Module State of the Art Research of Psycho-Social Aspects of APA (part 2)

general introduction

Prof. H. Van Coppenolle, co-ordinator

Psycho-Social Aspects are maybe the most important ones in APA

and maybe as well the most forgotten

Physical handicap what are the benefits of participation in sports on

the psychological and social domain when I am physically handicapped ? (blind, deaf, amputee, heartdisease, etc.)

excellent visual tool: “the awarded film ( Medal of Peace of the United Nations):” “I am not Disabled”

“The Winners”: “Everybody wins”

Psychological problems What are the benefits of

participation in APA and sports (psychomotor therapy) when I have psychological problems (depression, anorexia nervosa, schizophrenia) ?

Intellectual deficiency What are the positive aspects

in sports and APA for persons with an intellectual handicap?

These three groups of persons with a handicap

will be the subjects of research in this psycho-social area

Research data are mostly based on questionnaires

if I want to know what the meaning of a handicapped person about sportsparticipation is , then I have to ask him

so all data are based on meanings of the persons themselves because there is no other way

but these impressions are the only meaningful ones because nobody else can speak for them

on the other hand questionnaires have weak points

do the persons tell the truth? do they understand the

questions? are they motivated to fill out the

questionnaire in a serious way?

Personality, Behaviour and Social adjustment of persons with a handicap

R. Shephard (“Fitness in Special Populations”) Human Kinetics, 1990, pp.201-221)

Social Problems of the Disabled

The disabled individual faces many discouragement's during daily life. Schooling is hampered, employment prospects are poor, and the person faces much stigmatisation and stereotyping

Stigmatisation

a physical handicap creates a visible stigma that tends to be socially discrediting, encouraging others to avoid the affected person (Aufesser, 1982, Hunt, 1966)

often the handicapped are regarded as unproductive or socially deviant, and civilisations have considered them to be punished by the deity or a witch, or possessed by the devil (Adedoja,1987, Goffman, 1963)

unfortunately able bodied children seem to develop negative stereotypes of the disabled

in general sensory disabilities are the least stigmatised

physical handicaps rank next, and those with mental disorders are the most subject to ostracism

the cause of disability also influences perceptions surprisingly the process can also occur among the

disabled themselves

Stereotyping

the most stereotypes are a perceived lack of physical attractiveness, intelligence and ability

in many instances the entire stereotype is inaccurate and inappropriate:

the disabled are thus placed in special schools, and sheltered workshops, when in fact they are well able to cope with normal education and employment opportunities

negative stereotypes have contributed to conflicts over ownership of athletic contests

some able-bodied runners have wished to exclude wheelchairathletes from events such as the marathon

such exclusion immediately has an adverse impact on the majority of the handicapped participants who wish to be judged on their overall competitive performance rather than as blind or paraplegic patients

Lifestyle and Disability

the social problems faced by the disabled often cause a reactive depression and this can lead to an adverse lifestyle (abuse of tobacco, alcohol and drugs) (Nelipovich, 1983; Nelipovich §Parker, 1981)

Employment

despite negative stereotypes many employers, many supposed “cripples” are better motivated and more productive than their able-bodied peers

nevertheless employment prospects for the average disabled person remain relatively poor

Habitual Activity

following spinal trauma the leisure satisfaction of the injured individual in general decreases (Price, 1987)

participation in sports was likely to decrease relative to the individual’s pre-trauma situation

influence of the sportsorganisations for the disabled

among the various clinical types of disability the least active group where those affected by multiple sclerosis (maybe because for this group no special sportsorganisations exist)

smoking habits

the proportion of smokers among the wheelchair disabled substantially exceeded provincial norms

the heavy smokers were predominantly those with a type B personality on the Rosemann scale: they intended to have an external locus of control, there were also trusting, shy and of below average intelligence

alcohol consumption

it is very difficult to obtain accurate information on alcohol consumption from self-reports

Kofsky a,d Shephard found that 68% of their sample of paraplegics described themselves as no more than occasional drinkers

only 12 % admitted taking more than six alcohol drinks per week

Personality of the Disabled

inevitably the social problems tend to have an adverse influence not only on the lifestyle but also on the manifest personality of the disabled person

although some disabled athletes have as high a level of selfactualisation as the able-bodied

disturbed personality

many disabled people show evidence of maladjustment, retarded emotional development, social alienation, feelings of depression, etc.

immediately following spinal injury , ego strength is low and depression scores are very high

in subsequent months they have big problems adjusting to their handicaps

physical activity may be of considerable therapeutic and psychological benefit

during the early phase of rehabilitation helping the patient develop a sense of self-efficacy

and an awareness that is it not necessary to accept a life of total inactivity and dependency

subsequent participation in sports competition is also important to many disabled people not only for the physical gains

but because of the social respect, approval and prestige that is gained

involvement in sports holds the prospect of desinstitutionalization and reintegration into able-bodied society

Tucker found that the Cattell personality test of physically handicapped persons reflected greater intelligence, more introversion,and less practical attitude than able-bodied subjects

Harper used the Minnesota Multiphasic Personality Inventory (MMPI)

and found that the disabled were particularly prone to problems of social adjustment

other studies involved standard psychological tests, body image scales, locus of control tests, the status of blind athletes with reference to anxiety levels and mood states

of course the results on these paper -and pencil-tests depend on the truthfulness of the subjects

because most of the studies were cross-sectional in type

there is no proof as to whether an increase of physical activity is responsible for the favourable psychological characteristics of groups such as wheelchairathletes

or whether initially favourable psychological characteristics have allowed such subgroups to undertake more vigorous activity subsequent to the onset of their disability

Cattell Test Scores

on this personality test Goldberg and Shephard didn’t find significant differences of test scores relative to the general population

wheelchairathletes however were distinguished from more sedentary paraplegics on the factors intelligence, venturesomeness and tough-mindedness

wheelchairathletes differed from the general wheelchairpopulation on factor H (shy versus venturesome)

this could imply that much of the achievements that mark the disabled athlete is due not to some peculiarity of physiological endowment but rather to a strength of personality

and an achievement orientation that has assured a willingness to undertake vigorous training

Body Image

Tests of body image provide a numerical expression of how the self is perceived both physically and socially

if the image is poor a substantial gap develops between the ideal and the perceived image

early research suggested devaluation of self in various types of disability

Harper (1978) found that paraplegics often had problems of selfperception and poor body image

although no difference was found between those with congenital and those with traumatic lesions

Brinkmann and Hoskins noted a poor self-concept of hemiplegic patients

after a period of training the researchers reported significant gains on several subscales on the Tennessee self-concept scale

This subscales were: identity, physical self, personal self and social self

Patrick applied acceptance- of- disability scale and the Thennessee self concept scale

5 months after their first competition novice wheelchairathletes showed a significant improvement on this scale

The Kenyon/Mc Pherson instrument is one measure of body image

It develops scores for items such as “My body is as I would like to be” and “ The real me “ from a series of Likert scales, spanning contrasting adjectives such as beautiful and ugly

Goldberg and Shepard (1982) found that

the gap between the perceived and desired body image was larger in moderately actively spinally injured than in those who had achieved the status of wheelchair athletes

Locus of Control

the locus of control scale examines the extent to which an individual perceives an ability to control her or his environment

external locus of control is assumed when a person perceives an event as unpredictable or the result of luck, chance or fate

internal locus of control is deduced if events are seen as contingent upon personal behaviour

The locus of control of wheelchair-disabled individuals is usually external

the average score is almost twice than that described for young able-bodied people

the locus of control of the spinally injured person was uninfluenced by the level of the lesion or by habitual physical activity

Self-Actualisation

formal measurements of self-actualisation in elite ISOD competitors, using the personal orientation inventory of Shostrom demonstrated fairly high levels of selfactualisation

relative to non-elite competitors the subjects scored higher

Anxiety

many disabled groups such as the blind become acutely anxious following the onset of disability

they fear that they will be unable to support themselves

several reports suggest that the blind competitors particularly prone to anxiety during competition because of lack of normal visual cues

Profile of Mood States (POMS)

The POMS test is a simple one page questionnaire examining immediate mood state

disabled athletes demonstrated the “iceberg profile”which is typical for an able-bodied competitor

a high score for vigour and low scores for tension, depression, fatigue and confusion

Effects of training

It is logic that a favourable personality increases the ability to undertake training

and that an increased ability to perform daily activities and live an independent life would have a positive influence on the body image and psychological profile

in children with mental retardation participation in competition (Special Olympics) had a very positive impact on self-image and social interactions

For the physically disabled

Much depends on the establishment of a training program with realistic goals and expectations

trainers must take into account of inherent shifts in mood state and avoid making excessive physical or emotional demands that could damage an already fragile self-image

Exercise Motivation and Compliance

Initial recruitment to an activity class and subsequent compliance are major problems even with able-bodied subjects

well-designed programs attract no more than 20 to 30% of eligible adults

and as many as half of those who are recruited drop out of the organised activity within 6 months

Attitudes toward physical Activity

the Kenyon instrument examines the instrumental value to the individual of a global concept of exercise in seven specific domains

a series of contrasting adjectives (e.g. good/bad) rate the corresponding concepts (e.g.,( good/ bad ) rate the corresponding concepts (e.g. exercise as a means for fitness and health)

Delforge ( 1973) found no differences between handicapped and nonhandicapped students

Goldberg and Shephard 1982) found that paraplegics perceive five of the seven scales as did able-bodied individuals

wheelchairathletes showed more interest than the general population in exercise “as a pursuit of vertigo” and “exercise as an ascetic experience”

Perceived reasons for participation

M. Cooper (1986) used a paired comparison test to rank the main perceived reasons why the disabled individual participated in sport

the first seven reasons were in order: challenge of competition, fun and enjoyment, love of sport, fitness and health, knowledge and skills relating to sport , contribution to sport, and the team sport atmosphere

These seven items were all ranked significantly higher than items such as:

liking for other team members travel liking for the coach and status

Socialisation into and via Sport

disabled individuals generally show poor social relationships and a limited integration into their immediate society

potential expressions of maladjustment include shyness, timidity, fearful behaviour and other forms of withdrawal, concealment, refusal to recognise the reality, and actual delusions

Involvement in sport can sometimes help the process of integration

but whether it is effective, particularly in the long term depends not only on the attitude of the disabled individual

but also on the reaction of physical education majors and society as a whole

the primary perceived stimuli to sports involvement of a group of disabled athletes were

1. the initiative of the individual participant (29%)

2. encouragement of disabled friends (27%)

3. of Able-bodied friends (27%) 4. or the family (9%)

Hopper (1986) suggested however that:

other factors such as career and domestic happiness may have had a larger impact upon self-esteem than did success in wheelchaircompetition

Psychomotor Therapy for Psychiatric Patients

– is a form of treatment that has been systematically used in Belgium (Flanders) since 1965

– in that year a post-graduate course was started at the KU Leuven

– this form of treatment attempts to act systematically on the body perception and the behaviour in order to achieve therapeutic objectives

Observation Scales in Psychomotor Therapy

the Leuven Observation Scales for Objectives in Psychomotor Therapy

Adapted Physical Activity Quarterly, 1989, 6, 145-153

originally

psychomotor therapy goals were imposed or set by general therapy theories such as:

psychoanalysis phenomenology behaviour therapy, etc.

but this approach was not individualised

towards the patient and moreover was quite

speculative because most theories on which

this approach was based are quite speculative and unscientific as well

therefore

the therapeutic objectives are no longer based on these general theories

but on a specific observation method during movement situations

because everyone moves according his personality

and this movement behaviour can offer useful indications for PMT

development of the scales

an observation method should only give information about those aspects that are directly related to the goals

213 therapeutic goals for PMT were derived from literature

and named in 9 categories of goals who are important for psychiatric patients

the 9 groups of therapeutic objectives

improving: 1. emotional relations 2. self-confidence 3. activity 4. relaxation 5. movement control 6. focusing on the situation

other therapeutic objectives

7. movement expressivity 8. verbal communication 9. social regulation ability

in a second phase these objectives were made operational as observation items

by the following steps

a definition of each item for each item a 7 point scale was

established from -3 to + 3 the disturbed behaviour can present itself as

an excess or as a lack the zero score corresponds with non

disturbed behaviour

to operationalize further

general descriptions of the -2 and the + 2 scores were developed on the basis of adjectives

for example: underemotional relations are revealed in contact that is apathic, inhibited, detached, refusing, inaccessible, too formal

more specific descriptions more specific descriptions were developed

on the basis of very specific descriptions of behaviour for the - 2 and + 2 scores

for example: emotional underrelating can be revealed in the following descriptions

the patient does not react and shows no interest in contact if he is contacted by others

reliability of the observation scales (inter and intra)

was for the general LOFOPT ranging from 0.74-1.00

for the specific LOFOPT: 0.70-0.98

Body Experience and Body Composition in Anorexia Nervosa PatientsIssues in Special Education & Rehabilitation. Vol.8, No. 2, 1993, pp. 35-39

Introduction: a disturbed body experience is a central element in the AN syndrome

it is one of the four diagnostic criteria in DSM III Revised

it has a perceptual and an affective component

nevertheless studies indicate no significant over or underestimation of body measures

no significant difference from estimates by controls

these studies don’t refer to body composition

which is an important element because it can affect body satisfaction and perception

body experience has not been studied before and after a therapeutic program

this was the reason of this study we carried out with 43 AN patients

mean and range of age, height, weight, percentage of fat mass and fat free mass on admission

age:(years): 22.8 12.8-37.6 height (cm): 162.6 140.0-178.0 weight:(kg) :39.7 23.4-52.1 fat mass (%): 12.2 1.2-4.3 FFM (kg): 34.922. 22.2- 43.3

method

the subject group was re-evaluated after a therapeutic program: 21 patients

mean duration of hospitalisation: 159 days (range 117-184)

procedure

body experience was evaluated by the distortion technique

and by a self report instrument: the Body Attitude Questionnaire which examine body image satisfaction

the video distortion technique

a video camera is linked to a color monitor using a potentiometer in the monitor: a distortion

(widening or narrowing) of max. 33% can be achieved

the extent of the distortion is displayed by a voltmeter

a dummy was used as lifeless control the subject can turn a dial to widen or narrow her

image

4 tasks

adjust the thin or fat body image in full frontal and profile positions until she thought it represented her real image

third task: estimate the dummy in order to know whether the subject showed a more general perceptual disturbance or poor estimation abilities

finally the subject was asked to adjust her own frontal image to her ideal image

for each of these four tasks

the subjects were asked to perform six trials ad random

alternating between trials initially with a thin image and trials initiating with a fat image

the composite score was the sum of the six trials

the Body Attitude Test

consists of 20 items which examine body dissatisfaction

the maximum score is 100 the higher the score the more

dissatisfied the subject is with her body

the items are scored on a 5 point scale

Body Composition

was measured with densitometry techniques which uses the underwater weighing technique

the Psychomotor Program

Tries to influence the disturbance of the body image

through confrontation with and awareness of the body it attempts to alter the negative body experience in a more positive attitude

the movement situations consist of relation and confidence- improving techniques, non-verbal expression, body oriented sensory awareness and social skill exercises

results: body experience perception

significant underestimation was found on the four estimation tasks

but also the control dummy object was as well significantly underestimated, suggesting that a general perceptual disturbance could be the basis of the underestimation

body experience: ideal body measures

the ideal body measures correspond with the actual thin body appearance

this indicates that prior to a therapeutical program anorectic patients are satisfied with their emaciated bodies

body experience: dissatisfaction

the mean score on the BAQ was high: 46

and differed significantly from the control group of 103 students

they are dissatisfied with their body

relation between body experience and body composition

no significant relationship between body composition and scores on the body attitude questionnaire

some significant correlations with data from the videodistortion technique:

significant relations

the higher the weight, fat and fat free mass, the more the ideal images measures were narrowed

the less fat mass anorexics have the more they underestimate their measures this increases the perceptual disturbance

body experience after therapy

a decrease of the underestimation of body measures was noticed in frontal, profile and dummy estimations

patients ideal image adjustments continue to show significant underestimation

this means that after a considerable weight gain (39.3- 50.6) their basis wish to become thinner has not changed

body satisfaction after therapy

the mean dissatisfaction score on the BAQ decreases from 47.1 to 33.7

this means that following the therapeutical program the patients were less dissatisfied with their body

EXAMPLES OF GOOD PRACTICE

Different Films illustrating the theory concerning

psychosocial aspects of APA

“I am not disabled” “Psychomotor observation and therapy

in a psychotherapeutic community” Psychomotor therapy with anorexia

nervosa patients” “Fitnesstraining as psychomotor

therapy in depressive patients “A real slice of the action”