Physiotherapy management strategies in people with schizophrenia

What is Schizophrenia?[edit | edit source]

Schizophrenia is described as a mental health disorder which causes people to interpret reality abnormally through altered emotions, thinking and behaviour. Its cause is thought to be a mixture of genetic, neurobiological (excessive dopamine levels) and environmental factors. However, its true cause has never been established [1] [2].


Schizophrenia is a major public health problem and a leading cause of suffering and disability. The extent to which the condition affects people is variable.[3] 

Symptoms[edit | edit source]

This condition has both ‘positive’ and ‘negative’ symptoms[4]. The concept of positive and negative symptoms of mental health has been around for a long time but was first applied to schizophrenia in the 1970’s to support the differing types of psychopathological manifestations.[3] The positive symptoms are thinking or behaviours that the person with schizophrenia did not have before they became ill and so can be thought of as being added to their mental state. Whereas, negative symptoms describe thoughts or behaviours that the person used to have before they became ill but now no longer have or have to a lesser extent; thus have been lost or taken away from their mental state.[5] In many cases, negative symptoms are present before the onset of positive symptoms which can be seen in the psychotic phase.[3]

The figures below illustrate these symptoms:

Postivie and negative symptoms.png


The symptoms of schizophrenia affect the person holistically. It is important that these bio-psychosocial issues are understood by physiotherapists as they will impact on interaction and management of this patient group in terms of adopting different communication and treatment styles.

Poor Physical Health in People with Schizophrenia[edit | edit source]

It is well documented in the literature that people with schizophrenia have much poorer physical health than the general population. Despite having more contact with health services they have a much poorer life expectancy, dying on average 15-20 years earlier.[6] A key factor associated with poor physical health in this population is the high rate of physical inactivity and tendency to adopt a more sedentary lifestyle than the general population. [7][8][9]
In general, physical inactivity is associated with an array of health risks and is said to be one of the leading causes of long term and secondary conditions such as coronary heart disease, diabetes, obesity and different types of cancers. [10][11] It is important to remember that the same health risks apply to people with schizophrenia but due to the nature of their condition and other influencing factors the risk is much greater[12].

Poor health in schizophrenia.png


In people with schizophrenia, these factors, combined with physical inactivity and sedentary lifestyles significantly increase the risk of developing long term conditions compared to the general population.

Medications[edit | edit source]

The main medications used in schizophrenia are antipsychotics and tranquilizers. Physiotherapists need to be able to understand the effects these drugs will have on the patient's ability to interact with physical management. During an assessment or treatment session a physiotherapist also needs to be aware of how these medications will affect cognition. Proprioception and the patients’ body image may also be affected due to medications. [13].  It is important to recognise that patients will have different reactions to medications and therefore may experience side-effects to varying severity. FGA side effects are involuntary. Some experience akathisia and dystonia which are sometimes misdiagnosed as aggression .[14]

For further reading, the NICE guidelines[15]for Psychosis and Schizophrenia discuss which medications should be chosen and when. You can find this from section 1.3.5 and onwards.

The Side Effects of Schizophrenia Medication and Considerations for Physiotherapists[edit | edit source]

It should be noted that you may come across people with other mental health conditions who are experiencing similar side effects as they may be taking some of the same medications.[16]

It has been reported that 68-90% of individuals with schizophrenia do not adhere to their medication programmes because of the common reported side effects.[16][17]This can make symptoms worse leading to functional problems.

The main side effects of schizophrenia medications are:

  • Weight gain,
  • Impotence,
  • Insomnia,
  • Cognitive impairment
  • Chronic sedation and
  • Lack of ability to concentrate in activities of daily living. [18][16][13]


There have been a lot of studies about non-adherence. This is a major problem in this population, as patients who are not adherent to their medication are more likely to relapse, be readmitted to hospital and have a longer hospital stay[19].
This may be an area that physiotherapists can take part in as explaining why the medication is important for their wellbeing it may help with adherence. As physiotherapists are not experts in medication all advice given should be in line with what the prescribing medical staff recommend.

For patients with schizophrenia, cognitive impairment can make functional rehabilitation more difficult. Patients find having meaningful relationships, keeping employment and living independently difficult due to their impaired cognition.

Other considerations

  1. Smoking status affects how medication works for patients. [20]
  2. Poor physical health and low socio-economic position are associated with poor mental health. Physical activity has been linked to a reduced use of psychotropic medications in middle aged men and women [21]. Personally tailored exercise regimes are important because every patient is unique and will have different side effects from their medication[22].

Physiotherapy Management Approaches in People with Schizophrenia[edit | edit source]

Health Promotion[edit | edit source]

In general, the key role of physiotherapists and principle of physiotherapy is to ‘help restore movement and function when someone is affected by injury, illness or disability’[23]. As described earlier however, it is now recognised that physiotherapists are perfectly positioned to link mind and body.[24] A recent publication by CSP Scotland [25] suggests that the key role of physiotherapy in mental health is to improve the well-being of people with physical impairment associated with mental illness and improve their psychological health through a range of approaches.

If we look more specifically at schizophrenia, we already know that this population have very poor physical health and this is a major contributor to the significantly lower life-expectancy than the general population[26]. Despite this, many of the factors that contribute to the poor physical health in this population are said to be ‘modifiable’ i.e. they can be changed and it appears that physiotherapists are key to this process.[27]

A recent article by Kaur et al. [27]suggested that simple lifestyle modifications can result in improved health and quality of life in individuals with mental illness. When managing individuals with schizophrenia, health promotion is vital. This is “the process of enabling people to increase control over, and to improve, their health”. One of the main ways that physiotherapists promote health is by encouraging physical activity. The CSP believes that physiotherapists have a key role in “enabling physical activity for health promotion, disease prevention and relapse”.

A cross-sectional qualitative study by Stubbs et al.[9]looking at physiotherapists’ perspectives of their role in managing patients with schizophrenia also identified physical activity as one of the most important ways to promote health. 43.5% of respondents believed that physiotherapists should lead in the promotion of physical activity and structured exercise in people with schizophrenia. Encouraging people to live a healthier lifestyle was also identified as a key role as health promotion could help in the management of the various long-term conditions that arise[9]. Encouraging people to be more active has the potential to improve the physical health of people with schizophrenia whilst also having a positive influence on their mental health and social functioning [27].

NICE Guidelines for Schizophrenia and Psychosis in Adults[28] state that people with schizophrenia should be offered help to stop smoking even if previous attempts have been unsuccessful. Although physical activity is the main focus in this section of the wiki, it is important to be aware of the other ways we, as physiotherapists could influence an individuals health. 

Physical Activity[edit | edit source]

Physical activity is defined as “any bodily movement produced by skeletal muscles that requires energy expenditure”[29]. Exercise on the other hand is simply a specific type/form of physical activity which is said to be planned, structured and purposeful[30].

Physical activity can take any form and even simple everyday tasks constitute to being physically active. Some examples of everyday tasks and specific types of exercise can be seen below.

Types of exercise.png


Recommendations have been created as a guide to the amount and level of physical activity that the general population should be engaging in. Please take time to familiarise yourself with these recommendations.[31][31][47][57][57][81][112][112][112]

Specific exercise often requires higher rates of energy expenditure than simple everyday examples of physical activity. Where exercise intensities are higher, the health benefits are said to be greater[32]. Despite this, it is important to remember that people with schizophrenia are often very sedentary and have very low levels of physical activity engagement.[7]

Barriers to Physical Activity[edit | edit source]

Due to spending large periods of their time being sedentary, the majority of people with schizophrenia fail to meet the physical activity recommendations of 30 minutes per day [6]. The barriers to engaging in physical activity in people with schizophrenia could be grouped into 3 main categories. They are:

1. Symptoms as Barriers:
The symptoms of schizophrenia and side effects from medication are a major contributor to physical inactivity in this population. The table below highlights these barriers and the impact that they can have on physiotherapy management.[33][34][35][36]
2. Psychological Barriers

Psychological barriers are internal thoughts, feelings or beliefs that an individual has which cause them to feel they cannot do something or cannot complete a task.[37] Below are a number of common psychological barriers identified in the literature relating to people with schizophrenia. Each barrier is explained and the potential impact on physiotherapy management discussed.

Psychological barriers.png

3. Social/Environmental Barriers

A number of social and environmental factors have been identified as barriers to physical activity in people with schizophrenia.

  1. Lack of time
  2. Lack of Income
  3. The Environment


Due to lack of income, people with schizophrenia often live in poorer areas of the community[38]. As such feeling unsafe in their environment has been identified as another barrier to physical activity engagement as individuals are reluctant to leave their house[39]. Where you try and promote physical activity can also act as a barrier as individuals with schizophrenia often do not like being in new and unfamiliar environments[40].

Benefits of Physical Activity[edit | edit source]

Physical activity is known to have a number of physical and mental health benefits in the general population [32]. It has the potential to improve the quality of life of people with serious mental illness through two routes - by improving physical health and by alleviating psychiatric and social disability[41]. As discussed, physiotherapists have a key role in health promotion and encouraging physical activity is one of the main ways they look to achieve this. This section of the wiki looks to address the physical and mental health benefits of physical activity in people with schizophrenia. Physical and mental health benefits.png


The physical health benefits of physical activity are extensive. A narrative review by Warburton et al.[42] found that regular physical activity is extremely effective in the primary and secondary prevention of a number of chronic conditions e.g. cardiovascular disease, diabetes, obesity, cancer and hypertension.

A systematic review and meta-ethnographic synthesis which explored the experiences of individuals living with schizophrenia found that having enough fitness to get through an entire day was a great benefit to the individual[39]. The improvements to cardiorespiratory (CR) fitness have been quantitatively reported in a recent systematic review and meta-analysis[43]. The meta-analysis of pre + post test changes in CR fitness found that exercise significantly improved CR fitness (pooled mean predicted increase in VO2 max or VO2 peak was 2.87ml/kg/min p=0.001). Similarly, when compared to control groups, exercise significantly improved CR fitness (p=0.02). Although the overall sample size was small and there were limitations in reporting of important variables e.g. medication, it is clear that physiotherapy interventions should focus on improving physical fitness as it is achievable in this population and is also associated with reduced mortality rates.[42]


Along with improving physical health, physical activity also improves the mental health of people with schizophrenia [44]. One of the main benefits reported is a reduction in positive and negative symptoms. An early systematic review by Faulkner and Biddle [45]found that physical activity can reduce some of the negative symptoms of schizophrenia and act as a coping mechanism for positive symptoms. Further research has been carried out and more recent systematic review by Firth et al.[46] found that moderate-vigorous activity significantly improved total symptom score and positive and negative symptom sub-scales.

A number of qualitative studies have been conducted to establish the benefits from the individuals’ point of view. The systematic review and meta-ethnographic synthesis referred to earlier in this section found that physical activity was associated with; improved confidence and self-esteem to engage in the community, providing a sense of purpose to the individual and improved attitudes towards physical activity[39]. These findings were also similar to another systematic review by Holley at al.[47] which concluded that physical activity has a benefit on some attributes associated with psychological well-being. A list of these can be seen below. This study was limited by the fact that a range of instruments were used to measure physical activity and there were varying study designs meaning statistical analysis was impossible.

It is clear to see that physical activity can play an important role in improving both the physical and mental health of individuals with schizophrenia. The evidence surrounding schizophrenia alone is not that extensive and as such many of the studies have major limitations (almost always sample size or study design). In saying that, the evidence that is out there provides a good base to show that physical activity is beneficial in this population although it is clear more research is needed. Knowing about the individual experiences of a person living with schizophrenia and the impact that physical activity has had on their life is very valuable. 

Specific Therapy Interventions For People with Schizophrenia[edit | edit source]

As mentioned earlier the physiotherapist plays a key role in health promotion and encouraging physical activity in people with schizophrenia. This section of the wiki aims to expand your physiotherapy toolbox by discussing and evaluating common physiotherapy strategies used in mental health including aerobic and strengthening exercise prescription, touch based skills and movement based therapies.

Other techniques to be aware of which are effective in managing anxiety associated with schizophrenia are relaxation, breathing control and tension awareness which are learnt during cardio-respiratory studies in physiotherapy training [25].

Aerobic and Strengthening Exercise[edit | edit source]

It is recommended in the most recent NICE Guidelines[28] that people with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a physical activity/exercise programme by a health care professional. A systematic review on the benefits of exercise in people with schizophrenia[48] found that regular exercise programmes are possible in this population, and that they can have beneficial effects on both physical and mental health. Although, studies included in this review were small and used various measures of physical and mental health it is difficult to establish the true benefits of exercise.

Further to this, a systematic review and meta-analysis was undertaken by Pearsall et al.[49] which looked at exercise therapy in adults with serious mental health conditions. Exercise programmes in this review were found to have a modest beneficial effect on levels of exercise activity in this population, however no true benefits were found for relief of symptoms.

There were limitations to this review. Firstly the heterogeneity of programmes affected the impact and generalisability of studies found in the review. Secondly, studies failed to quantify the frequency and intensity of exercise in their programmes. And lastly, interventions tended to use non-standardised exercise programmes and a variety of outcome measures. This makes it challenging to recommend the most suitable and effective programme of exercise to individuals with serious mental illness including schizophrenia.

Having said this, there seems to be a lack of continuity between literature results as Rosenbaum et al[50] found through an extensive review of 39 RCTs that physical activity reduced symptoms of schizophrenia and improved aerobic capacity and quality of life among people with mental illness. 
In light of this, here are examples of exercise prescription that could be advised for people with schizophrenia:

Exercise prescription.png

Dodd et al.[51] found that group exercise classes which incorporated walking and aerobic elements were deemed feasible in the schizophrenic population with no negative effect and participants in this study experienced weight loss as a benefit. 
Furthermore, Richardson et al.[52] found that individual supervision is hard to do in group situations and treatment cannot be altered as easily to keep in line with individual patient progress. Fogarty et al.[53] carried out a study whereby 6 indivdulas with schizophrenia took part in a 3-month physical conditioning programme aimed at improving cardiovascular fitness, endurance and strength; walking and cycling appeared to be of most benefit and low cost. They found that the majority of participants improved their physical strength and endurance and exhibited enhanced weight control and flexibility. This alludes to the importance of tailored individual exercise plans as all participants in this study had varying degrees of improvement.

Touch Based Skills[edit | edit source]

We know that skilled touch is a distinctive skill possessed by physiotherapists. This is an essential skill to use when treating patients with mental health conditions such as schizophrenia as their need for physical contact is greatly increased as mental health declines.[54] Treatment such as therapeutic massage can be used as this is proven to reduce levels of anxiety and depression which can be present in this population.[55]

Man massage table.jpg



Further evidence has shown that touch based therapies can decrease blood pressure, cortisol levels, stress and gives relief from pain.[56] This is beneficial as people with mental health disorders often feel pain as a result of emotions and therefore physiotherapists can use gentle touch as a way of relieving this pain and increasing patient comfort.[57]

Movement Based Therapies[edit | edit source]

The importance of physical activity and exercise prescription has been presented to you which are forms of movement based therapies. More specific ones used in the rehabilitation of people with schizophrenia are Basic Body Awareness Therapy, The Alexander Technique, Tai Chi and Yoga.[25]

Basic Body Awareness Therapy

One of the therapies that is provided by physiotherapists in mental health for people with physical and psychological problems, evident in people with schizophrenia, is basic body awareness therapy (BBAT) which is seen to be growing in popularity.[58] This technique was firstly developed in Scandinavian countries around 40 years ago.[59] In order to practice this technique, physiotherapists must undergo specific training yet basic principles can be used in everyday practice. We have chosen to provide a brief overview of BBAT in order to let you know what treatment methods are currently in place in the mental health setting.

Roxendal[59] suggest that BBAT should be used where disturbances in body awareness are an important part of the pathological picture and hence can be a useful treatment in helping patients with schizophrenia.

BBAT goals.jpg

The number of therapy sessions needed depends upon the diagnosis and abilities of the patient. One study by Gyllensten et al.[60] found that improvements were seen in people with moderate depression or anxiety in 12 sessions, however, Roxendal[59] found that people with schizophrenia needed approximately 9 months or longer, so therapy can be a lengthy process.

The Impact of BBAT on Patients:

Gyllensten et al.[60] looked at the outcomes of BBAT in patients in psychiatric outpatient care. It was concluded that those who received BBAT had a reduction in their psychiatric symptoms and developed a far more positive attitude towards their body.
The results of the above study were very similar to a qualitative study by Hedlund and Gyllensten[61] which focused on experiences of BBAT in people with schizophrenia. 7 out of the 8 patients reported that they felt they had better contact with their bodies and had become more aware of their movement behaviour, postures and balance. They also reported becoming more physically active and felt they had increased self-esteem and were able to cope more effectively in social situations. A later study by Hedlund and Gyllensten[62] explored physiotherapists views on their experiences of using BBAT. They similarly reported that they notice a positive change in their patients' self esteem after treatment sessions. The physiotherapists in this study also shared experiences of patients reporting that their positive symptoms related to their condition such as hallucinations and hearing voices being were dampened when a state of postural balance was achieved.

The strength of how effective BBAT is also dependendant on how well the patient interacts with the treatment session - so keeping focus and engagement is paramount to patient progress.[63]

Communication Strategies[edit | edit source]

Most physiotherapists will, at some point in their career encounter individuals who suffer from a mental health condition[64]. It may be that the physiotherapist will be treating another condition, but in order to treat the individual holistically, it is important to understand how this condition may impact the delivery of treatment and require a modified approach.

The previously mentioned survey by Dandridge et al.[65] on the views of physiotherapy students towards treating individuals with mental illness, found that one of the key issues was regarding communication. Students raised concerns about how to approach someone with mental illness, discussing a lack of knowledge of how to communicate effectively or adjust their approach to individual needs.

Barriers to Communication[edit | edit source]

Impact of Negative Symptoms[edit | edit source]

In schizophrenia, while the positive symptoms (hallucinations and delusions) are widely recognised as the hallmarks of the condition, it is the negative symptoms which are harder to treat and are more indicative of the long-term ability of the individual to function in society [66]. These negative symptoms include poverty of thought and speech, apathy, anhedonia (inability to experience pleasure), lack of motivation and decreased engagement in social interactions [67]. These symptoms have a significant impact on how an individual experiences life. They usually exist prior to the emergence of positive symptoms and will often endure long after the psychotic symptoms have disappeared [68]. Negative symptoms also have implications for physiotherapy treatment as they will affect the client-physiotherapist interactions as well as the ability of the individual to participate actively with their treatment plan.

Deficits in Social Cognition[edit | edit source]

It has also been identified that individuals may experience deficits in social cognition which can impact their ability to interact socially with others. This can include difficulties with; interpreting facial expressions or tone of voice, recognising the emotions or intentions of others and understanding their own feelings and emotions[69]. Furthermore, a study by Lavelle et al. [70] on non-verbal communication found that poor social cognition and increased negative symptoms had an adverse impact on social interactions leading participants to perceive poorer rapport when having conversations with individuals suffering from schizophrenia. Interestingly, a higher level of rapport was reported with individuals exhibiting mild positive symptoms, possibly due to these symptoms manifesting as more engagement with the social interaction. As establishing a therapeutic relationship is essential in patient-therapist interactions [71], it is important that these deficits in social cognition are understood and that clinicians engage in strategies to help establish rapport and ensure effective communication is achieved.

Communication Skills[edit | edit source]

Approaches to Enhance Communication: from Pounds 2010[72][edit | edit source]

A qualitative and descriptive pilot study was carried out to investigate the interaction of an experienced mental health nurse specialist with 3 of her schizophrenic clients. The aim was to describe how she altered her verbal and non-verbal communication in order to enhance effective communication and develop a therapeutic relationship.

Some key approaches that emerged included:

Exaggeration of facial and vocal cues As mentioned above, individuals may experience deficits in social cognition, including difficulty reading facial expressions or tone of voice. In this study, the nurse exaggerated her facial expressions (for example, showing concern) or her verbal language (for example, greater inflection in her tone of voice, reflecting a clients’ statement back to them). When applied, these subtle changes in behaviour elicited responses from her clients (such as increased eye contact) and improved their engagement with the interaction.
Open body language Displaying open body language, such as leaning forward, smiling and nodding can demonstrate to the client that the clinician is willing to engage with them and can encourage an individual to be involved in the interaction.
Accepting silence/giving time to answer Some of the negative symptoms (as mentioned above) that an individual with schizophrenia may face are poverty of thought and speech. This means that when asked a question, a person may require longer to gather their thoughts and give an answer. In her interactions with her clients, there were often periods of silence whilst they were considering a question (lasting between 5-15 seconds).

Promoting Engagement with Treatment[edit | edit source]

Amotivation as a Key Problem[edit | edit source]

Lack of motivation (amotivation) is one of the main negative symptoms experienced by those with schizophrenia [67] and has been identified as having a significant impact on all aspects of behaviour [73]. Motivation is essential for engagement in self-care actions and has an important role in the process of change [74]. A qualitative study by Abed [75] identified lack of motivation to be a major factor that influenced health-related decisions and behaviour. Foussias et al. [76] conducted a longitudinal study and found that amotivation was responsible for 74% of variance in functional outcomes at baseline and 72% of variance at 6-month follow-up, therefore indicating that motivation has a crucial role in predicting the functional outcomes for individuals with schizophrenia. Addressing motivation is of great importance to promote engagement with change and healthy lifestyle choices within this population [74].

Strategies to Enhance Motivation[edit | edit source]

Goal Setting:

The importance of setting patient centered goals within this population will be discussed later on this physiopedia page in more detail. However, it is important to note that working with the individual to set personal meaningful goals can help combat amotivation and influence their willingness to be actively involved in their treatment [77]. Adams and Drake [78] discuss how individuals with serious mental illnesses are capable of meaningfully participating in decisions about their healthcare and it is therefore important to involve them in the planning of treatment. The setting of patient centered goals is one way in which a sense of control can be returned to the patient and can increase their self-determination [77]. Progression towards personal goals is also considered to be a powerful influencing factor in promoting psychological recovery [79].


Social Support:

It has been documented that social interactions can have a positive impact on adherence, enjoyment and motivation to change [80], however, individuals with schizophrenia often feel isolated by their condition and have a lack of social support [35]. This is due to a number of factors including paranoia, social skill deficits, social and emotional processing problems, negative symptoms and stigma [77]. A survey of mental health physiotherapists conducted by Soundy et al. [35] investigated the common forms of support they utilised to engage people with schizophrenia in physical activity. Forty physiotherapists provided in depth responses and from this, four dimensions of social support were identified: Informational, tangible, esteem and emotional support.
While the results from this survey may not be representative or generalisable, a number of key themes were seen to emerge. Many of these suggestions may be useful for physiotherapists to consider in order to better support their clients in their recovery [35].

Cognitive Behavioural Therapy[edit | edit source]

Cognitive behavioural therapy (CBT) is a therapeutic technique commonly used in the treatment of mental health conditions and in the UK the National Institute for Health and Care Excellence [28] recommends this as a standard treatment to be offered to all individuals with a diagnosis of schizophrenia. The aim of CBT is to change how individuals manage and view themselves, particularly in relation to how they experience their condition, and involves metacognition; the ability to think about one’s own thinking [77]. CBT as a specific treatment approach is usually carried out by psychologists or by staff who have undergone specialist training [81], but many of the principles of CBT may be useful within everyday physiotherapy practice.

CBT can be helpful in schizophrenia by challenging beliefs and reasoning in relation to their condition, and through enabling people to establish connections between their thoughts, actions, feelings and symptoms[28]. One example of this is in addressing compliance behavior in those who hear voices (responding to or acting on the commands of the voice). Trower et al.[82] used CBT to challenge beliefs about these hallucinations in a randomized control trial. They reported a decrease in compliance behaviour in addition to reductions in depression and distress scores. Whilst no change was observed in the nature or frequency of the hallucinations, the individuals perceived the voices to have less power over them. CBT used in this way for psychosis has shown strong effect sizes in comparison to no treatment [81], however the evidence shows little benefit when compared to other available therapies [83]. It has been reported in a number of studies that when positive symptoms have been targeted there has also been some improvement in negative symptoms and this has led to recent research into CBT to specifically target negative symptoms [84][68].
Principles of CBT that may be useful in practice

Initially, a trustworthy therapeutic relationship must be built between the client and the therapist and there must be no attempt to label the persons beliefs as irrational [81]. The aim is to help the individual recognise and process maladaptive behaviours and distorted thinking but this should be done collaboratively [85]. It may be helpful for some individuals to adapt a third-person perspective as though discussing someone else’s beliefs, and the therapist can pose questions to facilitate their evaluation of those beliefs [81]. Working with the therapist, behavioural goals are set and a plan is then developed in order to attain them, considering how personal barriers, dysfunctional thoughts and behaviours may be overcome. Systematic discussions are used to help individuals identify and modify their thoughts and behaviours and the use of carefully structured behaviour assignments can assist the person in bringing about these changes in their life[85]. CBT may be more useful to physiotherapists where an individual already has the desire to or is already trying to change [85].


The charity organisation MIND have produced this document about CBT for patients who want to understand more about this therapy. It may be useful for further reading on this topic or to provide information to clients who you feel may benefit from CBT.

Motivational Interviewing[edit | edit source]

Motivational interviewing is another technique that may be of use to help combat lack of motivation in individuals with schizophrenia. It can be described as a way of being with people and helping them to navigate change and must take place in the context of a supportive therapeutic relationship [74]. Motivational interviewing takes the form of a collaborative conversation that is goal-orientated and focused on change, with the purpose of strengthening personal motivation by eliciting and exploring the persons own reasons for change in a supportive environment [85]. It does not externally impose change, but supports change based on their own goals, desires and values [74].

Jackman [86] states that there are five principles:

  1. Expressing empathy
  2. Developing discrepancy
  3. Avoiding conflict and arguments
  4. Working with rather than fighting resistance 
  5. Supporting self-efficacy.

Five key communication skills are used in motivational interviewing:

  1. Open-ended questions
  2. Affirming
  3. Reflecting
  4. Summarizing
  5. Providing information[85].

In this way, the therapist can guide the thoughts of the client by understanding their position and by asking questions to enable them to reach a point where they are intrinsically motivated to change and feel empowered to do so.

There are courses available that teach motivational interviewing and if you think this may benefit your practice you could consider attending one. However, even without formal training the principles of motivational interviewing may be useful to integrate into your everyday client interactions.


A Cochrane review[87] on psychosocial interventions for people with severe mental illness (including schizophrenia) to combat substance abuse concluded that the quality of the evidence was low and there was no difference between motivational interviewing and usual care. However, it was stated that motivational interviewing may lead to short-term reductions in substance abuse with multiple sessions.

Vanderwaal[88] conducted a recent review of the literature on the impact of motivational interviewing for medication adherence in those with schizophrenia. This article concluded that motivational interviewing may be beneficial for some patients but should not be used as a first line on treatment.

In the promotion of physical activity, there is a lack of evidence on motivational interviewing within the schizophrenic population. However, a systematic review and meta-analysis[89]on those with chronic health conditions included severe mental ill health within their criteria. The results indicated that there was moderate evidence to support a small effect on increasing physical activity. Therefore the use of motivational interviewing within the care plan of an individual with schizophrenia may facilitate physical activity engagement.

A Patient Centered Approach: Goal Setting[edit | edit source]

A patient centered approach is vital in the management of people with schizophrenia, particularly with regards to treatment planning and goal setting. The practice of setting goals is common in mental health rehabilitation and in general case-management[79].

Goal-setting.jpg

Working towards achievable and meaningful goals that have been determined collaboratively can contribute to greater life satisfaction, promote self-management and reduce psychological symptoms. Moreover, attainment of goals improves the emotional and psychological wellbeing of an individual[79].

Clarke et al.[79] states that the levels of distress due to psychotic symptoms are related to goal progress, with greater symptom distress having a negative impact on the progression of goals.

Another study[90] discusses the types of goals set by individuals with psychiatric disorders (majority of participants suffered from schizophrenia) depending on the stage of recovery that they were in. This study found that those within early stages of recovery focused more on “avoidance” goals (reducing an undesirable outcome such as hearing voices) whilst those is later stages of recovery showed an increase in setting “approach” goals (moving towards a positive outcome).

It is suggested that when life goals become unachievable, simple daily goals may help keep depression at bay and provide a sense of purpose. There is therefore a higher prevalence of health goals at the early stage of recovery and it is likely that these more concrete initial goals must be at least partially met before the individual feels able to progress to goals associated with relationships, employment and personal development.[90]

Conclusion[edit | edit source]

A physiotherapist not only requires an understanding of each individual level of physical impairment, they also require an understanding of their mental health issues. Some patients may struggle with directions or remembering exercise sets, whilst others suffer from ill effect of their medications or a combination of both. A physiotherapist must remember all of these factors to aid functional rehabilitation. Furthermore, a physiotherapist can also talk to the individual about their non-adherence to their medications and provide support.

References [edit | edit source]

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  2. World Health Organisation. Mental Health: Schizophrenia. www.who.int/mental_health/management/schizophrenia/en (accessed 5 January 2016).
  3. 3.0 3.1 3.2 Weinberger DR, Harrison PJ. Schizophrenia. 3rd ed. Oxford: Blackwell Publishing, 2011
  4. NHS Choices. Symptoms of Schizophrenia. www.nhs.uk/Conditions/Schizophrenia/Pages/Symptoms.aspx (accessed 10 January 2016).
  5. Living with Schizophrenia. Negative Symptoms of Schizophrenia: Understanding Them. http://www.livingwithschizophreniauk.org/advice-sheets/negative-symptoms-understanding (accessed 23 January 2016).
  6. 6.0 6.1 McNamee L, Mead G, MacGillivray S, Lawrie SM. Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities. The British Journal of Psychiatry 2013;203:239-241. http://bjp.rcpsych.org/content/203/4/239.long (accessed 2 January 2016).
  7. 7.0 7.1 Lindamer LA, Mckibbin C, Norman GJ, Jordan L, Harrison K, Abeyesubge S, Patrick K. Assessment of Physical Activity in Middle-aged and Older Adults with Schizophrenia. Schizophrenia Research 2008;104:294-301.
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