Original articleBioenergetic exercises in inpatient treatment of Turkish immigrants with chronic somatoform disorders: A randomized, controlled study
Introduction
Several studies indicate that the incidence of psychological distress and mental disorders in diverse ethnic immigrant groups has increased all over the world, not only in comparison with follow countrymen remaining in their homeland, but also with the indigenous population in the country to which they immigrated [1], [2]. Interest in the cultural characteristics of mental illnesses has been stimulated by ever increasing awareness of cultural diversity in Western society [3]. Turkish immigrants constitute about 30% and, hence, the largest group, of all immigrants in central Europe [4]. According to Schmeling-Kludas et al. [5], most of the illnesses diagnosed in this population are some type of somatoform disorder (over 60%).
Cross-cultural stress contributes to emotional suppression. Indeed, among Turkish immigrants, expressions of distress range from open use of culturally traditional expressions to complete avoidance [6]. Both suppression and expression of anger might contribute to somatoform disorders [7], [8]. Somatoform disorders can be viewed as a process through which somatic symptoms are presented in order to eclipse emotional distress and social problems [9], [10]. This particular population, however, rarely views psychiatric treatment as an acceptable or valuable tool for recovery or as helpful in linking bodily symptoms to emotional distress [6].
Cultural styles of attribution might contribute to both the high rate of somatization in the Turkish immigrant population, as well as its rejection of, and response to, somatic or psychosocial treatment [11], [10]. The more traditional the culture, the less differentiation appears to exist between psychological disturbance and bodily symptoms [12]. For instance, although the separation between physical and emotional experience occurs most precisely in Western European languages, emotional perceptions are figuratively expressed through allegories of body sensations in the Turkish language [13], [14]. Body language is thus an important facet of Turkish communication [15] and, thus, becomes an essential aid for such patients. It functions to express subject matters that the patients can verbalize only with difficulty, or perhaps even not at all, such as childhood memories, sexuality, or aggression [16]. For Turkish patients, somatization not only occurs as an alternative to expressions of psychological distress but also as an accompaniment [15] and becomes, to a large extent, the focus [13]. Somatic symptoms show culturally mediated styles of communication, and therapists should allow for a sociocultural perspective to use effective therapeutic approaches [10].
Thus, body-oriented approaches in psychotherapy pave a special therapeutic avenue on account of their nonverbal focus [17], [18], [19]. One such approach, bioenergetic analysis, uses depth psychology-based body psychotherapy, which was further developed by Alexander Lowen, based on approaches from S. Freud and W. Reich. Its effectiveness has been relatively well researched [19], [20], [21], [22]. The central components of this method are interventions on the physical level derived from a psychoanalytical approach [21], [22]. The goal is to enable the patient to gain access to his or her own self through directed exercises connected with verbal therapy [21], [22]. Bioenergetic analysis presupposes that important life experiences are retained not only in the psychic subconscious but also in the body, where they find expression in respiration, posture, and movement, as well as experience and behaviour. The theoretical concept also postulates that mental, emotional, and physical processes are closely integrated. Hence, we hypothesized that this approach might be effective in the treatment of Turkish patients.
Randomized, controlled clinical studies on psychotherapeutic treatment of Turkish immigrants are rare, but indispensable, in light of how many Turkish immigrants live in Middle and Western Europe [5]. To the best of our knowledge, there are no studies that examine the effects of body-related psychotherapy in this patient group. The goal of this study was to examine whether bioenergetic exercises (BE) significantly influence the treatment results in inpatient psychotherapy for Turkish immigrants with chronic somatoform disorders.
Section snippets
Study subjects
The study was carried out in the Inntalklinik, a German hospital specializing in psychosomatics. Approximately 15% of the patients that are treated here are Turkish immigrants living either in Germany or Austria. Three Turkish psychologists and two Turkish physicians, as well as Turkish nursing staff, work in the hospital. Insurance carriers are familiar with its transcultural therapeutic concept and refer Turkish patients specifically to the hospital.
Every Turkish patient with a chronic
Results
The patients' sociodemographic data and their psychiatric comorbidity at the time of randomization are found in Table 1. Both groups were comparable in light of their sociodemographic data, comorbidity, and initial measurements with SCL-90-R and STAXI.
The following were diagnosed in the category of somatoform disorders: pain disorder [BEG: n=24 (37.5%); CG: n=21 (32.8%)], somatization disorder [BEG: n=31(48.4%); CG: n=35 (54.7%)], conversion disorder [BEG: n=5 (7.8%); CG: n=4 (6.2%)], and
Discussion
The results of our study indicate that BE positively affects the treatment results in Turkish patients with chronic somatoform disorders, when conducted in addition to the previously described treatment program. It improved symptoms of somatization, social insecurity, depressiveness, anxiety, and hostility; reduced anger levels and the tendency to direct anger inwards; and simultaneously increased spontaneous outward emotional expression. Specifically, BE resulted in a significantly greater
Acknowledgments
We thank Ann Marie Ackermann, JD, for translating and editing this article. The study was not funded.
References (40)
Cultural variations in the response to psychiatric disorders and emotional distress
Soc Sci Med
(1989)- et al.
Multiple medically unexplained physical symptoms and health care utilisation: outcome of psychological intervention and patient-related predictors of change
J Psychosom Res
(2004) - et al.
Treatment of aggression with topiramate in male borderline patients: a double-blind, placebo-controlled study
Biol Psychiatry
(2005) - et al.
Incidence of psychotic disorders in immigrant groups to The Netherlands
Br J Psychiatry
(2001) - et al.
Expatriate mental health
Acta Psychiatr Scand
(1998) - et al.
The place of culture in DSM-IV
J Nerv Ment Dis
(1999) Sozialmedizin und ärztliche Begutachtung
(2003)- et al.
Stationäre psychosomatische Rehabilitation für Türkische migranten: Was ist realisierbar, was ist erreichbar?
Rehabilitation
(2003) - et al.
Turkish migrant women encountering health care in Stockholm: a qualitative study of somatization and illness meaning
Cult Med Psychiatry
(2000) - et al.
Predominance of anger in depressive disorders compared with anxiety disorders and somatoform disorders
J Clin Psychiatry
(2002)
The relation between anger expression, depression, and somatic symptoms in depressive disorders and somatoform disorders
J Clin Psychiatry
Depression, somatization and the “new cross-cultural psychiatry”
Soc Sci Med
Culture and somatization: clinical, epidemiological, and ethnographic perspectives
Psychosom Med
Symptom attribution in cultural perspective
Can J Psychiatry
The impact of culture on the cognitive structure of illness
Cult Med Psychiatry
Transcultural aspects of the clinical-psychiatric pictures of foreign workers (guest workers) and their significance for neurological practice
Confin Psychiatr
The condition of “tightness”: the somatic complaints of Turkish migrant women
Acta Psychiatr Scand
Building bridges between body and mind: the analysis of an adolescent with paralysing chronic pain
Int J Psychoanal
Körperzentrierte Psychotherapie IKP, Ganzheits-Psychotherapie bei Angstzuständen
Ther Umsch
Ist körperorientierte Psychotherapie Frauensache? Eine klinische prozess-ergebniss Studie zur Konzentrativen Bewegungstherapie
Psychother Psychosom Med Psychol
Cited by (38)
Validation of the grounding assessment tool for identifying emotional awareness and emotion regulation
2021, Arts in PsychotherapyCitation Excerpt :The theory assumes that physical and emotional processes are intertwined, and that movement interventions for grounding improvement may facilitate both a change in breathing and stability and will also improve emotional awareness and emotion regulation (Lowen & Lowen, 1977; Mahr, 2003). Several studies, despite their small sample size and application of different interventions besides grounding techniques, indicate that strengthening the sense of support of the individual from the ground through physical sensory activities had a positive effect on emotional awareness, emotional expression, and emotion regulation in the following conditions: depression and anxiety (Pylvänäinen, Muotka, & Lappalainen, 2015; Röhricht, Papadopoulos, & Priebe, 2013), post-traumatic disorders (Ko, 2017), and somatoform disorders (Nickel et al., 2006). Among all of these conditions, the patients suffered from varying levels of alexithymia, impaired emotional awareness and emotional expression (Nickel et al., 2006; Pylvänäinen et al., 2015; Röhricht et al., 2013).
Symptom manifestation and treatment effectiveness, -obstacles and -facilitators in Turkish and Moroccan groups with depression in European countries: A systematic review
2019, Journal of Affective DisordersCitation Excerpt :This study showed that the group receiving additional bioenergetic therapy showed a greater reduction of somatization as well as of depressive, anxiety and hostility symptoms. They also showed a greater improvement regarding anger levels and anger expression (more directed outwards than inwards; Nickel et al., 2006b). This is the only documented study examining the effectiveness of the working elements of eclectic psychosomatic rehabilitation programs.
Blunted exercise-induced mobilization of monocytes in somatization syndromes and major depression
2014, Journal of Affective DisordersCitation Excerpt :Thus, an important result of our study is that exercise reduces the severity of somatoform symptoms in patients with somatization syndromes. One previous study conducted by Nickel and colleagues (Nickel et al., 2006) found that both a 6-week intervention of bioenergetic exercises and a gymnastic exercise intervention reduce symptom severity in patients with chronic somatoform disorders, while the bioenergetic exercise group achieved significantly better treatment results on most outcome measures. In the present investigation, we have demonstrated that even 1 week of regular exercise reduces the severity of somatoform symptoms in patients with somatization syndromes.
Physiotherapy for functional (psychogenic) motor symptoms: A systematic review
2013, Journal of Psychosomatic ResearchCitation Excerpt :Twelve articles with paediatric subjects were identified (Table 2). Seven articles were excluded on the basis that it was unclear if subjects had functional or organic motor symptoms [8–14]. These, together with the remaining excluded articles that were reviewed in full are detailed in supplemental online material.