https://orcid.org/0000-0002-1256-3754
Figures
Abstract
Background
Individuals with a psychotic disorder are at an increased risk of victimization, but evidenced-based interventions are lacking.
Aims
A body-oriented resilience therapy (‘BEATVIC’) aimed at preventing victimization was developed and its effectiveness was assessed in a multicenter randomized controlled trial.
Methods
105 people with a psychotic disorder were recruited from six mental health centers. Participants were randomly allocated to 20 BEATVIC group sessions (n = 53) or befriending group sessions (n = 52). Short term effects on risk factors for victimization (e.g. social cognitive deficits, inadequate interpersonal behavior, low self-esteem, internalized stigma, aggression regulation problems), physical fitness and secondary outcomes were expected. At six-month follow-up, the effect on victimization (either a 50% reduction or an absence of victimization incidents) was examined.
Results
Intervention-dropout was 28.30% for BEATVIC and 39.62% for befriending. In both conditions the majority of participants (60.5% BEATVIC vs 62.9% befriending) showed a reduction or absence of victimization incidents at six months follow-up, which was not significantly different according to condition. Multilevel analyses revealed no main effect of time and no significant time x group interaction on other outcome measures. Per protocol analyses (participants attending ≥ 75% of the sessions) did not change these results.
Conclusions
Although a reduction or absence of victimization was found at short term follow-up for the majority of participants, BEATVIC was not more effective than the active control condition. No short-term additional effects on risk factors of victimization were found. Analysis of the data at 2-year follow-up is warranted to investigate possible effects in the long-term.
Citation: van der Stouwe ECD, de Vries B, Steenhuis LA, Waarheid CO, Jans R, de Jong S, et al. (2022) BEATVIC, a body-oriented resilience therapy for individuals with psychosis: Short term results of a multi-center RCT. PLoS ONE 17(12): e0279185. https://doi.org/10.1371/journal.pone.0279185
Editor: Walid Kamal Abdelbasset, Prince Sattam Bin Abdulaziz University, College of Applied Medical Sciences, SAUDI ARABIA
Received: May 11, 2022; Accepted: November 30, 2022; Published: December 21, 2022
Copyright: © 2022 van der Stouwe et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly as it contains potentially identifiable pseudonymized personal data. Since participants have not given informed consent to have their personal data publicly shared, we cannot publicly post our data set. A specified dataset with all personal characteristics of the participants removed are therefore available upon request from the Rob Giel Research Center at the University Medical Center Groningen (contact via Dr. Ellen Visser, data scientist, email e.visser03@umcg.nl) for researchers who meet the criteria for access to confidential data.
Funding: This work was supported by the Netherlands Organization for Scientific Research (NWO) as part of the research program Violence against psychiatric patients (‘Geweld tegen psychatrisch patienten’), grant number 432-12-807. The funding source had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Individuals with a psychotic disorder are more susceptible to falling victim to a crime (‘victimization’) than people from the general population [1]. The five year prevalence rate for people with a psychotic disorder is 22% for violent victimization, 32% for sexual victimization and 20% for non-violent crime: this is four to six times as high as in the general population [2]. Victimization in people with psychosis is associated with substance abuse, depression [3], severe symptomatology and poorer prognosis [4]. An intervention focused on prevention of victimization is vital for this population.
To date, no evidence-based intervention aimed at preventing victimization in individuals with psychosis is available. Victimization is a form of trauma and may lead to PTSD symptoms, potentially causing a large burden on mental health [5]. PTSD symptoms have been associated with a worse prognosis and impaired daily functioning in people with psychosis [6]. Although there are effective evidence based trauma-focused therapies for this group [7] that lead to a reduction of revictimization [8], prevention of any victimization is preferred. For this aim BEATVIC was developed: a body-oriented resilience therapy with kickboxing exercises in group format. The therapy uses a body-oriented approach [9–11] combining elements of physical exercise, assertiveness training and social cognition training, allowing participants to recognize their own emotional and behavioral reactions in social situations, and to practice with new and adequate social behavior in a safe environment.
BEATVIC aims to prevent victimization and is based on a model that addresses risk factors for victimization which may be modifiable and feasible to improve [12, 13]. The first risk factor is social cognitive impairment, as individuals with a psychotic disorder show a deficiency in recognizing facial expressions, body language, mentalizing and theory of mind (ToM). This deficit could prevent accurate judgement of a risky social situation and/or leads to conflicts that may result in victimization [14, 15]. Another factor is self-stigma, which is associated with low self-efficacy [16], low self-esteem and reduced empowerment [17]. These factors may lead to difficulties in standing up for oneself in social situations and increasing the chance of victimization [18]. Furthermore, sometimes perpetration and victimization go hand in hand [19]. In 24% of the violent crime cases the victims were also perpetrators [20, 21]. Some individuals with a psychotic disorder may exhibit aggression regulation problems, or reduced clinical insight, which can be associated with aggressive behavior [22] and therefore enhancing risk for victimization [23]. To summarize these risk factors we constructed a model (see [12] on which the BEATVIC intervention was based).
In the feasibility study of BEATVIC, the intervention was deemed acceptable and feasible [13]. Participants attended an average of 85% sessions and evaluated BEATVIC as helpful in gaining self-esteem and assertiveness. Based on this study, small adjustments were made to the intervention and the research protocol. The current paper presents the results of a randomized controlled trial investigating the short term effectiveness of BEATVIC [12] comparing pre-, post- and the first follow-up assessment at six months. Short term effects on risk factors for victimization (e.g. social cognition, interpersonal behavior, self-esteem, internalized stigma, insight and aggression regulation) were expected, as these are directly targeted. Because incidents of violence do not occur often, it was hypothesized that effects on victimization would become apparent at six-month follow-up. A further decrease after one and two years (not here reported), is also expected. In addition, we examined effects on secondary outcome variables (e.g. recovery, social participation, quality of life, symptoms and PTSS symptoms), and on physical outcomes (e.g. physical activity and fitness).
Materials and methods
The study is funded by the Netherlands Organization for Scientific Research (NWO grant nr 432-12-807). All procedures involving patients were approved by the local ethical committee (University Medical Center of Groningen, The Netherlands; METc protocol number: NL52202.042.15). The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Although the trial was registered prospectively (Current Controlled Trials: ISRCTN21423535), it was classed as retrospective due to a delay in finalizing the registration in time for the recruitment to start. However, no deviations from the protocol were made as presented in the trial register. Recruitment of participants for baseline, post-treatment and follow-up assessments, lasted from February 2016 until March 2021. Recruitment stopped when the minimum amount of participants were included in both conditions and no further participants were found to be included in the study. For further details of this study, see the protocol paper [12].
Design
The study is designed as a multi-center randomized controlled trial including a pretest (T0), a posttest (T1) and three follow up assessments respectively at 6 (T2), 18 (T3) and 30 (T4) months. The current article presents the findings of assessment points T0, T1 and T2. Patients allocated to the intervention group receive the BEATVIC group training and patients allocated to the control group receive befriending sessions.
Participants and setting
Participants were recruited from six mental health care facilities in the Netherlands. The following inclusion criteria were used to identify potential participants:
- A diagnosis in the psychotic spectrum, according to DSM-IV-TR criteria. This was verified by use of the mini-SCAN.
- At least 18 years of age.
- Having the ability to provide written informed consent.
In addition, the following exclusion criteria were used to exclude participants:
- Severe psychotic symptoms (mean positive symptoms > 5 measured by PANSS)
- Substance dependence (not substance abuse), also verified by use of the mini-SCAN.
- Co-morbid neurological disorder of personality disorder, as verified by onsite therapist.
- Estimated IQ < 70, as judged by onsite therapist.
- Pregnancy.
The sample size was computed a-priori using the IBM SPSS Sample Power program (http://www.power-analysis.com/about_biostat.htm). The effect size was set at 0.5, because a lower effect size would not be considered as clinically relevant. In order to find a medium effect size on victimization with an alpha of 0.05 and a power of 0.80, a minimum of 48 participants per condition was required. Considering a drop-out of 25%, it was aimed to include a total of 120 participants in the current trial.
Intervention
BEATVIC.
In short, BEATVIC consists of five modules covering 20 weekly group sessions of 75 minutes led by a therapist trained in body and movement-oriented interventions (i.c. a psychomotor therapist (www.psychomot.org/) and an expert by experience). Sessions include a warming-up, technical kickboxing exercises and thematic exercises, a cooling-down and a group discussion to help transfer the acquired skills to application in daily life.
In the first module, basic kickboxing techniques are taught and discussion themes are centered around body posture, self-stigma and setting boundaries. The second module, ‘Recognizing dangerous behavior’, aims to improve social cognition and insight. The third module, ‘How others see me’, emphasizes patients’ own behavior and how they may appear to others. In the fourth module ‘Coping with aggression’ patients learn to regulate their own aggression and how to deal with aggressive behavior of others. In the final module, exercises were tailored to the specific needs of the group.
Control condition.
The control group participated in 20 weekly ‘befriending’ sessions of 75 minutes consisting of five modules: ‘Introduction’, ‘Media’, ‘Hobbies’, ‘Lifestyle’ and ‘Repetition and follow-up’. Goal was to provide a welcoming environment in which patients can socially interact. Befriending is deemed a credible and acceptable control condition with regard to enjoyment of therapy, expectancy and drop-out rate [24].
Primary outcomes
Victimization.
Treatment response (coded as yes or no) was assessed with the revised Conflict Tactics Scale (CTS2) [25], which assesses different forms of victimization and perpetration in the preceding year. The original CTS2 assesses partner violence but in this study an adapted version was used also assessing other social interactions. For this study, perpetration was not examined. The CTS2 assesses victimization in the following subdomains: psychological aggression, physical assault, sexual coercion, physical injury, and negotiation. Negotiation was not considered part of victimization and not examined. Participants had to indicate the frequency of victimization on 39 items in the previous six months, ranging from never, once, twice, 3–5, 6–10, 11–20 and > 20 times. We calculated a frequency score for total victimization using a midpoints substation scoring method [26]. Using percentage change scores in frequency from T0 to T2, the treatment response (yes/no) was coded. Treatment response on the CTS2 was defined as having reported no victimization incidents at T2 or reporting a 50% reduction in victimization at T2 compared to T0 (in line with previous research and expert discussions [27]).
To compare victimization rates with the general population, the victimization subscale of the Safety Monitor (IVM), a victimization survey that is the Dutch equivalent of the International Crime Victims Survey (ICVS [28]) was administered at baseline. Participants were asked whether they experienced different types of victimization in the past 12 months and in the past five years.
Social cognition.
The Faux Pas task is a Theory of Mind (ToM) test [29], in which participants have to indicate whether a faux pas is present in a story. If present, participants are asked questions to assess their understanding of this faux pas. In the analyses the percentage of correct answers was used.
Aggression regulation.
The Self-expression and Control Scale (SEC) is a 40-item Dutch translation of 4 subscales (internalizing and externalizing anger, and control of internalizing and externalizing anger) of the State-Trait Anger Expression Inventory [30]. In the analyses the total score on each of four subscales was used.
Internalized stigma.
Self-stigma was assessed with the Internalized Stigma of Mental Illness Scale (ISMI); [31]. The ISMI consists of the subscales stereotype endorsement, perceived discrimination, alienation, social withdrawal and stigma resistance and contains 29 items.
Social behavior.
The Scale for Interpersonal Behavior (SIB [32]) measures social anxiety and social skills using 50 items. The total frequency of social anxiety, and total social discomfort score was used for the analyses.
Self-esteem.
To assess self-esteem the 20-item Self-Esteem Rating Scale-Short Form (SERS-SF) was used [33]. Ten items asses positive self-esteem and ten items measure negative self-esteem.
Insight.
The 8-item Psychosis Insight Scale (PI [34]) measures insight in people with a psychotic disorder on three dimensions: attribution of symptoms, need for treatment and awareness of illness.
Secondary outcomes
Most secondary outcomes were administered at T0, T1 and T2, but physical activity and endurance only at T0 and T1.
Quality of life.
The total score of the 12-item Manchester Short Assessment of Quality of Life (MANSA) was used [35], which was designed for people with severe mental illness.
Recovery.
The total score of the Dutch 12-item National Recovery Scale (NRS [36]) was used (based on the Questionnaire about the Process of Recovery [37]).
Societal participation.
The 78-item Social Functioning Scale (SFS); [38] measures social participation and social functioning. The raw total score of 75 of the 78 items was used.
Symptoms.
The 13-item Brief Negative Symptom Scale (BNSS) [39] assesses negative symptoms using six subscales: anhedonia, distress, asociality, avolition, blunted affect and alogia. The mean score of subscales was used.
Trauma.
The total score of the 10-item Trauma Screening Questionnaire (TSQ [40]), was used to assess post-traumatic stress symptoms for those confirming experiencing or witnessing a life-threatening or shocking event in their lifetime.
Covariates
Demographic characteristics.
At T0 the participants indicated their age, gender, living situation, age of onset, number of psychotic episodes, number of hospital admissions, amount of family contact, and sport participation.
Substance use.
The total score of the 11-item Dutch Screening risk of substance dependence [45] was administered at T0, T1 and T2.
Procedure
Treating clinicians will screen patients based on the in- and exclusion criteria. Patients who meet the criteria will be contacted and asked if they are interested in participating in the study. Information letters will be sent to patients who are interested. Subsequently, patients have a two-week period to consider final participation. After written informed consent was obtained, diagnosis and absence of substance dependence and severe psychotic symptoms were verified by the miniSCAN and PANSS respectively.
Directly after baseline, participants were randomized by an independent randomizer. This was completed separately for each treatment center, in order to assure a comparable number of participants in both groups. The randomization procedure took place once the number of patients required for two groups (experimental and control) was included (20 patients per centre) or when the first participant from that specific center was included more than six weeks ago whilst at least 12 participants from that center were included overall. An independent team of researchers not involved in the trial performed the randomization procedure, which was stratified by gender and participation in an fMRI substudy [46].
To gain insight in the short-term effects, assessments on victimization incidents were conducted at baseline (T0) and six months post-treatment (T2). All other primary outcomes were assessed at T0, T1 and T2. At all sites, trained interviewers were available who were blinded to the study condition. BEATVIC trainers and patients cannot be blinded after treatment allotment. Patients were instructed not to inform the assessor about the study condition they were allocated to.
Statistical analyses
Demographic differences between groups were tested using Pearson chi-squared tests (categorical variables) and independent-samples T-tests (continuous variables). Continuous variables not normally distributed were tested using Mann-Whitney U tests. Tests were conducted two-tailed, with a significance level set at α = 0.05.
The primary outcome treatment response (yes/no) on total victimization was analyzed using two separate logistic regression analyses with treatment condition as independent variable. All participants were included regardless of attendance (intention to treat; ITT). Two additional models were fitted adjusted for predictors of treatment response for total victimization. Predictors (including age, gender, supported housing, family contact, diagnosis, age of onset, number of psychotic episodes, number of hospital admissions, participating in a sport, and group preference (kickboxing, befriending or no preference)) were entered in the logistic regression model using backward elimination.
The effects of BEATVIC on the continuous outcome measures were assessed with multilevel analyses as assessments (level 1) were nested within individuals (level 2) and clustered within sites (level 3). In MLwiN [47] a separate 3-level model was constructed for each of the outcome variables. The following predictors were entered as fixed effects: a) dummy variables representing time (T0, T1, T2); b) condition (BEATVIC, Befriending); and c) the interactions (T1*condition, T2*condition). The intercepts at levels 2 and 3, and the residual at level 1 were included as random effects. For each model it was tested whether the third level (site) was significant in the model by means of deviance tests [48]. If not, it was removed. To assess a main effect of time, significance testing was conducted using deviance tests between the model with time (T1 or T2), and without. Similarly, differences between BEATVIC and befriending at T1 and T2 were tested comparing deviance tests between the models with the interaction between time (T1 or T2) and condition (BEATVIC/befriending), and without. To correct for multiple testing, the significance level was set at α = 0.003 using Bonferroni (0.05/15 outcome measures).
Both multilevel and logistic regression analyses were repeated as per protocol, including participants who attended a minimum of 75% of the sessions (>15 sessions).
Results
Sample characteristics
In total, 105 participants were included of which 81 participants completed T1 and 73 completed the T2 assessment (Fig 1). Participants in BEATVIC and befriending did not differ significantly on baseline characteristics or victimization rates (IVM) (Table 1). There was no significant difference in the number of sessions attended (t = -1.89, df = 103, p = 0.06); BEATVIC mean 13.38 of 20 (SD 6.48), befriending 10.79 of 20 (SD 7.47). Attendance of 15 or more sessions was achieved by 60.38% of participants in BEATVIC and 40.38% of participants in befriending. Victimization incidents in both conditions consisted mostly of threats towards physical assault, followed by actual physical assault, with a small minority reporting sexual coercion.
Drop-out
For BEATVIC the attrition rate was 28.30% (15/53) and for befriending it was 39.62% (21/52). In both groups an equal number of participants dropped out due to their mental condition, unrelated to the intervention. As presented in the flow diagram (Fig 1) reasons for discontinuation of the therapy were unknown in respectively six and four cases because of study dropout.
Given the ITT design, participants were invited for post- and follow-up assessments irrespective of whether they had completed the intervention. Study drop-out on T1 and T2 was 24.5% and 30.2% in the BEATVIC condition compared with 21.2% and 32.7% in the befriending condition.
Effect of site
No significant contribution of treatment site was found in both the regression models or in the multilevel models. As such, site was not added to the models, and removed as a third level.
Logistic regression analyses
In Table 2, 60.5% participants from both BEATVIC and 62.9% of the befriending group reported a prevention of victimization, with no significant difference between groups (p = 0.84). In BEATVIC, 14 (60.9%) participants reported no victimization incidents at T2, and 9 (39.1%) participants reported a 50% reduction in incidents at T2. Adjusting for age, supported housing and family contact in the analyses did not change overall outcomes (p = 0.83). Rerunning the models for participants who completed at least 75% (>15) of sessions, did not change outcomes (p = 0.82). The model fit was tested on the model adjusted for covariates using the Hosmer and Lemeshow test, indicating a good fit (X2(8, 105) = 5.22, p = 0.73).
Multilevel analyses
Descriptive statistics for the risk factors and secondary outcomes at T0 and, if applicable, T1 and T2 are presented in Table 3. For the separate multilevel analyses per risk factor, no main effect of time was determined over the two periods (T0-T1 and T0-T2). Also no significant differences between groups over time (see Results in Table 4) were found.
Discussion
The current study compared the effect of a preventive body-oriented resilience therapy ‘BEATVIC’ with an active control condition in a multicenter randomized controlled trial. The aim of this study was to assess the short-term effects of BEATVIC on victimization, and its risk factors, in people with a psychotic disorder. More than half of the participants demonstrated a reduction in victimization or reported no new incidents (60.5% BEATVIC vs 62.9% befriending). However, there was no significant difference between BEATVIC or befriending. No differences were found in primary and secondary outcomes between BEATVIC and befriending at post treatment and six months follow-up.
For both conditions, victimization incidents either reduced over time, or did not occur, with very few new victimization incidents occurring during the period of the intervention and the 6 months follow-up. It is possible that both BEATVIC and befriending act on factors which allow the risk of victimization to be reduced or stabilized. A recent RCT showed that befriending is effective in increasing social contacts on the short term in people with schizophrenia [49]. An increase in social contacts may also indirectly contribute to reducing the risk of victimization, given that victimization in people with psychosis is correlated with poorer social functioning [50]. Possible differentiating effects of BEATVIC in comparison to befriending in the long-term will be examined at 18-month and 30-month follow-up. The long-term follow up will also demonstrate whether BEATVIC can prevent other types of victimization (e.g. sexual assault), given that most victimization incidents on the short-term in this study reflected psychological aggression.
There was no improvement on the risk factors of victimization in BEATVIC as compared to befriending on the short term. This contrasts the feasibility study (N = 24), in which participants subjectively indicated a positive effect of BEATVIC on recognizing others’ boundaries, identifying and setting boundaries, self-esteem, faith in own strength, confidence, recognizing dangerous situations and risk of victimization [13]. In addition, in the fMRI sub study including 27 participants, brain activation was examined during two social cognition tasks [46]. Findings demonstrated increased involvement of the salience network in processing angry and fearful faces in BEATVIC participants compared to befriending, suggesting an increased alertness for potentially dangerous faces. As this change was not found in the behavioral data in this study, it could be argued that short-term effects of BEATVIC are restricted to basic neuropsychological mechanisms (fMRI study) and subjective reports (feasibility study).
Previous research investigating body and movement oriented therapies demonstrated improvements on self-esteem, social interaction skills and psychiatric symptoms in people with a psychotic disorder [9, 51, 52]. Studies suggest that martial-arts training like kickboxing, could have a positive effect on aggression regulation and social interaction [53–55]. The aforementioned studies differ from the current RCT, in terms of: 1) a higher frequency (2 or 3 weekly sessions) and/or a longer duration (one year or longer) of interventions, 2) samples (children and/or adults from the general population), and 3) measures (observer rated and/or qualitative interviews/questionnaires).
Previous studies on exercise interventions reporting beneficial effects mostly investigated interventions with a higher frequency and duration. An average weekly exercise frequency of at least 2 times a week might be the minimum to achieve beneficial effects [46, 56]. BEATVIC consisted of weekly sessions and included therapeutic elements in addition to kickboxing exercises, and was therefore less intense than the aforementioned interventions. Another possible explanation a lack of effect, relates to the heterogeneity of the group of participants and the broad range of risk factors that were addressed in BEATVIC. For sub-assertive individuals experiencing difficulties standing up for themselves, exercises were aimed to increase empowerment and assertiveness. For others, exercises were aimed at aggression regulation problems and aimed at participants that may evoke conflicts ultimately leading to victimization. To promote change in this broad and heterogenic patient group, BEATVIC could be tailored to a specific victimization type, targeting fewer risk factors more efficiently, more frequently (>2 times per week) and for a longer duration.
Participants were not specifically selected based on risk factors of victimization, as the patient group has a-priori increased chances of victimization. When comparing the baseline rates of victimization in our sample with rates of victimization in the general population, our sample was 3–4 times as likely to report physical assault and 2 times as likely to report sexual assault in the past five years [57]. However, it is possible that participants who were not prone to victimization at that point in time were also included. Indeed, more than half of responders in both conditions did not report any incidents of victimization, and baseline data show that on average, participants did not have deviant scores on self-esteem, social cognition, insight, self-stigma, and aggression regulation. Furthermore, as our exclusion criteria prohibited people with severe psychotic symptoms or substance dependence (risk factors for victimization [2]) from taking part, the study could have precluded the most vulnerable patients. However, we chose to exclude patients with these vulnerabilities, because these risk factors also hinder structural participation in groups. For future research, it is recommended to examine if BEATVIC can also be effective for dual-diagnosis groups (e.g. psychotic disorder with comorbid substance dependence) as this group seems particularly prone to victimization [2]. Furthermore, replicating the current study using a larger sample size could also yield more power to detect differences between individuals vulnerable and not vulnerable to victimization, after taking part in the BEATVIC group sessions.
The current study made use of self-report quantitative measures, whereas previous studies investigating body-oriented therapies focused on observer rating measures and qualitative questionnaires. A previous study examining a martial arts intervention (similar to BEATVIC in terms of time/duration, and diagnostic characteristics) found an increase in self-control and sense of empowerment based on qualitative interviews [58]. The BEATVIC feasibility study showed promising results based on a semi-structured questionnaire and group evaluations [13]. Perhaps these subjective benefits are not easily objectified with standardized questionnaires. Common criticism concern the requirement of needing insight in one’s own behavior, the potential induction of social desirability bias, or biases related to timing [59]. Regardless, all measures used in the current study have good psychometric properties and were carefully chosen.
Strengths and limitations
Although individuals with a psychotic disorder have a higher risk to falling victim to a crime than people from the general population [1], no evidence-based intervention aimed at preventing victimization in individuals with psychosis is available. The current study is the first to develop and test an intervention aimed at preventing victimization for individuals with a psychotic disorder in a randomized controlled trial.
The current study also has limitations. The sample was not selected on the basis of victimization risk, and is heterogenous in terms of the type of crime the participants were victim of. The intervention was carried out using a lower frequency and duration in comparison to previous studies, and the study relied mostly on self-report outcomes.
Implications and future directions
Findings of the current study demonstrate that BEATVIC was not more effective at preventing victimization for individuals with a psychotic disorder than an active control condition at short term follow-up. However, the fact that victimization incidence decreased over time in both conditions is promising and analysis of the follow-up data is warranted to investigate long term effects on preventing victimization.
For future studies we recommend examining possible victimization types, enabling personalized predictions of who is at risk and tailor the intervention to these victimization types. Furthermore, proximal outcomes are recommended for future studies, such as non-verbal measures to test differences in arousal in social interactions and/or experience sampling to measure changes over time in interactions in daily life. For example, the PsychoMotor Diagnostic Instrument (originally developed for post-traumatic stress, PMDI [60]) may be suitable, as this assesses expected non-verbal outcomes of our intervention (e.g. stress level, physical fitness and vitality, trust and impulsive aggressive behavior). Last, it is recommended to replicate the current study using larger sample sizes and including other psychiatric populations as well, in order to further examine the effectiveness of the BEATVIC group sessions.
Acknowledgments
The authors express their gratitude to all patients who have participated in this study. We gratefully acknowledge the participating Mental Health Institutions: GGZ Drenthe, GGZ Friesland, University Medical Center Groningen, Lentis, Dimence and Arkin. We are indebted to the body-oriented therapists and the experts by experience Clement Waarheid, Stef Poel, Paco van der Reijden, Bryan Yorks, Erik Izaks, Jakob de Boer, Stefan Henstra, Linda de Jong, Michiel Wegh, Nienke Bonnema, Alexander Middeljans and Eelke Mollenbrok, and to Annerieke de Vos, Saskia Nijman, Nynke Boonstra, Aaltsje Malda, Boudien van der Pol, Erna van ‘t Hag, Stynke Castelein, Annelieke van der Waal, Marianne Dorst, Martijn Kikkert, for their help in setting up the trial, and to Julia Oldenhuis, Eline Swager, Esther Zeeman and other research assistants for their help collecting the data.
References
- 1. Morgan VA, Morgan F, Galletly C, Valuri G, Shah S, Jablensky A. Sociodemographic, clinical and childhood correlates of adult violent victimisation in a large, national survey sample of people with psychotic disorders. Soc Psychiatry Psychiatr Epidemiol. 2016;51: 269–279. pmid:26581211
- 2. de Vries B, van Busschbach JT, van der Stouwe ECD, Aleman A, van Dijk JJM, Lysaker PH, et al. Prevalence Rate and Risk Factors of Victimization in Adult Patients With a Psychotic Disorder: A Systematic Review and Meta-analysis. Schizophr Bull. 2018; 1–13. pmid:29547958
- 3. Fisher HL, Roberts A, Day F, Reynolds N, Iacoponi E, Garety PA, et al. Impact of crime victimization on initial presentation to an early intervention for psychosis service and 18-month outcomes. Early Interv Psychiatry. 2017;11: 123–132. pmid:25583091
- 4. Newman JM, Turnbull A, Berman BA, Rodrigues S, Serper MR. Impact of traumatic and violent victimization experiences in individuals with schizophrenia and schizoaffective disorder. J Nerv Ment Dis. 2010;198: 708–714. pmid:20921860
- 5. Berg DPG Van Den, Gaag M Van Der. Treating trauma in psychosis with EMDR: A pilot study. J Behav Ther Exp Psychiatry. 2012;43: 664–671. pmid:21963888
- 6. Mueser KT, Lu W, Rosenberg SD, Wolfe R. The trauma of psychosis: Posttraumatic stress disorder and recent onset psychosis. Schizophr Res. 2010;116: 217–227. pmid:19939633
- 7. van den Berg DPG, de Bont PAJM, van der Vleugel BM, de Roos C, de Jongh A, Van Minnen A, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA psychiatry. 2015;72: 259–67. pmid:25607833
- 8. van den Berg DGP, de Bont PAJM, van der Vleugel BM, de Roos C, de Jongh A, van Minnen A, et al. Trauma-Focused Treatment in PTSD Patients With Psychosis: Symptom Exacerbation, Adverse Events, and Revictimization. Schizophr Bull. 2016;42: 693–702. pmid:26609122
- 9. Röhricht F. Body, Movement and Dance in Psychotherapy Body oriented psychotherapy. The state of the art in empirical research and evidence-based practice: A clinical perspective. 2009;2979.
- 10. Scheewe TW, Jörg F, Takken T, Deenik J, Vancampfort D, Backx FJG, et al. Low Physical Activity and Cardiorespiratory Fitness in People With Schizophrenia: A Comparison With Matched Healthy Controls and Associations With Mental and Physical Health. Front Psychiatry. 2019;10: 87. pmid:30873051
- 11. Priebe Stefan, Savill Mark, Wykes Til, Bentall RP, Reininghaus Ulrich, Lauber Christoph, et al. Effectiveness of group body psychotherapy for negative symptoms of schizophrenia: multicentre randomised controlled trial. Br J Psychiatry. 2016;209: 54–61. pmid:27151073
- 12. van der Stouwe ECD, de Vries B, Aleman A, Arends J, Waarheid C, Meerdink A, et al. BEATVIC, a body-oriented resilience training with elements of kickboxing for individuals with a psychotic disorder: study protocol of a multi-center RCT. BMC Psychiatry. 2016;16: 227. pmid:27393604
- 13. De Vries B, van der Stouwe ECD, Waarheid CO, Poel SHJ, van der Helm EM, Aleman A, et al. Body-oriented resilience training with kickboxing for people with a psychotic disorder: A feasibility study. BMC Psychiatry. 2018; 18: 1–12. pmid:30537937
- 14. DePrince AP. Social cognition and revictimization risk. J Trauma Dissociation. 2005;6: 125–41. pmid:16150689
- 15. Baas D, van’t Wout M, Aleman A, Kahn RS. Social judgement in clinically stable patients with schizophrenia and healthy relatives: behavioural evidence of social brain dysfunction. Psychol Med. 2008;38: 747–754. pmid:17988413
- 16. Kleim B, Vauth R, Adam G, Stieglitz R-D, Hayward P, Corrigan PW. Perceived stigma predicts low self-efficacy and poor coping in schizophrenia. J Ment Heal. 2008;17: 482–491.
- 17. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Soc Sci Med. 2010;71: 2150–2161. pmid:21051128
- 18. Egan SK, Perry DG. Does low self-regard invite victimization? Dev Psychol. 1998;34: 299–309. pmid:9541782
- 19. Jennings WG, Piquero AR, Reingle JM. On the overlap between victimization and offending: A review of the literature. Aggress Violent Behav. 2012;17: 16–26.
- 20. Fitzgerald PB, de Castella AR, Filia KM, Filia SL, Benitez J, Kulkarni J. Victimization of patients with schizophrenia and related disorders. Aust N Z J Psychiatry. 2005;39: 169–174. pmid:15701066
- 21. Honkonen T, Henriksson M, Koivisto AM, Stengård E, Salokangas RKR. Violent victimization in schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2004;39: 606–612. pmid:15300370
- 22. Ekinci O, Ekinci A. Association between insight, cognitive insight, positive symptoms and violence in patients with schizophrenia. Nord J Psychiatry. 2012; 1–8. pmid:22616874
- 23. Witt K, van Dorn R, Fazel S. Risk Factors for Violence in Psychosis: Systematic Review and Meta-Regression Analysis of 110 Studies. PLoS One. 2013;8. pmid:23418482
- 24. Bendall S, Jackson HJ, Killackey E, Allott K, Johnson T, Harrigan S, et al. The Credibility and Acceptability of Befriending as a Control Therapy in a Randomized Controlled Trial of Cognitive Behaviour Therapy for Acute First Episode Psychosis. Behav Cogn Psychother. 2006;34: 277.
- 25. Straus MA, Hamby SL, Boney-McCoy S SDB. The Revised Conflict Tactics Scales (CTS2). J Fam Issues. 1996;17: 283–316.
- 26. Vega EM, O’Leary KD. Test-retest reliability of the revised Conflict Tactics Scales (CTS2). J Fam Violence. 2007;22: 703–708.
- 27. de Waal MM, Dekker JJM, Kikkert MJ, Christ C, Chmielewska J, Staats MWM, et al. Self-wise, Other-wise, Streetwise (SOS) training, an intervention to prevent victimization in dual-diagnosis patients: results from a randomized clinical trial. Addiction. 2019;114: 730–740. pmid:30461111
- 28. Van Dijk J. The International Crime Victims Survey 2. The International Crime Victims Survey. Transnatl Criminol Man. 2010;2: 631–650.
- 29. Baron-cohen S, Riordan MO, Stone V, Jones R, Plaisted K. A new test of social sensitivity: Detection of faux pas in normal children and children with Asperger syndrome: J Autism Dev Disord. 1999;29: 407–418.
- 30.
Spielberger CD. Manual for the State–Trait Anger Expression Inventory (STAXI). Odessa: FL: Psychological Assessment Resources; 1996.
- 31. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Res. 2003;121: 31–49. pmid:14572622
- 32. Arrindell W. A., \& Oosterhof L. De “Schaal voor het Interpersoonlijk Gedrag” (SIG) [The schale for interpersonal behavior]. Gedragstherapie. 1996;3: 201–206.
- 33. Lecomte T, Corbière M, Laisné F. Investigating self-esteem in individuals with schizophrenia: Relevance of the Self-Esteem Rating Scale-Short Form. Psychiatry Res. 2006;143: 99–108. pmid:16725210
- 34. Birchwood M, Smith J, Drury V, Healy J, Macmillan F, Slade M. A self-report Insight Scale for psychosis: Reliability, validity and sensitivity to change. Acta Psychiatr Scand. 1994;89: 62–67. pmid:7908156
- 35. Priebe S. Huxley P., Knight S. \& Evans S. Application and Results of the Manchester Short Assessment of Quality of Life (Mansa). Int J Soc Psychiatry. 1999;45: 7–12. pmid:10443245
- 36.
van Gestel-Timmermans JAWM, van Weeghel J, van Nieuwenhuizen C. Verslag project ‘Ontwikkeling Nationale Herstelschaal. 2013. Available: http://www.narcis.nl/publication/RecordID/oai%7B%5C%25%7D3Atilburguniversity.edu%7B%5C%25%7D3Apublications%7B%5C%25%7D2Ff441bfff-7de8-4810-9212-1254809a3eed
- 37. Law H, Neil ST, Dunn G, Morrison AP. Psychometric properties of the Questionnaire about the Process of Recovery (QPR). Schizophr Res. 2014;156: 184–189. pmid:24816049
- 38. Birchwood M, Smith J, Cochrane R, Wetton S, Copestake S. The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. Br J Psychiatry. 1990;157: 853–859. pmid:2289094
- 39. Kirkpatrick B, Strauss GP, Nguyen L, Fischer BA, Daniel DG, Cienfuegos A, et al. The brief negative symptom scale: Psychometric properties. Schizophr Bull. 2011;37: 300–305. pmid:20558531
- 40. Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, et al. Brief screening instrument for post-traumatic stress disorder. Br J Psychiatry. 2002;181: 158–162. pmid:12151288
- 41. Bassett DR, John D. Use of pedometers and accelerometers in clinical populations: validity and reliability issues. Phys Ther Rev. 2010;15: 135–142.
- 42. Servaas MN, Kos C, Gravel N, Renken RJ, Marsman J-BC, van Tol M-J, et al. Rigidity in Motor Behavior and Brain Functioning in Patients With Schizophrenia and High Levels of Apathy. Schizophr Bull. 2018; 1–10. pmid:30053198
- 43. Léger LA, Mercier D, Gadoury C, Lambert J. The multistage 20 metre shuttle run test for aerobic fitness. J Sports Sci. 1988;6: 93–101. pmid:3184250
- 44. Hassett LM, Harmer AR, Moseley AM, Mackey MG. Validity of the modified 20-metre shuttle test: Assessment of cardiorespiratory fitness in people who have sustained a traumatic brain injury. Brain Inj. 2007;21: 1069–1077. pmid:17891570
- 45.
Spijkerman, R., Hendriks, V.M. \& van der Gaag M. Screening risico op verslavingsproblemen [Screening risk of substance dependence]. 2011.
- 46. van der Stouwe ECD, van Busschbach JT, Opmeer EM, de Vries B, Marsman J-BC, Aleman A, et al. Neural correlates of victimization in psychosis: differences in brain response to angry faces. npj Schizophr. 2019;5: 14. pmid:31501442
- 47. Rasbash J, Charlton C, Jones K, Pillinger R. Manual supplement for MLwiN version 2.14. 2009.
- 48.
Snijders T.A.B. \& Bosker RJ. Multilevel analysis: an introduction to Basic and Advanced Multilevel Modeling. London: Sage Publishers; 2012.
- 49. Priebe S., Chevalier A., Hamborg T., Golden E., King M., & Pistrang N. Effectiveness of a volunteer befriending programme for patients with schizophrenia: Randomised controlled trial. Br J Psychiatry. 2020;217: 477–483. pmid:30829190
- 50. Chapple B, Chant D, Nolan P, Cardy S, Whiteford H, McGrath J. Correlates of victimisation amongst people with psychosis. Soc Psychiatry Psychiatr Epidemiol. 2004;39: 836–840. pmid:15669665
- 51. Holley J, Crone D, Tyson P, Lovell G. The effects of physical activity on psychological well-being for those with schizophrenia: A systematic review. Br J Clin Psychol. 2011;50: 84–105. pmid:21332522
- 52. Malchow B, Reich-Erkelenz D, Oertel-Knöchel V, Keller K, Hasan A, Schmitt A, et al. The effects of physical exercise in schizophrenia and affective disorders. Eur Arch Psychiatry Clin Neurosci. 2013;263: 451–467. pmid:23873090
- 53. Lakes KD, Hoyt WT. Promoting self-regulation through school-based martial arts training. J Appl Dev Psychol. 2004;25: 283–302.
- 54. Twemlow SW, Biggs BK, Nelson TD, Vernberg EM, Fonagy P, Twemlow SW. Effects of participation in a martial arts-based antibullying program in elementary schools. Psychol Sch. 2008;45: 947–959.
- 55. Zivin G, Hassan NR, DePaula GF, Monti DA, Harlan C, Hossain KD, et al. An effective approach to violence prevention: Traditional martial arts in middle school. Adolescence. 2001. pp. 443–459. pmid:11817627
- 56. Scheewe TW, Backx FJG, Takken T, Jörg F, van Strater ACP, Kroes AG, et al. Exercise therapy improves mental and physical health in schizophrenia: A randomised controlled trial. Acta Psychiatr Scand. 2013;127: 464–473. pmid:23106093
- 57.
Akkermans M., Gielen W., Kloosterman E., Moons E., Reep C., Winten M. Prevalentiemonitor Huiselijk Geweld en Seksueel Geweld 2020 (PHGSG 2020). In: CBS [Internet]. 2020. Available: https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2020/12/21/prevalentiemonitor-huiselijk-geweld-en-seksueel-geweld-2020/prevalentiemonitor-huiselijk-geweld-en-seksueel-geweld-2020.pdf
- 58. Hasson-Ohayon I, Kravetz S, Roe D, Rozencwaig S, Weiser M. Qualitative assessment of verbal and non-verbal psychosocial interventions for people with severe mental illness. J Ment Heal. 2006;15: 343–353.
- 59. Hogenelst K, Schoevers RA, Aan het Rot M. Studying the neurobiology of human social interaction: Making the case for ecological validity Commentary Studying the neurobiology of human social interaction: Making the case for ecological validity. Soc Neurosci. 2015;10: 219–229. pmid:25566795
- 60. van de Kamp MM, Emck C, Cuijpers P, Beek PJ. A psychomotor diagnostic instrument for patients with post-traumatic stress disorder. Body, Mov Danc Psychother. 2018;13: 33–49.