F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.12262.1 Clinical Practice Article Articles Behavioral Neuroscience Cancer Therapeutics A case series report of cancer patients undergoing group body psychotherapy

[version 1; peer review: 2 approved]

 Grossert Astrid Conceptualization Data Curation Formal Analysis Investigation Methodology Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing 1 2 Meinlschmidt Gunther Conceptualization Formal Analysis Methodology Validation Writing – Review & Editing a 1 3 4 5 Schaefert Rainer Conceptualization Formal Analysis Methodology Resources Validation Writing – Review & Editing b 1 4 Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland Department of Medical Oncology, University Hospital Basel, Basel, Switzerland Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland Faculty of Medicine, University of Basel, Basel, Switzerland Faculty of Medicine, University of Basel, Bochum, Germany gunther.meinlschmidt@usb.ch rainer.schaefert@usb.ch

Competing interests: AG had a mandate from the <i>Krebsliga Beider Basel</i> to conduct this group intervention &ldquo;<i>Krebs und K&ouml;rperwahrnehmung</i>&rdquo;. GM has received funding from the Korea Research Foundation within the Global Research Network Program under project no. 2013S1A2A2035364, and from the Swiss National Science Foundation under project no. 100014_135328. GM has been acting as consultant for Janssen Research &amp; Development, LLC. From the other author (RS) no potential competing interests were disclosed.

 5 9 2017 2017 6 1646 19 6 2026 Copyright: © 2017 Grossert A et al. 2017 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Disturbances in bodily wellbeing represent a key source of psychosocial suffering and impairment related to cancer. Therefore, interventions to improve bodily wellbeing in post-treatment cancer patients are of paramount importance. Notably, body psychotherapy (BPT) has been shown to improve bodily wellbeing in subjects suffering from a variety of mental disorders. However, how post-treatment cancer patients perceive and subjectively react to group BPT aiming at improving bodily disturbances has, to the best of our knowledge, not yet been described.

Methods: We report on six patients undergoing outpatient group BPT that followed oncological treatment for malignant neoplasms. The BPT consisted of six sessions based on a scientific embodiment approach, integrating body-oriented techniques to improve patients’ awareness, perception, acceptance, and expression regarding their body.

Results: The BPT was well accepted by all patients. Despite having undergone different types of oncological treatment for different cancer types and locations, all subjects reported having appreciated BPT and improved how they perceived their bodies. However, individual descriptions of improvements showed substantial heterogeneity across subjects. Notably, most patients indicated that sensations, perceptions, and other mental activities related to their own body intensified when proceeding through the group BPT sessions.

Conclusion: The findings from this case series encourage and inform future studies examining whether group BPT is efficacious in post-treatment cancer patients and investigating the related mechanisms of action. The observed heterogeneity in individual descriptions of perceived treatment effects point to the need for selecting comprehensive indicators of changes in disturbances of bodily wellbeing as the primary patient-reported outcome in future clinical trials. While increases in mental activities related to their own body are commonly interpreted as important mechanisms of therapeutic action in BPT, follow-up assessments are needed to evaluate intended and unintended consequences of these changes in cancer patients.

 body image body integrity body therapy case report group psychotherapy malignant neoplasm movement therapy tumor The author(s) declared that no grants were involved in supporting this work. Introduction

Cancer is related to high individual and societal burden worldwide, which is caused not only by mortality, but also morbidity and impairment, as indicated by recent analyses in the context of the Global Burden of Disease study and other consortia 1– 3 . Notably, while a significant proportion of cancer-related burden directly originates from the neoplasm and its treatment, psychosocial impairment represents another substantial aspect of cancer-related burden, which is triggered by the experiences and suffering related to cancer, that often persists beyond successful treatment of the tumor itself 4– 8 .

Disturbances in bodily wellbeing represent one key aspect of these psychosocial impairments related to cancer 9, 10 . Notably, the concept of cancer-related disturbances in bodily wellbeing and related constructs, such as perceived body integrity and body image, have been present for a long time, but with varying and sometimes conflicting definitions 10– 13 . In a recent report and analysis, Rhoten examined the concept of ‘body image disturbances’ in the context of cancer. She identified three relevant attributes of body image disturbance: (1) self-perception of a change in appearance and displeasure with the change or perceived change in appearance; (2) decline in an area of function; and (3) psychological distress regarding changes in appearance and/or function 12 . In line with these attributes, others have stressed that body image is a multidimensional construct, including elements such as perceptions, feelings, and attitudes toward the body, with body image disturbances being highly prevalent in cancer patients 10 . The broader term ‘disturbances in bodily wellbeing’ (or ‘bodily disturbances’) acknowledges the fact that subjective bodily disturbances related to cancer are multifaceted, including key aspects often subsumed under the term ‘body image disturbance’, such as disturbances and related distress in perceptions, feelings, and attitudes toward the body, as well as in subjective appearance and/or function of the body. The concept of bodily disturbances builds on the understanding of the polar relations between bodily and mental processes and experiences. This body-mind perspective has gained considerable attention over the past decade within the embodied cognition or embodiment approach 14 . In the context of the interventions described in this article, we put experiencing of the body in focus as a central pathway to experiencing and regulating the self, and regard the human being as a subjectively experiencing and embodied acting being that creates meaning in relation to the world 15, 16 .

Health-related quality of life improvements in cancer patients are typically intended to be achieved using medical interventions, such as the provision of cytotoxic agents 8 . Additionally, psychosocial interventions, including psychotherapy, for cancer patients and their caregivers have gained considerable attention in the past years 17 . However, meta-analyses of their efficacy have yielded mixed results, with some suggestive of rather small or no effects associated with classical interventions, such as cognitive behavioral therapy, which are well-established and largely effective in many non-cancer contexts 18– 21 . With regard to interventions that act via movement, there is ample evidence that physical activity and exercise i) are safe and feasible for cancer patients, ii) are linked to reduced cancer incidence (prevention), and iii) improve the quality of life and function of cancer patients, but with mostly small effects 22– 26 .

Furthermore, the past several years have seen a renaissance of interventions focusing on existential topics, such as meaning, which have been applied to patients with a variety of life-threatening diseases (e.g., cancer 27– 32 ), including ‘Meaning-Centered Group Psychotherapy’, with the aim of helping patients with advanced cancer sustain or enhance a sense of meaning, peace and purpose in their lives 33 . There is some evidence that body psychotherapy (BPT), defined as ‘psychotherapeutic treatment of mental disease or suffering, concomitantly using bodily and mental psychotherapeutic means’ 34 , is efficacious for the treatment of different mental disorders 35– 38 .

However, to the best of our knowledge, there are no data on the application of BPT in the context of cancer. Notably, given that BPT explicitly targets bodily aspects, such as perceptions, feelings, and attitudes toward the body, that are of paramount importance in the context of bodily disturbances in cancer patients (see above), elucidating BPT as an intervention to reduce disturbances of bodily wellbeing appears to be highly promising.

To conclude, disturbances of bodily wellbeing are highly prevalent in subjects with malignant neoplasm, and wellbeing often subsides despite successful interventions targeting the tumor itself. Therefore, identifying how to treat disturbances of bodily wellbeing in post-treatment cancer patients and therapeutic mechanisms is highly warranted, with BPT representing a highly promising and innovative approach.

To provide insight into the potential use of BPT in post-treatment cancer patients and to inform potential future clinical trials on this topic, we report on a series of six post-treatment cancer patients receiving group BPT aiming at improving bodily disturbances, focusing on how the patients perceived and subjectively reacted to the intervention. These patients are unique, and, to the best of our knowledge, these are the first published reports on the application of BPT in the context of cancer.

 Methods Therapeutic intervention

BPT was conducted by the first author of this case series (female, age = 35 years, Swiss citizen, trained psychologist and physiotherapist, four years of postgraduate training in body psychotherapy) and took place between October and December 2016. We describe here the key features of the intervention (structure of the description based on the ‘reporting recommendations for group-based behavior-change interventions’ 39 enriched by relevant elements from the ‘Template for Intervention Description and Replication (TIDieR) checklist and guide’ 40 ).

BPT represents an experience-oriented approach 34 , grounded in the notion that bodily and mental experiences and processes (including more existential topics, such as meaning in life) are closely and mutually related. More specifically, BPT takes advantage of the embodied, enactive and environmentally embedded nature of basic cognition, emotion, intersubjectivity, and experiencing 41 . In line with recently developed group body psychotherapy manuals for mental disorders (e.g., somatoform disorder, depression) that have been derived from disorder-specific intervention strategies 37, 42– 44 , our group BPT followed a general BPT framework. Therefore, it focused on specific pathological processes of key relevance in post-treatment cancer patients when applying body-oriented techniques to improve patients’ bodily awareness, perception, emotional connectedness, acceptance, and expression 45 .

The overall goal of this group BPT was to resolve bodily disturbances that are caused or triggered by the antecedent cancer and related treatments. Therefore, the group BPT aimed at supporting patients in learning to cope with untoward bodily sensations, feelings, and disturbances, such as changes in overt body image 46, 47 , as well as changes in attitudes toward and perceptions of their own body 48 , including feelings of insecurity and vulnerability 49– 51 , stigmatization 52 , impaired functioning 51, 53 , and feelings of disconnectedness from one’s own body 50 .

With regard to the setting, the BPT group (six participants) was provided under the auspices of the Krebsliga Beider Basel at their facilities. The group BPT consisted of six sessions of approximately 90 minutes each.

We chose a group setting because it offers advantages over individual therapy, including facilitation of specific therapeutic factors, such as vicarious learning and economic benefits 54, 55 , in the absence of strong evidence suggesting clear superiority in outcomes of one setting over the other when comparing group and individual psychotherapies 56– 58 .

The six sessions covered the following topics:

General introduction, fostering of group cohesion and focus on bodily perception;

Focus on bodily resources and grounding;

Focus on closeness and distance regulation;

Focus on social interactions and bodily impulses;

Focus on embodied emotions; and

Summary and transfer session.

Sequencing of the sessions was fixed, and every session consisted of four parts:

Introduction: Brief bodily exercise and exchange, preparing the specific topic of the session; review of the home task assigned during the past session, where appropriate;

Exercise: Psycho-educational element and an exercise triggering embodied experiences, focusing on the specific topic of the session;

Sharing: Exchange of experiences;

Closing: Résumé and farewell, hometask assignment, and outlook.

An outline of the content of each group BPT session is provided as Supplemental material (see Supplementary File 1). The execution of each session was tailored to the composition of the patient group and respective needs, acknowledging group processes that need to be addressed in connection with the content of each session.

The tools used during the sessions included materials, such as mats, ropes and balls.

The group BPT sessions were preceded by initial individual sessions (one per patient, maximum duration of 50 minutes) that were structured and documented using the basis documentation for Psycho-Oncology (PO-Bado) 59 , assessing sociodemographics, medical history, main symptoms, previous experiences, and individual core topics of relevance within the scope of the intervention. Additionally, validated questionnaires assessing distress and bodily wellbeing (German version of the Body Appreciation Scale [BAS]) were applied 60, 61 .

The patients were offered an additional facultative individual consultation session (one per patient, maximum duration of 50 minutes) following the last group BPT session to address open questions or to ensure ongoing therapeutic support.

 Data collection and integration

The group leader took written notes of key statements of the participants during and immediately after the six group therapy sessions. To collect information on the patients’ perspective of the therapeutic outcome of this group BPT, the participants provided written feedback at the end of the six sessions, focusing on the following topics: i) perceived changes, including subjective changes related to the perception of their own bodies; ii) group climate and cohesion; and iii) possibilities of creating new personal ties.

The data and collected information were integrated as follows: The key statements of the participants, enriched by information collected via PO-Bado, were sorted by the first author according to identified themes. These themes were derived from i) distress categories provided by the PO-Bado, and from ii) the list of psychosocial problems provided by the distress thermometer. This was complemented by iii) a resource perspective, and iv) common themes related to bodily experiences, focusing on the main topics of the respective sessions. The statements were then summarized, evaluated, and interpreted from a clinician perspective.

 Results Patient characteristics

Information on the six patients, including demographic and other patient-specific information, main symptoms and concerns, medical and psychosocial history, past oncological interventions and current cancer disease status, is provided in Table 1. The timeline of initial cancer diagnosis, medical treatment and BPT is depicted in Figure 1. Notably, there were two other post-treatment cancer patients who were interested in participating in the BPT, but ultimately did not participate in the intervention (no further information is provided here because no informed consent to report on their cases in scientific publications was obtained from these subjects). Of these eight patients (six participating and two non-participating in the group BPT), five were informed of the group BPT service by the Krebsliga Beider Basel, and three patients were informed of the group by the Department of Psychosomatics at the University Hospital Basel.

Information on socio-demographics, symptoms, medical history, and psychosocial history of the individual patients.
Patient A B C D E F
Socio-demographics
Age (range [years]) 51–75 25–50 25–50 51–75 51–75 25–50
Gender (female, male) female male female male female female
Current relationship (yes, no) no no no yes yes yes
Children (yes, no) yes yes no yes no yes
Main symptoms of distress
Overall distress a) 5 3 8 2 6 8
Fatigue/tiredness b) 2 1 2 2 4 3
Mood swings b) 3 2 3 4 3 3
Anxiety/worry/tension b) 0 1 3 3 4 4
Depression/grief b) 4 0 4 3 4 2
Impairment in daily activities b) 1 1 2 2 3 3
Other psychological problems b) 2 1 3 2 3 4
ECOG c) 0 0 0 0 1 0
Psychosocial treaments
Current professional psychosocial support yes yes yes yes no yes
Current psychoactive medication/opiates yes unknown no unknown no no
Previous psychological/ psychiatric treatment no unknown no yes yes yes
Medical history
Type/localization of tumor breast cancer, left diffuse large B cell lymphoma, mediastinal bladder cancer seminoma, right, and prostata tumor breast cancer, left breast cancer, right
Metastases no no no no no no
Year of current cancer diagnosis 2016 2016 2016 2015 2015 2015
Current cancer state (previous cancer diagnoses: type, year) second cancer diagnosis (breast cancer right, 1970s) first occurrence, in remission first occurrence first occurrence, in remission first occurrence, in remission first occurrence, in remission
Further relevant somatic illnesses unknown allergy unknown unknown structural changes cervical spine; arterial hypertension; stomach burning no
Oncological treatment
Operation x x x x
Radiotherapy x x
Chemotherapy x x x x
Hormonal treatment x x x
Immunotherapy x
Physical wellbeing
Body Appreciation Scale d) [sum score] 56 53 46 61 58 51
Comments
▪  “Previously, the body    was like an envelope;    currently (since    retirement), it feels like    it is about to become    filled like a container” ▪  Substantial    uncertainty about    being a woman ▪  Ambiguous feelings    regarding having a    body, mostly driven by    thoughts ▪  Conflicting attitudes    regarding body image    and age that are    attributed to him by    others based on his    physical appearance ▪  High level of    existential    uncertainity    in life and    regarding    the body ▪  Lack of    confidence in    the body ▪  Putting too many physical    demands on herself ▪  Unfamiliar with    limited bodily    functioning ▪  Irritating feelings    related to being    a woman, which    started with the bodily    changes that occurred    due to cancer

Abbreviations: BAS, Body Appreciation Scale; ECOG, Eastern Cooperative Oncology Group

Footnotes:

a) Distress thermometer 60 : visual analog scale, ranging from not stressed = 0 to extremely stressed = 10

b) Selected items from the basis documentation for psycho-oncology 59 , scale from 0 to 4: 0 = not at all; 1 = slightly; 2 = moderate; 3 = much; 4 = very much

c) Performance score of the ECOG 66 ; 0 = fully active, able to perform all pre-disease tasks without restriction; 1 = restricted in physically strenuous activity but ambulatory and able to perform light or sedentary tasks, e.g., light house work, office work; 2 = ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours; 3 = capable of only limited self-care; confined to bed or a chair more than 50% of waking hours; 4 = completely disabled; cannot perform any self-care; completely confined to bed or a chair; 5 = dead

d) Validated German version of the 13-item BAS 61 , with higher scores reflecting greater body appreciation

Timeline of cancer diagnoses in group BPT participants.

BPT, body psychotherapy; Dec, December; Jan, January; Oct, October; Sep, September. a) Two patients were still receiving hormonal treatment while they were attending the group body psychotherapy sessions.

The key statements of the patients are reported in Table 2 (for privacy protection, the statements are collapsed across patients). Notably, specific descriptions of progress showed substantial heterogeneity across subjects. Most patients indicated that sensations, perceptions, and other mental activities related to their own body intensified throughout the group BPT sessions.

Statements during the initial individual session and six group sessions made by the patients regarding symptoms, main concerns, and other topics <sup> <xref ref-type="other" rid="FN5">a)</xref> </sup>.
Initial individual session Physical distress: ▪  Persistent fatigue that impacts daily living and activities ▪  Polyneuropathy ▪  Persistent pain ▪  Loss of body parts ▪  Sexual dysfunction Bodily perception of being stressed: ▪  High level of uncertainty in life and unusual bodily feelings (e.g., bodily non-wellbeing, feeling of loss of body integrity, loss of function) ▪  Irritation related to gender identity; loss of the perception of being attractive Psychological distress & related resources ▪  Sleep disturbance ▪  Mood swings (including initial shock) and worries ▪  Cognitive impairment: problems concentrating ▪  Fear of relapse ▪  Feeling irritable (e.g., inner pain of loss, search for meaning) ▪  Feelings of depression/sadness ▪  Feelings of guilt (e.g., pertinent question: Is there a relationship between stress and disease?) ▪  Shame/loss of self-esteem and feelings of helplessness/despair ▪  Good social support by family and friends ▪  Disease allows a break in professional activities, enabling one to reflect on one’s life Psychosocial problems ▪  Divorce from partner and related separation from children ▪  Lack of intimate relationships ▪  Work-related problems (e.g., returning to work, daily conflicts, professional reorientation) ▪  Social withdrawal and isolation Further stressful factors ▪  Problems with physicians (e.g., feelings of not being understood) ▪  Long medical history preceding cancer diagnosis
1)  General introduction, fostering of group cohesion and focus on bodily perception ▪  Feelings of being relaxed: e.g., “ I feel more relaxed after the exercise”; “ The body scan seems to be a good exercise at home” ▪  Feelings of being welcomed: e.g., “ I feel very welcome in the group”; “I felt very happy” ▪  Body awareness: e.g., “I realize that I have better bodily awareness than previously expected”; “ I was able to be aware of my body without focusing on the pain” ▪  Feelings of agility: e.g., “I was more awake than at the beginning of the session”
2)  Focus on bodily resources and grounding ▪  Bodily perception of being stressed: e.g., “ Persistent fatigue causing impairment in daily life and irritable mood” ▪  Body awareness: e.g., “I start feeling my feet” ▪  Reduced psychological distress: e.g., “ The exercises help me to fall asleep faster”; “ With the body awareness exercise, the ruminations stop earlier” ▪  Enhanced psychological distress: e.g., “Comparisons and exchanges with other group members foster my reflections on my own physical abilities; they bring about feelings of grief because I always lag behind during the exercises due to my persistent (non-cancer-related) physical impairment” ▪  Psychosocial issues: e.g., “ Restart and reorientation at work causes distress”
3)  Focus on closeness and distance regulation ▪  Psychological resources: Gaining individual new knowledge about one’s own space: e.g., “I feel the space that I need; I will use this to allow for more time and to be more aware of myself, to be conscious of my needs and to seek opportunities to recharge my batteries” ▪  Gaining new individual knowledge about one’s boundaries: e.g., “ Boundaries have a function; I feel safe and secure enough to see them more clearly now”; “ My boundaries help me to feel better and to stay in closer contact with myself” ▪  Psychological distress: e.g., “Expressing my needs was not easy; in particular, it was intimidating to see how others were easily able to be aware of their own space”; “ I realize that I do not want to have boundaries around me; the boundaries narrowed my space”
4)  Focus on social interactions and bodily impulses ▪  Reduced psychological distress: e.g., “I have done something new: saying no to others, respecting my need for my own space” ▪  Enhanced psychological bodily distress, refuse the exercise, e.g., “ This kind of movement does not correspond to my feelings and will” ▪  Open questions: e.g., “ How my space can be transported into daily life – e.g., when the phone is ringing at inconvenient times” ▪  Psychosocial problem: e.g., “ Moving out of my family home is challenging for me; therefore, having my own space and being separated and lonely at the same is difficult. How can I deal with this discrepancy?” ▪  Awareness & presence: e.g., “ I was able to maintain my bodily presence in my daily life”; “ I felt very satisfied with successfully staying present in my body during a challenging situation”
5)  Focus on embodied emotions ▪  Awareness: e.g., “ I feel a change in anticipated burden from the fatigue; I try to stay active or perform one of the exercises” ▪  Psychological bodily distress and recourse: Addressing emotions: e.g., “ It took me a long time to speak about personal feelings such as shame”; “ Anger was a strong feeling” ▪  Psychological bodily distress: e.g., “ When I feel excessive demands, I start feeling dizzy” ▪  Observer position: e.g., “ I realize that I have to build up my boundaries during this exercise”
6)  Summary and transfer session ▪  Psychological distress and recourse: e.g., “ It took courage being part of this group and therefore being highly visible”; “Seeing others with similar feelings helped me to understand my own processes of how to cope with this fate; I have learned to observe myself from a new perspective” ▪  Self-contact and self-esteem: e.g., “ The most important person in my life is me”

The statements reported here illustrate the most relevant topics and statements made by the participants throughout the therapeutic process. The collection is based on written notes from the group psychotherapist recorded during and directly after the sessions.

Footnote: a) To protect the participants’ privacy, the statements are reported without assigning them to individual patients.

Summary of main therapeutic processes and statements emerging throughout the group BPT sessions and at the end of the therapy

At the beginning of the group BPT, a majority (5/6) of the participants referred to feelings of being left alone and partially helpless with the disease. Disturbances of bodily wellbeing and feelings of insecurity were commonly reported (4/6).

At the end of the six BPT sessions, most participants reported improvements in wellbeing (5/6). They mentioned being more aware of physical and emotional boundaries and, therefore, having better knowledge of their coping strategies in conjunction with stress reduction in daily life (5/6). One participant referred to the observation of having gained a new sense of wholeness between body and soul.

In response to the question “what has been supportive and what has felt effective”, most (5/6) patients stated that they enjoyed the exchange between cancer patients and learning about similar or even completely different experiences related to cancer. Others (3/6) mentioned having time and room to explore bodily wellbeing. One subject mentioned the solidarity and empathy within the group.

All participants reported feeling comfortable (4/6) or very comfortable (2/6) during the group sessions.

All participants reported that they felt they were being taken seriously and were supported, and they reported having enjoyed participating in the sessions.

The majority of the participants (4/6) reported that they were neither under- nor over-challenged by the sessions. One participant reported that the movement sessions were challenging due to unfamiliarity, and one person with serious hearing problems was challenged in understanding and following exercises without direct visual contact.

In response to the question “what was difficult for you”, half (3/6) of the participants replied that their perception was that not all participants had the same willingness or readiness to share their experiences in the group context. One participant stated not having felt a need to perform movement-related exercises, and, therefore, the related sessions were perceived as being too numerous.

All participants reported that they would recommend this group BPT intervention to other patients.

With regard to their satisfaction with the number of sessions provided, half of the participants (3/6) were satisfied with six sessions, and half of the participants (3/6) wished to have a minimum of two more sessions (one subject would have preferred 12 sessions).

No adverse or unanticipated events were reported. All participants were able to ask questions or formulate their concerns. One subject stated that the room was too cold.

 Discussion

Despite the subjects having undergone different types of medical treatment for different cancer types and locations, all reported having appreciated the intervention and having progressed in how they perceived their body.

Most of the participants stated that they felt ready to address the bodily dimension of the experience of being affected by cancer and its treatments. The participants also appreciated that the group BPT offered space for them to achieve a new level of experiencing themselves from new perspectives. There were indications that the (bodily) presence of participants was enhanced across the group BPT sessions.

Nevertheless, group attendance and confrontation with one’s body (feelings and expression) were sometimes challenging and triggered temporary uncertainty in some subjects. Sharing these and other (bodily) experiences was helpful for integrating the bodily experiences.

The structure of the group BPT appeared to be appropriate to achieve the intended goals. Addressing body experiences and vulnerability following the experience of cancer was highly appreciated in this population. The participants felt positively about gaining new perspectives with regard to their bodily sensations and becoming more aware of relationships between thoughts, emotions and bodily actions. Despite the limited duration of the intervention, patients appeared to transfer this new knowledge into actions in their daily life.

Strengths and limitations

This case series has several strengths. To the best of our knowledge, this is the first report on group BPT for cancer patients. The study participants showed certain heterogeneity regarding age, gender, and cancer type, increasing the generalizability of the findings. Furthermore, we collected information not only on the overall subjective outcomes, but also on the perception of therapeutic processes. There are also several limitations that should be noted. We only collected information up to the end of the group BPT intervention. Future studies should also include follow-up assessments. Furthermore, application of established assessment instruments will provide important additional and complementary information on therapeutic efficacy of the intervention. Last, additional information, such as data collected via video or audio-taping, will provide additional methods for exploring therapeutic processes related to the group BPT in more detail.

With regard to future studies, the observed heterogeneity in individual descriptions of perceived treatment effects point to the need to select rather comprehensive indicators of changes in disturbances of bodily wellbeing as a primary patient-reported outcome in future clinical trials. Patients reporting on group BPT triggering changes with regard to the meaning in life and other existential topics encourage more detailed exploration of this domain. Furthermore, linking and reconciling integrative BPT approaches, such as ‘integrative body therapy’ that assumes a ‘selfreflexive socioculturally embedded subject’, with recent insights from the fields of neuroscience and psychobiology, may be essential, though challenging, to fully exploit the current understanding and newly gained knowledge of cancer-related disturbances in bodily wellbeing and related interventions 16, 62– 65 .

 Conclusion

The findings from this case series encourage and inform future studies aimed at identifying whether group BPT is efficacious in post-treatment cancer patients and related mechanisms of action. The observed heterogeneity in individual descriptions of detailed treatment effects point to the need to select rather comprehensive indicators of changes in disturbances of bodily wellbeing as a primary outcome in future clinical trials. While increases in mental activities related to one’s own body are commonly interpreted as an important mechanism of therapeutic action, follow-up assessments are needed to evaluate the intended, as well as unintended, consequences of these increases.

 Consent

Each patient provided written informed consent to report his/her case, including clinical and diagnostic information within this case series.

 Ethics statement

Ethical clearance was acquired from the Ethikkommission Nordwest- und Zentralschweiz in Basel, Switzerland (EKNZ) (EKNZ BASEC Req-2017-00513).

 Supplementary Material

Supplementary file 1: Outline of the content of the group BPT sessions

Click here to access the data.

Acknowledgements

Provision of the intervention was supported by the Krebsliga Beider Basel ( http://www.klbb.ch).

We thank all participants for taking part in the BPT and for enriching the group, as well as for their openness toward the publication of this case series.

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Am J Clin Oncol. 1982;5(6):649–55. 7165009 10.1097/00000421-198212000-00014 10.5256/f1000research.13275.r25724 Reviewer response for version 1 Thielen Manfred 1 Referee Institute for Body Psychotherapy, Berlin, Germany

Competing interests: No competing interests were disclosed.

 10 10 2017 Copyright: © 2017 Thielen M 2017 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

The article is a clearly structured report on the results of the study and as such is both coherent and comprehensible. The scientific framework and the socio-demographic aspects of the study are exactly specified.

The findings of the body psychotherapeutic group therapy with cancer patients are exceedingly interesting, particularly as the group therapy was a short-term therapy of only 6 sessions. It is clear from the combined, differentiated statements of the group participants that all of them have profited from the therapy, especially from the body psychotherapeutic approach. They have all attained new insights into their perceptions of body sensations and the relationship between thoughts, feelings and body activities. 5 of the 6 patients stated that their awareness of their physical and emotional borders had improved and that they are therefore able to reduce stress in their daily lives.

The study shows impressively and probably for the first time, that this body psychotherapeutic group therapy with cancer patients has had very positive results.

Of course these first positive results will have to be confirmed and elaborated by further studies. Since Wilhelm Reich (1948, 2001) there have been several approaches in body psychotherapy to the study of the origins and therapy of cancer, but the aspect of group therapy has not until now been examined. This study does therefore have an important pioneering aspect.

In the light of the its merits my critical comments of the study are of minor significance. But I would have wished that the exact interventions and exercises, and their origins in which body psychotherapy approach, had been specified. It would also have been interesting to learn how the patients reacted to specific body psychotherapy interventions.

Also I have some questions to the short-term-setting of the study. From my own experience over many years as leader of body psychotherapeutic groups, I see groups as having a more sustained long term effect if they take place over 2-3 years than if they are short-term.

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes

Is the background of the cases’ history and progression described in sufficient detail?

Yes

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes

Is the conclusion balanced and justified on the basis of the findings?

Yes

Reviewer Expertise:

I am from my scientific background Dr. phil. and Dipl.-Psych. and lecturer at the university of Magdeburg-Stendal. I have written numerous scientific articles in the field of Body Psychotherapy and be editor of some books to Body Psychotherapy. I work since 1984 as Body Psychotherapist and be director of the Institut für Körperpsychotherapie Berlin where trainings in Body Psychotherapy take place. I am the president of the German Society of Body Psychotherapy (Deutsche Gesellschaft für Körperpsychotherapie, DGK). I have organized a congress to the theme: Body Psychotherapy in groups 2011 and written an article: “ The body in the filed of the group” ((Thielen, M. ). Der Körper im Feld der Gruppe. Charakteristika der Körpergruppenpsychotherapie. In Thielen, M. (Hrsg.), (2013). Körper-Gruppe-Gesellschaft. Neue Entwicklungen in der Körperpsychotherapie. Gießen: Psychosozial-Verlag)).

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

References : Entdeckung Des Orgons. Orgone Inst. Press. .1948, 2001;1: : Discovery of the Orgone, Volume II: The Cancer Biopathy. 1973; Meinlschmidt Gunther Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland

Competing interests: No competing interests were disclosed.

 23 8 2018

Dear Dr. Thielen,

We thank you very much for providing us with insightful and constructive reviewer comments on our article. We would like to take the opportunity to reply to your comments and provide a revised version. We considered all points raised and include our point-by-point responses below:

Comment 1: “In the light of the its merits my critical comments of the study are of minor significance….”

We thank the reviewer for the overall positive feedback.

Comment 2: “I would have wished that the exact interventions and exercises … had been specified.”

We agree with the reviewer that more information on the interventions and exercises would be an asset. We therefore plan to publish an in depth description of the intervention as separate publication in the upcoming year. We thereby intend to take advantage of F1000 articles as ‘living’ („even after peer review is complete: Authors can ‘update’ their articles at any time (and at no extra charge) if there have been small developments relevant to the findings“) and will insert into the article a link to this separate publication as soon as possible.

Comment 3: “I would have wished that (…) their origins in which body psychotherapy approach, had been specified.”

The concept of this group body psychotherapy approach is rooted in the integrative body psychotherapy (IBP) movement, conceptualized by Jack Lee Rosenberg. The IBP approach is described in more detail in reference 42. In the revised version of the manuscript, we have added an additional reference (Rosenberg, J.L., Rand, M. L. and Asay, D. (1985); Body, Self, and Soul. Sustaining Integration. Humanics Limited, Humanics New Age; Atlanta, Georgia) in which the origins are further outlined.

Comment 4: “It would also have been interesting to learn how the patients reacted to specific body psychotherapy interventions”

We completely agree with the reviewer that information on how the patients reacted to specific body psychotherapy interventions would be highly interesting. Unfortunately, we didn’t collect respective data this time, but intend to do so in future studies. We added a respective sentence in the discussion section of our manuscript:

“We did not systematically assess how patients reacted to specific body psychotherapy interventions, which however would have been highly interesting, for example with regard to inform current efforts to develop more modular, individualized/personalized modular interventions.”

Comment 5: “Also I have some questions to the short-term-setting of the study. From my own experience over many years as leader of body psychotherapeutic groups, I see groups as having a more sustained long term effect if they take place over 2-3 years than if they are short-term.”

We fully agree that whether short- or long-term body psychotherapy interventions for cancer patients show better and more sustained effects is a very interesting question, which however goes beyond the scope of this project. We added a respective sentence in the discussion section, highlighting that this is a relevant issue for further studies:

“Notably, we here provide information on short-term body psychotherapy. Comparing the effects and their sustainability of short- and long-term body psychotherapy should be addressed in future studies.”

10.5256/f1000research.13275.r25718 Reviewer response for version 1 Sollmann Ulrich 1 Referee German - Chinese Academy for Psychotherapy, Heidelberg, Germany

Competing interests: No competing interests were disclosed.

 15 9 2017 Copyright: © 2017 Sollmann U 2017 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

Goal, structure and results of the report are described very clearly. The report is comprehensible, understandable and verifiable. The results include enough data about the socio-demographic aspects in medical history etc. The results mirror also, and this is very important, individual and personal statements which are related to the individual sessions in the group as well as to the individual patients and their concerns. The combination of both kinds of results seems to be a helpful illustration so that somebody who didn’t join the group can imagine better what the patients experienced in the group; personally and bodily. This also gives a deep inside into the therapist`s perspective, the therapist’s awareness and perception.

The structure (six sessions in the group) is short and long enough to establish a process of body self-experience. The group-setting invites to get a really competent overview of what had happened and why it happened.

I guess that the distinction between positive effects on the group-level in comparison with the individually perceived treatment could be very interesting for future research.

It’s remarkable that the authors refer elaborated on various literature of the field of body-psychotherapy. This could be an important step to better integrate body-psychotherapy in the field of psychosomatic medicine. What is urgently needed.

There are some remarks I want to add and which could be considered in future research:

It could be helpful to define the specific concept of body-psychotherapy in the group and thus included relevance of psycho-educative aspects.

It would be very helpful to get a better understanding of a specific concept of body-psychotherapy which was used in the group. The field of body-psychotherapy offers a very big variety of approaches in body-psychotherapy. It could be helpful to better understand the background. This understanding could be necessary to better understand and interpret the results of such a study.

According to the literature on working with body-psychotherapy in the group with cancer-patients there is more literature being available of course for many years. It could be interesting to discuss the results of such a study on the background of scientific research in the period of the last 25 years.

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Yes

Is the background of the cases’ history and progression described in sufficient detail?

Yes

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Yes

Is the conclusion balanced and justified on the basis of the findings?

Yes

Reviewer Expertise:

As a body-psychotherapist I work beside others with cancer-patients for more than 25 years already. I usually publish case-studies in the field of qualitative research. Research is done by my own or together with colleagues under certain perspectives. My first publication on body-psychotherapy in a group setting with cancer-patients was published in 1990. I do research in Germany as well as in China.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Meinlschmidt Gunther Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland

Competing interests: No competing interests were disclosed.

 23 8 2018

Dear Dr. Sollmann,

We thank you very much for providing us with insightful and constructive reviewer comments on our article. We would like to take the opportunity to reply to your comments and provide a revised version. We considered all points raised and include our point-by-point responses below:

We thank the reviewer for the overall positive feedback

Comment 1: It could be helpful to define the specific concept of body-psychotherapy in the group and thus included relevance of psycho-educative aspects.

We agree with the reviewer that more information on the interventions and exercises would be an asset. We therefore plan to publish an in depth description of the intervention as separate publication in the upcoming year. We thereby intend to take advantage of F1000 articles as ‘living’ („even after peer review is complete: Authors can ‘update’ their articles at any time (and at no extra charge) if there have been small developments relevant to the findings“) and will insert into the article a link to this separate publication as soon as possible.

Comment 2: It would be very helpful to get a better understanding of a specific concept of body-psychotherapy which was used in the group. The field of body-psychotherapy offers a very big variety of approaches in body-psychotherapy. It could be helpful to better understand the background. This understanding could be necessary to better understand and interpret the results of such a study.

The concept of this group body psychotherapy approach is rooted in the integrative body psychotherapy (IBP) movement, conceptualized by Jack Lee Rosenberg. The IBP approach is described in more detail in reference 42. In the revised version of the manuscript, we have added an additional reference (Rosenberg, J.L., Rand, M. L. and Asay, D. (1985); Body, Self, and Soul. Sustaining Integration. Humanics Limited, Humanics New Age; Atlanta, Georgia) in which the origins are further outlined.

Comment 3: According to the literature on working with body-psychotherapy in the group with cancer-patients there is more literature being available of course for many years. It could be interesting to discuss the results of such a study on the background of scientific research in the period of the last 25 years.

We thank the reviewer for pointing this out and expanded the discussion section:

“ these findings are in line with previous reports (e.g. 64) “