Atlas›Domain IV · Body-oriented psychotherapy›Guide 080
Guide IV-080

Dutch psychomotor therapy

Netherlands and Flanders
A 22 · L 61 · M 1730 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Dutch psychomotor therapy (psychomotorische therapie, PMT) as set out in the NVPMT-sponsored handbooks Psychomotor Interventions for Mental Health – Adults (De Lange, Glas, Van Busschbach, Emck & Scheewe, eds., 2019) and – Children & Adolescents (Emck, De Lange, Scheewe, Van Busschbach & Van Damme, eds., 2021), with the Dutch multidisciplinary depression guideline module on PMT (NVvP, 2024) as the clinical reference. Where the Dutch sources give no procedure, the closely related Leuven (Flemish) PMT tradition as described by Probst (2017) is used and named. Only the publisher previews (front matter, introductions, tables of contents) of the Dutch handbooks are drawn on, not the chapters themselves, so chapter-level procedures are marked [uncertain] wherever they are mentioned.

PMT is not a single manualised therapy. It is a Dutch and Flemish professional discipline (one of the vaktherapieën, the Dutch "arts and psychomotor therapies"), with its own bachelor training and professional association (NVPMT). Under one heading it covers a family of movement- and body-oriented interventions for mental health problems. The general introduction to the adult handbook calls "psychomotor interventions" an umbrella term for movement- and body-oriented therapies developed and practised mainly in the Netherlands and Flanders [source: Emck, 2019, General introduction, preview]. The guideline defines PMT as the personalised use of combinations of methods aimed at body experience (lichaamsbeleving) and movement behaviour (bewegingsgedrag) [source: NVvP 2024 depression module].

How change happens, in the sources' terms. The client learns by doing (al doende ervaren). A movement situation is set up that draws out the client's usual way of handling tension, emotion, contact, limits or effort. The client experiences this in the body. With the therapist, the client links the experience to meaning and practises alternatives in the same here-and-now situation. They then transfer those alternatives to daily life [source: NVvP 2024; De Lange 2010 introduction, preview; GGZ Friesland client information]. Probst puts it like this: the experiences in PMT, and the responses they bring out, "function as a dynamic source of change" [source: Probst 2017]. The adult handbook describes PMT as having two roots, or "pillars": physical education (movement-oriented work) and body-oriented psychotherapy (body-oriented work) [source: Emck & Scheffers, 2019, ch. 1 headings, preview].

2. Framework

PMT has no fixed number of phases across all applications. What follows is the generic methodical cycle as the sources describe it. Disorder-specific programmes (depression, anxiety, eating disorders, aggression, PTSD, psychosis, dementia, children) sit inside this cycle [source: GGZ Friesland; Probst 2017; NVvP 2024; Boom previews].

Three approaches, chosen per client [source: NVvP 2024; Probst 2017]

  • Health-oriented (gezondheidsgericht): physical health, activity level and lifestyle, for example in sedentary clients or clients with medication-related metabolic risk.
  • Psychosocial / psychophysiological: skills in and through the moving body, such as attention, cooperation, stress and arousal regulation, relaxation, breathing, endurance and strength training, and mindfulness-derived exercises.
  • Psychotherapeutic: movement as a gateway to social-affective functioning and to practising alternative behaviour. The focus is the client's experience, not the activity. It can be embedded in a behavioural, cognitive or psychodynamic frame.

Two working modes (aggression work in people with mild intellectual disability, generalisable [synthesis]) [source: Bellemans et al. 2018]

  • Experience-oriented (ervaringsgericht): building awareness and insight, for example of body signals and emotions.
  • Action-oriented (handelingsgericht): repeating and automating skills until they become habit.

Phase A. Referral and indication. The treatment coordinator (regiebehandelaar) and the client decide together whether PMT fits, and the client is referred [source: GGZ Friesland]. Guideline indications include:

  • complaints that show in movement and body experience [source: NVvP 2024];
  • for PTSD, as an add-on when trauma is hard to put into words, when response to trauma-focused treatment is insufficient, or when arousal or dissociation block the first-choice treatment [source: NVvP PTSD guideline module].

Phase B. Intake, psychomotor observation and assessment. Goals of this phase:

  • get acquainted and explain PMT;
  • take a movement history (bewegingsanamnese) and do a somatic screening, consulting a physician if there is a somatic condition [source: NVvP 2024];
  • observe the client in movement.

Probst describes observation across psychomotor, cognitive, affective, behavioural and symbolic dimensions, with guiding questions such as who takes the lead and who follows. It can be structured with the Louvain observation scales (LOFOPT). These rate nine goal areas: emotional relationship, self-confidence, activity, relaxation, movement control, focus on the situation, movement expressivity, verbal communication and social regulation. Standardised tools are added where relevant:

  • motor and fitness tests (Bruininks, six-minute walk, Léger, Spartacus);
  • body experience questionnaires (Body Attitude Test, Physical Self-Description Questionnaire, Physical Self-Perception Profile);
  • activity questionnaires (IPAQ, SIMPAQ).

[source: Probst 2017] Describe these instruments only; do not reproduce their items. In aggression work, only a minority of Dutch therapists used structured measures, such as the Anger Bodily Sensations Questionnaire or a heartbeat-awareness test [source: Bellemans et al. 2018]. The Dutch handbook's chapter on psychomotor diagnostics is not drawn on [uncertain].

Phase C. Goal setting and treatment plan. Goals are concrete, agreed with the client, and cover both physical and psychological targets. The plan also sets individual versus group format and frequency [source: Probst 2017; GGZ Friesland]. In depression work, goals are kept realistic and individual so that they produce success experiences [source: NVvP 2024].

Phase D. Treatment. Format and dose found in the sources:

  • Probst: early treatment mostly individual and focused on the presenting problem; later stages bring in more group and interactive work.
  • GGZ Friesland: at least 8 sessions, then a joint decision on whether to continue.
  • Tolbrug "Voel je lijf" pain module: 10 weekly sessions of 60 minutes in a sports hall, with a fixed theme per session.
  • Supervised aerobic activation in the depression evidence: on average 3 sessions of about 45 minutes a week for about 9 weeks. Relaxation helped only in programmes longer than 8 weeks.
  • Radboud day-treatment depression programme (PMT within CBT): three phases. First, psychoeducation and identifying dysfunctional thoughts and behaviour. Second, challenging automatic thoughts and life rules (leefregels) by trying out alternatives in movement. Third, consolidating alternative thoughts and behaviour.

[source: Probst 2017; GGZ Friesland; JBZ/Tolbrug 2023; NVvP 2024; De Lange 2010, ch. 1 preview]

Phase E. Evaluation and moving on. Criteria for moving between phases:

  • Move from awareness work to skills practice once the client can recognise the target signal (tension, anger, fear, a limit) during activity, not only afterwards [synthesis, from the experience-oriented to action-oriented sequence in Bellemans et al. 2018].
  • Move from individual to group or interactive work once the client can tolerate the basic activities and the setting [source: Probst 2017].
  • Review after the agreed block of sessions [source: GGZ Friesland].
  • Clients in physical activation keep a log of motivation, frequency, duration and intensity, which feeds the review [source: NVvP 2024].
  • Systematic, planned evaluation runs alongside the treatment [source: Probst 2017].

Phase F. Ending and transfer. Review what was learned, decide which behaviours to keep and which to reduce, and write a relapse-prevention plan [source: JBZ/Tolbrug 2023; Bellemans et al. 2018]. For activation programmes, plan how the client will keep exercising independently [source: NVvP 2024].

3. Guiding principles

  • Learning by doing, not talking about doing [source: NVvP 2024; Probst 2017]: build the session around an activity that brings out the theme, then reflect. Do not use the gym as a backdrop for verbal therapy.
  • More than exercise [source: Probst 2017]: what matters is what the client experiences in the activity, not how fit or skilled they are. Prescribing "sport" without explanation is counterproductive for clients with severe mental illness.
  • Here and now [source: De Lange 2010, ch. 5 heading, preview]: work with what happens in this session's movement, such as how the client starts, gives up, competes or avoids contact.
  • Body experience as a target in its own right [source: NVvP 2024; Scheffers et al. 2019 as cited there]: in depression, eating disorders and after trauma, the relationship with one's own body (attitude, satisfaction, awareness) is itself a treatment goal.
  • Challenge within safety [source: Emck et al. 2021 preface vignette; Probst 2017]: set tasks just beyond the client's current comfort, with support, encouragement and clear rules. The child climbing poles of increasing height is the handbook's example.
  • Success experiences [source: NVvP 2024; Probst 2017]: grade tasks so that the client succeeds, especially in depression.
  • Link body signals to coping [source: Bellemans et al. 2018]: an early body signal becomes the cue for a chosen response. Always connect awareness work to an action.
  • Transfer [source: GGZ Friesland; JBZ/Tolbrug 2023]: every theme ends with something to try at home. The final sessions build a relapse-prevention plan.
  • Shared goals and informed consent [source: Probst 2017]: explain the what, why, where, when and how of treatment, and set goals together.
  • Dialogue, not a ready-made solution [source: Probst 2017]: invite rather than prescribe. What is obvious to the therapist may not be obvious to the client.
  • No right or wrong in movement [source: GGZ Friesland]: the client must feel safe enough to show themselves. Mistakes and clumsiness are material for the work, not failures.
  • Modelling and positive reinforcement [source: Bellemans et al. 2018; Probst 2017]: the therapist shows the behaviour and reinforces small steps, acting as a "healthy role model" in personality-disorder work.
  • Multidisciplinary embedding [source: Probst 2017; GGZ Friesland; Bellemans et al. 2018]: PMT is usually one part of a treatment plan. Coordinate goals with the treatment coordinator and, where useful, with family or staff.
  • Screen before exertion [source: NVvP 2024]: take a movement history and somatic screening first, and consult a physician if there are somatic conditions.
  • Trauma-sensitive attunement [source: NVvP PTSD module]: pay particular attention to disturbed or negative body experience, especially after sexual trauma. Work within the client's window of tolerance.
  • Developmental lens with children [source: Emck et al. 2021 preview]: work with the child and the parents, and target self-esteem, coping with stress and anxiety, and a positive body attitude.

4. Intervention inventory

Scope. The sources name techniques but rarely give step-by-step procedures. Each entry therefore separates two things:

  • what the sources say: the technique, its purpose and its context, with a [source] tag;
  • the operational steps added so you can run it in session, tagged [synthesis].

The Dutch handbooks' chapter-level protocols are not drawn on [uncertain]. Rules that apply to every entry:

  • No exertion-based work without the movement history and somatic screening described in section 2 [source: NVvP 2024].
  • Any technique involving touch requires specific training and supervision, plus a check of what your licence and jurisdiction allow [synthesis, per house rules].
  • Every session opens with a check-in and closes with a reflection round [synthesis, consistent with "doing, then reflecting" in Probst 2017 and GGZ Friesland].

A. Observation and awareness

4.1 Structured psychomotor observation in activity

  • Purpose / when: Assessment at intake and re-assessment at review. Shows how the client moves, initiates, follows, competes, gives up and makes contact, which tests cannot capture [source: Probst 2017].
  • Steps:
    1. Choose two or three short activities with different demands, for example a free ball game, a cooperative task and a quiet relaxation task [synthesis].
    2. Observe across the psychomotor, cognitive, affective, behavioural and symbolic dimensions, for example "Who takes the lead? Who follows?" [source: Probst 2017].
    3. Rate the LOFOPT goal areas if you are trained in the scale [source: Probst 2017].
    4. Add motor or fitness tests and body experience questionnaires where indicated [source: Probst 2017].
    5. Feed the observations back in plain words and turn them into goals with the client [synthesis].
  • Example language (illustrative): "I noticed you stopped as soon as someone else took the ball. Does that happen elsewhere too?"
  • Watch for: Being observed can itself raise shame or performance anxiety [source: Probst 2017]. Say what you are looking at and why.

4.2 Tension thermometer

  • Purpose / when: Makes tension or anger visible and gradable, so the client can notice it early. Core in aggression-regulation work [source: Bellemans et al. 2018].
  • Steps [synthesis]:
    1. Draw or lay out a scale on the floor, for example 0 to 10 with tape.
    2. The client marks the body signals that belong to low, middle and high levels, such as a tight jaw, heat or fists.
    3. During every activity, stop at set moments and ask the client to stand on, or name, their current level.
    4. Agree an "action point" level at which a coping step (4.3, 4.8, 4.9) starts.
    5. Carry the scale into homework.
  • Example language (illustrative): "Where are you on the thermometer right now? What tells you that in your body?"
  • Watch for: Scores that jump from low straight to high are a sign of poor interoceptive awareness. Slow the activity down and check in more often.

4.3 Interoceptive awareness and body-signal registration

  • Purpose / when: To notice body signals in general and the signals linked to anger, fear or pain in particular. This is the main objective alongside coping skills in Dutch aggression PMT [source: Bellemans et al. 2018]. Used in the first sessions of the pain module [source: JBZ/Tolbrug 2023].
  • Steps:
    1. Set personal goals.
    2. Do one sensory exercise in full attention: listen to a favourite song, feel which clothes are comfortable, walk outside noticing smells and sights, or taste something slowly [source: JBZ/Tolbrug 2023].
    3. During a movement exercise, the client notes signals as they come up.
    4. Afterwards, the client logs the signals felt in the session and at home, and reflects on how thoughts, places, people, emotions and activities change them [source: JBZ/Tolbrug 2023].
    5. Some therapists use a heartbeat-perception task [source: Bellemans et al. 2018]. The procedure was not described [uncertain].
  • Example language (illustrative): "Just notice, without changing anything: where in your body do you feel the effort now?"
  • Watch for: Clients with trauma or dissociation can find inward attention destabilising. Keep eyes-open options and an external anchor [synthesis; trauma-sensitive attunement per NVvP PTSD module].

B. Arousal regulation and body-oriented work

4.4 Progressive and applied relaxation

  • Purpose / when: To lower arousal and teach a usable regulation skill. Used for depression (the guideline recommends considering relaxation via PMT for adults), anxiety, somatic symptoms, aggression and stress [source: NVvP 2024; Bellemans et al. 2018; Probst 2017].
  • Steps [synthesis; the sources name the methods without giving procedures]:
    1. Lying on a mat or sitting.
    2. Tense one muscle group for a few seconds, then release it, attending to the contrast. Move through the body in a fixed order.
    3. Over sessions, shorten the sequence towards release-only and cue-word relaxation.
    4. Then rehearse it in standing and moving positions, and right after exertion ("applied").
    5. Close with slow return to activity and a reflection on what changed.
    6. Give home practice.
  • Example language (illustrative): "Tighten your hands into fists… hold… and let go. Notice the difference."
  • Watch for: Relaxation-induced anxiety or intrusions, and clients who fall asleep. Benefit in the depression evidence appeared only with programmes longer than about 8 weeks [source: NVvP 2024], so plan for a block.

4.5 Autogenic training

  • Purpose / when: Named alongside muscle relaxation as a PMT relaxation method for depression [source: NVvP 2024].
  • Steps: Not described in the sources [uncertain]. Use the standard autogenic formulae only if trained in them.
  • Watch for: As for 4.4.

4.6 Breathing exercises

  • Purpose / when: To regulate stress, breath and energy, and to reduce arousal. Used for emotion regulation in depression, aggression regulation and eating disorders [source: NVvP 2024; Bellemans et al. 2018; Probst 2017].
  • Steps [synthesis]:
    1. Sit or stand comfortably.
    2. Notice the breath without changing it.
    3. Then lengthen the out-breath slightly for a few minutes.
    4. Link it to the tension thermometer (4.2): practise at a low level, then right after a demanding game.
    5. Close by asking what changed.
  • Example language (illustrative): "Let the out-breath be a little longer than the in-breath. No need to breathe deeply."
  • Watch for: Light-headedness or tingling: stop deep or fast breathing and return to normal breath. Panic-prone clients may fear breath focus, so start with eyes open and short durations.

4.7 Guided imagery and "favourite place"

  • Purpose / when: Relaxation and a sense of safety [source: Probst 2017]. The pain module asks clients to find or create a favourite place and describe its effect on them [source: JBZ/Tolbrug 2023].
  • Steps [synthesis]:
    1. After a short relaxation, invite the client to imagine or recall a safe or pleasant place in sensory detail.
    2. Ask them to notice how the body responds.
    3. Return attention to the room.
    4. Talk it through.
    5. Homework: visit or create such a place.
  • Watch for: Some clients have no safe-place reference. Offer a neutral or external one, such as an object or a real spot in the building.

4.8 Stepping out of the situation

  • Purpose / when: An adaptive coping response once the tension thermometer reaches the action point [source: Bellemans et al. 2018].
  • Steps [synthesis]:
    1. Agree a signal and a place to step out to within the gym.
    2. Rehearse it calmly first.
    3. During games, the client uses it when they notice the agreed level.
    4. They then use breathing (4.6) and return when lower.
    5. Reinforce the use itself, not only the outcome.
  • Example language (illustrative): "You stepped out at a six. That is exactly the skill. Come back in when you are ready."
  • Watch for: Use of the step-out as avoidance of every challenge. Agree a time limit and a return plan.

4.9 Body awareness, posture and mirror work (body experience)

  • Purpose / when: To rebuild a realistic body image and a more positive body attitude. Central in eating disorders, depression and after trauma [source: Probst 2017; NVvP 2024; NVvP PTSD module].
  • Steps [synthesis; Probst lists posture, mirror and "self-confrontation" exercises without procedures]:
    1. Start with neutral body awareness in movement, for example how the feet meet the floor while walking.
    2. Then posture work: compare a habitual and an upright or grounded stance and notice the difference in mood.
    3. Only later, and with consent, short mirror exercises focused on describing the body neutrally and functionally rather than evaluatively. Time-limit them and talk them through.
  • Example language (illustrative): "Describe what you see as if you were describing a landscape, without judging it."
  • Watch for: Rising shame, disgust or self-harm urges, especially after sexual trauma. The swimming case in Probst shows how exposure of the body can trigger anxiety, shame and self-harm urges [source: Probst 2017]. Never push mirror or clothing-related exposure. Agree a stop and check in afterwards. In eating disorders, keep the focus off weight and shape numbers [house rule].

4.10 Massage and physical contact (touch-based work)

  • Purpose / when: Probst lists massage among the body-experience methods for eating disorders. The anxiety chapter of the adult handbook names "physical contact" as a technique [source: Probst 2017; De Lange et al. 2019 preview].
  • Steps: Procedures not given in the sources [uncertain]. Minimum consent steps [synthesis]:
    1. Explain what touch, where (for example hands, shoulders, back over clothing) and why, before any contact.
    2. Ask explicitly, and offer a no-touch alternative such as self-massage, a ball against a wall or pressure through an object.
    3. Agree a stop signal.
    4. Check in during and after.
    5. Record consent.
    6. Peer-to-peer touch in groups needs the same steps for every pair.
  • Watch for: Freezing, compliance without real consent, dissociation. Touch requires specific training and supervision, and a check of what your licence and jurisdiction allow. Never touch sexual or genital areas.

4.11 Mindful movement: yoga, tai chi, aqua therapy and mindfulness-derived exercises

  • Purpose / when: To reduce tension and hyperactivity (eating disorders), regulate arousal (PTSD; yoga showed the largest effects in the PTSD guideline's meta-analyses) and support depression [source: Probst 2017; NVvP PTSD module; NVvP 2024]. In the Pro Persona anxiety clinic, attention-focused PMT is a named module [source: Pro Persona leaflet].
  • Steps [synthesis]:
    1. Slow, simple forms with attention on breath and sensation.
    2. Invite choices ("you can stay or come out of the pose") and use non-commanding language.
    3. Close with a short rest and a reflection.
  • Watch for: Use trauma-sensitive adaptations for trauma clients. Only teach forms you are trained in.

C. Movement-oriented work

4.12 Running therapy and aerobic physical activation

  • Purpose / when: Depression is the main indication. Running therapy was the first PMT method researched in the Netherlands (Bosscher, 1991). The guideline recommends physical activation via PMT, including running therapy, with attention to both movement behaviour and body experience, for young people, adults and older adults. It is also used in psychosis programmes [source: NVvP 2024; Probst 2017].
  • Steps:
    1. Take a movement history and somatic screening; consult a physician if there are somatic conditions [source: NVvP 2024].
    2. Discuss the pros and cons with the client [source: NVvP 2024].
    3. Set realistic individual goals that produce success experiences [source: NVvP 2024; Probst 2017].
    4. Run supervised sessions, typically several per week, as in the trials: about 3 × 45 minutes a week for about 9 weeks [source: NVvP 2024].
    5. Structure each session as: short check-in, gradual warm-up, run or walk-run at a conversational intensity the client chooses, cool-down, and reflection on body experience and mood [synthesis].
    6. The client keeps a log of motivation, frequency, duration and intensity [source: NVvP 2024].
    7. Build towards independent exercise before ending [source: NVvP 2024].
  • Example language (illustrative): "Today the aim is not distance. Notice what your body tells you and what your mind says about it."
  • Watch for:
    • Self-criticism about pace or shape: return the focus to experience.
    • Drop-out: drop-out was lower with trained therapists [source: Stubbs et al. 2018 as cited in NVvP 2024].
    • In eating disorders, hyperactivity is often the problem, so aerobic work may be contraindicated or replaced by calming work [source: Probst 2017].
    • Set no weight or calorie targets [house rule].

4.13 Strength training, swimming, cycling, Nordic walking, "Start to walk" and sport modules

  • Purpose / when: Fitness, activation and success experiences in depression; the health-oriented approach in psychosis [source: Probst 2017; NVvP 2024 (strength and fitness training in older adults: 3–5 sessions a week of 30–45 minutes for 3–4 months, in the cited trials)]. Sport, swimming and running modules are offered in the Pro Persona anxiety clinic [source: Pro Persona leaflet].
  • Steps [synthesis]: Use the same frame as 4.12: screen, set goals, grade, log, reflect. For swimming, deal with changing rooms, swimwear and being seen as their own steps, given the shame and self-harm risk shown in Probst's case.
  • Watch for: Social anxiety about being watched in physical activity [source: Probst 2017]. Start individually or in small groups.

4.14 Challenge-while-noticing games (interoceptive challenge)

  • Purpose / when: To link body signals to coping under pressure. Dutch aggression PMT uses a basketball exercise in which clients attend to body signals while being challenged [source: Bellemans et al. 2018].
  • Steps [synthesis]:
    1. Play a familiar ball game.
    2. Add a pressure element, such as a time limit, an opponent or a score.
    3. Stop the game at intervals for a tension-thermometer rating (4.2).
    4. When the action point is reached, the client applies the agreed coping step (4.6 or 4.8).
    5. Resume, then debrief on early signals and choices.
  • Example language (illustrative): "Freeze! Thermometer check. What did you notice just before you threw the ball so hard?"
  • Watch for: Escalation beyond the window where reflection is possible. Lower the pressure until the client can still notice.

4.15 Push-and-pull activity to music

  • Purpose / when: Movement expression and contact/strength work in a structured form [source: Probst 2017].
  • Steps:
    1. Warm up.
    2. A 2-minute music sequence.
    3. About 15 minutes of pushing and pulling to music, starting in as small a space as feasible [source: Probst 2017].
    4. If it involves partner contact, run the consent steps in 4.10 first, and offer pushing against a wall or a mat instead of a person [synthesis].
    5. Close with a calm-down and a reflection on strength, resistance and giving way [synthesis].
  • Watch for: Re-enactment of power struggles or trauma. Keep a clear stop rule.

4.16 Dance and expressive movement (goal-directed vs expressive)

  • Purpose / when: Dance and expression are part of the PMT repertoire [source: Probst 2017]. The adult handbook's anxiety chapter uses Buytendijk's distinction between goal-directed and expressive movement [source: De Lange et al. 2019 preview; chapter procedures, uncertain].
  • Steps [synthesis]:
    1. Alternate tasks with a clear goal (pass, reach, hit a target) and tasks that express a quality (move "heavy", "light", "wide").
    2. Notice which mode feels safer.
    3. Gradually extend the expressive range.
    4. Reflect.
  • Watch for: Embarrassment. Start in parallel rather than watched, and allow small movements.

4.17 Cooperative problem-solving games (Leuven repertoire)

  • Purpose / when: Attention, cooperation, communication, problem solving and social regulation in groups, used in the psychosocial and psychotherapeutic approaches [source: Probst 2017]. Debrief questions such as which thoughts were involved turn each game into reflection material.
  • Steps (game structures as described by Probst; debrief wording is your own):
    • Calculator: number cards 1–30 lie scattered in a square. One player at a time enters and taps them in order as fast as possible. Variations: 30 to 1, or every other card. Older adults may tap with a foot.
    • Duplo game: subgroups of three. A "go-between" views a hidden model and may answer only yes/no questions while the builders reconstruct it.
    • Blind squares: blindfolded participants form two squares from ropes.
    • Carpets: a group standing on a 70 × 70 cm carpet must turn it over without touching the floor, with more people added as the task progresses.
    • Window with 16 sections: letters are moved horizontally or vertically to form a sentence.
    • Seesaw: the group keeps a balance construction of benches and mattresses level for at least 5 minutes.
  • Debrief [synthesis]: Who led, who followed, what you thought when it failed, what you would try differently, and where this pattern happens in daily life.
  • Watch for:
    • Blindfolds can be frightening for trauma clients; offer closed eyes or no blindfold.
    • Close-contact games need the consent steps in 4.10.
    • Check balance safety (mats, spotting).

4.18 Graded challenge and trust in movement (climbing, balance, new movements)

  • Purpose / when: To build self-confidence and trust in the body through tasks just beyond current ability, with support. The children's handbook preface describes a child climbing six wooden poles of increasing height while the therapist encourages unaided steps and use of the arms for balance; the father is asked to step back so the child can jump into his arms [source: Emck et al. 2021 preview]. In pain rehabilitation, clients choose movement forms they want to try, notice tension signals and give the body time to adjust [source: JBZ/Tolbrug 2023].
  • Steps [synthesis]:
    1. Agree a ladder of tasks with the client.
    2. Start where success is likely.
    3. Provide physical safety (mats; spotting by a trained person, with touch consent per 4.10).
    4. Encourage, then gradually withdraw help.
    5. Celebrate each step.
    6. Reflect on what the client told themselves before and after.
  • Example language (illustrative): "You decide how high. I'm right here."
  • Watch for: Exposure-like fear. Let the client set the pace and never force a step. For clients with anxiety disorders, treat the steps as graded exposure and agree beforehand on the option to stop.

4.19 Anger expression and kickboxing-based PMT

  • Purpose / when: To redirect internalised anger, used in eating disorders and depression. Boerhout and colleagues developed a brief body- and movement-oriented aggression-regulation intervention for eating disorders, tested in two RCTs, that helps clients "reframe and redirect" anger away from the eating disorder. A Dutch PMT application of kickboxing for depression is described by Bluming (2016) [source: Tijdschrift voor Psychiatrie abstract; NVvP 2024 references; De Lange et al. 2019 preview]. Session content is not drawn on [uncertain].
  • Steps [synthesis; do not treat as the published protocol]:
    1. Screen first (see contraindications below).
    2. Agree safety rules: target only pads or bags, a stop word, no contact with people.
    3. Start with grounded stance and breath.
    4. Build controlled strikes on a pad held by a trained therapist or fixed to a bag.
    5. Add voice only if the client wants it.
    6. Work with control (start, stop, vary force) rather than discharge.
    7. Close with a calm-down and talk through what was felt and what the anger is about.
  • Contraindications and screening [synthesis, from house rules; not stated in the sources]:
    • Cardiovascular or respiratory illness, pregnancy, epilepsy, recent injury or surgery.
    • Severely underweight or medically unstable eating-disorder clients (medical sign-off).
    • Psychosis, severe dissociation, active suicidality.
    • Recent trauma without stabilisation.
    • Forensic clients with poor impulse control unless the setting is specialised.
  • Watch for: Escalation rather than regulation, dissociation, or shame afterwards. Stop and regulate (4.6). Aim for chosen, controlled expression, not catharsis.

D. Psychosocial and skills work

4.20 Personal space and boundaries exercise

  • Purpose / when: To recognise and set physical and personal boundaries and to say "no" [source: JBZ/Tolbrug 2023; GGZ Friesland lists recognising and communicating limits as a core PMT goal].
  • Steps:
    1. Explore intimate, personal and social distance [source: JBZ/Tolbrug 2023].
    2. Operationally [synthesis]: the client stands still while the therapist or a peer approaches slowly from across the room. The client says "stop" (or raises a hand) at the moment they feel the edge of comfort.
    3. Repeat from different directions and at different speeds. Swap roles.
    4. Then practise saying "no" with posture and voice.
    5. Reflect on situations that build tension, such as struggling to say no [source: JBZ/Tolbrug 2023].
  • Example language (illustrative): "Say stop the moment you feel it, not when you think you should."
  • Watch for: Late "stop" (signal noticed too late) or freezing. Practise with more distance and a slower approach, and praise early stops.

4.21 Communication line (subassertive – assertive – directive)

  • Purpose / when: Assertiveness [source: JBZ/Tolbrug 2023].
  • Steps: Place yourself physically on a line between subassertive (only considering others), assertive (considering self and others) and directive (only considering self), using examples. Describe the old and a newly tried communication style [source: JBZ/Tolbrug 2023]. Then try the assertive stance in a short movement role play [synthesis].
  • Watch for: Clients equating assertive with aggressive. Model the difference in voice and posture.

4.22 Role play in movement

  • Purpose / when: To practise new behaviour socially after body signals and coping options are identified [source: Bellemans et al. 2018].
  • Steps [synthesis]:
    1. Choose a recent real situation.
    2. Set it up physically (positions, distance).
    3. Play the old response, noting the thermometer level.
    4. Replay with the new response (stance, breath, words, stepping out).
    5. Give feedback and positive reinforcement. Repeat until it is fluent (action-oriented mode).
  • Watch for: Over-arousal while re-enacting. Use a lower-intensity version first.

4.23 Values, acceptance and defusion exercises (pain module)

  • Purpose / when: In the Tolbrug "Voel je lijf" pain module, these give direction and reduce struggle with pain [source: JBZ/Tolbrug 2023].
  • Steps:
    • Values exercise: narrow a set of values over three rounds to a final four, then reflect on how present they are in life.
    • Distinguish "suffering" (the alarm response, which drains energy) from "pain" (observed without fighting it), and identify moments of each during therapy.
    • Strict-rule exercise: choose a limiting rule, note the feeling, record it on the phone, then record it again in a silly voice with a voice-changer app and note how the feeling changes.
    • Plan one values-based action each week (express an emotion, set a limit, take a break).
    • [source: JBZ/Tolbrug 2023]
  • Watch for: The module is ACT-informed. Use these as PMT tools only if you understand the acceptance rationale [synthesis].

4.24 Self-portrait of the body

  • Purpose / when: To make body image explicit: how the client sees their body, what they are proud of and what is difficult [source: JBZ/Tolbrug 2023].
  • Steps: The client draws the self-portrait as homework. Discuss it in the next session [source: JBZ/Tolbrug 2023]. Link it to the body-experience work in 4.9 [synthesis].
  • Watch for: Intense negative self-evaluation. Ask about the strengths part first.

4.25 Intimacy and sexuality theme (verbal, voluntary)

  • Purpose / when: In the pain module, reflection on what intimacy means and how complaints affect it. Participation is explicitly voluntary [source: JBZ/Tolbrug 2023].
  • Steps: A verbal and written reflection only, with practical tips. The client may prepare in advance and discusses it with a partner only if they choose [source: JBZ/Tolbrug 2023]. This theme involves no physical exercise and no touch.

4.26 Psychoeducation and lifestyle coaching

  • Purpose / when: Explaining the body, physical activity, fitness, stress and communication rules; lifestyle education [source: Probst 2017]. In somatic symptom disorders, psychoeducation is combined with four focus areas: creating rest, activation, emotion regulation and social interaction [source: De Lange et al. 2019 preview, ch. 4 summary].
  • Steps [synthesis]: Keep it short and tied to what the client just experienced, for example why the heart raced in the game and what that means and does not mean.

4.27 Home assignments and logs

  • Purpose / when: Transfer [source: Bellemans et al. 2018; JBZ/Tolbrug 2023; NVvP 2024].
  • Steps: Examples from the sources:
    • arousal reduction practice when tense;
    • a daily photo of a valuable moment;
    • a sensory activity;
    • a body-signal log;
    • an exercise log of motivation, frequency, duration and intensity.
    • Review the homework at the start of each session [synthesis].

4.28 Relapse-prevention plan and closing session

  • Purpose / when: Consolidation at the end of a block [source: Bellemans et al. 2018; JBZ/Tolbrug 2023].
  • Steps:
    1. List the behaviours to reduce and those to keep, review insights and write the plan [source: JBZ/Tolbrug 2023].
    2. In aggression work, the client's relapse-prevention plan is worked through and practised in PMT situations [source: Bellemans et al. 2018].
    3. Include early body signals, chosen responses and who to contact [synthesis].

4.29 Family and parent involvement (psychomotor family therapy)

  • Purpose / when: Children's PMT works with the child and the parents. The children's handbook has a chapter on psychomotor family therapy; the 2010 handbook describes resilience training for children with parents involved, and psychomotor family therapy [source: Emck et al. 2021 preview; De Lange 2010 preview].
  • Steps: Chapters not drawn on [uncertain]. The preface vignette (4.18) shows the parent being given a role in the movement task, such as stepping back and catching.

E. Named Dutch PMT programmes whose procedures are not drawn on [uncertain]

These are listed so that you can find the manuals; do not improvise them as if they were the published versions:

  • Emotion-regulation group PMT for anxiety and depressive disorders (Bosman et al., 2017).
  • Aggression regulation in addiction care, and the individual Horizon method for children with intellectual disability after sexual abuse (De Lange 2010, chapters 2 and 7).
  • PMT model for conversion disorder (De Lange 2010, chapter 4).
  • Modules at the Pro Persona anxiety, OCD and PTSD centre: attention-focused PMT, PMT emotion exposure, panic module, interactive PMT, and individual processing-focused PMT.
  • Aquamentia (aquatic programme for dementia, De Lange et al. 2019, chapter 12).
  • Stress-management training for young people with psychotic disorders (De Lange & Bosscher 2005).
  • Disorder chapters in the 2019 and 2021 handbooks (PTSD, psychosis, personality disorders with themes of identity, self-direction, empathy and intimacy, substance use, ADHD, autism, developmental coordination disorder, attachment disorders, ultra-high risk for psychosis).

5. Handling problems

The sources give little explicit guidance on difficulties. Their points are tagged [source]; everything else is [synthesis].

  • Shame, performance anxiety and fear of being judged in physical activity. This is common in severe mental illness. Unexplained "sport" is counterproductive [source: Probst 2017].
    • Explain the why of each activity.
    • Start individually or in parallel tasks rather than watched ones.
    • Make clear there is no right or wrong [source: GGZ Friesland].
    • Grade so that the first sessions are successes [source: NVvP 2024] [synthesis for the sequencing].
  • Body exposure triggering anxiety, shame or self-harm urges (swimming, changing rooms, mirror, tight clothing). Probst's case shows this can happen [source: Probst 2017].
    • Ask about these triggers at intake.
    • Let the client choose clothing.
    • Break exposure into steps, agree a stop, and check self-harm urges after the session.
    • Coordinate with the treatment coordinator [synthesis].
    • If self-harm or suicidal ideation emerges, follow standard risk assessment and safety planning in the team, including means-safety counselling about storage and removal [synthesis; house rule].
  • Overwhelm, hyperarousal or dissociation in activity.
    • Stop the activity.
    • Orient to the room: name objects, feel the feet, keep eyes open.
    • Use a slow breath or step-out (4.6, 4.8).
    • Lower intensity next time.
    • Work within the window of tolerance [source: NVvP PTSD module on arousal regulation; responses are synthesis].
    • For PTSD, PMT is an add-on. When arousal or dissociation block trauma-focused treatment, use PMT to stabilise rather than to process [source: NVvP PTSD module].
  • Stuck: client does the activity but nothing is learned ("just sport").
    • Re-introduce a reflection moment inside the activity, not only after it (freeze-and-rate, 4.2/4.14).
    • Ask what the client noticed just before the moment of interest.
    • Link it explicitly to a daily-life situation [synthesis, from the experiential principle in Probst 2017 and NVvP 2024].
  • Stuck: client talks but avoids moving. Shorten the talk. Offer a low-threshold activity, such as walking side by side or throwing a ball, and reflect while moving [synthesis].
  • Escalation in competitive or aggression-related games.
    • Pre-agree rules, a stop signal and a step-out place.
    • Pause at the agreed thermometer level.
    • Reinforce the use of coping, not winning.
    • Lower competitive pressure.
    • [source: Bellemans et al. 2018 for thermometer, stepping out, reinforcement; protocol synthesis]
    • In forensic or high-risk settings, follow the service's violence-risk procedures [synthesis].
  • Non-adherence to exercise or homework.
    • Use the log to look at patterns without judgement.
    • Shrink the task.
    • Revisit pros and cons [source: NVvP 2024 on discussing pros/cons and logs].
    • Tie the task to the client's values (4.23) [synthesis].
    • Supervised sessions reduce drop-out [source: NVvP 2024].
  • Compulsive over-exercise or hyperactivity (eating disorders, some anxiety). Do not prescribe more activity. Shift to calming, awareness and relaxation work [source: Probst 2017]. Coordinate medical monitoring with the team [synthesis].
  • Touch-related problems: compliance without consent, freezing, trauma reminders.
    • Switch to the no-touch alternative.
    • Re-run consent and debrief.
    • Document it.
    • Do not resume touch without explicit renewed agreement and supervision [synthesis].
    • Touch requires specific training and a check of what your licence and jurisdiction allow.
  • Ruptures (the client feels pushed, humiliated in a game, or let down when an exercise "failed").
    • Name it, take your share ("I set that too hard").
    • Ask what would have helped.
    • Re-grade.
    • Use the rupture as here-and-now material about how the client handles disappointment [synthesis].
  • Group-specific problems: dominance, scapegoating, a member withdrawing. Use the debrief questions about who leads and who follows [source: Probst 2017]. Change teams or roles. Protect the withdrawn member with an individual role, such as timekeeper or go-between in the Duplo game, as a step back in [synthesis].
  • Medical issues during exertion (chest pain, faintness, breathlessness out of proportion).
    • Stop and follow the service's medical procedure.
    • Do not resume until the physician has cleared it.
    • [source: NVvP 2024 on screening and physician consultation; acute response synthesis]
  • Unclear indication or overlap with physiotherapy or sport coaching. Keep goals psychological and experiential, as the guideline frames PMT, and agree the division of tasks with the team [source: NVvP 2024; Probst 2017 on multidisciplinary embedding].

Sources

Sources:

Books and papers cited (only previews, abstracts or citations seen):

  • De Lange, J., Glas, O., Van Busschbach, J., Emck, C., & Scheewe, T. (Eds.) (2019). Psychomotor Interventions for Mental Health – Adults. Amsterdam: Boom.
  • Emck, C., De Lange, J., Scheewe, T., Van Busschbach, J., & Van Damme, T. (Eds.) (2021). Psychomotor Interventions for Mental Health – Children & Adolescents. Amsterdam: Boom.
  • De Lange, J., & Bosscher, R. (Eds.) (2005). Psychomotorische therapie in de praktijk: ervaringsgericht behandelen door vaktherapeuten. Amsterdam: Boom.
  • De Lange, J. (Ed.) (2010). Psychomotorische therapie: lichaams- en bewegingsgerichte interventies in de ggz. Amsterdam: Boom.
  • Bosscher, R. (1991). Runningtherapie bij depressie. Doctoral thesis, Vrije Universiteit Amsterdam.
  • Bosman, M., et al. (2017). Emotion-regulation group PMT for anxiety and depressive disorders. Federatie Vaktherapeutische Beroepen.
  • Bluming, M. (2016). In mijn kracht met de ander. Kickboksen en psychomotorische therapie in de praktijk. Tijdschrift voor Vaktherapie.
  • Boerhout, C., & Glas, O. (2021). Beroepscompetentieprofiel Psychomotorisch Therapeut. NVPMT (not drawn on).
  • Bellemans, T., Didden, R., Visser, R., Schaafsma, D., Totsika, V., & Van Busschbach, J. T. (2018). Body, Movement and Dance in Psychotherapy, 13(4), 234–250.
  • Probst, M. (2017). Psychomotor therapy for patients with severe mental health disorders. In Occupational Therapy – Occupation Focused Holistic Practice in Rehabilitation, IntechOpen.
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