Atlas›Domain IV · Body-oriented psychotherapy›Guide 090
Guide IV-090

Norwegian psychomotor physiotherapy

Aadel Bülow-Hansen, Trygve Braatøy1946Oslo, Norway
A 28 · L 47 · M 2525 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: Norwegian psychomotor physiotherapy (NPMP, psykomotorisk fysioterapi) as set out in Berit Heir Bunkan's "Principles and guidelines" (Tidsskr Nor Lægeforen 2001), the Bülow-Hansen tradition as summarised by Thornquist (Store norske leksikon), and the case-based account in Thornquist (2022). Where later qualitative studies (Ekerholt & Bergland 2008, 2014) describe practice differently, this is flagged.

What it is. NPMP is a specialist physiotherapy method, not a psychotherapy. Physiotherapist Aadel Bülow-Hansen (1906–2001) and psychiatrist Trygve Braatøy (1904–1953) developed it in the psychiatric department of Ullevål Hospital, Oslo, starting in the late 1940s. They first used it with psychiatric inpatients, then extended it to ordinary physiotherapy patients. Accounts of the collaboration's dates differ: Store norske leksikon (SNL) gives 1947 to Braatøy's death in 1953; Dragesund & Øien give 1946–1951 [uncertain]. Braatøy's original aim was to reduce bodily resistance so that patients in psychoanalytic treatment could reach their feelings more easily. The method later came to be used mainly for musculoskeletal tension and pain, and to some extent for mild anxiety and low mood. It became a physiotherapy specialisation in 1952. Training is now at master's level at UiT, Western Norway University (HVL) and OsloMet [source: Bunkan 2001; SNL; Houge 2001; Dragesund & Øien 2022].

Core idea of change. Muscle tension, breathing, movement and emotion are held to restrict and regulate one another. The body is treated as a functional whole that "remembers" past experience. Bodily habits and feelings are said to be mutually binding and mutually liberating. The therapist works indirectly, through massage, movement and positioning, towards a general bodily reorganisation (omstilling) of posture, muscles and above all breathing, rather than treating the symptom. Relaxation then follows by itself rather than being forced. As the body becomes more flexible, the patient comes closer to feelings, can put them into words, and gains both more access to them and more control over them [source: Bunkan 2001; Thornquist 2022; SNL].

For psychotherapists. In Norway the hands-on work is done by physiotherapists with specialist NPMP training, often alongside a psychotherapist or physician. A psychotherapist can (a) refer and collaborate, or (b) use the no-touch and talk elements described here, once trained. Any touch requires specific training and supervision, and a check of what your licence and jurisdiction allow [source: Bunkan 2001; Ekerholt et al. 2014; brief requirement].

2. Framework

NPMP is individually tailored and is not sequenced as a fixed manual. Dragesund & Øien (2022) call it difficult to standardise. The phases below are the course the sources describe. Where the move between phases is inferred, it is marked [synthesis].

Phase 0: Referral and history-taking. Most referrals come from GPs. A physician can request a body examination and assessment without committing the patient to treatment [source: Bunkan 2001]. The history comes first and sets the tone, and the patient's own account takes priority [source: Thornquist 2022]. Map how long the pain has lasted, and whether the patient has had, or is at risk of, a psychotic breakthrough [source: Bunkan 2001].

Phase 1: Examination as trial treatment (1 or more sessions).

  • Goal: assess the body's flexibility (overall mobility, and the ability to let oneself be moved) and versatility (mainly how readily breathing adjusts, plus tension level, temperature regulation and the ability to yield) [source: Thornquist 2022].
  • Content: posture, respiration, movement and muscle consistency, with respiration and movement weighted most. The therapist intervenes with words and hands throughout, so the examination is already treatment [source: Bunkan 2001; Thornquist 2022].
  • Formats: the classical trial treatment, with findings described in words, or structured instruments: GPE-52, ROBE, CBE or GBE (see 4.3) [source: Bunkan 2001; Dragesund & Øien 2022].
  • Close: the patient says what they understood. The therapist explains treatment as a joint project, and patient and therapist agree a shared goal. The therapist judges whether the patient is suitable and motivated, and can send written feedback to the physician [source: Thornquist 2022; NHI 2023].
  • Move on when: the patient can take in the educational side of the method, findings are not so extreme that chronicity or psychotic risk makes treatment pointless or unsafe, and a goal is agreed [source: Bunkan 2001].

Phase 2: Main treatment. Choose one of two orientations from the extent of the findings:

  • Major findings, fragile patient or trauma: a stabilising, supporting approach. Emphasise stability, body control and centring of the joints of the trunk and lower body. Tone relaxation down. Treatment is slow, careful and long [source: Bunkan 2001; Thornquist 2022; Ekerholt et al. 2014].
  • Moderate findings: a loosening, liberating approach. Emphasise flexibility, body experience, relaxation and reorganisation of breathing. This often brings the patient closer to feelings [source: Bunkan 2001].
  • Format: individual sessions, usually weekly. Bunkan's session template is about 45 min treatment, 10 min rest and 5 min closing. NHI gives "up to an hour" [source: Bunkan 2001; NHI 2023]. Some services add group movement sessions [source: NHI 2023; Dragesund & Øien 2022].
  • Order within the body: the whole body is examined and treated. In one published case the work went from the bottom up: feet first, the neck, throat and face last [source: Thornquist 2022].
  • Move from stabilising to loosening when: breathing begins to release without signs of overload (see 5.1), and the patient tolerates touch and reactions between sessions without sleep, temperature or palpitation problems [synthesis, from Thornquist 2022 on "body systems switching"].

Phase 3: Tapering and consolidation. Sessions become fortnightly or three-weekly, then monthly or less often [source: Bunkan 2001; Thornquist 2022]. Acute ergonomic or stress-related problems can improve quickly. Long-standing hard or slack musculature, fixed life situations, personality structure or emotional conflict make treatment longer [source: Bunkan 2001]. For traumatised patients treatment often lasted 1–2 years [source: Ekerholt et al. 2014], and one published case ran for 10 years [source: Sviland thesis, as summarised]. No source gives a standard total number of sessions [uncertain]. Taper when: the patient uses self-regulation (sigh, shaking, relaxation, accepting feelings), does home exercises independently and notices early warning signals [synthesis, from Bunkan 2001].

3. Guiding principles

  • Treat the whole body, not the symptom. Examine and treat the whole body even when only one area hurts, because treatment aims at a general reorganisation and is not diagnosis-specific [source: Bunkan 2001; Thornquist 2022].
  • The body is a functional whole. Look for links between distant parts. For example, knees that tend to flex can push the head forward, which can strain the neck and cause headache, so working on the knees can change the neck [source: Bunkan 2001].
  • Work from all sides. Combine areas so that tension does not simply move elsewhere, and aim for good centring in every joint [source: Bunkan 2001].
  • Breathing is the guiding thread and the dosing gauge. Watch breathing continuously. It tells you how much to do and when to stop [source: Bunkan 2001; Houge 2001].
  • Change breathing indirectly. Bülow-Hansen held that breathing change should come indirectly, through massage, movement and positioning, not through active breathing exercises or steering the breath [source: SNL]. Some later practice does ask patients to breathe into the belly [source: Ekerholt & Bergland 2008] [uncertain: version difference; this guide follows the indirect principle].
  • No more feeling than the patient can carry. Bunkan's postulate is that the patient should bring up no more feelings than they have "bein å stå på og rygg til å bære" (legs to stand on and a back to carry them) [source: Bunkan 2001].
  • Start where the patient can be. Choose exercises for the patient's current phase of reorganisation. Stabilise before you loosen [source: Bunkan 2001; Thornquist 2022].
  • Gradual change, not catharsis. Early practice was experimental, but later practice deliberately avoided quick fixes and emotional discharge [source: Thornquist 2022].
  • Balance tension and release. Build pauses into the work so that passive exhalation can occur. Relaxation comes after the breathing work and is never forced [source: Bunkan 2001].
  • Keep the pain element small. Never overdose or provoke. If the patient reports pain, reduce immediately [source: Bunkan 2001].
  • Assessment never stops. Treat every intervention as a test, and keep adjusting to the patient's reactions in small steps [source: Thornquist 2022; Ekerholt & Bergland 2008; Ekerholt et al. 2014].
  • Help to self-help. The method is educational: the patient learns to notice, regulate and look after themselves [source: Bunkan 2001; NHI 2023].
  • Talk starts from the body. Use what the body shows as the starting point for reflection, but do not act as a psychologist. Equally, do not ignore what you see [source: Bunkan 2001; Thornquist 2022].
  • Confirm pain without amplifying it. Show the patient you understand what they feel (you can read it in muscle consistency), but do not dwell on pain, because that can increase somatisation [source: Bunkan 2001].
  • Optimistic but realistic. Keep the atmosphere hopeful without promising too much [source: Bunkan 2001].
  • No parallel body treatments at the start. Advise against other training and body treatments early in the course [source: Bunkan 2001].
  • Teamwork. Work closely with the physician, and with a psychiatrist or psychologist when needed. Complicated cases should not rest on the physiotherapist alone [source: Houge 2001; Bunkan 2001].
  • Time and trust come first. Give enough time and space. The relationship carries the process [source: Dragesund & Øien 2022; Sviland, as summarised].
  • Use your own body as an instrument. NPMP training follows a master–apprentice model and includes self-treatment, and your embodied sensitivity is part of the method [source: SNL; Dragesund & Øien 2022].

4. Intervention inventory

The sources name techniques and give clinical vignettes, but no published manual specifies grips, durations or repetitions. Bülow-Hansen taught by demonstration, rarely wrote anything down, and her methods survive mainly through 10 instructional films and a 1976 compendium [source: SNL]. Neither of those is drawn on here. Steps below that go beyond what the sources state are marked [synthesis].

Touch protocol (applies to every hands-on item below).

  • From the sources:
    • Explain treatment as a joint project [Thornquist 2022].
    • Respect a refusal of touch and start with exercises without touch [Thornquist 2022, "Anne" case].
    • Leave out the small pain grip if the patient is anxious, has been exposed to violence, or reacts negatively [Bunkan 2001].
    • Reduce at once when there is pain [Bunkan 2001].
  • Added steps [synthesis]:
    • Before each new area, name the area and the kind of touch, and ask permission.
    • Agree a verbal and a hand stop signal, and offer a no-touch alternative (the patient does the movement themselves).
    • Check in during the touch ("Is this all right?") and after it. Record consent.
  • Limits:
    • Touch is limited to the areas named in the sources: feet, legs, back, shoulders, chest wall and epigastrium, neck, jaw and face.
    • Bunkan lists the jaw, tongue, anus, lower abdomen and raised internal pressure as places where hidden tension may show in reactions. These are observed, never touched, and sexual or genital touch is never part of the method [synthesis].
    • Touch requires NPMP or equivalent training, supervision and a check of what your licence and jurisdiction allow.

4.1 Opening history and first conversation

  • Purpose: establish the patient's account and the relationship, and screen for risk. Use at first contact.
  • Steps:
    1. Let the patient tell the story of the complaints in their own words before any body work.
    2. Ask how long the pain has lasted and what makes it better or worse.
    3. Ask about previous psychotic episodes, and about trauma or violence (this decides whether to use the small pain grip).
    4. Ask about current life situation and other treatments [source: Thornquist 2022; Bunkan 2001].
    5. Add medical screening (see 5.9) [synthesis].
  • Example language (illustrative): "Before I look at your body, I'd like to hear in your own words what brings you here and how it affects your days."
  • Watch for: how the patient sits and breathes while talking. In NPMP that is part of the data [synthesis, from Thornquist 2022].

4.2 Examination as trial treatment (classical)

  • Purpose: assess flexibility and versatility, see how breathing responds to intervention, and decide between a stabilising and a loosening approach. Use in the first session(s), and repeat later to evaluate.
  • Steps (components reported in Thornquist's 2022 case of "Peter"; order and timing [synthesis]):
    1. Habitual sitting. Ask the patient to sit as they usually do. Observe posture and breathing, then assist small changes in the sitting position and watch whether breathing follows.
    2. Assisted forward bend. Standing or sitting, the patient bends forward. The therapist supports the movement and asks them to let the neck and arms go.
    3. Isolated contraction. Ask the patient to tense one muscle group, for example one thigh, and then to do it with less effort. Observe whether tension spreads elsewhere, and whether breathing is held.
    4. Prone palpation. The patient lies prone. Palpate muscle consistency along the back. With a flat hand on the low back, ease the pelvis gently toward the feet to reduce lumbar lordosis, using long, calm strokes and loosening grips.
    5. Quick stimulating grips. Use brief, quick grips, for example just above vastus medialis, and watch the reaction.
    6. Jaw and neck. With consent, gently assist opening and stretching of the jaw, and apply gentle traction to the neck with the patient supine.
    7. Breathing throughout. Note whether breathing deepens, slows and frees after each intervention: the respiratory response. In Peter's case breathing did not release as expected, which was itself a finding.
    8. Closing talk. Ask the patient what they noticed. Explain the findings in everyday terms and frame treatment as a joint project.
  • Example language: Thornquist reports the therapist asking Peter to "use less energy". Illustrative: "Notice what happens in your breathing when I let go of your arm."
  • Watch for: sighs, yawns, swallowing, a distant gaze, dimmed eyes, jaw tension, tears, holding the breath, overexertion. Touch needs consent (see the touch protocol).

4.3 Structured body examinations (GPE-52, ROBE, CBE, GBE) and BARQ

  • Purpose: standardised documentation of findings, for outcome evaluation and research [source: Dragesund & Øien 2022; Bunkan 2001].
  • What they are:
    • GPE-52 (Global Physiotherapy Examination) has 52 single tests across five domains: posture, respiration, movement, muscle and skin. It grew out of Sundsvold's assessment method.
    • ROBE is the Resource-Oriented Body Examination. ROBE-II is a shorter version.
    • CBE (Comprehensive Body Examination) is built on ROBE. Bunkan describes it as having 13 psychometrically based subscales shown as a profile, standardised at Ullevål.
    • GBE (Global Body Examination) merges GPE-52 and CBE into domain sub-scores and a total score.
    • BARQ / BARQ-R (Body Awareness Rating Questionnaire) is a self-report questionnaire on body awareness.
  • Steps: use only the published forms and scoring manuals after training. Items are not reproduced here.
  • Watch for: a score is not a substitute for the dialogue of the trial treatment [synthesis].

4.4 Session opening check-in

  • Purpose: link today's body to the patient's life since the last session [source: Bunkan 2001].
  • Steps:
    1. Begin with a short conversation that starts from the body. Bunkan's open question is "Hvordan har du det?" (How are you?).
    2. Ask about reactions after the last session: sleep, temperature, palpitations, mood, home exercises [synthesis, from Thornquist 2022].
    3. Decide today's dose from the answers [synthesis].
  • Example language (illustrative): "How has your body been since last time, and how did you sleep the night after?"
  • Watch for: delayed reactions to the last session. These are a signal to stabilise (see 5.1).

4.5 Psychomotor massage (long calm strokes and loosening grips)

  • Purpose: reduce tension, give body experience, and indirectly release breathing. It also gives patients who struggle to name feelings something concrete to relate to [source: Bunkan 2001; Thornquist 2022; Ekerholt et al. 2014].
  • Steps:
    1. Follow the touch protocol.
    2. Position: the patient lies supine, prone or on the side, supported by cushions [synthesis on side-lying and cushions].
    3. Use long, calm strokes and loosening grips over the area being worked. Areas named in the sources include feet and legs, back, shoulders and chest, neck, jaw and face [source: Thornquist 2022].
    4. Work from several areas, and in fragile patients work from the periphery upward [source: Bunkan 2001; Thornquist 2022].
    5. Pause regularly with your hands still or lifted, so that passive exhalation can come [source: Bunkan 2001].
    6. Stop or soften as soon as breathing becomes rapid or held, or there are signs of distress.
    7. Duration: not specified. It sits within about 45 minutes of treatment [source: Bunkan 2001].
  • Example language (illustrative): "I'll work along your calves now with slow strokes. Just let your breathing do what it does."
  • Watch for:
    • Working: the patient experiences the massage as mostly pleasant, breathing becomes freer and fuller, the skin warms, the patient sighs, and the muscles soften [source: Bunkan 2001; Ekerholt & Bergland 2008].
    • Too much: nausea, tears the patient cannot contain, or dissociation (see 5.1, 5.3).

4.6 Stretching grip over the epigastrium (respiratory stimulation)

  • Purpose: stretch the muscles over the epigastrium (below the sternum, along the costal arch) to stimulate respiratory movement, especially where the rib cage is collapsed and breathing is restricted [source: Bunkan 2001, figs 1–2, described in text].
  • Steps:
    1. Explain the grip and ask consent, agreeing a stop signal.
    2. Position: supine, knees supported [synthesis].
    3. Place your hands flat on the soft tissue of the epigastric area and along the lower costal margin. Give a slow, gentle stretch of the tissue, timed with exhalation, then release and wait [synthesis on hand placement and timing; the source names the grip and its aim but the figure was not seen].
    4. Observe whether breathing movement spreads.
  • Example language (illustrative): "You may feel a stretch under your ribs. Let the breath out whenever it wants to go."
  • Watch for: pressure in the diaphragm region, which Bunkan lists among transient reactions. Avoid this grip in pregnancy, after recent abdominal surgery or with abdominal pathology [synthesis]. [uncertain: exact grip technique]

4.7 The small pinch and the "adequate response" (det lille knipet)

  • Purpose: a brief, small pain stimulus that makes the patient's habitual way of meeting discomfort visible, and then trains a freer, more active response [source: Bunkan 2001].
  • Screening (from the source): omit if the patient is anxious, has been exposed to violence, or reacts negatively to it. Keep the pain element small and never provoke [source: Bunkan 2001]. Added [synthesis]: omit with trauma not yet stabilised, dissociation, bleeding or skin conditions, and fragile tissue.
  • Steps:
    1. Explain the purpose and the brief sensation, and get explicit consent.
    2. Give a short, small pinch-type grip in a large muscle. Bunkan's example is the calf.
    3. Observe the habitual response. Bunkan lists closing the mouth, holding the breath, stiffening or curling up, hidden tension (jaw, tongue against palate, pelvic floor, raised internal pressure), and "dying" (going limp, distant and numb).
    4. Bunkan describes the adequate response as a marked in-breath with a sound on the out-breath (such as "au"), and letting the motor reaction come, for example a small, emotionally charged kick, or letting go of a stretch. Encourage it.
    5. Later in treatment: ask the patient to mark, that is, to move toward the stimulus and stretch rather than shrink. Bunkan notes that simply withdrawing may lower tension but reinforces compliant, "nice" traits.
  • Example language (illustrative): "This will be a quick, small pinch. Let any sound or movement come. You can say 'ow'."
  • Watch for:
    • Working: the patient shows a full breath and a voiced exhalation instead of freezing.
    • Stop and switch to stabilising: the patient goes limp, numb or distant.
    • This is a mild-discomfort technique, not cathartic discharge. Do not escalate to hitting or screaming [synthesis, consistent with Thornquist 2022 on avoiding catharsis].

4.8 Passive movement of the limbs (being moved)

  • Purpose: test and train the ability to let oneself be moved, which is one aspect of flexibility [source: Thornquist 2022].
  • Steps:
    1. With the patient supine, take the weight of an arm or leg at the wrist and elbow, or at the ankle and knee.
    2. Move it slowly through a comfortable range, pausing often.
    3. If the patient helps or resists, say so neutrally and wait [synthesis on handholds].
    4. Ask what they notice.
  • Example: in Thornquist's case, Katrine found it hard to let her arm be moved and commented on how hard it could be. Illustrative: "I notice your arm is helping me. See whether you can let me carry it."
  • Watch for: rapid breathing, a sigh, a distant gaze, dimmed eyes, jaw tension. These can precede tears and memories (see 4.15).

4.9 Jaw stretch and neck traction

  • Purpose: release jaw clenching and neck tension, which often go with held breathing and with headache [source: Thornquist 2022].
  • Steps:
    1. Follow the touch protocol. Face work is intimate, so ask separately before working on the face [synthesis].
    2. Jaw: the patient lies supine. Assist a slow opening and gentle stretch of the jaw, or let the patient open it themselves under guidance as a no-touch alternative.
    3. Neck: cradle the occiput with both hands and give a gentle, sustained traction toward you. Release slowly [synthesis on handhold].
    4. Pause and watch breathing.
  • Example language (illustrative): "I'm going to support the back of your head and give a very gentle pull. Tell me if you want me to stop."
  • Watch for:
    • Swallowing, yawning, or breathing that frees up.
    • Avoid traction with neck instability, recent whiplash, or vascular conditions affecting the neck arteries [synthesis].

4.10 Quick stimulating grips

  • Purpose: activate a hypotonic or under-used area, for example just above vastus medialis [source: Thornquist 2022].
  • Steps: give brief, brisk grips on the muscle and repeat a few times. Ask the patient to feel the area and, if suitable, to activate it [synthesis].
  • Example language (illustrative): "These are quick, light grips to wake up this part of your thigh. Notice the difference."
  • Watch for: improved sense of the area and of standing stability [synthesis].

4.11 Centring and stabilising exercises (trunk and lower body)

  • Purpose: give stability, body control and a sense of "bodily anchoring" in patients with major findings, severe distress or trauma. In these patients relaxation is toned down [source: Bunkan 2001; Ekerholt et al. 2014; Thornquist 2022].
  • Steps (principle from the sources; the specific movements are [synthesis]):
    1. Choose positions in which the patient feels safe, often sitting or standing.
    2. Work toward a centred position in each joint, avoiding habitual end-of-range positions. Examples: knees neither locked nor collapsed, pelvis neither tipped forward nor tucked under, trunk stacked over the pelvis.
    3. Use small, slow movements around the centre, such as slight bending and straightening of the knees, or shifting weight between the feet. Let the patient find the centre again each time.
    4. Keep the patient's eyes open and attention on contact with the floor or chair.
    5. Give few repetitions, with pauses. Stop before fatigue or loss of control.
    6. Ask what feels steadier.
  • Example language (illustrative): "Let your knees be soft, not locked and not bent. Find the place where you feel you are standing on your own legs."
  • Watch for:
    • Working: calmer breathing, the patient reports feeling steadier, and they tolerate more emotional material in psychotherapy [source: Ekerholt et al. 2014].
    • Too much: increased anxiety or dissociation. Reduce the inward focus further and use more external orientation [synthesis].

4.12 Standing, grounding and finding the centre of gravity

  • Purpose: feel the feet's contact with the ground and the body's balance point. Patients report that this supports freer breathing and self-control [source: Ekerholt & Bergland 2008, patient reports; detail thin].
  • Steps:
    1. The patient stands barefoot or in socks, feet about hip-width apart, knees soft [synthesis].
    2. Invite a slow sway forward and back, and side to side, narrowing gradually to the point where the weight feels centred [synthesis].
    3. Draw attention to the soles of the feet and to the breath moving by itself.
    4. Finish by walking a few steps and noticing the difference [synthesis].
  • Example language (illustrative): "Let your weight sink down through your feet. Sway a little and let yourself come to rest in the middle."
  • Watch for: dizziness or a fall risk, in which case use a chair or wall for support. A felt sense of ground suggests it is working. [uncertain: no source gives the exercise's exact form]

4.13 Working with breathing (indirect respiratory reorganisation)

  • Purpose: respiratory change is the most important element of treatment [source: SNL]. Ekerholt et al. (2014) put it this way: "A full NPMP treatment will focus on relaxation related to passive respiration."
  • Steps:
    1. Do not instruct deep breathing. Create the conditions for breathing to change through massage (4.5), stretch grips (4.6), positioning and movement, then pause [source: SNL; Bunkan 2001].
    2. In the pauses, let the exhalation run out passively. Invite the patient to "let go of" the out-breath rather than to breathe in [source: Bunkan 2001].
    3. Observe the respiratory response: whether breathing movement becomes visible from the groin to the chest, slows and deepens [source: Bunkan 2001, describing the full yawn].
    4. Variant reported by patients in later practice: the therapist's hands guide the breath along the spine toward the pelvis and belly, and the patient is asked to breathe down into the belly or toward an area [source: Ekerholt & Bergland 2008] [uncertain: departs from Bülow-Hansen's indirect principle; use sparingly].
    5. For patients who hyperventilate, exercises can give a sense of control over breathing [source: Ekerholt & Bergland 2008].
  • Example language (illustrative): "You don't need to do anything with your breath. Just notice when the out-breath wants to leave, and let it."
  • Watch for:
    • Working: breathing becomes a free, full movement and the patient feels relaxation [source: Ekerholt & Bergland 2008].
    • Too much: nausea, unease or anxiety when breathing first changes [source: Ekerholt & Bergland 2008].
    • This is not breath intensification. Never use forced or rapid breathing. With asthma, COPD, cardiac disease or panic disorder, keep breathing changes small and medically agreed [synthesis].

4.14 Allowing autonomic "primitive reactions" (yawn, sigh, shaking)

  • Purpose: Braatøy described autonomic reflexes and impulses such as yawning as "primitive reactions". In NPMP they are signs that the body is reorganising, and patients learn to let them come [source: Bunkan 2001].
  • Steps:
    1. Do not ask for a yawn. Bunkan states that the full yawn does not come from asking the patient to yawn. It develops when the body is flexible enough and the patient can let the deep breath in.
    2. When a yawn, sigh or stretch begins, pause your work and let it complete. A full yawn sends a stretch impulse through the body, opens the airways, and ends in passive exhalation and general relaxation [source: Bunkan 2001].
    3. Expect possible follow-on reactions: light flushing, warmth and wellbeing, and sometimes gut sounds, tears, flatulence, swallowed air or saliva. Normalise them [source: Bunkan 2001].
    4. Teach sighing and shaking as self-regulation tools (4.19).
  • Example language (illustrative): "That yawn is welcome. Let it run all the way through." Or: "Stomach sounds are common here. It's your body adjusting."
  • Watch for: transient reactions from internal organs, such as pressure around the diaphragm, a frequent urge to empty the bladder or bowels, or altered secretions. The physician should know these can happen [source: Bunkan 2001].

4.15 Putting bodily experience into words (verbal reflection)

  • Purpose: connect what happens in the body with the patient's life, at a pace they can carry [source: Thornquist 2022; Bunkan 2001].
  • Steps:
    1. When you see a reaction, such as a sigh, a held breath, a distant gaze or tears, briefly and neutrally name what you observe [source: Thornquist 2022, "Katrine"].
    2. Leave space for the patient to talk, and follow their associations rather than interpreting.
    3. If the patient links a bodily pattern to the past, help them relate it to the present. Katrine linked shoulders pushed forward to a childhood state of preparedness [source: Thornquist 2022].
    4. Then return to the body. Physiotherapists "should not act as psychologists" [source: Thornquist 2022]. When material needs psychotherapeutic work, refer or coordinate (4.23).
  • Example language (illustrative): "I noticed your breathing stopped for a moment when I moved your shoulder. Did you notice anything?"
  • Watch for: tears with relief suggest it is working. Flooding means you should stop the talk and stabilise (5.1).

4.16 Reformulating and reflective questions

  • Purpose: foster the patient's own understanding and responsibility [source: Bunkan 2001].
  • Steps:
    1. Reformulate what the patient says, or answer a question with a question. Bunkan's classic question is "Hva tror du selv?" (What do you think yourself?).
    2. Ask when the pain, anxiety or discomfort comes, which situations it is connected with, and what makes it better or worse.
    3. Confirm that you understand the pain, since you can feel it in muscle consistency, but do not dwell on it [source: Bunkan 2001].
  • Example language (illustrative): "You ask why it gets worse on Mondays. What do you think yourself?"
  • Watch for: growing insight is a sign of progress. If the patient keeps returning to pain, gently shift the focus to what the body can do [source: Bunkan 2001, on turning focus away from pain].

4.17 Rest period and closing

  • Purpose: let the reorganisation settle, and send the patient out regulated [source: Bunkan 2001].
  • Steps:
    1. After about 45 min of treatment, leave the patient resting, lying under a blanket, for about 10 min. Stay present or nearby, as the patient prefers [source: Bunkan 2001; the staying-present detail is synthesis].
    2. In the last 5 min, help the patient sit up slowly, check orientation, and briefly ask what they noticed and how they feel now.
    3. Agree home practice and say when to get in touch if delayed reactions occur [synthesis].
  • Example language (illustrative): "Take your time sitting up. What do you take with you from today?"
  • Watch for: dizziness on getting up, and any lingering dissociation. Do not let the patient leave until they are oriented [synthesis].

4.18 Starting without touch (exercises first)

  • Purpose: an entry for patients who dislike or fear touch [source: Thornquist 2022, "Anne"].
  • Steps:
    1. Accept the condition. Anne said she would come only if not touched.
    2. Begin with active exercises the patient does themselves.
    3. Over weeks, and only on the patient's invitation, introduce touch at the periphery. With Anne the therapist started with the feet, and moved to other areas only as she tolerated it.
    4. Keep checking reactions. Early touch on the feet made Anne nauseous. Later she accepted touch over most of the body.
  • Example language: "We can do exercises," as reported in the case [Thornquist 2022]. Illustrative: "We'll only add touch if and when you want it, starting with your feet."
  • Watch for: nausea or freezing, which means slow down. Continued attendance and daily home practice, as with Anne, suggest it is working.

4.19 Self-regulation tools and home exercises

  • Purpose: help to self-help, and carrying the change over into daily life [source: Bunkan 2001; NHI 2023; Thornquist 2022].
  • Steps:
    1. Teach a few tools, chosen from what worked in the session: sighing, shaking out, relaxation, and accepting one's own feelings [source: Bunkan 2001].
    2. Give one or two simple exercises from the session, such as a centring exercise in standing, or letting the out-breath go in a resting position. Have the patient demonstrate them before leaving [synthesis].
    3. Teach the patient to probe their own limits. Ekerholt & Bergland report the therapist's words as "Take your time. Probe your pain limit."
  • Example language (illustrative): "When you notice your shoulders creeping up at work, try a long sigh and a shake of the arms."
  • Watch for: daily use and a sense of mastery mean it is working [source: Ekerholt & Bergland 2008].

4.20 Increasing tolerance of feelings and spotting early signals

  • Purpose: the method can both bring feelings forward and increase control over them. Patients learn to accept feelings without violent outbursts, and to detect early signals of aggression or anxiety [source: Bunkan 2001].
  • Steps:
    1. When a feeling arises, keep it at a level the patient can stay present with, using the breath and contact with the couch or floor [synthesis].
    2. Help the patient name the first bodily sign, for example a tight jaw or a held breath, and practise a regulating response such as letting the breath out or marking (4.7) [synthesis, from Bunkan 2001].
  • Example language (illustrative): "Where in your body did you notice the irritation first?"
  • Watch for: outbursts. Bunkan advises against violent outbursts, so dial down rather than encourage discharge.

4.21 Supportive problem-solving conversation

  • Purpose: a more supportive mode for patients in difficult life situations [source: Bunkan 2001].
  • Steps:
    1. Invite the patient to put problems into words, weigh alternatives and consequences, and take responsibility for their own choices.
    2. Reduce the loosening body work while doing so [source: Bunkan 2001; the second step is synthesis].
  • Example language (illustrative): "What options do you see, and what would each cost you?"
  • Watch for: if the needs are beyond the scope of physiotherapy, refer to a psychiatrist or clinical psychologist [source: Bunkan 2001].

4.22 Group movement sessions

  • Purpose: movement in a group with an emphasis on looseness and free movement [source: NHI 2023]. An RCT evaluated long-term NPMP in groups [source: Dragesund & Øien 2022].
  • Steps: no source describes a session structure [uncertain]. [synthesis]:
    1. Open with a check-in round.
    2. Move on to standing centring and grounding exercises (4.11–4.12).
    3. Continue with loose swinging and free movement, with pauses for the out-breath.
    4. Finish with rest lying down and a short reflection round.
    5. Use no hands-on work unless separately consented.
  • Watch for: comparison and shame, and a pace that is too fast for some members. Offer an individual alternative [synthesis].

4.23 Concurrent collaboration with a psychotherapist

  • Purpose: combine bodily anchoring with psychological work [source: Ekerholt et al. 2014; Houge 2001].
  • Steps:
    1. Agree roles. The physiotherapist works with body awareness, passive respiration, flexibility and stabilisation. The psychologist links sensations to emotions and helps the patient put reactions from the body sessions into words [source: Ekerholt et al. 2014].
    2. Hold regular joint meetings and tell the patient about them [source: Ekerholt et al. 2014].
    3. If two therapists at once is too demanding for the patient, do not start the collaboration, or stop it promptly [source: Ekerholt et al. 2014].
  • Example language (illustrative): "Your psychologist and I meet every month to coordinate. Is there anything you want me to pass on, or not pass on?"
  • Watch for: splitting between the two therapists, and overload [synthesis].

4.24 Physician involvement when expected relaxation does not occur

  • Purpose: Bülow-Hansen tracked how tension patterns changed from session to session in relation to breathing. If the expected relaxation did not come, factors maintaining the tension were looked for, and if physiotherapist and patient could not find them, the physician or a psychiatrist was brought in [source: Houge 2001].
  • Steps:
    1. Compare findings across sessions.
    2. Explore with the patient what might maintain the tension.
    3. If nothing is identified after several sessions, consult the referring physician [source: Houge 2001; the timing is synthesis].
  • Watch for: NPMP has little effect if the maintaining cause is not identified [source: Houge 2001].

4.25 Video consultation

  • Purpose: continuity when hands-on work is impossible, as used during COVID-19 [source: Dragesund & Øien 2022].
  • Steps: use exercises, breathing observation and talk only [synthesis]. Confirm the patient's location and an emergency contact [synthesis].
  • Watch for: without touch the therapist must rely on sight and hearing alone, so observation channels are reduced [source: Thornquist 2022].

5. Handling problems

5.1 Overwhelm: "body systems switching" and too much release.

  • What it looks like: Braatøy warned that relaxation or breathing release can be stronger than the patient can tolerate emotionally. It then shows as palpitations, disturbed sleep or temperature problems, often between sessions [source: Thornquist 2022]. Patients also describe nausea, unease, anxiety, or reliving earlier experiences [source: Ekerholt & Bergland 2008].
  • Response from the sources:
    • Reduce the dose straight away.
    • Switch from a loosening to a stabilising approach: centring the joints of the trunk and lower body (4.11), with less relaxation and less inward attention [source: Bunkan 2001; Ekerholt et al. 2014].
    • Introduce elements in very small steps [source: Ekerholt et al. 2014].
  • Added [synthesis]:
    • In session, have the patient sit up, open the eyes, press the feet into the floor and name objects in the room.
    • Next time, shorten the hands-on time and lengthen the rest.
    • Ask about delayed reactions at every check-in.

5.2 Strong emotion (tears, anger) during touch.

  • Response from the sources: note and respect the response. Let tears come, and let the patient talk if they want to [source: Thornquist 2022].
  • Aim for tolerance without violent outbursts [source: Bunkan 2001].
  • [synthesis]: do not deepen with more touch at that moment. Keep a still, supportive hand only if the patient has said they want one, otherwise take your hands away, and slow down the out-breath together.

5.3 Dissociation, "dying" and numbness.

  • What it looks like: in response to discomfort the body goes slack and numb [source: Bunkan 2001]. Traumatised patients can stand only small amounts of focus on bodily sensation before dissociating or feeling they are losing control [source: Ekerholt et al. 2014].
  • Response:
    • Stop the small pain grip and any loosening work, and move to stabilisation [source: Bunkan 2001; Ekerholt et al. 2014].
    • [synthesis]: orient externally (eyes open, look around, use the patient's name), move to sitting or standing, use active movement rather than passive, and keep each period of inner focus brief.
    • Coordinate with a trauma-focused psychotherapist, and expect a treatment course of 1–2 years [source: Ekerholt et al. 2014].

5.4 Aversion to touch, or touch triggering past experience.

  • Response: start with exercises without touch and introduce touch gradually from the periphery, only if the patient agrees (4.18) [source: Thornquist 2022].
  • Touch can activate experiences the patient cannot yet process. With trauma, stabilise before loosening [source: Thornquist 2022].
  • [synthesis]:
    • Let the patient choose the area, the duration and whether to stay clothed.
    • Use a stop signal.
    • Never make touch a condition of treatment.

5.5 Overcontrol, overexertion, "helping".

  • What it looks like: the patient holds tension, works too hard, and breathing does not release, as in Peter's case [source: Thornquist 2022].
  • Response:
    • Ask for less effort (Thornquist reports the therapist saying "use less energy").
    • Give more bodily experience and less intellectual explanation [source: Thornquist 2022].
    • Sviland notes that treatment challenges patients' sense of control, so trust is essential [source: Sviland, as summarised].
  • [synthesis]: name the pattern kindly, make the tasks smaller, and praise doing less.

5.6 No change despite treatment.

  • Response:
    • Look for maintaining factors: work, relationships, conflicts, other treatments.
    • Bring in the physician or a psychiatrist if they cannot be identified [source: Houge 2001].
    • Recheck the indication. Large deviations with chronicity make treatment ineffective [source: Bunkan 2001].
  • [synthesis]: repeat the examination to compare findings, review the goal, and consider ending or a break with a plan.

5.7 Focus on pain, and somatisation.

  • Response: confirm the pain experience, but turn the focus away from pain and toward what the body can do and what situations the pain is linked to [source: Bunkan 2001].

5.8 Non-adherence to home practice.

  • [synthesis]:
    • Cut the exercise down to one tool that takes under a minute (a sigh or a shake-out) and link it to a daily cue.
    • Ask what got in the way, and practise it in session.
    • Remember that NPMP requires the patient to take in the educational side of the method. Low engagement over time is a reason to review suitability [source: Bunkan 2001].

5.9 Medical and psychiatric screening and contraindications.

  • From the sources:
    • NPMP is not recommended with very large deviations from ideal body conditions, because of chronicity or the risk of psychotic breakthrough.
    • Use a long-term, cautious approach with major body findings and/or personality problems.
    • Map any history or risk of psychosis [source: Bunkan 2001].
  • Added [synthesis], before hands-on or breathing work:
    • Ask about pregnancy, cardiovascular and respiratory disease (asthma, COPD), epilepsy, recent injury or surgery, osteoporosis, anticoagulation, skin conditions, active psychosis, severe dissociation, active suicidality, and recent trauma that has not been stabilised.
    • Adapt or postpone the work accordingly, and get medical clearance where needed.
    • Never present NPMP as a treatment for cancer or other physical disease. Claims of effect on migraine, asthma, hypertension and similar conditions were presented as clinical claims, not documented effects [source: Bunkan 2001].

5.10 Transient visceral reactions (diaphragm pressure, frequent urges, altered secretions).

  • Response: explain them in advance. The physician should know they can occur and follow them up if needed [source: Bunkan 2001].
  • [synthesis]: new or persistent symptoms need medical assessment, not reinterpretation as "release".

5.11 Suicidality or self-harm emerging.

  • [synthesis]:
    • Pause the body work.
    • Assess risk using your service's standard structured risk assessment, and make a collaborative safety plan, including counselling on safe storage and removal of means.
    • Involve the GP or psychiatrist the same day if risk is raised.
    • Resume body work only in a stabilising form, coordinated with mental health care.

5.12 Ruptures (feeling pushed, misunderstood or exposed).

  • [synthesis]:
    • Name the shift.
    • Invite the patient's view ("What do you think yourself?" [Bunkan 2001]) and own your part, such as too much, too fast, or touch that was not discussed enough.
    • Renegotiate the joint project, and go back to a level of touch and pace the patient chooses.

5.13 Two therapists too much, or splitting.

  • Response: do not start, or end promptly, if parallel therapy overloads the patient [source: Ekerholt et al. 2014].
  • [synthesis]: agree one lead clinician, and agree what is shared between the two therapists.

5.14 Expecting a quick fix.

  • Response: explain that the reorganisation is gradual and long-term, but that acute stress-related or ergonomic problems can improve quickly. Keep the atmosphere optimistic but realistic [source: Bunkan 2001].

5.15 Scope and boundaries for the clinician.

  • Response: do not act as a psychologist inside a physiotherapy role, and do not ignore what you observe [source: Thornquist 2022]. Complicated cases should not rest on one professional [source: Houge 2001].
  • [synthesis]: a psychotherapist using NPMP elements should keep to the no-touch elements (4.11–4.13, 4.15–4.21) unless trained and licensed for touch.
  • Note that in 2001 the title "psykomotoriker" was not protected [source: Bunkan 2001]. Check that a referral partner has recognised NPMP training.

Sources

Sources

Further reading (not drawn on) [uncertain where relied on]

  • Braatøy, T. (1947). De nervøse sinn. Oslo: Cappelen.
  • Braatøy, T. (1954). Fundamentals of Psychoanalytic Technique. New York: Wiley.
  • Bunkan, B. H., Houge, N., Hødal, T., & Hanssen, H. (1976). Psykomotorisk behandling (compendium).
  • Psykomotorisk behandling: Festskrift til Aadel Bülow-Hansen (1982).
  • Thornquist, E., & Bunkan, B. H. (1990/1991). What is Psychomotor Therapy? Oslo: Norwegian University Press.
  • Sviland, R. (2014). Norwegian Psychomotor Physiotherapy and Embodied Narrative Identity (PhD thesis, University of Bergen).
  • Kvåle, A., & Ljunggren, A. E. (2007). In Body and Mind Therapies. Springer.
  • Sundsvold, M., & Vaglum, P. (1975). Muscular tension and psychopathology. Psychotherapy and Psychosomatics.
  • Bülow-Hansen's 10 instructional films (physiotherapy education programme, Bergen), not viewed.
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