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  EMPIRICAL STUDY Opening toward life: Experiences of basic body awarenesstherapy in persons with major depression LOUISE DANIELSSON, RPT, MSc (PhD-student) 1,2,3 & SUSANNE ROSBERG,RPT, PhD, Assistant Professor 1,2 1 Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg,Sweden,  2 University of Gothenburg Centre for Person-Centred Care (GPCC), Gothenburg, Sweden, and   3  Na¨ rha¨ lsanGibraltar Rehabilitation Centre, Gothenburg, Sweden Abstract Although there is a vast amount of research on different strategies to alleviate depression, knowledge of movement-basedtreatments focusing on body awareness is sparse. This study explores the experiences of basic body awareness therapy(BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinicaltrial. Hermeneutic phenomenological methodology inspired the approach to interviews and data analysis. The participants’experiences were essentially grasped as a process of enhanced existential openness,  opening toward life , exceeding the tangiblecorporeal dimension to also involve emotional, temporal, and relational aspects of life. Five constituents of this meaningwere described:  vitality springing forth ,  grounding oneself  ,  recognizing patterns in one’s body ,  being acknowledged and allowed to beoneself  , and  grasping the vagueness . The process of enhanced perceptual openness challenges the numbness experienced indepression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear.Inspired by a phenomenological framework, the results of this study illuminate novel clinical and theoretical insight into themeaning of BBATas an adjunctive approach in the treatment of depression. Key words:  Embodiment, lived body, physical therapy, person-centred care, movement-based therapies (  Accepted: 7 April 2015; Published: 7 May 2015  ) Depression is a global threat to public health thatis steadily increasing in its negative impact and iscurrently one of the leading causes of functionaldisabilityworldwide(Whitefordetal.,2013).Lifetimeprevalence is approximately 20% in the Westernworld,withgenerallyhigherestimatesinhigh-incomecountries (Kessler & Bromet, 2013). Although anti-depressant medication and psychotherapeutic inter-ventions are effective treatments, about one-third of people with depression will have an insufficient recov-ery, encouraging research on adjuvant interventions.The concept of the life-world refers to the humanworld of immediately and concretely lived experi-ences, preceding theoretical explanations (Husserl,1970/2010). Fundamentally, the life-world is char-acterized by meaning. According to Merleau-Ponty(1962),thewaywecan relatetoandaccessthisworldis through our lived bodies. The lived body issimultaneously both a perceiving subject, and aperceived object, always directed to the world butalso already inhabiting it, immersed into it. Accord-ing to Heidegger’s (1953/2010) concept of   Dasein as a way to understand human existence, humans arethrowninto thelife-world, ‘‘being-in-the-world,’’ andinvolve themselves in it by attuning to it. The worldand our situatedness in it can only matter to usbecause we have the capacity to be open to lettingthings appear and reveal themselves to us, and thisopenness is the  Dasein . Drawing on Heidegger,this perceptive and responsive openness to what isencountered is impaired in depression (Aho, 2013;Boss, 1983; Fuchs & Schlimme, 2009; Svenaeus,2007). This impairment means a narrower range of moods and a more limited way for us to attune to theworld. The depressed person feels ‘‘corporealized,’’encapsulated in his or her body as an object, whichlimits the potential to engage in life’s events (Fuchs,2005). The whole ‘‘bodying forth’’ (Boss, 1983) of  Correspondence: L. Danielsson, Na¨rha¨lsan Gibraltar Rehabilitation Centre, Gibraltargatan 1 C, SE-411 32 Gothenburg, Sweden. E-mail: International Journal of Q ualitative Studieson H ealth and W ell-being  # 2015 L. Danielsson & S. Rosberg. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 InternationalLicense (, allowing third parties to copy and redistribute the material in any medium or format and to remix,transform, and build upon the material for any purpose, even commercially, provided the srcinal work is properly cited and states its license. 1 Citation: Int J Qualitative Stud Health Well-being 2015,  10 : 27069 - (page number not for citation purpose)  specific human ways of being is restrained. Instead,nothing stands out as significant any longer, as inHeidegger’s (1953/2010) analysis of profound ‘‘bore-dom’’: ‘‘The often persistent, smooth and pallid lackof mood, which must not be confused with a badmood,isfarfrombeingnothing.Rather,inthis Dasein becomes tired of itself. The being of the there has,in such a bad mood, become manifest as a burden’’(p. 131). Related to the life-world perspective, thenotion of   Dasein  as the perceptive openness thatcreates an embodied attunement to and engagementwith the world was a theoretical inspiration to thepresent study.In our previous work related to the embodiment of depression, we found that the participants’ experi-ences were essentially captured as an  ambiguousstriving against fading  , struggling to resist the urge towithdraw, but simultaneously needing to pausefrom life (Danielsson & Rosberg, 2014a). The bodyfelt confined, estranged, and heavy, but momentarilyameanstosensinglifeandseekingbelongingness.Ex-tendingtheseresults,wewereinterestedinthebodyasthemediatorofengagementwiththelife-world,whichdirected us toward a treatment perspective.Movement-based embodied contemplative practices(Schmalzl, Crane-Godreau, & Payne, 2014) haverecently received increased attention in the treatmentof depression, for example mindfulness medita-tion (Teasdale et al., 2000), yoga (Balasubramaniam,Telles, & Doraiswamy, 2013; Cramer, Lauche,Langhorst, & Dobos, 2013), tai chi (Lavretsky et al.,2011; Tsang et al., 2013), and dance and movementtherapy (Koch, Kunz, Lykou, & Cruz, 2014). Thesuggested working mechanisms are biological andneurological mechanisms that are shared by othertypes of physical activity, but recent theories alsohighlight neurophenomenology and enactive dimen-sions (Schmalzl et al., 2014).The construct of body awareness refers to aparticular kind of mindful, non-judgmental awarenessand a sense of self, groundedin physical sensations inthe present moment (Mehling et al., 2012). Scandi-navian physical therapists use a treatment methodcalled BBAT, which aims to enhance awareness of body and self through exploration of basic movementprinciples such as functional balance, free breathing,mental awareness, and embodied presence (LundvikGyllensten, 2001; Skjaerven, Kristoffersen, & Gard,2010). BBAT involves both activating and experien-cing one’s body through movement, acknowledgingthat these experiences touch different dimensions of existence: physical (like the organic matter of bonesand muscles), physiological (processes such as bloodcirculation), psychological (attention, emotions),and existential (the sense of ‘‘I am’’) (Hedlund,2014). The theories of BBAT have been mainlyinspired by the works of Swedish physical therapistRoxendal and French movement educator Dropsy;they are influenced both by Eastern movementtraditions such as tai chi chuan and Zen medita-tion and by Western traditions such as dance andmovement pedagogy (Hedlund, 2014). BBAT hasbeen found to be beneficial for various disorders, forexamplelong-termmusculoskeletalpain(Malmgren-Olsson, Armelius, & Armelius, 2001), fibromyalgia(Gustafsson, Ekholm, & Broman, 2002), irritablebowel syndrome (Eriksson, Mo¨ller, So¨derberg,Eriksson,&Kurlberg,2007),schizophrenia(Hedlund& Gyllensten, 2010), and eating disorders (Catalan-Matamoros,Helvik-Skjaerven,Labajos-Manzanares,Martı´nez-De-Salazar-Arboleas, & Sa´nchez-Guerrero,2011). In psychiatric out-patients, a period of BBATimproved sleep, self-efficacy, and physical copingresources (Gyllensten, Hansson, & Ekdahl, 2003a).Patients’ experiences of BBAT related to increasedbalance, awareness, handling of body signals, andmovement control (Gyllensten, Hansson, & Ekdahl,2003b).Theirself-confidencegrewastheydevelopedsensitivity to body cues and mastering their bodies inmovement. The authors concluded that the patients’experiences of the relationship with the physicaltherapist seemed to affect their view of the mean-ingfulness of BBAT. The patient’s ability to opento and trust the physical therapist was suggested tobe important for a positive outcome (Gyllenstenetal.,2003b).Inasimilarway,schizophrenicpatientsdescribed enhanced awareness and self-esteem fol-lowing BBAT (Hedlund & Gyllensten, 2010). Theyalso noted that BBAT helped with affect regulation,social abilities, and thinking more clearly. Anotherstudy on patients with moderate psychiatric illnessand pain found that BBAT provided a situation tocreate new meanings for one’s lived body, as thepatientsexperiencedtheirbodiesinanewway,feelingmore whole and ‘‘at home’’ with themselves (Johnsen& Ra˚heim, 2010). This meant an expanded self-knowledge and changed ways to relate, but it wasconnected to thresholds because the changes tooktime.Studies on BBAT in mental health often involvemixed samples, indicating a need to address whatit is like to take part in BBAT while enduring aspecific illness. Moreover, a life-world-based researchperspective for studying BBAT is rare. A recentrandomized controlled trial evaluating BBAT formajor depression indicated that more research isneeded both to conclude effects and to deepen theunderstanding of how BBAT is experienced du-ring depression (Danielsson, Papoulias, Petersson,Carlsson, & Waern, 2014b). Thus, for the presentstudy, we were interested in lived but unpronouncedaspects of BBAT during depression, how BBAT is L. Danielsson & S. Rosberg  2 (page number not for citation purpose) Citation: Int J Qualitative Stud Health Well-being 2015,  10 : 27069 -  lived through and given meaning to by persons whoare depressed. To gain insight into this experience,we phrased the following research question: Whatmeanings do persons with major depression give totheir experiences of BBAT? The purpose of thisstudy was to explore the phenomenon of BBAT asexperienced by persons with major depression. Method Hermeneutic phenomenology is concerned withreflection, in an open and wondering way, on thebasic structures of the lived experience of humanexistence to achieve access to the world as weexperience it pre-reflectively (Van Manen, 2014).This study commits to the life-world of personsdiagnosed with depression, searching for meaningin their immediate and intuitive experience of BBATas a wondering approach to  what shows itself   in thisexperience and  how it shows itself  . By ‘‘borrowing’’their experiences of BBAT and allowing ourselvesto be absorbed by them, we can enrich our under-standing of what the experience means. This en-deavour involves the phenomenological reduction,or what is referred to by others as  bracketing   or  epoche´  (Norlyk & Harder, 2010). These expressions signifywithholding existential claims of the phenomenonby suspending previous ideas and prejudices, so thatthe phenomenon can be approached with an openmind. However, to grasp embedded meaning beyondpure description, the researcher’s stance and activecollaboration with the participants inevitably involvean interpretative dimension (Dahlberg, Dahlberg, &Nystro¨m, 2008; Van Manen, 2014). Here, we concurwith Heidegger’s (1953/2010) and Gadamer’s (2004)views of interpretation as always founded upon ourpreconceptions; without these we can never apprehendanything. Thus, our reflexivity as researchers, with ourown experiences, knowledge, and beliefs, and theinterrelation between researcher and participantswere dynamically intertwined with the generationand analysis of data.In phenomenological research, the vocative andlinguistic dimension is central to the analysis, espe-cially to the writing (Van Manen, 2014). We workedtoembrace,ontheonehand,asystematicexplorationof the meaning structures and, on the other hand, anattempt toevokeresonance in thereader. This meansthat we sought language that would capture theexperiences in awaythat would create a certain sensein the reader. The experiences described should feelplausible, recognizable even though the reader hasnot experienced them personally. Thus, the languageneeds to be rich and creative, to make somethingunderstandable that, in fact, lies beyond spoken andwritten language  *  ideally, as Merleau-Ponty (1973)says, ‘‘a language that sings the world.’’ Participants In phenomenological research, sampling is not re-lated to statistics or to saturation in the sense that noadditional views appear (Van Manen, 2014). Rather,sampling means gathering enough examples of ex-perientially rich descriptions to be able to help usconnecttolife asitislived(VanManen, 2014).Here,we included 15 participants diagnosed with majordepression 1 accordingtothecriteriaoftheDiagnosticand Statistical Manual of Mental Disorders, 4thedition (American Psychiatric Association, 2000),who had taken part in a BBAT intervention ina randomized controlled trial presented elsewhere(Danielsson et al., 2014b). The severity of depres-sion was the primary outcome, measured usingthe Montgomery A˚sberg Depression Rating Scale(Montgomery&A˚sberg,1979).Inthetrial,62adultswith major depression were randomized to participatefor 10 weeks in one of the three following interven-tions, in addition to antidepressants: 1) exercise, 2)BBAT, or 3) advice on physical activity in daily life.Experienced physiotherapists guided the interven-tions. Effects on psychological, functional, and phy-siological parameters were compared across groups.In the BBAT group, participants began treatmentwith two individual sessions and then trained for8 weeks, twice weekly, in small groups of five to eightparticipants. For this qualitative study, we attemptedto recruit participants who had attended at least fivesessions altogether (individual and group sessions),because we assumed that, with fewer sessions, it wouldbe difficult for participants to express experiences of treatment in a way that would provide rich descrip-tions.Amongthe20participantsrandomizedtoBBATin the intervention study, 12 were initially invited totakepartin thepresent study.Weeventually includeda thirteenth participant who was originally in thecontrol group, but subsequent to follow-up receiveda similar program of BBAT. The reason for thisinclusion was that we wanted another example of experiences to move our understanding further, par-ticularly the experiences of a young person becausethe sample contained few young people. Duringthe analysis, we considered the idea that a negativetreatment experience would give important nuancesto the results, and we therefore contacted two par-ticipants who had dropped out during the trial; theseparticipantsprovideduswithwrittenrecountsoftheirexperiences. However, one of these participants hadattended fewer than the stated minimum numberof sessions (three sessions in total). The participantsrepresented a variation of background characteristics Opening toward life Citation: Int J Qualitative Stud Health Well-being 2015,  10 : 27069 -  3 (page number not for citation purpose)  (sex, age, occupational and marital status, baselinedepression severity, and number of sessions com-pleted). The demographic and clinical data of theparticipants are presented in Table I. The structureand main content of the BBAT intervention arepresented in Table II. Interviews Semistructured interviews were conducted at thehealth centre at which the intervention had takenplace,asweassumedthatrecallingexperienceswouldbe easier at the locale of the treatment. An effort wasmade to use the actual training room for the inter-views, although this was not always possible due toother regular activities at the centre. Moreover, it washoped that using a room that was familiar to theparticipants would facilitate an atmosphere of trust.Theinterviewswereheldinthestyleofaconversationtoencouragetheparticipanttotalkfreelyaboutherorhis experiences. Emphasis was placed on creating acollaborative relationship with the interviewer (LD)acting as an interested guide, using follow-up ques-tions to help the participant elaborate and reflecton the experiences described. Two topic areas wereemployed:1)experiencesofBBATduringdepressionand 2) narrative about a situation or situations fromBBAT that the participant particularly remembered.After the first four interviews, to enhance theimmediate experiences, the interviewer began offer-ing to lead the participants in some BBAT move-ments. Four participants chose to take part in this.This experience deepened the subsequent verbalreflection for one participant, although for the otherthree, we found no clear advantage to this strategy intermsoffacilitatingricherdescriptions.Theinterviewswere audio-recorded with a digital device and lasted35    75 min. The interviewer also took working notesto remember key expressions in the participants’statements and to note non-verbal elements of theinterview such as body language, emotional expres-sions, tone of voice, and atmosphere in the room.Shortly after each interview, the interviewer tran-scribed the recording verbatim. Data analysis Initially, both authors independently read the tran-scripts to get a sense of the whole material. The firstimpression of meaning that came forth in these brief readings was noted in the reflexive journal, togetherwith working notes and thoughts emerging from theinterviews.Next,eachtranscriptwasanalysedclosely,onitsownterms,whichmeantthoroughreadingsandsystematic structuring of the textual data using tables(see Table III, for example), extracting statements,condensing the meanings involved, and reflectingon the structure of embedded meanings. Reflective Table I. Background and clinical data for the participants included in a study exploring experiences of basic body awareness therapy inpersons with major depression Number of participantsTotal sample  n  15Age Median age  47, range 19    64Sex Women 10Men 5Occupational status Full-time work 3Part-time work 5Student 3Full sick-leave/pension 3Unemployed 1Depression severity before intervention Median MADRS  22 points, range 15    27 B 20 MADRS points 5 ] 20 MADRS points 10Number of completed sessions (max 18) Median  13, range 3    18Fewer than 5 sessions 15    10 sessions 511    18 sessions 9Time from end of intervention to the interview Median time (weeks)  2, range 1    14 B 2 weeks 72 weeks    1 month 61    3 months 2 MADRS, Montgomery A˚sberg Depression Rating Scale (Montgormery & A˚sberg, 1979), a 10-item assessment with a maximum score of 60 points. Generally, scores below 20 indicate mild depression, 20    35 points signifies moderate depression and   35 points representssevere depression. L. Danielsson & S. Rosberg  4 (page number not for citation purpose) Citation: Int J Qualitative Stud Health Well-being 2015,  10 : 27069 -  discussions between the two authors enhanced thispartoftheanalysis.Thediscussionswereextendedbytalks with the physiotherapy leader of the BBATgroup, who had observed, moved, and reflected withthe participants, and by connecting to LD’s experi-ences from leading BBAT groups with other de-pressed patients. Parallel to the discussions, readingsof comprehensive literature inspired a deeper inter-pretation of the data. However, in accordance withour phenomenological approach, we wanted to puttheoretical models ‘‘on hold’’ so that meaning wouldarise from descriptive, empirical data. The analysiscontinuedthroughaniterativeprocessofmovingbackand forth between the separated meaning units andtheir meaning structure and between each individualinterview and the material as a whole. With this ana-lytic movement, we sought a thematic structure andpresentation that would capture and lie close to theparticipants’ descriptions yet reveal meaning beyondthese descriptions,enabling ustounderstandtheminanovelway,withthetheoreticalframeworkasatoolinthe interpretation. Here, the analysis resulted in anessential theme with five constituents that illuminatethemeaningoftheparticipants’experiencesofBBAT. Handling of own subjectivity in the process Theresearcher’ssubjectivityisameanstounderstandthe participants’ experiences, both regarding whatcan be considered relevant in the data collection andas a tool in the interpretation process. On the otherhand, that subjectivity needs to be reflected on inorder tobe able to ‘‘bridle’’ it (Dahlberg et al., 2008),inthesenseofstayingopentolettingtheparticipants’descriptions lead the way to disclosing meaning. Thepre-understanding at hand was that LD is a physicaltherapist specialized in treating patients with mentalhealth problems in psychiatric and primary caresettings; she is educated and trained in BBAT. Shehas previously done research on the embodimentof depression from a phenomenological perspective.SR is a physical therapist experienced in psychiatricphysiotherapy and in body awareness therapy, cur-rently involved in education and research, and with atheoretical foundation in hermeneutic phenomenol-ogyanddanceandmovementtherapy.Asatoolinthereflective process of keeping openness to novelty andthe participants’ voices, we outlined our consciouspreconceptions in relation to the research questionin a reflexive journal. During the study, we went backto reflect on these assumptions and their relation tothe emerging results. Table IV gives an example of the work with our pre-understanding during theanalysisprocess.Tofurtherpromotephenomenologicalopenness, we engaged in an attentive and empathicpresenceintheinteractionwiththeparticipants,bothregarding the collaborative style of interviewing andin terms of embodied, non-verbal communicationattempting to reach an empathic understanding of the participants’ experiences. Table II. Content and structure of the basic body awareness therapy intervention that was explored in a study of participants’ livedexperiences of the treatment Structural frame of each session Examples of exercises Main purposePreparationphase(voluntary)15 minbeforesessionRoom open, matson the floor, pillowsavailable, calmbackground musicResting in sitting or lying down position Calming down,preparing for sessionPhase 1 About 20minSupine movementson the floor, on matsBody scanning, exploring contact withthe ground and breathing pattern,stretching and releasing movementsGrounding, relaxation,and connecting toone’s bodyPhase 2 About 20minStanding and walkingexercisesBalancing in and exploring a functionalposture and wholeness, for example:slowly moving up and down along one’smidline, flexing in the knees and hips,letting the arms float up when rising,and softly sinking down when loweringone’s body, integrating the wholemovement with breathingPostural stability, flowand rhythm of movements, force,coordinationPhase 3 About 10minSeated meditation Aligning and anchoring oneself in aseated position on a meditation cushionor stool, 5 min silent focus on featuresof the body, such as the breathingPostural stability, freebreathing, mentalawarenessPhase 4 5    10 min Verbal reflection Taking turns to share something abouttoday’s experiences, answering thequestion: What did you notice duringtraining today?Sharing andverbalizing bodyexperiences Opening toward life Citation: Int J Qualitative Stud Health Well-being 2015,  10 : 27069 -  5 (page number not for citation purpose)
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