The ASO Newsletter - Helping you stay connected to Alexander Technique related research.

The ASO Newsletter - 19th Edition

This edition of the newsletter is a paper written specially for the ASO community by Debbie Kinsey (PhD, ClinPsyD) and Lesley Glover (PhD, MSTAT) about their recently published review paper. The authors acknowledge that the paper is a bit of a dense read, hence this piece to summarise the findings and make them easier to navigate. A link to the full paper can be found here. As ever, thank you for your interest in Alexander Technique research and we welcome comments in the comments box at the bottom of the page.

Psychological and other ‘non-physical’ changes following Alexander Technique lessons - what they are and how they come about: Making sense of a realist review.

Debbie Kinsey (PhD, ClinPsyD) and Lesley Glover (PhD, MSTAT)

We recently published a review paper on how learning the Alexander Technique (AT) can lead to psychological and ‘non-physical’ outcomes (which can be read for free here). However, we realise the paper itself is quite dense and not the easiest of reads – in part because of the amount of detail we needed to include due to the less commonly used methodology. Effective research dissemination is vital for research to be of any use, and so we’re writing this blog to summarise our findings and make them a bit easier to navigate. We’ll start by giving some background to the review, and then present a summary of the findings.  We have also provided a summary at the end of the post so skip straight to that if you prefer.

Why was the review needed? What were we trying to find out?

Excitingly, there has been increasing research interest in the AT. The main areas of research have been in how lessons affect movement or postural tone, musical or sports performance, and health issues such as chronic pain or Parkinson’s. A number of these studies included psychological or emotional outcomes for the student, however these were largely secondary findings and not often given spotlighted attention. Many AT teachers will tell you that learning and applying the AT is helpful for stress, anxiety, and wellbeing, however the research evidence for these types of outcomes has never been put together and highlighted, and there is a lot more than might be expected! We wanted to bring together these findings to discover what, and how much, evidence there was for them. We also wanted to understand how these kinds of outcomes come about from the process of learning the AT, and if there are specific groups of people that experience them. We hoped this would provide another step towards understanding the process of change that goes with learning the AT.

What are ‘non-physical’ outcomes?

Firstly, we had to define our ‘terms of reference’, or what it is we would be including in the review. This was a challenge, as the AT is a psychophysical approach, and is based on the understanding that there is no separation between mind and body. As written above, we wanted to focus on psychological or emotional outcomes in particular, as they have received less attention than other outcomes but how can you decide what is, and is not, a psychological or emotional outcome when everything is connected?

We spent a great deal of time thinking about this issue before we started the review. A purely psychophysical approach of seeing all outcomes as part of a non-dualist whole would have meant including all studies on the AT with any kind of outcome, which would have made the review incredibly large and unwieldy, and ultimately less useful. We therefore made a pragmatic decision to take a more dualist approach in identifying outcomes, and separated “physical” and “non-physical”. We used “non-physical” as a short-hand way of encompassing psychological and wellbeing outcomes, for example mood, sense of self, cognitive processes (such as the way people think), confidence, and emotion. This in contrast to “physical” outcomes such as daily functioning, gait and posture which have been the focus of previous research. Some outcomes, such as pain, were more difficult to categorise, even using this dualist approach, so we made decisions on a case-by-case basis according to the kind of measures generally used by studies in that area.

However, it is important to note that taking this dualist approach to categorising outcomes does not mean we were taking a dualist approach to the AT in general. We still defined the AT as a psychophysical approach, so when we were considering the process of change due to AT lessons, we tried to ensure we were then integrating the “physical” and “non-physical”.

What are the “realist methods” we used for the review? Why did we use this approach?

All reviews gather together the evidence on a particular topic and present a synthesis of the findings in order to answer a question about that topic. The methods you use to do that depend on the type of evidence you’re looking at and what your question is.

The kind of studies we were using to gather evidence included both quantitative (numerical) and qualitative (non-numerical, e.g. interviews) data, and a wide range of outcomes. We also wanted to know more than simply what the “non-physical” outcomes were – we wanted to find out how those outcomes came about, how they may be connected, and whether there were particular contexts in which the AT might work better than others in leading to these particular outcomes.

The realist approach enabled us to work with a range of data types, and to consider questions of how as well as what. Realist methods are very useful for questions involving ‘how’, and are increasingly used in healthcare and social policy research because offering the same intervention in different populations doesn’t always give the same results. For example, randomised controlled trials can give you an idea of whether an intervention is working in a particular setting or with one group of people, but can’t tell you why it works brilliantly in one place and less well with another.

Realist approaches are heavily theory-based, which is why they can be a bit convoluted and dense to read. They are designed to answer explanatory questions – asking how, in what circumstances, and for whom outcomes are generated. The end result of realist reviews is evidence-based theory, with ‘theory’ meaning a description of how an intervention leads to particular outcomes. Another way of thinking about it, rather than ‘theory’, is pathways or processes that lead to outcomes.

A little more detail about realist approaches (you can skip this bit if you’d rather)

Realist approaches understand outcomes, such as reduced anxiety, to be generated by an interaction between the context and mechanisms (sometimes written as C+M=O). The “mechanisms” are the resources offered by the intervention and the participant’s reasoning or response to those resources. The “context” is anything which can trigger a mechanism, including participant characteristics (e.g. personal history or demographics), environment (e.g. where the intervention takes place), and wider culture and politics (e.g. policy or cultural norms). Where an intervention or programme happens over time (such as over a number of AT lessons), an outcome can become a new context, such as trust being built (or not built) in an early phase of an intervention (outcome), becoming the context for how and whether the intervention proceeds in the next phase.

This means when you’re doing realist work, you’re identifying “CMO” patterns in the studies, which might be full CMOs or might be only part of the pattern like “C=O”). You then compare all the different patterns in the different studies to try and develop CMO pathways for the outcomes you are interested in. Because most studies don’t use realist methods, they don’t talk about outcomes or causes of outcomes in this CMO way, so as researchers we try to fit their results in the pattern together. For example, one of the studies might include an idea about how an outcome might be happening but no data to support it, and a different study might have some data to back up that idea.

What did we find?

Despite the lack of focus on these kinds of outcomes, we found a surprising amount of evidence about them! We found 36 studies that met our criteria, a range of different ‘non-physical’ outcomes, and some different pathways that might lead to them. It’s important to say first that reviews are entirely based on the evidence that exists, which means that there may be other outcomes or different pathways but there aren’t studies about them yet. These findings are simply a first step to exploring this area more.

The range of “non-physical” outcomes we found were:

• Sense of control or confidence

• Increased self-efficacy

• General wellbeing

• Increased quality of life

• Improved relationships

• Self-acceptance

• Increased optimism/hope for the future

• More holistic sense of self

• Decreased fear/anxiety

• Decreased depression / low mood

• Decreased anger

• Decreased stress

• For some, it was also about a changed relationship with pain or difficult emotions (such as fear), rather than a decrease in symptoms

• Difficult emotions can arise in lessons

We found a number of pathways through which these outcomes could come about. We’ve presented them here (and in the paper) in three separate sections to make them easier to follow. (In the diagrams below, blue = context, yellow = mechanism, green = outcome).

(i) Overarching pathways to ‘non-physical’ outcomes

The studies suggested two main ways people can experience ‘non-physical’ outcomes. For some, they feel psychologically better through moving with more ease or having reduced pain, for example being able to walk without pain leading to feeling happier. This is a more direct link between physical improvements leading to psychological improvements (Theory 1). For others, the process is a more profound shift in ways of thinking. Through exploring their physical habitual responses, they gain an experience of a mind-body integration, and start consciously applying the AT to non-physical habitual patterns, which results in non-physical outcomes (Theory 2).

These can appear to be dualist explanations, but they actually highlight the psychophysical nature of the AT – in lessons which do not specifically address, for example, a person’s relationship patterns with their friends or fears about the future, and do not include talking therapy, a person can still nevertheless have changes in these areas. We’ll talk about this more in the “what does this review tell us” section at the end.

(ii) Specific non-physical outcome pathways

Within the two main, overarching theories, there was evidence of a number of specific ways people could experience “non-physical” outcomes. In the diagram below, you can see pathways about becoming aware of possibilities and making informed choices (Theory 3), the ripple effect of positive changes (Theory 4), the confidence to resume previously avoided activities (Theory 5), and how the use of touch in the AT can elicit positive or negative emotions (Theory 6).

(ii) Difficult emotions as an outcome

Our final set of specific pathways are about how difficult emotions can be a non-physical outcome of the AT, and can shape the process of learning, or interrupt learning, impacting other outcomes.

Difficult emotions can arise at the beginning of learning to apply AT lessons (Theory 7), and at any time during the course of lessons (Theory 8). How the teacher responds to this is important.

So what does the review tell us?

The AT is a psychophysical approach that is largely taught within the physical domain (i.e. it is not a talking therapy or explicitly focused on mood, for example, but mainly works with physical activity and movement). This review found that the AT has a huge range of ‘non-physical’ effects even though it may not be explicitly working on the “non-physical”. Importantly, we found this isn’t simply a secondary effect because of physical benefits, such as pain improving so general wellbeing improving, but it can also be a direct, and sometimes profound, effect on the “non-physical”, even where a person’s lessons are purely working with, for example, physical habits with no mention of the “non-physical”. This supports, and provides evidence for, the AT as being a psychophysical process.

The findings also lead to a number of recommendations, as well as more questions.

Recommendations from the review:

• AT teachers need to be aware that difficult emotions can arise at any point in lessons, as well as early in the process where there may be feelings of vulnerability related to touch, or feelings of destabilisation when students first change long held habits. AT teachers should not be expected to be counsellors or psychotherapists, however, given the importance of the teacher’s response to emotions arising in lessons, AT teachers should be equipped to manage this empathetically within lessons. AT teacher training should always include training such as in the principles of assessment and non-judgemental listening as in mental health first aid.

• In healthcare settings, for example where referral to the AT is part of a pain management clinic or in research trials, support should be provided to help improve individuals’ capacity to attend regular lessons, for example by providing transport, childcare, or group lessons to reduce costs.

• A key context in some of our pathways included the importance of the person being open to the AT, or self-management approaches in general. This could be usefully assessed prior to referral in healthcare settings, or support to help the person feel more open in this way added before referral, in order for them to gain the most benefit.

• The healthcare studies in this review were mainly based around pain and pain management, but the findings here suggest the AT could be a useful intervention more broadly due to the holistic, long-term impact. It may be that some people with mental health difficulties who struggle with talking therapy could benefit from the more indirect approach of the AT, but we need research on the AT with this group of people to see if this is the case.

• More research is also needed on these kinds of outcomes more generally, and the ideas we present here. As previously said, these pathways are not definitive, and are open to being tested, changed, and developed further. There’s a lot we don’t know, for example how many lessons are needed to get these kinds of benefits, or which people experience significant mind-body integration and which don’t, alongside needing more exploration and evidence for these pathways in general.

• The huge range of “non-physical” outcomes we found were not always captured very well by quantitative measurement, and they more often appeared in qualitative data like interviews. This means that research in the future should consider mixed methods approaches, to ensure unexpected or more nuanced outcomes are captured and understood.
  

A quick summary if I don’t want to read all that.

Having AT lessons can lead to a wide range of “non-physical” outcomes, including improved general wellbeing and increased sense of control and confidence. These outcomes can be generated through improvements in physical wellbeing, and through experience of mind-body integration and subsequent application of AT skills to non-physical areas. The AT may be a useful approach in a range of settings for psychophysical, long-term outcomes, and further research is warranted and needed. Given patients’ desire for increased provision of self-care services within the NHS, research could particularly focus on refining these theories and the use of the AT in healthcare settings. AT lessons may provide a significant way to improve mental wellbeing and increase agency. Further research should seek to understand its application beyond the traditionally perceived areas of movement, posture, and pain.

References

Kinsey D.,  Glover L. & Wadephul F. (2021) How does the Alexander Technique lead to psychological and non-physical outcomes? A realist review. European Journal of Integrative Medicine, 46, 101371. https://doi.org/10.1016/j.eujim.2021.101371

Debbie Kinsey is a post-doctoral researcher at Exeter University, and has worked on a variety of different projects in health research. She became interested in how the Alexander Technique may bring about change after working as an assistant on research by Lesley Glover investigating the AT as a tool for managing fear of falling in older people. Debbie's broader research interests include disability and chronic health conditions (particularly those acquired in adulthood), the arts and health, wellbeing, health and social care, and accessibility in its many forms.

Lesley Glover qualified as a teacher of the Alexander Technique in 2014 from the York Alexander Technique School and has a practice in East Yorkshire, UK. She is a member of the STAT Research Group and has been active in Alexander Technique research since 2007. Her background is clinical psychology and she worked for many years both in clinical practice and in academia.

Thank-You!

Thanks for being here and for your interest in research on the Alexander Technique and its teaching. Special thanks to Debbie Kinsley and Lesley Glover for their contributions to this blog post, and to all community members who have contributed to ASO so far.

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