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The Arts in Psychotherapy 47 (2016) 55–65

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The Arts in Psychotherapy

linical outcomes from The BodyMind ApproachTM in the treatment of atients with medically unexplained symptoms in primary health are in England: Practice-based evidence

elen Payne, MPhil, PhD, UKCP Reg. Psychotherapist, ADMP UK, AVR a,∗, usan D.M. Brooks, BSc, MA, MA, MBA b

School of Education, University of Hertfordshire, De Havilland Campus, Hatfield, Hertfordshire AL10 9EU, England, United Kingdom Pathways2wellbeing, 27 Bridge Street, Hitchin, Herts SG5 2DF, England, United Kingdom

r t i c l e i n f o

rticle history: vailable online 18 December 2015

eywords: he BodyMind ApproachTM

edically unexplained symptoms rimary care ractice-based evidence

a b s t r a c t

This article builds on Payne (2015) and reports on practice-based evidence arising out of the delivery of a new and innovative service using The BodyMind ApproachTM (TBMA) for the treatment of patients with medically unexplained symptoms (MUS) in primary care in the National Health Service (NHS) in Hertfordshire, a county near London, England, in the UK. The analysis of data collected for three groups (N = 16) over 18 months used standardised assessment tools and other relevant information at pre, post and at a 6 month follow up. The outcomes for patients in this small scale piece of practice based evidence indicated that there were reductions in symptom distress, anxiety and depression, increased overall wellbeing and improvement in activity levels. Patients developed self-management of their symptoms through understanding, acceptance and coping strategies. The increased knowledge, exchange of expe- riences together with understanding and acceptance from others promoted a sense of wellbeing. Thus,

the programme was experienced to be a beneficial intervention. In addition to the clinical outcomes reported here there are other benefits for NHS England for example, savings on medication and referral costs and General Practitioner (GP) capacity enhanced. The clinical service is based on previous research conducted by Payne and Stott (2010). This article focusses solely on the analysis and interpretation of clinical outcomes from the practice-based evidence.

ntroduction

The innovative clinical service reported in this article is being ffered to primary care patients with medically unexplained symp- oms (MUS) through the National Health Service (NHS) in a county n England. Edwards, Stern, Clarke, Ivbijaro, and Kasney (2010) efine MUS as ‘a clinical and social predicament, includes broad pectrum of presentations, difficulty accounting for symptoms ased on known pathology’ (p. 1). They go on to say in Diagnos- ic and Statistical Manual for Mental Disorders (DSM IV-TR) that

he nomenclature for MUS has several categories including soma- isation disorder, conversion disorder, pain disorder, and that the riteria is cumbersome and unhelpful in practice.

∗ Corresponding author. Tel.: +44 1707 285861. E-mail addresses: [email protected] (H. Payne),

[email protected] (S.D.M. Brooks). URLs: http://www.herts.ac.uk (H. Payne),

ttp://www.pathways2wellbeing.com (S.D.M. Brooks).

ttp://dx.doi.org/10.1016/j.aip.2015.12.001 197-4556/© 2015 Elsevier Ltd. All rights reserved.

© 2015 Elsevier Ltd. All rights reserved.

Both the DSM-5 and the proposed International Classification of Diseases – 11th Revision (ICD-11) change the criteria for MUS and replace the term by Somatic Symptom and Related Disorders (SSD). In DSM-5 F45.1 SSD is cross-walked to ICD9 code 300.82 (ICD10-CM F45.1). SSD is defined in DSM-5 as symptoms that are distressing or result in significant disruption to feeling, thoughts and behaviour, related to somatic symptoms as manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms, or persistently high lev- els of anxiety about health symptoms and excessive time and energy devoted to these symptoms of health concerns (Diagnostic and Statistical Manual of Mental Disorders-5, 2013). It states that somatic symptom and related disorders includes the diagnoses of somatic symptom disorder, illness anxiety disorder, conversion dis- order (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder other

specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. All of the disorders share a common feature: the prominence of somatic symptoms associ- ated with significant distress and impairment. Such patients are

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ommonly found in primary care and less encountered in mental ealth settings. The term is thought to be more useful than that of US in primary care (Creed et al., 2010). SSD includes the former somatisation disorder, undifferenti-

ted somatoform disorder, and pain disorder. The change is that he diagnostic criteria are no longer based on the presence of

US, but focuses on one or more somatic symptoms that are dis- ressing and/or result in significant disruption of everyday life. lthough there are criticisms (Frances, 2013; Voigt et al., 2012)

his change removes the diagnostic problem of having to distin- uish between medically explained and unexplained symptoms Creed et al., 2010). The shortcomings of the MUS category is he mind-body dualism present in the unreliable classification of omplaints as medically explained or not (Creed, 2009; Sharpe, ayou, & Walker, 2006) and the random categorisation into dif-

erent somatoform disorders (Leiknes, Finset, Moum, & Sandanger, 008).

This dualism reinforces the GP training to address physical ather than mental health issues and the patient’s perception that heir symptom is purely physical because of the sensory experi- nce. It reinforces dualistic thinking and the idea that illness is ither biological or psychological. The term defines the illness by hat it is not, i.e. it implies no organic cause which is not neces-

arily accurate and limits treatment. Research has shown that most atients prefer a positive description of symptoms, i.e. an explana- ion of what it is rather than what it is not. The term MUS may seem lib communicating that nothing can be done. Cognitive Behaviour herapy (CBT) with relaxation and/or graded exercise has some ffectiveness for some symptoms (Whiting et al., 2001). Although sychological treatment may work in some cases this does not eflect that the symptoms are necessarily psychological (Creed, enningsen, & Fink, 2011). Other terms in use in a Department f Health (DH) recent document on MUS (DH, 2014) are claimed o be more acceptable to patients such as persistent physical symp- oms or functional syndromes/symptoms (FS) (Stone et al., 2002). The erm “functional” here is used because it is assumed that the disor- er is one of function, which may be physical and/or psychosocial unction, rather than anatomical structure (Sharpe, 2000).

The clinical outcomes of TBMA as a treatment reported here are ased upon the definition and criteria for MUS used in DSMIV, i.e. efore the changes made with reference to MUS in DSM-5.

The treatment service is delivered in the English NHS primary are setting by a University of Hertfordshire spin-out company athways2Wellbeing (P2W)TM. Primary care in the NHS refers to he first port of call for patients in the community which involves Ps working in local practices. Secondary care involves hospitals nd other medical establishments or treatments to which GPs refer atients. GPs act as the access, by way of referral, to any specialist

nterventions in either primary or secondary care. The treatment ervice offered by P2W is called Symptoms Groups to patients and he MUS Clinic to the GPs referring patients with various medically nexplained symptoms (such as fibromyalgia, IBS, chronic pain or hronic fatigue) from primary care. At no time is the term MUS used ith patients.

The groups use TBMA, which is based on a bio-psychosocial odel derived from aspects of interpersonal therapy, embodied

roup psychotherapy (dance movement psychotherapy/authentic ovement), the arts and mindfulness. It is not designed as a form of

sychotherapy, but an adaptation for non-psychologically minded atients deriving from an integration of the above. The groups are alled workshops and the treatment is a course. This approach has een hitherto researched and delivered as a service in the NHS

ith patients with medically unexplained symptoms (MUS) (pre-

iously termed psychosomatic conditions). These patients have ery limited pathways for supporting their wellbeing in primary are and are high health utilisers (Bermingham, Cohen, Hague, &

sychotherapy 47 (2016) 55–65

Parsonage, 2010). They suffer with chronic, physical symptoms or conditions which do not appear to have an organic, medical diagno- sis and normally with co-occurring anxiety and/or depression. The negative impact of the conditions and lack of curative treatments means effective non-pharmacological interventions that promote better coping abilities need to be developed.

TBMA treatment aims to bridge the gap between mental and physical health services for these patients with chronic MUS. It uses the inter-relationship between body and mind for the treat- ment of such patients with these persistent symptoms. Further details on the approach can be found in Payne (2015) and Lin and Payne (2014). The University’s newly endorsed company P2W is the vehicle for the service with the knowledge arising from the pilot research being transferred into a real world service delivery as clinical progress reporting. This recent service delivery project (2012–2013) was funded by the DH initiative Quality, Innova- tion, Productivity and Prevention (QIPP) scheme in a competitive bid from the authors and Hertfordshire Primary Care Trust (Men- tal Health). The delivery took place in community settings with patients referred by GPs from primary care. The service was free at the point of delivery. The naturalistic delivery and the lessons learned from the experience are documented in Payne (2015). This article focusses solely on an evaluation of the clinical outcomes for the patients from a small scale implementation of TBMA in the NHS. The small sample size (N = 16) and the lack of a control arm means that the outcomes cannot be generalised with any confi- dence. However, the indicative outcomes which are very positive are consistent with a previous pilot study conducted at the Univer- sity of Hertfordshire (Payne & Stott, 2010) and may be transferable.

Medically unexplained symptoms

Patients with chronic MUS (presenting for over 6 months with the same symptom/s) are quite complex and are high health utilisers for whom there are few pathways for support and self- management other than (for a few symptoms) CBT and/or pain relief. In a recent practice guideline published by the UK DH, (July 2014) as a part of Improving Access to Psychological Therapies (IAPT) initiative, it is concluded that “community mental health teams and primary care mental health services have not been suc- cessful in engaging with patients experiencing MUS, as patients often do not perceive their condition to be related to mental health problems, and attempting to engage them in traditional mental health approaches is often ineffective” (DH, 2014, p. 5).

Therefore to review the research on self-management in CBT is not relevant to the purpose of this article.

A systematic review of research (Du et al., 2011) was conducted for the self-management programmes on pain and disability for chronic musculoskeletal pain conditions (not necessarily MUS). For chronic back pain, there was insufficient evidence to deter- mine the effectiveness of self-management programmes. In a more recent review (Oliveira et al., 2012) for non-specific low back pain results showed moderate-quality evidence that self-management has small effects on pain and disability which challenge the endorsement of self-management in treatment guidelines.

MUS patients are high utilisers of health care resources. In 2008–2009 approximately £3 billion was spent on patients with MUS in the NHS (11% of total budget) rising to £18 billion includ- ing the cost to the wider economy through lost productivity (Bermingham et al., 2010).

No serious medical cause was the diagnosis in 25–50% of all pri-

mary care visits (Barsky & Borus, 1995) and only 10–15% of the 14 common, physical symptoms seen in half of GP consultations over 12 months were found to be caused by an organic illness (Morriss, Dowrick, & Salmon, 2007), resulting in 85–90% being of

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nknown biological aetiology. These patients are often taking med- cation, regularly visit health professionals (more than five times er year) and for longer consultations than the 11 min per visit er symptom allowable in the NHS. Furthermore, they use many esources accounting for as many as one in five new consultations Bridges & Goldberg, 1985). They frequently have high cost referrals o secondary care for tests and scans and usually present with anx- ety and/or depression, which is understandable (Aguera, Failde, ervilla, Diaz-Fernandez, & Mico, 2010; Simon, VonKorff, Piccinelli, ullerton, & Ormel, 1999).

Dimsdale, Sharma, and Sharpe (2011) showed that although US/somatoform disorders are common, for those health pro-

essionals seeing such patients there is considerable confusion egarding the diagnostic terminology and a reluctance to use hese diagnostic labels. For example, GPs rarely use the terms

US or somatoform disorder to their patients, instead diagnosing bromyalgia, ME, IBS, chronic fatigue, etc. Neither do GPs routinely se the ICD-10 subcategories of various somatoform disorders. onsequently, in the experience of the authors the specific number f this huge population in each GP practice is hidden from the GP ractice database. However, GPs can identify those known as heart- ink, frequent flyer and fat file patients whom they refer to the MUS linic. As a result of a systemic lack of classification many patients ho have MUS/somatoform disorder are not able to be identified

o receive the support of the MUS Clinic. Grover et al. (2014) found no significant differences between

he various subcategories of somatoform disorders with regard o the prevalence of somatic symptoms (including somatoform ain disorder), anxiety or depression and psychological correlates f alexithymia, hypochondriasis and somato-sensory amplifica- ion. Their findings also supported the co-occurrence of anxiety nd depression in two-thirds of this population. Anxiety disor- er (formally hypochondriasis) or functional neurological disorder formally conversion) may also be diagnosed.

Khan, Khan, and Harezlak (2003) call for better management trategies to be developed in primary care for prevalent, medically nexplained, persistent somatic symptoms which are a health care riority and a long-term condition. Currently patients either attend hysical or mental health services and the treatment is separately elivered as medication/pain management or psychological ther- pies, respectively. This system is unhelpful to the patient since t splits off mental from physical health aspects. In England, CBT or three conditions: IBS; chronic fatigue and fibromyalgia, has een found to help mental health in the short term and encour- ged through a government initiative called Improving Access to sychological Therapies (IAPT) which also targets people with long- erm conditions in which MUS can be categorised. However, only a hird of MUS patients with varied symptoms attend this treatment Hague, 2008), probably due to their physical explanation for their ymptoms and the stigma attached to mental health services. Thus t seems CBT is unacceptable to this patient population, they require n accessible and integrated approach which acknowledges their odily based physical experience whilst exploring this at emotional nd cognitive levels.

he research on which TBMA is founded

A pilot study into the TBMA intervention took place near Lon- on, England in 2005–20071 (Payne, 2009; Payne & Stott, 2010).

rom these earlier research studies, specifically the proof of concept ilot study (Payne & Stott, 2010), patient benefits from TBMA inter- ention were improved wellbeing and activity levels; decreased

1 Funded by the East of England Development Fund and The University of Hert- ordshire.

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symptom/anxiety/depression levels; improved self-management of symptoms; and lower or stabilised medication levels. For GPs the benefits included reduced attendance at GPs and/or hospitals and reduced costs of medication.

Furthermore, a previous health economic analysis of TBMA com- pared with CBT showed that the cost savings would be large in primary care but that secondary care they would be even greater (Payne & Fordham, 2008) the findings of which are supported by a report from the DH (2012). Thus this evidence makes TBMA courses attractive for the NHS due to the current austerity situation in England.

Following extensive consultation with primary care GPs in a market research study by Payne, Eskioglou, and Story (2009), funded by the East of England Development Agency, a need was identified by the GPs for a pathway for the treatment and sup- port of this patient population, for most of whom they thought CBT/psychological therapies was inaccessible and/or inappropriate. In support of the lack of accessibility for patients of psychological therapies and/or referrals from GPs psychologists in IAPT com- plained that they were not getting enough referrals from GPs. When TBMA was described to these GPs in a focus group (and later in the QIPP project) as a possible pathway it was welcomed enthusiasti- cally as being more acceptable and providing choice for patients.

The pilot study led to the development of a manual for the delivery of TBMA by experienced and qualified Masters level dance movement psychotherapists trained in TBMA by path- ways2wellbeing. This manual is not a recipe for sessions but rather offers nudges for the planning, specific themes which need to be covered and when and for the conducting of group sessions. The mind-set/attitude of the facilitator is described as the most impor- tant ingredient for promoting change. The facilitator is encouraged to be mindful, sensitive, adapting practices to each group’s needs, ensuring interventions, aims and outcomes are explained clearly to patients and addressing needs as they arise rather than being prescriptive. The manual content gives examples of sessions and case studies, emphasising the facilitator’s competencies expected. The manual was further refined as the QIPP service delivery was conducted in an evaluation by the facilitators during the delivery, and no doubt it will be honed still further with each new delivery of the groups by more facilitators.

As well as the manual being continuously updated TBMA is being evaluated as an on-going process during delivery of the service. Manuals developed for conducting psychological therapies in research studies are not widely distributed and their contents do not appear to have been evaluated (Payne, Westland, Karkou, & Warneke, 2014). Research findings based on the application of treatment manuals have led to the endorsement of psychological treatments based on the use of brand names, e.g. Body Orien- tated Psychotherapy, CBT or Interpersonal Therapy. Endorsing brand-named treatments assumes they are practised in a man- ner consistent with the research treatment manuals but without evidence to support this assertion. In this service delivery treat- ment integrity has been ensured by a triangulation (a three-way comparative analysis) between what patients have said about their experience of the approach what the facilitator says she did in the pilot study (Payne, 2009), and the manual which will continue to be evaluated by the facilitators and by expert opinion evaluators external to the delivery.

The BodyMind ApproachTM

There are many different definitions of psychotherapy, for example ‘The treatment of disorders of the mind or personal- ity by psychological methods’ (Oxford English Dictionary, 2015) or ‘the informed and intentional application of clinical methods

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nd interpersonal stances derived from established psychologi- al principles for the purpose of assisting people to modify their ehaviours, cognitions, emotions, and/or other personal character-

stics in directions that the participants deem desirable’ (Campbell, orcross, Vasquez, & Kaslow, 2013, p. 98). It is normally the

esponse to specific or non-specific signs of clinically diagnosable nd/or existential crises, often dubbed talking therapy aiming to elp clients to fulfil their potential or cope better with the emo- ional problems of life.

Whilst TBMA is not psychotherapy in the narrow definition of he term it has its roots in a psychotherapy school of thought. It orks not only with the mind, emotions and cognition but also ith the physical symptoms, it is a bio-psychosocial model.

TBMA can be seen as one solution to the problem of patients with US. It has been designed specifically to be accessible to this patient

opulation and to provide choice. It aims towards integrating body nd mind, starting with the bodily symptom and its sensory expe- ience to promote self-management and wellbeing in people with hronic MUS. It employs somatic mindfulness (or bodymindful- ess) – movement, a moment-to-moment awareness of the body

n motion or stillness, from the discipline of Authentic Movement Adler, 2002; Chodorow, 1992; Payne, 2006; Whitehouse, 1999) hich is sometimes employed in dance movement psychotherapy. uthentic movement is where the mover moves spontaneously ith eyes closed/downwardly focussed in the presence of a wit- ess. In TBMA authentic movement is coupled with mindfulness ractices, adapted to be accessible to people with persistent symp- oms employing simple practices scaffolding them into elements f the final form. There is no pressure to engage with anything ith which patients might be uncomfortable. The facilitator always

ffers alternatives and choices. Kabat-Zinn (1982), Kabat-Zinn, Lipworth, and Burney (1985)

nd Kabat-Zinn, Lipworth, Burney, and Sellers (1986) pioneered the evelopment of mindfulness meditation with patients with chronic ain and a mindfulness stress reduction programme for psoriasis Kabat-Zinn et al., 1998) as well as applying it to patients with anxi- ty (Miller, Fletcher, & Kabat-Zinn, 1995). Since then there has been

prolific study of mindfulness. It has been shown to reduce depres- ion as well as anxiety. Hofmann, Sawyer, Witt, and Oh (2010) onducted a meta-analysis of 39 studies that explored the use f mindfulness-based stress reduction. The researchers concluded hat mindfulness-based therapy may be useful in altering affec- ive and self-regulatory processes that underlie multiple clinical ssues particularly anxiety and/or depression. Others have sup- orted these findings, for example, Vøllestad, Nielsen, and Nielsen 2012), Roemer et al. (2009) and an earlier study by Grossman, ieman, Schmidt, and Walach (2004). A systematic review con- ucted by Sharma and Rush (2014) found that out of 17 studies ombining mindfulness meditation and yoga 16 demonstrated pos- tive changes in psychological or physiological outcomes related o anxiety and/or stress. Williams (2008) reviewed four stud- es showing a correlation between measures of mindfulness as a rait and cognitive features of depressive vulnerability, specifically ecreased rumination, avoidance of internal experiences and an

ncrease in the relinquishment of negative thoughts and unattain- ble goals. Other studies demonstrate that a mindful or experiential ode of self-attention in depressed subjects is relatively more

onducive to both improved memory for autobiographical events Watkins & Teasdale, 2004) and improved problem solving ability Watkins & Moulds, 2005).

Nevertheless none of these approaches address the lived bodily elt sensory experience from a phenomenological perspective

r address the importance of body awareness as a vehicle for hange. The subjective experiencing body (Gallagher & Zahavi, 007), whether engaging with the world’s affordances (Gibson, 979) through the tactile sense, movement or in stillness, is

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the fundamental basis for all feelings, sensations, perceptions or object manipulation which in turn actively underlies cognition and meaning-making (Dewey, 1991; Merleau-Ponty, 1962, 1965). There is thus an integration of physical and mental aspects, per- ception and action, doing and being. TBMA builds on this notion of the body functioning as a dynamic constituent of the mind rather than serving the mind. This enactive, subjectively body-felt sense, as described by Gendlin (1982), expresses basic mean- ing from a sensory–motor modality and reflects the individual’s life history and current situation. It is pre-verbal and prelimi- nary to habitual/pre-conceptual/abstract thinking patterns. During TBMA the body is therefore experienced from inside-out, as a lived container of sensations, images, thoughts and feelings, etc. Joint attention with the facilitator or another participant as wit- ness extends the experience as reflections are embodied from the outside-in as well. This opportunity to experience the connection between the body and mind whilst doing/being it opens up possi- bilities for new discoveries about the nature, and the meaning of, symptoms as located in the bodymind. This is an embodied way of knowing (Panhofer & Payne, 2011), contrasting with conceptual knowing.

Several disciplines cultivate mindfulness, such as yoga, tai chi and qigong, although most of the research literature has concen- trated on mindfulness developed through mindfulness meditation. This self-regulation practice trains attention and awareness to bring mental processes under greater voluntary control thereby promoting wellbeing and/or capacities such as calmness, clarity and concentration (Walsh & Shapiro, 2006).

Mindfulness refers to a psychological state of awareness, the practices that promote this awareness, a mode of processing information and a character trait and can be defined as a moment- to-moment awareness of one’s experience without judgement. In this sense, mindfulness is a state and not a trait. While it might be promoted by certain practices or activities, such as meditation, it is not necessarily synonymous with them. TBMA by using kinetic mindful practices engages with the patient’s attention to, and rela- tionship with, their bodily symptoms (including pain), for example by exploring the sensory experiences, and engaging in action-based inquiry such as examining the nature and purpose of the symptoms. This mindful relationship to the body and symptoms helps patients become less attached to/identified with their symptoms as well as less reactive to them which diminishes their experience of them.

TBMA coaches patients through exercises involving postures and movement, breath and voice, mindfulness and body aware- ness. Practicing such exploratory exercises regularly in the group session (and at home) the patient may regain balance and self- regulation. For example, practising focussing on the breath (or the symptoms), then noticing any thoughts, images or bodily sensa- tions, followed by re-focussing on the breath, and then reflecting on the experience through the creative arts thus nurturing a deep awareness of the body. By putting difficult emotions and sensations in a bodily context an indication of a new perspective and accom- panying meanings can be gained. By holding all these aspects, including pain, in direct sensory awareness metaphor/imagery can be generated spontaneously. These can be drawn, made out of clay or written about in a personal journal often leading to further meaning-making and understanding of the role/nature/purpose of the symptoms. Participants are engaged in synchronous, effort- ful movement together in a circle (accompanied by music or not) which has been shown to reduce pain and act as a way to increase group cohesion (Tarr, Launay, Cohen, & Dunbar, 2015).

TBMA helps patients to connect cognitive and emotional aspects

with reference to their sensory/bodily states through the enact- ment of expressive movement in structured exercises. Cognitive activities are inseparable from the body as the brain takes an impor- tant part in intentionality which involves the process of perceiving

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nd meaning-making (Koch, Caldwell, & Fuchs, 2013; Mills, 2005). here is no explicit involvement of any underlying psychological onflicts or the interpretation/identification (or subsequent modi- cation of) unhelpful thought patterns. Patients learn to notice their odily signals and explore their symptoms often without the need or verbalisation (McWhinney, Epstein, & Freeman, 1997), thoughts hange as a result of the embodied experience.

TBMA differs significantly from CBT in that it focuses on the hysical symptom within an experiential inquiry-led learning ramework to support patients to live well and cope better in a

ore meaningful way. There is an evidence base for the practice f CBT with some specific conditions included in the MUS cate- ory, e.g. IBS (Mahvi-Shirazi, Fathi-Ashtian, Rasoolzade-Tabatabaei,

Amini, 2012) and fibromyalgia (Woolfolk, Allen, & Apter, 2012) ut the method does not address the body-felt sensory experience f the symptoms, favouring solely the mental aspects of depres- ion and/or anxiety. CBT has been researched in large trials and s recommended by the National Institute for Clinical and Health are Excellence (NICE) for chronic fatigue and fibromyalgia. How- ver, patients and GPs in the service delivery reported in this rticle spoke about patients’ reluctance to attend anything con- erned with psychological/mental ill health, etc. There is evidence Sartorius, 2007) to suggest that these patients are very wary of he stigma attached to any mental health label. It can be concluded hat patients with MUS may be less willing to access CBT as they elieve they have an organic cause rather than give a psycholog-

cal explanation for their symptoms. Allen and Woolfolk (2010) nd Gonzalez, Williams, Noel, and Lee (2005) demonstrate that this atient population are often resistant to CBT.

In contrast TBMA is not presented to patients as a psychological herapy. It allows patients in the early phase to concentrate on their ensory experience and action patterns involved in the symptom. owever, there is often a subtle psychological component to the

reatment discovered by the patient later in the process. Hence atients do not concern themselves with the question of stigma

n relation to participating in the treatment. Furthermore, TBMA ddresses a range of symptoms and the symptom itself. It can nclude a number of different symptoms for a number of patients n the same group, together with various accompanying aetiology uch as alexithymia (Ogrodniczuk, Joyce, & Piper, 2013), in which here is confusion between emotions and bodily experiences, poor ffect regulation and a fearful/insecure attachment style (Payne, 016).

In TBMA the patient directs her/his attention to inner expe- iences of self, actively reflecting and commenting on bodily ensations as they are raised into awareness. Gradually participants ecome more connected to their embodied, direct experience of elf. A more positive re-association with the body emerges which as often become dissociated due to the patient’s symptom distress.

n embracing the wisdom held by the symptom through the embod- ed, enactive dream state the patient enters into a more meaningful ialogue with their body. Levy Berg, Sandahl, and Bullington (2010)

n a study of patient perspectives of the process of change in ffect-focussed body psychotherapy for generalised anxiety disor- er found that ‘getting in touch with one’s body’ was a key (p. 151). his in turn gave rise to feelings of being in control, for example oticing bodily signals such as muscular tension and being able to

nfluence them, and understanding the link between bodily symp- oms and emotions. They found that patients managed to integrate odily feelings into their perception of themselves resulting in a eeper experience of their lived body.

tructure of the TBMA course

TBMA groups are short term for up to 12 patients per group; here are three groups per programme. Each session is two hours

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for 12 sessions over 10 weeks as in brief therapy (Yalom & Leszcz, 2005). Groups are run locally in a suitable community setting. Following the groups in phase one, in phase two, and over the following 6 months contact is maintained. For example, a self- addressed letter written by the participant in session 12 is sent 8 weeks after the end of the group, as is a letter personalised for each participant written by their facilitator in month three after the end of the group. Finally, a text/email message is sent asking how they are doing, and, if indicated by their response to the question, in month nine, a referral to a self-help group is made, otherwise a discharge letter is sent to their GP.

Practice-based evidence

As well as the traditional trials in the evidence-based practice paradigm another form of evidence is being derived from natural- istic practice settings termed practice-based evidence (Barkham & Mellor-Clark, 2000).

Practice-based evidence is described by Guy, Thomas, Stephenson, and Loewenthal (2011) as complementary to the quantitative, and dominant, randomised control trial-based approach to evidence. A United Kingdom Council for Psychother- apy (UKCP) report (Ryan & Morgan, 2004, cited in Thomas, Stephenson, & Loewenthal, 2006) suggests that practitioners and service users need to be given a voice, acknowledging that they have direct knowledge and experience of what works and alter- natively what needs to change, and how. Practice-based evidence can give them these opportunities.

P2W employs this practice-based methodology, albeit with smaller numbers. It contrasts with evidence-based practice in that it starts with practitioners and patients in real-world settings and builds up the evidence rather than as with the traditional top down evidence-based medical paradigm. Furthermore, it uses national/common psychological therapies and primary care out- come measures such as PHQ9 for measuring depression. Patient evaluations of experience and outcomes form an important part of the evidence. Additionally, it is using real-world patients electing to participate in the treatment group, rather than selected samples willing to participate in research to which they would be blindly allocated to either the treatment/treatment as usual without exert- ing any choice.

With this practice-based methodology and its evaluation using qualitative and quantitative patient feedback and the standardised psychological assessment tools there is an opportunity to build an evidence base rooted in routine service delivery. This could com- plement the Cochrane data base2 and together with it, yield a more robust knowledge base for the psychological/arts therapies.

This methodology values expert opinion and acknowledges the need to adjust practice according to the needs and preferences of the client and their socio-economic background. This complemen- tary paradigm of practice-based evidence also provides a means for practitioners to own and generate an evidence base embedded in routine practice. Both paradigms are needed as the aim for all practitioners and researchers alike is best practice.

Description of patients in the sample

Ethnicity: White British – 10; Chinese – 2; Indian – 4 (we do not know if born in Britain from this background or if their country of

2 An international not-for-profit organisation preparing maintaining and promot- ing the accessibility of systematic reviews of the effects of health care.

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hospital visits and improvement in their social support. For the majority of patients’ depression scores were mild or

moderate reducing to zero, one patient reduced in her score from severe to moderate. The literature (Löwe, Spitzer, Williams,

0 20 40 60 80

Percent age Improveme nt

Percentage Im proveme nt

0 H. Payne, S.D.M. Brooks / The Ar

ssessment to follow up at 6 months. This reflects the literature hereby more women than men somatise.

Age distribution: Results from this small sample of 16 suggest hat adults of all ages are likely to experience MUS. The biggest ge group category was the 50–59 year olds (5/16 were from this ategory). The youngest patient was just below 20 years of age and he eldest patient was over 80 years old.

Number of patients in each group: Group 1: four; Group 2: six; roup 3; six.

Number at completion: 16/19 patients completed the full pro- ramme over the two phases to the end of the 6 month follow-up.

The number of group sessions attended per patient ranged from to 11.

Attendance figures: Group 1 had 67%, Group 2 – 86% and for Group it was 90%.

The following shows engagement throughout the programme: Number entering treatment groups: 19 (one missed the intake

eeting but attended the first two sessions then withdrew, a fur- her one withdrew after first two sessions as too unwell and one ad to have an operation and could not drive so had to discontinue).

Number remaining in treatment: 17 (one remained until session 0 but could not sustain thereafter).

Number completing TBMA group treatment through to follow up: 6.

nalysis of questionnaire data

The majority of patients were in the moderate or mild cate- ories for anxiety which is broadly consistent with the literature hich states that at least two-thirds of patients with MUS will ave anxiety (Grover et al., 2014). Higher levels of anxiety show ore of an improvement than at these lower levels. The majority

f patients were women, a finding consistent with the literature Speckens, VanHemert, Bolk, Rooijmans, & Hengeveld, 1996). They ere of a mixed educational background similar to that found by imnuan, Hotopf, and Wessely (2001). Some studies claim that

hose unemployed, senior women and those from a non-Western rigin experience more MUS (Verhaak, Meijer, Visser, & Wolters, 006). However, participants in this project were from a variety of ackgrounds and ages. This is inconsistent with some other stud-

es which found, for example, the older age group to be overly epresented or, in contrast, younger, employed women to be over epresented (Nimnuan et al., 2001). However, all of these outcomes n the demographics in the project are consistent with the previous ilot study.

Educational background: Patients came from a range of educa- ional backgrounds.

Employment status: 5/16 retired, one of which was due to ill ealth. 7/16 patients were in full-time employment; two in part ime employment; one was unemployed and one a student.

Types of symptoms: There were 26 different symptoms for the hole cohort of 16 patients completing the programme to follow p. These included:

breathlessness, headaches, chronic pain, tiredness, insomnia, hand pain, leg pain, chronic fatigue,

IBS, ME, palpitations, seeing white lights,

sychotherapy 47 (2016) 55–65

• pain in the chest, • backache, • leg spasm and • insomnia.

Assessment measures

Patients were assessed using standardised measures over the telephone by a clinical psychologist on three occasions. Firstly at pre-group, secondly in the final week of the group and thirdly at 6 months follow up. The measures used were:

PHQ9: This is a client rated tool for depression. It scores each of the nine depression DSM-IV criteria as “0” (not at all) to “3” (nearly every day).

Measure Your Medical Outcomes Profile (MYMOP2): This is an individualised outcome questionnaire, problem-specific (measures two symptoms chosen by the patient), including general wellbeing and impact of symptoms on a chosen activity. The greater the score, the more severe the symptoms will be experienced.

Generalised Anxiety Disorder 7 (GAD7): This is a brief measure for assessing Generalised anxiety disorder on a 7-item self-rating scale. It scores each item as “0” (not at all) to “3” (nearly every day) for each item. Severity of generalised anxiety is graded based on the GAD7 score as 0–4 none/5–9 mild/10–14 moderate/15–21 severe.

The Global Assessment of Functioning Scale (GAF): A clinician rat- ing tool used to measure overall level of psychological, social and occupational client functioning on a scale ranging from 1 to 100. The higher the score, the higher the level of functioning will be. GAF covers the range from positive mental health to severe psy- chopathology.

P2W questionnaire: During a telephone interview the asses- sor collected self-reported information on the participant’s age, gender, ethnicity, socio economic group, occupation, educational levels, type and number of symptoms, amount of leisure activ- ity, social support, work/school attendance, use of medication, and attendance at GP/hospital. In addition, GP referrals contained case histories and medical information.

Post-group outcomes from the standardised assessments

The outcomes are also presented as pie charts for greater visual impact and ease of interpretation by the general reader.

Interpretation of outcomes pre to post group

Improvements are noted in all areas shown from pre to post group on the Pie Charts 1–7 and in Graph 1. Particularly impor- tant are improvements in the scores from pre to post group as shown in Table 2 indicating decreased levels of depression, anxiety and symptom severity. There are also improved feelings of overall wellbeing, social support, activity levels and global functioning. In addition, patients report decreased GP visits, medication usage and

medica�on social support

GP visits Hospita l visits

Pie Chart 1. Patients reporting reduced feelings of depression 81.25% of patients reported a reduction in depression.

H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65 61

depression

81.25% re duce d 6.25% increased

12.5% no change

Pie Chart 2. Percentage of patients reporting improved global functioning 81.25% of patients report and improvement in global functioning.

global func�oning

81.2 5% improved 6.25% redu ced 12.5% no change

Pie Chart 3. Percentage of patients reporting increased overall score for MYMOP including activity, symptom severity and wellbeing 81.25% of patients report improvement in overall scores.

mymop overall

81.2 5% in creased 6.25% de creased 12.5% no change

Pie Chart 4. Percentage of patients reporting reduced anxiety levels 68.75% of patients reported a reduction in anxiety.

anxi ety

68.75% reduced 12.5% increased 18.75% no change

Pie Chart 5. Percentage of patients reporting symptom severity 65.3% of patients reported an improvement in symptoms.

symptom severity

65.3% decrease 7.6%incre ase 26.9%no change

Pie Chart 6. Percentage of patients reporting increased general wellbeing 62.5% of patients report improvement in their feeling of general wellbeing. Key: blue = 62.5%; green = 25%; red = 12.5%.

general wellbeing

increas ed wellb ein g decreas ed well bei ng no change

Pie Chart 7. Percentage of patients reporting improved activity 56.25% of patients report improved activity.

MYMOP2 ac�vity

improved worsened no change

Graph 1. Example of percentage improvement in social support, medication, GP and hospital visits.

Table 1 To show pre to post group analysis of questionnaire.

Test Improved Worsened No change

Leisure 9/16 (56%) 3/16 (19%) 4/16 (25%) Support 7/16 (44%) 0/16 (0%) 9/16 (56%) Absence from work (Group 3 only) 1/6 (17%) 0/6 (0%) 5/6 (83%) GP visits (Groups 2 and 3 only.

Missing data: 1 person) 4/11(36%) 4/11 (36%) 3/11 (28%)

Hospital visits (Groups 2 and 3 only)

7/12 (58%) 1/12 (8%) 4/12(33%)

Medication 3/16 (19%) 1/16 (6%) 12/16 (75%) Number symptoms 12/16 (75%) 0/16 4/16 (25%) Employment status 0/16 (0%) 0/16 (0%) 16/16 (100%)

NB one person changed to a different type of medication and was entered under no change.

Mussell, & Schellberg, 2008) states most patients with MUS will have mild to moderate depression; consequently; the sample of patients were more or less in a similar category in this regard. 13/16 of patients reported feeling less depressed after attending the group intervention.

Global functioning (psychological, social and occupational) lev- els also increased for 13/16 of patients post group. This is an important finding as functioning is usually impaired as a result of MUS causing inactivity, unemployment and a reduced capacity to study. Furthermore, social support collected by a questionnaire post group showed improvement for 7/16 of patients (Table 1) and this increased for 9/16 patients following attendance post group. This may refer to relationships with family and friends improv- ing which could result from the higher levels of wellbeing – a positive sign, especially for those with insecure attachments. This increased social support (frequently continuing long after the facil- itated group workshops have ended) may help to account for why patients continue to improve long after the groups finish.

The overall MYMOP scores improved considerably for 13/16 of patients at post group assessment when compared to pre group. This groups the scores of wellbeing, activity, and symptom distress, together to make an overall score. It is no surprise that this percent- age is high when individual percentages for each aspect of MYMOP2 improved.

Anxiety levels decreased for 11/16 of patients at post group when compared to pre-group scores. 3/16 showed no change and 2/16 worsened in their scores for anxiety when comparing pre- group with post group. It appears from this result that patients reduce their levels of anxiety after the group experience. How- ever, without a control group it is not possible to reliably attribute improvements to TBMA as a group experience solely.

Symptom severity is measured by up to two symptoms per person being reported to be better, worse or no change. 17/26 of

symptoms were reported as improved post group compared with scores at pre-group. This improvement in symptom distress may help patients to feel less depressed and anxious and enable them to engage in more activity day-to-day. Increase in activity may in

62 H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65

Table 2 To show patient changes in function of pre to post group.

Test Improved Worsened No change

Depression PHQ9 13/16 (81%) 1/16 (6%) 2/16 (13%) Global functioning GAF 13/16 (81%) 1/16 (6%) 2/16 (13%) Overall MYMOP2 13/16 (81%) 1/16 (6%) 2/16 (13%) Anxiety GAD7 11/16 (69%) 2/16 (13%) 3/16 (19%) Symptoms MYMOP2 17/26 (65%) 2/26 (8%) 7/26 (27%) General wellbeing MYMOP2 10/16 (63%) 2/16 (13%) 4/16 (25%) Activity MYMOP2 9/16 (56%) 0/16 (0%) 7/16 (44%)

Table 3 To show patient changes in function post group to 6 months follow up.

Test Improved Worsened No change

Depression PHQ9 3/14 (21%) 9/14 (64%) 2/14 (14%) Global functioning GAF 4/14 (29%) 4/14 (29%) 6/14 (43%) Overall MYMOP2 8/14 (57%) 5/14 (36%) 1/14 (7%) Anxiety GAD7 3/14 (21%) 5/14 (36%) 6/14 (43%) Symptoms MYMOP2 10/27 (37%) 5/27 (19%) 12/27 (44%) General wellbeing MYMOP2 3/14 (21%) 6/14 (43%) 5/14 (36%) Activity MYMOP2 7/14 (50%) 3/14 (21%) 4/14 (29%)

NB percentages have been rounded up; symptoms category reflects numbers of symptoms (up to 2 per patient).

ac�vity

56.25% improve d ac �vity

0% de creased ac�vity 0%

43.75%no change

t f

b s g r t

t r t b i

t p

P a

C o

w

g

depression

reduced increased no change

Pie Chart 9. Percentage of patients reporting global functioning.

global func�oning

improved worsened no change

Pie Chart 8. Percentage of patients reporting depression.

urn bring about greater social interaction resulting in improved eelings of wellbeing.

For 10/16 of patients there was improvement in general well- eing as measured by overall MYMOP2. In problem specific ymptoms almost all patients improved as well as in the cate- ory of symptom severity. Furthermore, the number of symptoms eported by patients pre-group reduced at post-group in over half he sample.

Activity levels increased for 9/16 (Table 2) of patients with half he sample increasing their leisure pursuits (Table 1) probably as a esult of the increased functioning levels, which in turn could lead o feelings of wellbeing. No patients reduced their activity levels to elow those at pre-group. For the remainder there was no change

n activity levels at post group when compared to pre-group levels. These results, albeit based on a small sample, suggest that at

he post-group assessment, using standardised psychological tests, atients report feeling the benefits of attending TBMA groups.

ost group to 6 month follow up outcomes from standardised ssessments

See Table 3.

omparison between post group and the 6 month follow up utcomes as demonstrated on the standardised assessments

The percentage for depression in Pie Chart 8 in particular orsened for 9/143 patients (it was the highest percentage of all

3 There are now 14 patients because two patients withdrew in the 6 month post roup to follow up assessment period.

Pie Chart 10. Percentage of patients reporting overall score for MYMOP2.

categories) as did general wellbeing in MYMOP2 at 6/14 of patients (see Pie Chart 13) at follow up when compared to post group data analysis. However, as there had been (13/16 patients) reduction in depression at the earlier post group stage the worsening of this percentage is not as great as might at first be thought. The post group analysis for depression and general wellbeing had improved for all but a very tiny percentage of patients when compared to pre-group. Consequently, it could be said that there is a reduc- tion in the maintenance of the improvement shown at post-group. The higher percentage of increased depression at follow up may be due to the loss of the support of the group during the 6 months post-group to follow up. In contrast there were some participants who improved on their previously improved or no change post- group score for depression, others remained at the same level of improvement. It would be understandable that general wellbeing would decrease if depression increased. However, at follow up 3/14 patients improved in general wellbeing and 5/14 patients showed no change when compared to the post group improvement. Conse- quently, it could be said that 8/14 patients improved or maintained their overall wellbeing.

It could be speculated that GPs advising that medication for depression be tapered over a period of time influenced patients’ perception of their levels of depression. Patients on anti-depressants could want to give them up if they were feel- ing better, however GP advice to remain on the medication due to physiological dependency will prevent them from doing this (Pie Chart 9).

Global Assessment of Functioning (GAF) appears to have been about the same for each of the improvement and no change cat- egories when comparing post to follow up. 10/14 patients either improved still further from their post group scores or maintained their improvement whilst only 4/14 patients reported feeling worse at follow up than at post group (Pie Chart 10).

8/14 patients showed a large improvement in their overall MYMOP2 score, whilst 5/14 got worse only 1/14 showed no change when compared to the improvement shown in the post-group score (Pie Chart 11).

Anxiety, as measured by GAD7, showed that there was improve- ment in anxiety (i.e. reduction) in 3/14 patients and no change from the post group levels of improvement for 6/14. Hence

approximately 9/14 of patients reported either improvement or maintenance of their anxiety levels from post group as measured at follow up. 5/14 patients reported feeling more anxious at follow up

H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016) 55–65 63

mymop overall

improved worsened no change

Pie Chart 11. Percentage of patients reporting anxiety.

Anxiety

Reduced Increased No Ch ange

Pie Chart 12. Percentage of patients reporting symptom severity.

symptom severity

reduced increased no change

w t t

s 1 r i

s p r o c

o 6 w 1 o i t i

w m a c

e s m

MYMOP2 general wellbeing

improved worsened no change

Pie Chart 13. Percentage of patients reporting general wellbeing.

hen compared to post group. On balance most patients continued o remain less anxious at the 6 month follow up when compared o post group analysis (Pie Chart 12).

There was a reduction in symptom severity distress 10/27 of ymptoms (as in the pilot study outcomes) at follow up, with 2/27 reporting no change. Hence approximately 22/27 of patients eported either improvement or the same levels of symptom sever- ty distress.

Even though some still experienced their symptoms maybe ome could manage them better. Others remained the same as at ost-group where there had been an improvement in coping. 5/27 eported a worsening of their symptoms. Once again the majority f patients had maintained their improvement post group or had ontinued to improve still further to the 6 month follow up stage.

8/14 of patients reported either improvement or maintenance f their general wellbeing at 6 months follow-up. A larger number, /14 patients, than at post group reported a decrease in general ellbeing via MYMOP2 scores at follow up as shown in Pie Chart

3. This is inconsistent with the sustained improvement scores on ther instruments. It is unclear why this is the case; perhaps miss- ng the support of the group, leaving them feeling more alone with heir symptoms. Nevertheless, 5/14 reported no change and 3/14 mproved still further at follow up (Pie Chart 14).

Levels of activity further increased at follow up in 7/14 patients hen compared to post group demonstrating some capacity to do ore, and feel better for it perhaps. This is contrary to the percent-

ge feeling worse for general wellbeing of 6/14 at follow up when ompared to immediately post group.

Consequently, despite feeling less well overall in terms of gen- ral wellbeing and more depressed than at post group patients were till able to continue to maintain and even increase their engage- ent in activity perhaps as result of increased global functioning,

Pie Chart 14. Percentage of patients reporting activity levels.

reduced symptom distress and anxiety levels experienced at follow up.

Trends in the data

An important trend shown in the 6 month follow up data anal- ysis is that the improvements made at post group are not only sustained at 3 months post group, as in the previous pilot research study, but patients report continued improvement at the 6 month stage.

Patients maintained or improved their levels of progress on a number of measures including overall global functioning, over- all MYMOP, anxiety, symptom distress and activity. In the pilot research study previously conducted with a bigger sample, which had been followed up randomly in case studies to 4 years post follow up, patients reported sustained improvement at that stage too.

It is not possible to know precisely why improvement continues so long after post group but it could be speculated that this may be linked to their embodied change in perception towards their body (and symptoms), the action plan to change the way they manage their life (and symptoms) which is tailor-made by each patient, as well as because of the group experience and the individual contact experienced in phase one and two. From the Participant Experience Form (PEF) patients appear to have enjoyed the group experience and hence attendance at all the groups was excellent.

Discussion

This is a very minor piece of practice-based evidence and as the numbers are still very small any interpretation must be under- taken with extreme caution. Interestingly, some patients develop new symptoms. Whilst this was not demonstrated previously in the earlier pilot study (Payne & Stott, 2010), it has been reported in the literature.

Patients appear to have found the programme acceptable and were committed to attend the groups. From the PEF, they said that they had benefited from the group experience having no hesitation in recommending it to friends and family.

Therefore there are some hints from this treatment intervention data analysis about how Symptoms Groups can mobilise patients towards self-management. There is no alternative treatment avail- able and appealing. This is because patients do not see the more widely offered CBT as relevant as most have a physical explanation rather than a psychological one for their symptoms. In addition the stigma attached to psychological interventions means that they feel unable to access such therapy.

These patients are extremely high utilisers of health resources and consequently, supporting these patients is essential not only for the patients but for saving NHS resources and increasing GP

capacity. The frustration experienced by both patients and GPs as a result of the lack of treatment options to support these high health utilisers can be resolved through delivery of programmes via The MUS Clinic.

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4 H. Payne, S.D.M. Brooks / The Ar

ummary

First indications from the delivery of TBMA in primary care uggest that it can benefit patients with MUS and the health ervice by encouraging coping strategies which promote patient elf-management thereby reducing the demand for and cost of ser- ices. In addition, it is acceptable to patients and provides more atient and GP choice of treatment for MUS. Furthermore, we know rom patient self-reporting that the courses helped GP practices o conserve costs by reducing consultation time, and increasing apacity crucial in these times of low GP recruitment in the NHS n England. If the apparent positive trends indicated in this very mall sample were maintained after the sample is scaled up, with ddition of a control, the findings would be of great interest. This is herefore a subject for further research.

P2W intends to continue to improve the lives of patients ith MUS in Hertfordshire, England and are actively pursu-

ng similar service delivery elsewhere through the training of acilitators qualified in the fields of dance movement psychother- py, body psychotherapy and appropriately qualified counsel- ors/psychotherapists/health professionals. P2W has trained 30 roup facilitators in TBMA so far with a view to them facilitating roups privately under licence and in the NHS and/or in the private ealth care sector.4

cknowledgements

The authors wish to express gratitude to the UK Department of ealth for their funding of this project and to Hertfordshire PCT, s was, in particular the mental health lead commissioner Graham unn, the patient participants, and the group facilitator Silvana

eynolds.

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