Physiotherapy · Atlas

1. Introduction

Version followed: physiotherapy as World Physiotherapy describes it in its policy statement Description of physiotherapy (re-approved May 2023), with the mental health specialty as World Physiotherapy's IOPTMH page (checked October 2026) and Probst (2017) describe it, Basic Body Awareness Therapy (BBAT) as Skjærven and Sundal (2016) describe it, Norwegian psychomotor physiotherapy as Bunkan (2001) describes it, pain neurophysiology education as the Noigroup (Butler and Moseley, Explain Pain) evidence page presents it, and NICE NG193 (2021) for chronic primary pain. UK regulation per the Chartered Society of Physiotherapy (CSP) and HCPC; consent per CSP Consent and physiotherapy practice (reviewed July 2025); US regulation per FSBPT and APTA.

What it is. Physiotherapy (US: physical therapy) is a registered health profession, not a psychotherapy. World Physiotherapy defines it as services provided by physiotherapists to develop, maintain and restore movement and function across the lifespan, wherever ageing, injury, pain, disease or environmental factors threaten movement. Physiotherapists are autonomous practitioners who can be first-contact practitioners and refer on when findings fall outside their expertise [source: World Physiotherapy PS 2023].

Who may practise and who regulates.

UK: the Health and Care Professions Council (HCPC) is the statutory regulator; to practise physiotherapy in the UK a person must by law be HCPC-registered. "Physiotherapist" and "physical therapist" are protected titles: only people on the HCPC register may use them, and the public can check the register [source: CSP, Regulation of physiotherapy (page last reviewed 2016); HCPC, physiotherapist registration renewal notice 2018, which lists both titles]. Registration is renewed every two years and requires professional liability insurance [source: CSP, Regulation of physiotherapy]. The CSP is the professional, educational and trade union body; it is not the regulator. Physiotherapy support workers are not HCPC-registered [source: CSP, Regulation of physiotherapy]. The current HCPC Standards of proficiency took effect on 1 September 2023 and expect registrants to actively demonstrate them in practice, with added emphasis on equality, diversity and inclusion, service-user focus, public health, registrants' own mental health, digital skills and leadership; the Standards of conduct, performance and ethics (the ethical framework for all 15 HCPC professions) were updated 1 September 2024 [source: CSP, HCPC standards for physiotherapists]. HCPC's Standards of proficiency for physiotherapists (in force 1 September 2023) set 15 top-level standards; those most relevant to mental health work are 2.7 (obtain valid consent: voluntary, informed, with capacity considered, proportionate and recorded), 2.11 (recognise the power imbalance in healthcare and never abuse it), 5.8 and 12.9 (psychological, social and cultural needs and factors), 8.5 (recognise anxiety and stress in service users and offer support) and 3.1–3.4 (the registrant's own mental and physical wellbeing and fitness to practise) [source: HCPC, Standards of proficiency – physiotherapists].
US: physical therapists must be licensed in every jurisdiction (all 50 states, DC, Puerto Rico and the US Virgin Islands), and physical therapist assistants are licensed or certified in the same jurisdictions [source: APTA, About PT and PTA Licensure], by state licensing boards working under their own statutes. The Federation of State Boards of Physical Therapy (FSBPT) is the membership body of 53 jurisdiction boards and owns the National Physical Therapy Examination (NPTE); the American Physical Therapy Association (APTA) is the voluntary professional association; entry programmes are CAPTE-accredited [source: FSBPT FAQs for educators]. APTA states that it does not license PTs or PTAs; licences must be renewed regularly, most states require continuing education for renewal, and licensure requires passing the NPTE and graduating from a CAPTE-accredited programme [source: APTA, About PT and PTA Licensure]. Check the individual state board's licence lookup before referring [synthesis].
International: World Physiotherapy (formerly WCPT) is the global federation of national associations. Its specialty group for mental health, the International Organisation of Physiotherapy in Mental Health (IOPTMH; its 2018 newsletter uses "International Organization of Physical Therapists in Mental Health"), was accepted at World Physiotherapy's General Meeting in Amsterdam in 2011 and reconfirmed in 2015 and 2019; its stated aim is to foster co-operation between physiotherapists practising in mental health worldwide, and the World Physiotherapy page lists 27 member countries or territories [source: World Physiotherapy, IOPTMH page, checked October 2026]. The international conference series (ICPPMH) began in Leuven in 2006 and has met in Bergen, Lund, Edinburgh, Utrecht, Madrid and Reykjavik (2018) [source: IOPTMH Newsletter 6(2), June 2018]. IOPTMH's own site (ioptmh.org) is not drawn on here [uncertain]. In the UK the specialty network is Chartered Physiotherapists in Mental Health (CPMH), a CSP professional network and founder member of IOPTMH [source: CPMH, About CPMH].
Other countries have their own regulators; check the local register before referring [synthesis].

Core idea of change (as the profession publishes it). In mental health, physiotherapy aims to improve wellbeing and empower people through functional movement, movement awareness, physical activity and exercise, linking physical and mental health within a biopsychosocial model, delivered person-centred, individually or in groups, in multidisciplinary teams [source: World Physiotherapy IOPTMH page; Probst 2017]. In BBAT, change comes from learning to be present in and aware of everyday movement, improving movement quality [source: Skjærven and Sundal 2016]. In persistent pain, pain neurophysiology education reframes pain as a protective response to perceived threat rather than a simple sign of damage, which lowers threat and supports activity [source: Noigroup evidence page].

The psychotherapist's role. You do not deliver physiotherapy. Your work is to recognise when a physiotherapist could help, refer or suggest referral, collaborate, prepare and support the client (including around consent to touch), integrate psychological work with what the client learns in physiotherapy, and pass on concerns. Basic Body Awareness Therapy as a body-oriented method in its own right may also be covered in the body-psychotherapy domain (Domain X); this guide treats it only as a physiotherapy method. This guide gives no exercise prescriptions: dosage, type and progression of exercise belong to the physiotherapist [synthesis].

2. Framework

This is a profession with a generic clinical process, not a manualised therapy, so the framework below is (A) the physiotherapy process as World Physiotherapy describes it and (B) the psychotherapist's parallel pathway [synthesis].

A. The physiotherapy episode [source: World Physiotherapy PS 2023]

Examination and assessment: history, observation and tests. In mental health, Probst (2017) describes assessing history and context, lifestyle, mood and anxiety, illness behaviour and wellbeing, and observing posture, breathing and movement; some clinicians use the SCEGS frame (soma, cognitions, emotions, behaviour, social environment). BBAT uses the observational Body Awareness Rating Scale (BARS) for movement quality [source: Skjærven and Sundal 2016]. In chronic pain, NICE asks for a person-centred assessment of contributing factors and how pain affects life, work, sleep and relationships [source: NICE NG193 1.1.1, 1.1.8].
Evaluation, diagnosis and prognosis through clinical reasoning.
Plan with measurable goals agreed with the person (and family or carers where relevant); NICE calls this a care and support plan built on the person's priorities, abilities and goals [source: NICE NG193 1.1.17, 1.1.19].
Intervention (see section 4).
Re-examination and adjustment.
Discharge when goals are met or benefit is no longer evident. NICE stresses activity that the person can sustain after a formal programme ends [source: NICE NG193 1.2.2 rationale].

Session count and format. No source cited gives a standard number of sessions for physiotherapy in general; it varies by setting and service [uncertain for typical episode length]. Formats include individual and group work in primary, community, inpatient and outpatient care [source: IOPTMH page; Probst 2017]. One BBAT study abstract used twelve sessions delivered live or online [source: Kontadaki and Kamari 2022]; BBAT uses a treatment contract and a diary for home practice [source: Skjærven and Sundal 2016]. Norwegian psychomotor physiotherapy is usually weekly, in sessions of about an hour (roughly 45 minutes of treatment, 10 of rest, 5 of closing), tapered gradually to monthly or less; long-standing problems take longer than recent ones [source: Bunkan 2001]. NICE recommends a supervised group exercise programme for chronic primary pain, tailored to needs, preferences and abilities, without prescribing the type [source: NICE NG193 1.2.1].

B. The psychotherapist's pathway [synthesis]

Notice the indication (section 4, intervention 1) and discuss with the client.
Refer or signpost (via GP, direct access or the team); obtain consent to share information.
Collaborate during the episode: agree shared goals and language, exchange updates with consent.
Integrate: use what the client experiences in physiotherapy (body awareness, changed pain beliefs, regained activity) as material in therapy.
After discharge: support maintenance of what was learned and relapse planning.

Moving between steps: move from noticing to referral when the client agrees and there is a body, movement, pain or physical-health need beyond your competence; from referral to collaboration once the client has an appointment and consents to contact; to post-discharge work when the physiotherapist discharges [synthesis].

3. Guiding principles

Separate scopes. Physiotherapy is a registered profession with protected titles; you neither give exercise or movement prescriptions nor second-guess the physiotherapist's plan. Practical meaning: route all questions about what exercise, how much, or whether to push through pain to the physiotherapist [source: CSP regulation page; synthesis].
Check registration. Practical meaning: confirm the practitioner is on the HCPC register (UK) or state-licensed (US) before referring [source: CSP regulation page; FSBPT].
Person-centred, biopsychosocial care. Practical meaning: frame body and mind as linked, never as "it's all in your head" versus "it's purely physical" [source: IOPTMH page; Probst 2017; Noigroup].
Shared decision-making and agreed goals. Practical meaning: help the client clarify their own priorities before and during physiotherapy [source: NICE NG193 1.1.17; World Physiotherapy PS 2023].
Physical health matters in mental illness. People with mental health problems have higher rates of cardiovascular disease, metabolic syndrome and obesity, partly due to medication, and physical comorbidity reduces life expectancy [source: Probst 2017]. Practical meaning: treat inactivity, deconditioning and physical complaints as legitimate referral reasons, not side issues.
Consent to touch and explanation in advance. The CSP requires consent before any assessment or treatment, treats it as continuous during ongoing care, and names three conditions for valid consent: capacity, agreement without pressure, and enough information to choose; a capacitous adult's refusal must be respected and recorded; explicit (spoken or written) consent is preferred over implied consent; capacity questions fall under the Mental Capacity Act 2005 (England and Wales) or the Adults with Incapacity (Scotland) Act 2000; Gillick-competent under-16s can consent themselves [source: CSP, Consent and physiotherapy practice, reviewed July 2025]. Touch is common in physiotherapy; the CSP advises that handling be clearly explained beforehand and notes that people with mental health or capacity issues are particularly vulnerable [source: CSP PD104 2023]. Practical meaning: prepare clients, especially trauma survivors, to ask questions, set limits, withdraw consent and request a chaperone.
Presence and awareness in movement (BBAT). Practical meaning: value the client's reports of how movement feels, not only what they can do [source: Skjærven and Sundal 2016].
Pain is protective, not a damage meter (pain science). Practical meaning: keep your psychoeducation consistent with the physiotherapist's pain explanation [source: Noigroup].
Interprofessional collaboration. Physiotherapists in mental health work in multidisciplinary teams and refer on when needed [source: Probst 2017; World Physiotherapy PS 2023]. Practical meaning: agree who does what and how you communicate.
Medication belongs to the prescriber. NICE NG193 advises against starting several drug classes for chronic primary pain and asks for shared review of existing use [source: NICE NG193 1.2.10–1.2.11]. Practical meaning: never suggest starting, stopping or changing a medicine; route questions to the prescriber.
Not for everyone. Skjærven and Sundal note BBAT is not suitable for every musculoskeletal problem or every person. Practical meaning: present physiotherapy options as possibilities to assess, not promises [source: Skjærven and Sundal 2016].

4. Intervention inventory

Part A describes what physiotherapists deliver, at the level their professional bodies and guidelines publish it, so you can explain it to clients and collaborate. You do not deliver these. Part B gives the psychotherapist's own interventions. No exercise types, amounts or progressions are given; those are set by the physiotherapist.

Part A. What physiotherapists deliver (descriptive)

A1. Physiotherapy assessment in mental health

Purpose / when used: the start of any episode; establishes needs, goals and a plan [source: World Physiotherapy PS 2023].
What happens (descriptive): history and context, lifestyle, mood and anxiety, illness behaviour and wellbeing; observation of posture, breathing and movement; sometimes the SCEGS frame (soma, cognitions, emotions, behaviour, social environment) [source: Probst 2017]. In BBAT, movement quality may be rated with the observational Body Awareness Rating Scale (BARS) [source: Skjærven and Sundal 2016]; a variant, BARS-MQE, is used in research [source: Kontadaki and Kamari 2022]. Items are not reproduced here.
Example language (illustrative): "The first appointment is mostly talking and watching how you move, breathe and stand. You can say what you are and are not comfortable with."
Watch for: clients who fear being judged on their body; anxiety about undressing or being touched (see B3).

A2. Basic Body Awareness Therapy (BBAT)

Purpose / when used: a movement awareness approach used in physiotherapy for anxiety, depression and post-traumatic conditions, schizophrenia (body image, affect regulation, wellbeing), borderline personality disorder in groups, eating disorders (more realistic body image), and long-lasting pain including chronic pelvic pain and fibromyalgia [source: Skjærven and Sundal 2016]. Probst (2017) describes it as group-based and person-centred, focused on movement quality in daily life.
Origins: developed by French movement educator and psychotherapist Jacques Dropsy in the 1960s; introduced into physiotherapy by Swedish physiotherapist Gertrud Roxendal in the late 1970s; developed further by the International Association of Teachers in BBAT [source: Skjærven and Sundal 2016].
What happens (descriptive): simple, small, soft movements in everyday positions (lying, sitting, standing, walking), plus relational movements and massage, needing only a floor, mat and chair. Emphasis on postural stability, free breathing and mental awareness, and on form, flow, rhythm, energy and intention. The physiotherapist acts as a guide, uses metaphors and imagery, and invites reflective dialogue about the movement experience. Learning follows a seven-step Movement Awareness Learning Cycle: contact, explore, experience, integrate, create meaning, master, conceptualise/reflect. A treatment contract and a diary support home practice [source: Skjærven and Sundal 2016].
Training: licensed BBAT teachers; a postgraduate Basic Body Awareness Methodology (BBAM) programme at Bergen [source: Skjærven and Sundal 2016]. The BBAM programme at Western Norway University of Applied Sciences (HVL), coordinated by Liv Helvik Skjærven, recruited internationally: its 2015–2017 cohort had 27 graduating students from 15 countries, with ERASMUS partners including Leuven, Utrecht, Almería, Lund, Arcada and Metropolia [source: HVL BBAM symposium page]. Outside Norway, BBAT is also taught within undergraduate physiotherapy, e.g. a 40-hour movement-awareness course (20 hours theory, 20 practical) for fourth-year students in a Spanish–Norwegian study [source: Bravo et al. 2022]; a BBAT continuing-education listing exists at Tartu Health Care College, Estonia, but its details were not visible [uncertain]. The International Association of Teachers in BBAT and its licensing route are [uncertain]; ask the physiotherapist where they trained [synthesis].
Example language (illustrative): "This physio approach is less about getting fitter and more about noticing how you stand, breathe and walk, and finding a steadier way of moving."
Watch for: reports of feeling "more coherent" or steadier (the kind of change the authors describe); also dissociation or distress during awareness work, which the client should feel free to tell both you and the physiotherapist [synthesis]. Cross-refer: BBAT as a body-oriented method is also considered in Domain X.

A3. Norwegian psychomotor physiotherapy and psychomotor approaches

Purpose / when used: psychomotor therapy ranges from functional training to psychotherapeutically oriented approaches; the Norwegian psychomotor approach works with breathing, posture and massage [source: Probst 2017]. Norwegian psychomotor physiotherapy was developed in the late 1940s by psychiatrist Trygve Braatøy with physiotherapist Aadel Bülow-Hansen, originally to reduce bodily resistance and ease access to feelings for patients in psychoanalytic treatment. It is not diagnosis-specific: it treats the body as a whole, linked to emotions and social context, aiming at a flexible, stable body without unnecessary tension, with free breathing and movement. Indications described include raised or lowered muscle tension and myofascial pain linked to habits, ergonomics or mild emotional problems; other claimed uses rest on limited evidence [source: Bunkan 2001].
What happens (descriptive): referral usually comes from the GP, and an examination can be requested without committing to treatment. The examination looks at posture, breathing, movement and muscle consistency, with most weight on breathing and movement; standardised examinations exist (items not reproduced). Sessions take place in a private room and combine massage, specific movements and some conversation; breathing is watched throughout and guides how much is done. Small, brief pain grips are used to reveal habitual tension, and the patient is encouraged to respond (with breath, movement or a sigh) and to assert themselves rather than withdraw. Emotional reactions are treated as part of recovery: patients learn to notice early signs of unwanted feelings and to tolerate them, and are taught self-help ways of releasing discomfort (sighing, shaking out, relaxing, accepting feelings). Usually weekly, tapered to monthly or less [source: Bunkan 2001]. Training: originally a three-year part-time postgraduate qualification (Oslo from 1994, Tromsø from 2000); "psykomotoriker" is not a protected title [source: Bunkan 2001]. OsloMet now offers it as a part-time three-year, 120-ECTS master's specialisation for authorised physiotherapists, with at least 200 supervised patient treatments and 72 hours of group supervision (no intake in 2026) [source: OsloMet programme page, checked October 2026].
Example language (illustrative): "Some physiotherapists are trained in approaches that work with breathing, posture and tension in a way that links to feelings. It is worth asking whether your local service offers that."
Watch for: strong emotional reactions to touch or breathing work; agree in advance how the client will tell you about them. Bunkan (2001) advises caution where there is a risk of psychotic breakthrough, says the pain grip should not be used with patients who are anxious, have experienced violence or react negatively to it, notes the method needs some capacity to learn its educational part, and mentions temporary bodily reactions the referring doctor should know about [source: Bunkan 2001]. Tell the physiotherapist (with consent) about trauma history or psychosis risk before treatment starts [synthesis].

A4. Relaxation and breathing approaches

Purpose / when used: physiotherapists in mental health use progressive muscle relaxation, applied relaxation, autogenic training and breathing work [source: Probst 2017].
What happens: taught by the physiotherapist individually or in groups; specific scripts not given here.
Example language (illustrative): "If the physio teaches you a relaxation or breathing method, bring it here and we can look at when it helps and when it doesn't."
Watch for: relaxation-induced anxiety or panic in some clients [synthesis]; avoid duplicating or contradicting the physiotherapist's method; agree one method between you.

A5. Physical activity and exercise in mental health

Purpose / when used: to address physical health risks in people with mental illness (cardiovascular disease, metabolic syndrome, obesity, partly medication-related) and mental symptoms such as depression and anxiety [source: Probst 2017; IOPTMH page].
What happens (descriptive): the physiotherapist assesses and agrees an individual or group programme. No prescription is given in this guide.
Example language (illustrative): "A physiotherapist can work out with you what kind of activity is safe and realistic for you; that is their expertise, not mine."
Watch for: compulsive or compensatory exercise in eating disorders (CPMH has an eating disorders lead, reflecting this specialist area) [source: CPMH About page; synthesis]; inform the team rather than advising on activity yourself.

A6. Mind-body methods used within physiotherapy

Purpose / when used: Probst (2017) lists yoga, tai chi, qigong, Pilates, mindfulness-based stress reduction and Feldenkrais among methods used in the specialty, and educational systems such as Mensendieck that teach about bodily function and movement patterns.
What happens: delivered by physiotherapists with relevant training; details vary [uncertain].
Example language (illustrative): "If you are drawn to something like tai chi or yoga, the physio can help you find a version that suits your body and health."
Watch for: confusing a registered physiotherapist's programme with unregulated classes; check who is delivering it [synthesis].

A7. Pain neurophysiology education (pain neuroscience education, "Explain Pain")

Purpose / when used: for persistent pain; teaches the biology of pain in plain language, covering the whole body and nervous system with a focus on the brain, including thoughts, attitudes, perceptions and beliefs as well as tissue damage and healing. Pain is presented as an individual response to threat, real or perceived, not necessarily a sign of damage; the approach is described as giving "a biological base to the psychological factors" [source: Noigroup evidence page].
What happens (descriptive): one-to-one sessions, group education, combined with motor control training, exercise classes or aquatic exercise, or a patient book (Explain Pain, Butler and Moseley) [source: Noigroup evidence page]. Noigroup advises that patients can understand this content though professionals often underestimate them.
Example language (illustrative): "The physio may explain that pain is your body's protection system and can stay switched on after tissues have healed. That fits with what we notice here about stress and fear turning the volume up."
Watch for: clients hearing "pain is in your brain" as "it's imaginary"; check understanding and correct this. Evidence is described by Noigroup as supportive but not certain [source: Noigroup evidence page].

A8. Chronic primary pain care as NICE NG193 sets it out

Purpose / when used: adults 16 and over with chronic primary pain (England and Wales guidance).
What NICE says (descriptive): person-centred assessment and a care and support plan (1.1); offer a supervised group exercise programme taking needs, preferences and abilities into account (1.2.1); encourage people to stay active for long-term health (1.2.2); consider ACT or CBT for pain from appropriately trained professionals (1.2.3); do not offer biofeedback (1.2.4); consider a single course of acupuncture or dry needling under stated service conditions (1.2.5); do not offer TENS, ultrasound or interferential therapy (1.2.6); no practice recommendation on manual therapy (research recommendation only) [source: NICE NG193]. NICE also advises against initiating several drug classes for chronic primary pain and asks for shared review of existing use; these are prescriber matters [source: NICE NG193 1.2.10–1.2.12].
Example language (illustrative): "National guidance suggests supervised group exercise and psychological therapy like ours can both help with this kind of pain. Would you like to ask your GP about a physio referral?"
Watch for: clients expecting passive treatments NICE does not recommend; let the physiotherapist discuss options.

A9. Cognitive-behavioural and self-management elements within physiotherapy

Purpose / when used: Probst (2017) describes physiotherapists using goal setting, self-management and relapse prevention within cognitive-behavioural and psychosomatic approaches.
What happens: integrated into the physiotherapy plan; not a substitute for psychotherapy [synthesis].
Example language (illustrative): "Your physio and I are both working on goals and setbacks; let's make sure we are using the same plan."
Watch for: two parallel goal lists that conflict; agree one shared set (see B5).

Part B. The psychotherapist's interventions

All of Part B is [synthesis] built on the sources above unless a source is named.

B1. Recognising when to suggest physiotherapy

Purpose / when to use: when a client's difficulties include movement, persistent pain, deconditioning, physical health risk, or a disturbed relationship with the body that physiotherapy addresses.
Steps: (1) Listen for: persistent pain limiting life; fear of movement or of re-injury; long inactivity in depression or psychosis; physical health risks in serious mental illness [source: Probst 2017]; body image and movement problems in eating disorders [source: Skjærven and Sundal 2016]; tension, breathing and posture problems in anxiety or trauma. (2) Ask what the client has already tried and with whom. (3) Name physiotherapy as an option, including mental health physiotherapy or BBAT where available. (4) If any new, worsening or unexplained physical symptom is present, suggest medical review first.
Example language (illustrative): "A lot of what you describe lives in your body: the pain, the stiffness, not trusting your back. A physiotherapist could look at that side while we work on the rest. How would you feel about that?"
Watch for: clients who hear the suggestion as "you are sending me away"; make clear therapy continues.

B2. Making the referral and checking registration

Purpose: connect the client to a registered practitioner.
Steps: (1) Explain routes: via GP or team, or direct access where available (World Physiotherapy notes physiotherapists can be first-contact practitioners) [source: World Physiotherapy PS 2023]. (2) UK: check the HCPC register; in the US: check the state licence [source: CSP regulation page; FSBPT]. (3) For mental health physiotherapy in the UK, CPMH is the specialist network [source: CPMH]. (4) With written consent, send a short referral note: reason, client goals, relevant mental health context, risk information as needed, how the client prefers to be approached (e.g. touch or trauma considerations), your contact details. (5) Agree with the client what you will and will not share.
Example language (illustrative): "I'd like to send a few lines saying what you're hoping for and that being touched without warning is hard for you. Is that okay, and is there anything you don't want me to include?"
Watch for: practitioners using titles without registration; long waits that erode motivation (plan for the wait in therapy).

B3. Preparing the client for touch, undressing and consent

Purpose: physiotherapy is, in the CSP's words, a "touching" profession often with patients undressed; the CSP advises handling be explained in advance, offering a chaperone before intimate examinations, private undressing, cover such as towels or gowns, and recording chaperone discussions. Family or friends cannot act as chaperones. People with mental health or capacity issues are particularly vulnerable, and therapists are asked to consider how they react to touch and read its intent [source: CSP PD104 2023].
Steps: (1) Ask how the client feels about being examined or touched. (2) Explain what they can expect and what they may ask for: an explanation before any handling, keeping clothes on where possible, a chaperone, a same-gender practitioner if available, pausing or stopping at any time. (3) Rehearse a short phrase to say "stop" or "please explain first." (4) For clients with trauma histories, agree (with consent) to tell the physiotherapist ahead of time. (5) Afterwards, ask how it went.
Example language (illustrative): "You can ask the physio to explain before touching, keep your clothes on where possible, have a chaperone, or stop at any time. Would it help to practise how you'd say that?"
Watch for: freezing or dissociation during examination; an unexplained intimate examination or unclear boundaries, which should be raised through the service's complaints route and, if serious, the regulator [synthesis; HCPC conduct standards apply to registrants, source: CSP HCPC standards page; HCPC proficiency standards 2.6 and 2.11 require relationships based on respect and trust and no abuse of the power imbalance, source: HCPC Standards of proficiency].

B4. Psychoeducation aligned with pain science

Purpose: reinforce, not contradict, the physiotherapist's pain explanation.
Steps: (1) Ask the client what they were told about their pain. (2) Check for misreadings ("it's imaginary"). (3) Link pain-as-protection [source: Noigroup] to what you see in sessions: stress, sleep, mood and fear raising pain. (4) Encourage the client to bring questions about tissues, movement and safety to the physiotherapist.
Example language (illustrative): "Pain being real and pain being influenced by fear can both be true. What did your physio say that made sense, and what didn't?"
Watch for: your own drift into giving movement advice; stop and route it back.

B5. Collaborative care and information sharing

Purpose: physiotherapists in mental health work in multidisciplinary teams [source: Probst 2017; IOPTMH page].
Steps: (1) With consent, agree a contact plan (e.g. a short update at the start, midway and at discharge). (2) Agree shared goals in the client's words, aligned with the physiotherapy plan [source: NICE NG193 1.1.17]. (3) Agree shared language (e.g. "pacing", "setback plan") so the client hears one message. (4) Clarify roles: the physiotherapist leads on movement and activity; you lead on psychological work. (5) Record contacts.
Example language (illustrative, to colleague): "She's working with me on fear of flare-ups; could we use the same setback plan so she isn't getting two versions?"
Watch for: role drift on either side; mixed messages.

B6. Integrating body awareness work into psychotherapy

Purpose: BBAT gives weight to reflective dialogue about movement experience [source: Skjærven and Sundal 2016]; psychotherapy can extend that reflection.
Steps: (1) Invite the client to describe what they noticed in physiotherapy (steadiness, breathing, feelings). (2) Explore meanings and links to emotions, memories and relationships. (3) Note what they want to continue at home (their diary, if they use one). (4) Avoid teaching the movements yourself unless you hold the relevant training.
Example language (illustrative): "You said you felt 'more solid' standing at the end of the session. When else have you felt like that?"
Watch for: emergence of trauma material; pace and stabilise in therapy.

B7. Integrating psychological therapy for pain

Purpose: NICE recommends considering ACT or CBT for chronic primary pain alongside supervised group exercise [source: NICE NG193 1.2.1, 1.2.3].
Steps: (1) If trained, offer ACT or CBT for pain (see those guides). (2) Coordinate timing so the client is not overloaded. (3) Use physiotherapy goals as valued-action or behavioural-experiment material, in agreement with the physiotherapist.
Example language (illustrative): "Your physio is helping your body do more; here we can work on what gets in the way, like the worry that you'll pay for it later."
Watch for: overlapping homework; agree one plan.

B8. Engagement, ambivalence and fear of movement

Purpose: support attendance and engagement without advising on exercise.
Steps: (1) Explore ambivalence (hopes, fears, past bad experiences). (2) Identify barriers (pain fear, shame about the body, low mood, practicalities). (3) Encourage the client to raise concerns about pain or exercise with the physiotherapist. (4) Never tell the client to do more, less, or to push through pain.
Example language (illustrative): "It sounds like part of you wants to go and part of you dreads it. What would make it easier to tell your physio how you really feel?"
Watch for: missed appointments after a painful session; discuss with consent.

B9. Monitoring and passing on concerns

Purpose: you may be the first to hear of warning signs.
Steps: (1) Pass on (with consent, or under safeguarding duties without it where required): new or worsening physical symptoms, injuries, falls, signs of compulsive exercise or medical instability in eating disorders, and reports of inappropriate touch. (2) Urgent or alarming symptoms: urge immediate medical care. (3) Questions about pain medicines go to the prescriber [source: NICE NG193 1.2.10–1.2.12].
Example language (illustrative): "That's something your GP needs to know about this week. Shall we call now, together?"
Watch for: suicidality linked to pain; follow your service's standard risk assessment and safety planning.

B10. Support after discharge

Purpose: NICE emphasises activity the person can keep up after a formal programme ends [source: NICE NG193 1.2.2 rationale].
Steps: (1) Review what the client learned and found helpful. (2) Build a maintenance and setback plan in their own words, based on the physiotherapist's advice. (3) Agree when to seek re-referral.
Example language (illustrative): "What from physio do you want to keep, and what would tell you it's time to go back?"
Watch for: loss of gains after discharge; low mood returning with inactivity.

5. Handling problems

The sources cited do not address the psychotherapist's problems in this collaboration; everything below is [synthesis] except where a source is named.

Client refuses physiotherapy ("I've tried physio, it made it worse"). Explore what happened (being pushed, not believed, painful handling). Distinguish that experience from approaches such as mental health physiotherapy, BBAT or pain education. Respect a no; revisit later if goals change.
Fear of movement or of flare-ups blocks engagement. Work on the fear psychologically (see B7, B8); ask the client to tell the physiotherapist directly so the plan can be adjusted. Do not reassure that a movement is safe; that is the physiotherapist's judgement.
Client stuck: "Physio isn't helping." Check what goals were agreed, whether the client has said this to the physiotherapist, and whether psychological barriers (low mood, shame, avoidance) are interfering. Suggest a review conversation with the physiotherapist. World Physiotherapy frames discharge around goals met or no further benefit [source: World Physiotherapy PS 2023], so stopping can be a legitimate outcome.
Non-adherence to home practice. Explore meaning (overwhelm, perfectionism, pain fear) rather than urging compliance; link practice to the client's values; encourage them to renegotiate the plan with the physiotherapist.
Overwhelm or dissociation in body awareness or breathing work. Help the client recognise early signs and agree a stop signal; with consent, inform the physiotherapist so pacing can change; stabilise in therapy. Skjærven and Sundal note BBAT is not for everyone [source: Skjærven and Sundal 2016].
Distress about touch or an examination. Validate; clarify what happened. If touch was explained and consented, help the client process it and plan for next time (B3). If handling was unexplained, intimate without a chaperone offer, or boundaries seemed crossed, support the client to raise it with the service; serious concerns can go to the regulator (HCPC in the UK; the state licensing board in the US). CSP guidance stresses advance explanation, chaperone offers and documentation [source: CSP PD104 2023].
Mixed messages between professionals (e.g. you encourage pacing while the physio encourages graded increases). Contact the physiotherapist with consent and agree one framework and shared words. Defer on activity content to the physiotherapist.
Rupture with you ("you think it's all in my head"). Acknowledge; restate a biopsychosocial view where pain and distress are both real [source: Noigroup; IOPTMH page]; ask what made it sound dismissive.
Rupture with the physiotherapist. Help the client name what went wrong; support them to raise it or request another practitioner; avoid taking sides.
Requests for exercise advice from you. Decline kindly and route to the physiotherapist or GP; you can help the client prepare questions.
Questions about pain medicines or wanting to stop them. Route to the prescriber; NICE asks for shared decision-making on existing medicines and discusses withdrawal problems, which is the prescriber's role [source: NICE NG193 1.2.11–1.2.12].
Eating disorders: exercise as compensation. Raise with the treating team; do not set or endorse activity levels yourself. CPMH recognises eating disorders as a specialist physiotherapy area [source: CPMH].
Serious mental illness and physical health neglect. Treat physical health as part of care; support referral and attendance; share concerns with the care team [source: Probst 2017].
Unregistered or unclear practitioners offering "body work" under a physio-like title. Check the register; in the UK, "physiotherapist" and "physical therapist" are protected titles [source: CSP regulation page; HCPC 2018 notice]. Specialist labels are not always protected: in Norway, "psykomotoriker" was not a protected title [source: Bunkan 2001], so check the underlying physiotherapy registration [synthesis].
Risk. Pain and loss of function can raise suicide risk; follow standard risk assessment and safety planning, and share with the team under your service's policies.

Sources

Online sources:

Books cited (details as listed on the Noigroup evidence page):

Butler DS, Moseley GL (2013). Explain Pain, 2nd edition. Noigroup Publications.
Butler DS (2000). The Sensitive Nervous System. Noigroup Publications.

UK protected titles, HCPC registration and Standards of proficiency, CSP consent guidance, US licensure (APTA, FSBPT), IOPTMH's status and history (via World Physiotherapy and its 2018 newsletter), Norwegian psychomotor physiotherapy and BBAM training rest on the pages listed above. Still [uncertain]: details that only IOPTMH's own website, the CSP Commissioning mental health services document or the International Association of Teachers in BBAT would confirm, and a typical length for a general physiotherapy episode.

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