Disorder-oriented movement therapy

1. Introduction

Version followed: the German "clinical movement therapy" (klinische Bewegungstherapie) tradition of Gerd Hölter and colleagues. The adult version is Hölter (2011), Bewegungstherapie bei psychischen Erkrankungen, chapter 4, "Störungs- und altersorientierte Behandlungsansätze" (disorder- and age-oriented approaches). The child and adolescent version is Thimme, Deimel & Hölter (2021). For schizophrenia, this guide uses the practice recommendations of the Arbeitskreis Bewegungstherapie in der Psychiatrie (Stammer 2012). For depression, it uses the Berliner Sportprogramm (Erkelens & Golz 1998) and the Dortmund depression work as reported by Heimbeck (2008). Where the parallel "störungsspezifische" version of Integrative Movement Therapy (Waibel & Jakob-Krieger 2009) adds something, it is labelled IBT. Only the front matter and tables of contents of the Hölter (2011) and Thimme et al. (2021) books are drawn on. Their disorder chapters are not drawn on, so the detail in this guide comes mostly from the open sources named above. [source: Hölter 2011 preview; Thimme et al. 2021 preview; Stammer 2012; Heimbeck 2008]

What it is. Disorder-oriented movement therapy is not a single manualised therapy. It is a way of planning clinical movement therapy, and Hölter uses "klinische Bewegungstherapie" as an umbrella term for methods that use movement, play and sport as actions with instrumental, sensory, social and symbolic functions (Hölter 2008, as cited in Heimbeck 2008). Within that field, the disorder-oriented approach works in four steps: diagnostics, then indication, then intervention, then evaluation. Goals, content and dosage are chosen to fit the specific way a disorder shows up in the body, in movement and in relationships. Each disorder chapter in Hölter (2011) follows the same template: clinical information, movement therapy for that disorder, disorder-oriented notes, application examples. Most of the application examples are group sport and play activities. In Germany the approach is mainly delivered by movement and sport therapists and psychomotor therapists in inpatient psychiatry, psychosomatics and child and adolescent psychiatry. [source: Hölter 2011 preview; Heimbeck 2008; socialnet Mototherapie]

How change is thought to happen. Mental disorders show up in body perception, drive, motor regulation and social behaviour. Structured movement experience can therefore target the triggering and maintaining factors of a disorder, not just general fitness. Proposed mechanisms include:

immediate mood improvement that rewards continued activity;
self-efficacy gained from mastering movement tasks;
corrective bodily and social experiences in a structured group.

The authors also stress common factors: the therapeutic climate and the relationship. [source: Heimbeck 2008; Stammer 2012; Thimme et al. 2021 preview]

2. Framework

Process cycle (all disorders). [source: Hölter 2011 preview (structure); Stammer 2012 (four-step planning model)]

Diagnostics. Qualitative movement observation, for example the Leuven observation scale for psychiatric movement therapy (LOVIPT) or the Weinsberg observation sheet (WSBB). These are set alongside the psychopathology, the ICD-10 diagnosis and the history. Questionnaires can be added, and for children motor tests (KTK, MOT, M-ABC-2). Fitness can be checked with field tests such as the 2-km walking test (used by Heimbeck). [source: Stammer 2012; Thimme et al. 2021 preview; Heimbeck 2008]
Goal setting. Broad aims (Richtziele) and specific targets (Feinziele) are derived from the findings and linked to the disorder's mechanisms. [source: Stammer 2012; Heimbeck 2008 (chapter titles)]
Therapy structure. Choose an individual or a group setting, the content area and the dosage. The approach is resource-oriented, and the therapist reflects on their own behaviour. [source: Stammer 2012]
Therapy control. Repeat the movement observation, integrate the work with the treatment team, and use supervision. Mood can be measured before and after a session (Heimbeck used the Basler Befindlichkeitsfragebogen). [source: Stammer 2012; Heimbeck 2008]

Phase-matched groups (schizophrenia, after Stammer 2012). Separate groups run for the acute, post-acute, stabilisation and chronic stages. Individual therapy is used only for a specific indication. As the patient stabilises, demands rise and support falls. Before discharge to outpatient or day-clinic care, the focus moves to leisure and sport the patient can continue alone. Stammer's phase-by-phase tables are not drawn on here [uncertain]. A reasonable criterion for moving a patient up a group is that they can follow simple instructions, tolerate the group's level of stimulation without their symptoms getting worse, and take part in most sessions [synthesis].

Typical dosage (depression).

Berliner Sportprogramm: 32 sessions over 12 weeks, 2–3 per week. Endurance activities (running, walking) are embedded in perception, reflection and relaxation phases. [source: Heimbeck 2008, reporting Erkelens & Golz 1998]
Heimbeck & Süttinger (2007), inpatient: 3 sessions per week of 50 minutes for 4 weeks, in either a walking group or a calmer themed disorder-specific group. [source: Heimbeck 2008]
The literature Heimbeck reviews suggests roughly three 30–60-minute sessions a week for at least 8 weeks, at moderate intensity. [source: Heimbeck 2008]

Session phases. The Hölter school texts do not give a fixed session template [uncertain]. Two models from the sources can be used:

Stammer's principle of a strongly structured session that alternates load and recovery. [source: Stammer 2012]
The IBT four-phase ("tetradic") model: initial phase (warm-up, contact, choosing a theme), action phase (exploring and deepening), integration phase (reflecting), reorientation phase (trying out new behaviour and transfer). Patients can skip a phase or return to an earlier one. [source: Waibel & Jakob-Krieger 2009 preview]

This guide uses a three-part session: arrival and warm-up, main movement task, then closing reflection and transfer. It matches the "embedded in perception, reflection and relaxation" design of the Berliner Sportprogramm [synthesis].

Format. The approach is mostly group-based (open or semi-open inpatient groups), with individual, family or couple formats where indicated. In child and adolescent psychiatry, play-based groups are preferred over pure sport tasks such as running or machines. [source: Hölter 2011 preview; Thimme et al. 2021 preview; socialnet Mototherapie]

3. Guiding principles

Disorder-oriented and resource-oriented together. Choose content for what the disorder disturbs, and build on what the patient can already do. In practice: name one disorder-linked target and one strength for every patient. [source: Thimme et al. 2021 preview; Stammer 2012]
Address what triggers and maintains the disorder, not only symptoms. In practice: for depression, work on inactivity, harsh self-evaluation and low self-efficacy, not only on fitness. [source: Heimbeck 2008]
Plan the load deliberately. Set intensity, duration, frequency, volume and density on purpose, so the patient is neither under- nor over-loaded, and respect contraindications. In practice: write the planned load for each patient down and adjust it every week. [source: Thieme 2017, Sporttherapie bei Schizophrenie abstract]
Strong structure for disorganised patients. Give simple, clear, unambiguous instructions, fixed routines, and alternation of effort and rest. In practice: one instruction at a time, shown as well as said. [source: Stammer 2012]
Avoid symptom-provoking conditions. Too much stimulation, time pressure and too much closeness can provoke symptoms. In practice: in a psychosis group, no races against the clock, no crowded tag games, no forced physical closeness. [source: Stammer 2012]
Action before explanation. Let patients experience first and talk briefly afterwards. In practice: keep the reflection round short and concrete. [source: Stammer 2012]
Feedback for reality testing and self-concept. Give clear feedback on success and correct movement errors. For self-concept work, use person-centred verbal feedback and positive reinforcement from the leader, plus feedback from the group. In practice: name exactly what the patient did well. [source: Stammer 2012; Thimme et al. 2021 preview (citing Wagner & Alfermann 2006; Seyda 2011)]
Emotionally steady, non-competitive climate. In practice: the therapist stays even-toned, and scoring is downplayed or dropped. [source: Stammer 2012]
Integrate methods rather than defend a school. Choose a method by the goal and by the patient's expectations, interests and abilities. In practice: a running group, a ball game and a perception exercise can all serve the same goal. [source: Heimbeck 2008]
The relationship and common factors matter. In practice: invest in alliance and group cohesion before demanding tasks. [source: Heimbeck 2008; Thimme et al. 2021 preview]
Understanding ("Prinzip des Verstehens"). Read symptoms and movement behaviour in the context of the patient's life and relationships. In practice: ask what the observed behaviour (for example withdrawal in team games) means for this person. [source: socialnet Mototherapie]
Team integration. Movement findings feed into the overall treatment. In practice: report observations at ward rounds and coordinate with the medical team on medication and somatic risks. [source: Stammer 2012]
Step down support over time. Raise demands and reduce support as the patient stabilises, ending with independent activity. In practice: plan the move to a self-run activity before discharge. [source: Stammer 2012]
Touch is graded (IBT). Work can be without touch (gaze, voice, posture, space), with self-touch, or with therapist touch. In practice: start without touch. Therapist touch needs explicit consent, specific training, supervision, and a check that the clinician's licence and jurisdiction allow it. [source: Waibel & Jakob-Krieger 2009 preview; synthesis for the consent requirement]

4. Intervention inventory

Note on completeness: the disorder chapters of Hölter (2011) and Thimme et al. (2021) are not drawn on, so their own application examples are not reproduced here. This section covers every intervention named in the sources used. Where the sources name a technique but give no procedure, the steps are marked [synthesis], and any detail not in a source is marked [uncertain].

General safety and screening (applies to every active intervention). Before patients take part in exercise, clear them medically, following ward practice. Check for:

cardiovascular and respiratory disease, recent injury or surgery, pregnancy, epilepsy;
medication effects such as sedation, low blood pressure on standing (orthostatic hypotension), impaired heat regulation, or metabolic effects of antipsychotics;
in eating disorders: compulsive exercise, being underweight, or electrolyte problems, with medical clearance before any activity.

The sources only say that contraindications must be respected. This list is added [synthesis]. In eating disorders, give no calorie, weight or exercise-volume targets.

A. Movement-therapy diagnostics (qualitative movement observation)

Purpose / when: at intake and repeated during treatment. It shows how the disorder appears in movement (drive, tension, use of space, contact, boundaries) and sets the goals. [source: Stammer 2012]
Steps:
1. Observe the patient in a standard first session: free walking in the room, a simple partner ball task, a group task. [the choice of tasks is synthesis]
2. Rate on a structured observation instrument (LOVIPT, WSBB; for children KTK, MOT, M-ABC-2, or the qualitative KMP or Laban Movement Analysis). These instruments are licensed; use the original forms. [source: Stammer 2012; Thimme et al. 2021 preview]
3. Add the psychopathology findings, the diagnosis and the history, plus questionnaires where needed.
4. Write down two or three movement-based goals and agree them with the patient. [synthesis]
5. Re-observe at set intervals and report to the team. [source: Stammer 2012]
Example language (illustrative): "Today I'd simply like to see how you move and what feels easy or hard. There's no right or wrong."
Watch for: observation that feels like a test, especially to paranoid or perfectionistic patients. A sign of good diagnostics is goals that link a disorder feature to an observable behaviour (for example "stays at the edge of the room, avoids passes").

B. Load planning and session-level mood monitoring

Purpose / when: for every training-type intervention, to avoid under- or overload and to show the patient a mood change straight after exercise. [source: Thieme 2017; Heimbeck 2008]
Steps:
1. Set the load parameters: intensity, duration, frequency, volume, density.
2. In depression programmes the sources describe moderate intensity, using heart-rate ranges or perceived exertion.
3. Ask for a short mood rating before and after the session (Heimbeck used the Basler Befindlichkeitsfragebogen; a simple 0–10 rating can stand in [synthesis]).
4. Review the ratings with the patient every week and adjust.
Example language (illustrative): "On a scale of 0 to 10, how is your energy right now? We'll check again at the end and see whether moving made a difference."
Watch for: breathlessness, dizziness, pain or panic-like arousal. Reduce the load immediately. It is working when patients notice the mood rise after the session themselves (the "reward" mechanism). [source: Heimbeck 2008]

C. Endurance training embedded in perception, reflection and relaxation (Berliner Sportprogramm, depression)

Purpose / when: depression in outpatient or inpatient settings. It builds activity, fitness, self-efficacy and mood. [source: Heimbeck 2008, reporting Erkelens & Golz 1998]
Steps:
1. Group meets 2–3 times a week, 32 sessions over 12 weeks.
2. Opening perception phase: notice breath, heartbeat, mood and energy level. [content synthesis]
3. Core endurance phase: walking or running at a conversational pace. Patients choose their own speed within a range, and walking breaks are allowed.
4. Reflection: what was noticed, what was achieved.
5. Relaxation phase to close.
6. Optional psychological variant: add CBT topics, such as setting realistic demands on oneself (aspiration level) and working on learned helplessness, while the movement content stays the same. [source: Heimbeck 2008]
Example language (illustrative): "Go at a pace where you could still talk. If you need to walk, walk. Finishing at your pace counts."
Watch for: comparing oneself with others, and all-or-nothing judgements ("I only managed 10 minutes, so it's pointless"). Signs it is working: regular attendance, self-chosen increases, and patients linking activity to mood. The two variants showed similar long-term effects. [source: Heimbeck 2008]

D. Walking group (inpatient depression)

Purpose / when: short inpatient stays, low-threshold activation. [source: Heimbeck 2008, Heimbeck & Süttinger 2007]
Steps:
1. Three sessions a week, about 50 minutes, for 4 weeks.
2. Brisk walking at moderate intensity, monitored by heart rate or perceived exertion.
3. Short check-in before and after on how the patient feels.
Example language (illustrative): "We'll walk together for about 40 minutes. Notice how your body feels at the start, and again at the end."
Watch for: patients dropping back alone; pair them up [synthesis]. Mood before and after a session is the short-term marker.

E. Themed disorder-specific movement-therapy group (depression)

Purpose / when: an alternative to pure endurance training for depressed inpatients. It is calmer, and each session has a theme. [source: Heimbeck 2008]
Steps: in the study, 150 minutes a week were split into themed sessions. The themes are listed in Heimbeck's Table 10 ("modules of disorder-specific movement therapy for depression"), which is not drawn on here [uncertain]. Each module was apparently linked to an aim derived from depression theory and to a homework sheet, "Ideen für Vorsätze zu Hause" (ideas for resolutions at home) [uncertain as to content]. The following plausible themes come from the aetiology factors Heimbeck discusses, not from the module list [synthesis]:
- activation and drive;
- noticing and enjoying pleasant body sensations;
- self-efficacy through graded movement tasks;
- interrupting rumination through absorbing movement;
- self-worth and competence.
Example language (illustrative): "Today's theme is 'small successes'. Each of you picks a movement task you're fairly sure you can do, and then one notch harder."
Watch for: themes that turn into talk-heavy sessions. Keep movement as the medium. A sign it is working: patients carry one resolution into the ward routine or home.

F. Strength training and yoga as disorder-adapted options

Purpose / when: strength training adds variety, gives visible progress, and suits patients with poor endurance. Yoga showed positive effects in schizophrenia studies, and strength training is little studied there. [source: Thieme 2017]
Steps:
1. Choose simple, well-supervised exercises with body weight, bands or machines.
2. Use progressive loading with plenty of rest.
3. For yoga, use simple standing and lying postures with slow breathing, and avoid strong breath-holding or forceful breathing techniques [synthesis].
Example language (illustrative): "Let's write down today's starting point so you can see your progress in two weeks."
Watch for: antipsychotic-related dizziness and falls, and over-ambition. Progress shows in a rising training log.

Schizophrenia: goal domains after Scharfetter's ego-psychopathology model (G–K). Stammer (2012) links each disturbed ego domain to a type of exercise. He names the type of exercise but gives no step-by-step procedure, so the steps below are illustrative versions of the named exercise types [synthesis]. All of them follow the session rules in L. Use eyes-open work, short durations, and no forced closeness. [source: Stammer 2012; the eyes-open rule is synthesis]

G. Vitality: making breath, pulse and movement energy noticeable

Purpose / when: patients who feel they are fading away, numb, or afraid of dying. [source: Stammer 2012]
Steps (synthesis):
1. Standing in a circle, march or jog on the spot for 30–60 seconds.
2. Stop and put a hand on your own chest to feel the heartbeat and breathing. This is self-touch only.
3. Say one word for what you notice.
4. Repeat 2–3 times, with a little more energy each time.
5. Close with calm walking.
Example language (illustrative): "Put your hand on your chest. Can you feel your heart working? That is your body, alive and working."
Watch for: patients reading heartbeat sensations as threatening or as signs of somatic delusions. If that happens, switch the focus to the feet and the floor. It is working when the patient reports "warm", "awake" or "there".

H. Activity: self-directed movement with objects and others

Purpose / when: patients who feel externally controlled or unable to start actions. [source: Stammer 2012]
Steps (synthesis):
1. Each patient chooses a ball or another object.
2. They decide how to move it (roll, bounce, throw).
3. Give the instruction "You decide when to start and stop."
4. Move on to passing to a partner, where the patient decides who to pass to and when.
5. Debrief briefly: "Who decided?"
Example language (illustrative): "You are the one who starts the ball and the one who stops it."
Watch for: freezing when given choice. If so, offer two options instead of open choice. It is working when the patient starts actions without prompting.

I. Consistency: body schema and structure

Purpose / when: patients who feel fragmented or lose the sense of their body as a whole, or whose thinking is disorganised. [source: Stammer 2012]
Steps (synthesis):
1. Standing, name and move one body part at a time from feet to head (tap the feet, bend the knees, circle the hips, shrug the shoulders).
2. Combine all the parts into one whole-body movement, such as a stretch or a step forward with a reach.
3. Optionally use rhythm: clap and step to a simple count.
4. Keep it to 5–10 minutes.
Example language (illustrative): "Feet... knees... hips... shoulders... and now all of you together."
Watch for: confusion with complex sequences; simplify. It is working when the patient can follow and repeat the sequence.

J. Demarcation: clear spatial markers and closeness–distance partner work

Purpose / when: patients whose boundaries between body, thought and feeling are blurred. [source: Stammer 2012]
Steps (synthesis built on the named materials):
1. Each patient takes a hoop, a mat or a rope circle as "my space" and explores moving inside it and stepping out and back in.
2. Partner distance: partner A walks slowly towards B, and B says "stop" or raises a hand where the distance feels right. Swap roles.
3. Keep a safe distance and use no touch.
4. Debrief on where the comfortable distance was.
The "stop"/"no" boundary exercise also appears in the IBT version. [source: Waibel & Jakob-Krieger 2009 preview]
Example language (illustrative): "This hoop is your space. Nobody comes in unless you invite them." / "Say stop when the distance is right for you, and I will stop."
Watch for: paranoid misreading of an approach. Keep the approach slow, visible and predictable. It is working when the patient sets and keeps a distance confidently.

K. Identity: the floor as stability; perceiving the self with equipment, materials or partners

Purpose / when: patients who are unsure who they are or feel they have lost their identity. [source: Stammer 2012]
Steps (synthesis):
1. Stand with feet hip-width apart and press the soles into the floor. Shift weight slowly forward and back, then side to side, for 1–2 minutes.
2. Sit or lie on a mat and feel the contact points.
3. Roll a soft ball along your own arms and legs (self-applied) to feel the body's outline.
4. Name one thing that "belongs to me": a preferred movement or a pace.
Example language (illustrative): "The floor holds you. Feel where your feet meet it."
Watch for: lying down or slow inward focus that increases derealisation. Stay standing, eyes open, and keep it short. It is working when the patient reports feeling steadier or "more here".

L. Structured session design for psychosis groups (stress–recovery alternation)

Purpose / when: every session with psychotic or disorganised patients. [source: Stammer 2012]
Steps:
1. Use the same opening ritual each time.
2. Give one simple instruction at a time and demonstrate it.
3. Alternate short active blocks with rest blocks.
4. Keep the atmosphere non-competitive.
5. Give success feedback and correct movement errors to support reality testing.
6. Use the same closing ritual each time.
7. Match the stimulation level to the illness phase (acute, post-acute, stabilisation, chronic).
Example language (illustrative): "First we walk once around the hall. Then we rest. Then the ball game."
Watch for: rising restlessness, hallucination-driven distraction, or withdrawal. Reduce the stimulation. It is working when attendance is steady and patients cope with gradually higher demands.

M. Playful practice with small equipment (balls, ropes, sticks)

Purpose / when: activation and regulation, attention and concentration, communication and social interaction, mainly in schizophrenia groups. Individual, partner and group forms allow corrective social experiences. [source: Stammer 2012]
Steps (synthesis):
1. Start solo, for example bouncing a ball while walking.
2. Move to partner work: passing at a set distance, or holding a stick between two people and walking together.
3. Then a group task, such as keeping a balloon or ball in the air together, or passing in a set order.
4. Raise the complexity only once the simpler form is stable.
5. Close with a short round on what worked.
Example language (illustrative): "Let's see how long the group can keep the balloon up. Everyone helps."
Watch for: competition creeping in, and patients being left out. It is working when there is more spontaneous interaction and fewer dropped turns.

N. Phase-graded progression to leisure and sport

Purpose / when: stabilised patients approaching discharge. [source: Stammer 2012]
Steps:
1. Raise demands and reduce therapist support step by step.
2. Introduce activities the patient can continue in the community (walking groups, local sports clubs, swimming, running groups).
3. Do one session at the community venue if possible [synthesis].
4. Agree a written plan [synthesis].
Example language (illustrative): "Which of the things we've done here could you keep doing after you leave, and where?"
Watch for: losing structure after discharge. Link the plan to outpatient care.

O. The four relational areas as a planning grid (Krietsch & Heuer)

Purpose / when: to structure goals in psychiatric movement therapy along four relationships: to one's own body, to space and time, to objects, and to other people. [source: Stammer 2012]
Steps (synthesis):
1. For each patient, rate which of the four areas is most disturbed.
2. Plan at least one session element per week for that area: body (perception tasks), space and time (walking paths, rhythm), objects (ball and rope work), people (partner and group tasks).
Example language (illustrative): "This week we'll focus on how you use the room. Where do you like to be, and where do you avoid?"
Watch for: sessions that only ever serve one area.

P. Cooperative problem-solving games (children with ADHD or impulsivity), e.g. "Urwalddurchquerung"

Purpose / when: self-control, waiting, and agreeing on a strategy in a group. [source: Thimme et al. 2021 preview]
Steps:
1. Up to four children stand on a mat ("the boat").
2. The task is to cross the "river" (the hall) together without anyone touching the "water".
3. Before starting, the children must agree on a strategy and wait for each other.
4. The therapist stops the game if needed so the group can renegotiate.
5. Reflect briefly afterwards.
The exact rules and debrief are not given in the preview, so steps 2–5 are a synthesis of the described aim [synthesis].
Example language (illustrative): "Before the boat moves, the whole crew has to agree on a plan. Who has an idea?"
Watch for: one child taking over, and frustration. Reinforce waiting and turn-taking specifically. The case report describes improved self-control at school and at home.

Q. Basic movement skills and sensory compensation (children with conduct problems linked to motor deficits)

Purpose / when: motor deficits (for example poor spatial orientation or eye–hand coordination) that lead to exclusion and aggression in games. [source: Thimme et al. 2021 preview (case "Matthias")]
Steps (synthesis):
1. Identify the deficits with motor tests.
2. Practise the target skills in small, success-oriented steps (catching with large, then smaller balls; obstacle courses for spatial orientation).
3. Gradually re-enter group games, with roles the child can succeed in.
Example language (illustrative): "Let's practise catching with the big ball first. When it feels easy, we'll switch."
Watch for: shame in front of peers; practise individually first. It is working when there is less aggression during games.

R. Person-centred feedback for self-concept work

Purpose / when: low self-worth (depression, eating disorders, adolescents). [source: Thimme et al. 2021 preview]
Steps:
1. After a movement task, the leader gives specific, positive verbal feedback.
2. Then invite group feedback on what each person did well.
3. The patient names one thing they are satisfied with.
Example language (illustrative): "You kept going on the last stretch even though you were tired. That was your decision."
Watch for: patients dismissing praise; ask them to describe what they did rather than evaluate it.

S. Content areas named by the Hölter/Deimel school (procedures not drawn on)

Thimme et al. (2021, chapter 2.2) organise the content of child and adolescent movement therapy into these areas:

play and playing;
practising and training;
adventure and risk;
representing and creating;
relaxation and mindfulness;
movement in water;
martial arts;
an excursus on equine-assisted therapy.

Related chapters in an edited volume by Deimel & Thimme cover therapeutic climbing, therapeutic archery, outdoor experiential (adventure-education) methods, relaxation methods, HIIT for ADHD, the "Mutmacher" (courage-builder) approaches for anxiety, body-image and affect work in eating disorders, attachment-oriented dance therapy, and sport therapy in substance use. Only the titles were seen, so their procedures are not described here [uncertain]. The "socialnet" Mototherapie entry lists similar adult content areas after Hölter: playing, performing and competing; relaxation and contemplation; communication and interaction; exploration and awareness; expression and creative design. [source: Thimme et al. 2021 preview; Lehmanns TOC; socialnet Mototherapie]

If you use these areas:
- Climbing and martial arts need specific instructor qualifications and safety equipment [synthesis].
- With anxious patients, graded challenge in adventure tasks should always be voluntary [synthesis].
- In eating disorders, avoid calorie-burning framing and monitor compulsive activity [synthesis].
- On water: an older source cited by Thimme et al. (Asperger 1968) describes warm baths as calming and cold water as arousing.

T. Calling up supportive inner figures (IBT version)

Purpose / when: difficult situations in anxiety or trauma-related work within the IBT disorder-specific version. [source: Waibel & Jakob-Krieger 2009 preview]
Steps: the preview names the mechanism ("evoked internalised personalities") but gives no procedure [uncertain]. A cautious application is to have the patient stand in a stable posture, imagine a supportive person beside them, and notice any change in posture and breath [synthesis].
Example language (illustrative): "Who would you like standing next to you right now? Notice how you stand when you imagine them there."
Watch for: traumatic memories being evoked; return to orienting to the room.

5. Handling problems

The sources say little about specific problems. Except where a source is tagged, the guidance below is [synthesis].

Low drive and non-attendance (depression).
- Lower the entry threshold: a short walk, a fetch from the ward, a fixed time.
- Use the before-and-after mood rating so the patient sees the gain for themselves (the reward mechanism). [source: Heimbeck 2008 for the mechanism]
- Praise attendance, not performance. Frame it as "doing it at 30 percent is still doing it".
- Agree one small resolution for the ward or home, in the spirit of the "Vorsätze" sheet. [source: Heimbeck 2008 for the existence of the sheet]
Perfectionism and self-devaluation. Set realistic demands on oneself (aspiration level), as in the psychological variant of the Berliner Sportprogramm. Agree process goals rather than outcome goals, and have patients describe what they did rather than judge it. [source: Heimbeck 2008 for the aspiration-level topic]
Overexertion, or arousal that feels like panic (anxiety, depression with anxiety).
- Explain beforehand that a racing heart and breathlessness are normal effects of exercise.
- Raise the load gradually.
- The patient controls the pace and can pause at any time.
- If panic occurs: slow walking, longer out-breath, orienting to the room. Resume once calmer.
- Screen for cardiac causes before attributing symptoms to anxiety.
Overstimulation or worsening of psychotic symptoms. Reduce stimulation, time pressure and closeness, which are the conditions Stammer names as symptom-provoking. Return to a simpler structure, a smaller group or individual work, and move the patient to a lower-phase group if needed. Inform the ward team. [source: Stammer 2012 for the provoking conditions]
Paranoid reactions to approach or touch. Make every movement predictable and announced. Work without touch, keep distance, give the patient control over stopping (J), and avoid eyes-closed tasks.
Dissociation or derealisation during perception tasks. Keep eyes open, stay standing, make the tasks active and outward-focused (ball work), keep inward attention short, and use grounding through the feet.
Refusal or reactance. In the IBT version, pressure is said to produce counter-pressure, so trust-building matters. [source: Waibel & Jakob-Krieger 2009 preview] Offer choices and an observer role (for example keeping time), and allow joining in later.
Exclusion and conflict in team games (children and adolescents). Exclusion can trigger aggression (case "Matthias"). [source: Thimme et al. 2021 preview] Assign roles that guarantee involvement, use cooperative rather than competitive formats (P), and stop the game to renegotiate rules. Chapter 4.2.2 of Thimme et al. on challenging behaviour is not drawn on [uncertain].
Gender and peer norms. Social norms, for example that boys should not show emotion, can limit acceptance of expressive or perception methods. [source: Thimme et al. 2021 preview] Offer sport-framed entry points such as training, martial arts or climbing.
Compulsive exercise (eating disorders).
- Do not use activity in a compensatory way, and set no calorie or volume targets.
- Coordinate with the medical team on clearance.
- Favour perception, relaxation and playful, social movement over endurance.
- Watch for secret extra exercise.
Medication side effects (sedation, dizziness, weight gain). Check standing blood pressure risk, start sessions slowly, and coordinate timing with medication rounds. Use activity to support metabolic health without weight-loss targets.
Suicidality. Movement therapy is not a crisis intervention. If a patient reports suicidal thoughts or shows acute risk, follow standard risk assessment and the ward's safety protocol, and inform the responsible clinician the same day. Outdoor or off-ward sessions need risk clearance.
Ruptures (patient feels exposed, criticised or pushed). Name it, take responsibility for the pace, ask what would make taking part possible, and adjust. The relationship is treated as a central effective factor. [source: Heimbeck 2008 for the relationship weighting]
Scope of practice. In Germany this work is done by trained movement and sport therapists, psychomotor therapists and physiotherapists. A psychotherapist adopting it should get training in exercise safety and movement observation, use supervision, and check what their licence and jurisdiction allow, especially for any touch and for strenuous exercise.

Sources

Sources:

Further reading (not drawn on): Springer 2025, "Bewegung in der Psychiatrie: Ein Leitfaden…"; Thieme 2003 PDF (s-2003-814895).