clients, an active component in therapy involves learning to tolerateuncomfortable situations, negative emotions, or stressful life events. For example,an adult male client with Obsessive-Compulsive Disorder was able to overcomehis problems when he learned to endure the anxiety and worry that were triggeredby many common situations (see Overholser, 1991). Clients can develop severalstrategies to be used for creating a calm feeling, a sense of control, and an awarenessof the time-limited nature of the discomfort. Tolerance training can help to confrontthe client’s tendency to avoid feelings of emotional distress or situations laced withinterpersonal evaluation, rejection, or conflict.

CONCLUSIONS

Traditional psychotherapy relies on a thoughtful dialogue between two peo-ple. A nontraditional approach to therapy encourages more action and movementto bring about change. Discussing emotional problems can provide an outlet thatallows for the release of negative emotions. However, similar to the temporaryrelief that follows a massage, a pure verbal exchange may not promote lastingchange. Instead, action and movement may facilitate a more lasting impact fromtherapy. Strategies from physical therapy can help keep psychotherapy focused onefficient strategies for change. Through the use of therapeutic exercises, patientscan gradually increase their tolerance of pain and discomfort, thereby learning toexpand their comfort zone. Clients do not try to reduce their feelings of pain, butwork to improve their functioning by increasing their strength, endurance, and tol-erance (Schramm, 1997). Contemporary psychotherapy can work to make therapyFAST: using activities to promote Flexibility, Awareness, Strength, and Tolerance.When therapy ends, clients may be able to understand several simple exercises thatthey can continue practicing on a regular basis in order to maintain their gains.

Despite the difficulties in bringing action and emotion into most psychother-apy sessions, it can be useful for therapists to ponder “what did you DO in sessiontoday?.” It is also useful to end most sessions by asking clients “What do you thinkmight be useful for you to do during the week in order to continue working onthe issues we discussed today?.” When sessions are limited to a verbal exchange,

372 Overholser

therapy will progress at a slow pace. However, activities and exercises can bringenergy and positive change into the therapy session. When therapists devise atreatment plan that incorporates action and emotion into the treatment strategies,therapy may move beyond a traditional talking cure. A clear goal and specificstrategies can be used to guide therapy sessions (Kaslow, 2002).

Realistically, many psychotherapy sessions do not include action or emo-tion. The core element of psychotherapy remains a healing dialogue based on athoughtful exchange of words. Also, warmth is a requirement for effective ther-apy. Without a warm, supportive relationship, clients are unlikely to persist withthe emotional demands of therapy. For some clients and some disorders, talkingcan provide an effective outlet and an opportunity to begin changing attitudes andbehaviors. However, many clients can benefit from treatment strategies that bringaction and emotion into the treatment plan. In general, psychotherapy may becomemore effective and more efficient through the adaptation of treatment strategiesused in physical therapy.

ACKNOWLEDGMENTS

As editor of the Journal of Contemporary Psychotherapy, I want to thank thenumerous people who have helped to advance the field and improve the journal.During the past year, the editorial board members have reviewed and critiquednumerous manuscripts, and they have provided many thoughtful comments forrevising manuscripts. I am especially grateful to David Rudd who served as guesteditor for the special issue on the treatment of suicidal clients. Also, I wouldlike to welcome Ernesto Spinelli to the editorial board. In addition, numerousprofessionals have served as ad hoc reviewers to facilitate the editorial reviewprocess. In addition to the active members of the editorial board, I want to thankthe following colleagues for serving as external reviewers during the past year:Tom Widiger, Jacques Barber, Eric Chen, Leigh McCullough, Gerald Schoenewolf,Sam Warner, Libby Williams, Jim Reich, David Allen, Forest Scoggin, Don Black,Frank Kush, Glenn Callaghan, Michelle Lee, Denise Ben-Porath, Scott Hall, JimYokley, Tim DeJong, Gillian Woldorf, Mike Zaccariello, Pam Wiegartz, Bill Hale,Lesa Dieter, Doug Grossman-McKee, Jana Clarke, and Vesna Kutlesic. One lastnote—I am saddened by the loss of Jim Lantz, who passed away during the last year.The current issue includes one of his final papers on existential therapy. Althoughrelatively new to the editorial board, Jim has been a long-time contributor to thefield of psychotherapy. He will be missed.

REFERENCES

Alexander, F. (1948). Fundamentals of psychoanalysis. New York: Norton.Alexander, F. (1950). Analysis of the therapeutic factors in psychoanalytic treatment. Psychoanalytic

Quarterly, 19, 482–500.

Moving Beyond Dialogue 373

Alexander, F. (1951). Principles and techniques of briefer psychotherapeutic procedures. ResearchPublications of the Association for Research in Nervous and Mental Disease, 31, 16–20.

Alexander, F. (1954a). Psychoanalysis and psychotherapy. Journal of the American PsychoanalyticAssociation, 2, 722–733.

Alexander, F. (1954b). Some quantitative aspects of psychoanalytic technique. Journal of the AmericanPsychoanalytic Association, 2, 685–701.

Alexander, F., & French, T. (1946). Psychoanalytic therapy: Principles and application. New York:Ronald Press.

American College of Sports Medicine. (1991). Guidelines for exercise testing and prescription.Philadelphia: Lea & Febinger.

Baumeister, R., Muraven, M., & Tice, D. (2000). Ego depletion: A resource model of volition, self-regulation, and controlled processing. Social Cognition, 18, 130–150.

Bohart, A. (1993). Experiencing: The basis of psychotherapy. Journal of Psychotherapy Integration,3, 51–67.

Casey, G. (1973). Behavioral rehearsal: Principles and procedures. Psychotherapy, 10, 331–333.Colson, J. (1975). Progressive exercise therapy in rehabilitation and physical education (3rd ed.).

Bristol, England, UK: Wright and sons.DiFilippo, J., & Overholser, J.C. (1999). Cognitive–behavioral treatment of panic disorder: Confronting

situational precipitants. Journal of Contemporary Psychotherapy, 29, 99–113.Ellis, A. (1979). The issue of force and energy in behavioral change. Journal of Contemporary Psy-

chotherapy, 10, 83–97.Ellis, A. (2001). Overcoming destructive beliefs, feelings, and behaviors. Amherst, NY: Prometheus.Farrell, J., Drye, C., & Koury, M. (1994). Therapeutic exercise for back pain. In L. Twomey & J. Taylor

(Eds.), Physical therapy of the low back (2nd ed., pp. 379–410). New York: Churchill Livingstone.Fidaleo, R., Proano, T., & Friedberg, R. (1999). Using imagery techniques to treat PTSD symptoms in

bereaved individuals. Journal of Contemporary Psychotherapy, 29, 115–126.Gloth, M., & Matesi, A. (2001). Physical therapy and exercise in pain management. Clinics in Geriatric

Medicine, 17, 525–535.Hassan, D., Arnetz, B., Jelveus, L., & Edelstam, B. (2004). A randomized clinical trial of the effects

of massage compared to relaxation tape recordings on diffuse long-term pain. Psychotherapy andPsychosomatics, 73, 17–24.

Howell, D. (1988). Therapeutic exercise and mobilization. In G. Hunt (Ed.) Physical therapy of thefoot and ankle (pp. 257–284). New York: Churchill Livingstone.

Jehle, P., & McCullough, J. (2002). Treatment of chronic major depression using the Cognitive Behav-ioral Analysis System of Psychotherapy. Journal of Contemporary Psychotherapy, 32, 263–271.

Kaslow, F. (2002). Shifting from treatment plans to action plans: Solidifying the therapeutic alliance.Journal of Contemporary Psychotherapy, 32, 83–92.

Kipper, D. (1986). Psychotherapy through clinical role playing. New York: Brunner/Mazel.Kisner, C., & Colby, L. (1985). Therapeutic exercise: Foundations and techniques. Philadelphia: Davis.Mahrer, A., Boulet, D., & Robson, J. (1998). Lifelong mild bad feelings: A review and solution to a

psychotherapeutic enigma. Journal of Contemporary Psychotherapy, 28, 173–185.Mangine, R., Heckmann, T., & Eldridge, V. (1989). Improving strength, endurance, and power. In R.

Scully & M. Barnes (Eds.), Physical therapy (pp. 739–762). Philadelphia: Lippincott.Meilman, P. W. (1984a). The management of the chronic pain patient: Clinical considerations. Journal

of Orthopaedic and Sports Physical Therapy, 5, 305–307.Meilman, P. W. (1984b). Chronic pain: The nature of the problem. Journal of Orthopaedic and Sports

Physical Therapy, 5, 307–308.Meilman, P. W. (1984c). Chronic pain: Basic assumptions regarding treatment. Journal of Orthopaedic

and Sports Physical Therapy, 5, 308–310.Meilman, P. W. (1984d). Choices for dealing with chronic pain. Journal of Orthopaedic and Sports

Physical Therapy, 5, 310–312.Meilman, P. W. (1984e). Legitimizing chronic pain. Journal of Orthopaedic and Sports Physical

Therapy, 5, 312–315.Meilman, P. W. (1984f). Chronic pain: The benefits of being sick. Journal of Orthopaedic and Sports

Physical Therapy, 6, 7–9.Moyer, C., Rounds, J., & Hannum, J. (2004). A meta-analysis of massage therapy research. Psycho-

logical Bulletin, 130, 3–18.

374 Overholser

Overholser, J. C. (1991). Prompting and fading in the exposure treatment of compulsive checking.Journal of Behavior Therapy and Experimental Psychiatry, 22, 271–279.

Overholser, J. C. (1996). Cognitive–behavioral treatment of depression, Part VII: Coping with precip-itating events. Journal of Contemporary Psychotherapy, 26, 337–360.

Overholser, J. C. (2002). Cognitive–behavioral treatment of social phobia. Journal of ContemporaryPsychotherapy, 32, 125–143.

Overholser, J. C., & Nasser, E. (2000). Cognitive–behavioral treatment of generalized anxiety disorder.Journal of Contemporary Psychotherapy, 30, 149–161.

Richardson, D. (2002). Physical therapy in spasticity. European Journal of Neurology, 9(Suppl. 1),17–22.

Schramm, D. M. (1997). Applications of physical and occupational therapy in chronic pain syndrome.Journal of Back and Musculoskeletal Rehabilitation, 8, 223–235.

Spielholz, N. (1990). Scientific basis of exercise programs. In J. Basmajian & S. Wolf (Eds.), Thera-peutic exercise (5th ed.). Baltimore: Williams & Wilkins, pp. 49–76.

Twomey, L., & Taylor, J. (1994). Intensive physical rehabilitation for back pain. In L. Twomey &J. Taylor (Eds.) Physical therapy of the low back (2nd ed., pp. 275–283). New York: ChurchillLivingstone.

Zachazewski, J. (1989). Improving flexibility. In R. Scully & M. Barnes (Eds.), Physical therapy(pp. 698–738). Philadelphia: Lippincott.

Zinker, J. (1977). Creative process in Gestalt therapy. New York: Brunner/Mazel.