Treatment and Counselling Methods

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Therapeutic Boxing


In therapeutic boxing (TB), participants experience psychological and physical self-empowerment and strengthening with the help of movements, techniques and other boxing content.
Unlike conventional boxing, there is no direct physical contact between the practitioners in therapeutic boxing. While the goals in conventional boxing are primarily athletic, therapeutic boxing primarily pursues therapeutic goals with all the exercises and materials used. The setting is fundamentally therapeutic. Ideally, experiences that are considered positive in therapeutic boxing are transferred to the participants' life experience outside of training. In therapeutic boxing, every exercise is a co-operation and there is no competitive component to trainings. Accordingly, there is no sparring. Psychological and physical aspects of the patients participating in therapeutic boxing and their respective diagnosed complaints and disorders are taken into account in the planning and execution of the training. No previous knowledge of boxing or martial arts is required. Therapeutic boxing as a sports and exercise therapy intervention is suitable for almost all age groups. The aim of therapeutic boxing is to transfer and integrate the experiences gained by the boxing students during training (including increased self-efficacy) into their daily lives outside of training (see Klug, Flentje and Flentje, 2024).

People with a wide range of psychological and psychosomatic symptoms can benefit from therapeutic boxing: Depressive disorders, all subtypes of attention deficit hyperactivity disorder (ADHD), complex and conventional post-traumatic stress disorder (CPTSD/PTSD) and trauma-related disorders, emotion regulation and personality disorders such as emotionally unstable personality disorder (borderline personality disorder), burnout syndrome and some anxiety and panic disorders are among the indications for which therapeutic boxing is used (see Klug, 2022).
The primary psychological objectives of therapeutic boxing, which has been part of sports therapies for about 15 years, include improved access to one's own emotions, the processing and reduction of fears and insecurities, as well as a reduction of the level of perceived stress and inner tension. A temporary interruption of distressing mind loops, the recognition and respect of personal boundaries and the strengthening of social relationships are also among the objectives. Female victims of early and prolonged experiences of violence in particular are often unable to express anger outwardly (Solomon and Heide, 1999) In addition, prolonged experiences of violence can result in learned helplessness (Foa et al., 1989). Consequently, facilitating an accepting and appreciative sensation and expression of anger and aggression in a safe therapeutic context is an important objective, which will be discussed in more detail below.

Primary somatic objectives of therapeutic boxing include building or improving strength and endurance, improving posture and body awareness, improving physical coordination, balance, stability and gait, as well as improving the ability to react and concentrate (cf. Klug, 2022).

Therapeutic boxing training programme

The boxing students gradually learn basic steps, punches, evasive skills and cover techniques of boxing. Depending on the existing symptoms, they are introduced to punching techniques on hand punch pads, possibly wall punch pads or double end bag, as well as exercises for maintaining, increasing, recovering, and overcoming distance. Trainings can be held as individual or group training, depending on the needs of the participants. Within groups, individual and partner exercises can be mixed, initially only individual exercises may be carried out. The first training session for each participant is preceded by a detailed preliminary discussion in which the participant's individual goals, individual needs, potential triggers and personal boundaries are discussed and documented. Each therapeutic training session is preceded by a conversation in which potential daily modifications regarding the above-mentioned parameters are evaluated. During each session it is emphasised that communicating personal needs and limits is explicitly encouraged. The therapeutic boxing lesson is preceded by both a general and boxing-specific warm-up. With regard to the individual lesson, the boxing content should not be too complicated or advanced, and the boxing therapist should be able to spontaneously adapt the content of the training session to the current needs of the participants. At the end of each therapeutic boxing session, a cool-down takes place in which both the intensity of the boxing student’s physical (muscular and cardiovascular) activity and the boxing mindset that was activated during session are slowly adapted for the post-training state. This is followed by a debrief and closing.


Therapeutic boxing for CPTSD

In the case of complex posttraumatic stress disorder, it is extremely important to clarify the particular type of trauma with the individual participant before the first training session. At the same time, it is essential to avoid describing their traumatic experiences in too much detail, in order to avoid the risk of re-traumatisation. It is important to evaluate whether there are any traumas associated with physical violence. If this is the case, an even more cautious/delicate handling of the impact pads, demonstration of techniques, etc. is necessary. Possibly still active mechanisms of the offender-victim dynamic (Sheik and McNamara, 2024; Cantor and Price, 2007, Dutton and Painter, 1993) must be considered. For example, it must be clarified how close or how quickly one may approach the respective boxing student during lessons. It must be determined whether the person in question a) knows their own boundaries and b) how clearly they are able to communicate them during a particular experience. It is equally important to evaluate how far the participant has already progressed in their trauma-therapeutic process, for example with regard to the question to what extent the student has already developed skills to deal with trigger situations or trauma-associated flashbacks (i.e. intrusive, sudden, intense perception or experience of feelings associated with past experiences. These are often experienced as very intense and may be experienced as a reliving of emotions related to previous trauma. Triggers may include gestures, voices, movements, smells, calendar dates or various visual or auditory sensory impressions). Individual boundaries and any risk factors with regard to potential trigger situations, as well as the foundation of future communication between the participant and the boxing therapist need to be discussed prior to the therapeutic training sessions.


Current state of research on therapeutic boxing

Lyon et al. (2020) were able to show a statistically and clinically significant reduction in specific PTSD-associated complaints as part of their mixed methods study ('Left Write Hook'). In the area of professional martial artists, martial artists and contact athletes, it was shown that healthy behaviours and a higher perceived quality of life correlate with their sporting activities in the athletes studied (Kortaska et al., 2019).
In a 2022 scoping review, Bozdarov et al. concluded that therapeutic (non-contact) boxing "appears to provide a cathartic release of anger, aggression, stress, and a discharge of tension" after a more extensive literature review that also included MEDLINE; PsychINFO, and Google Scholar. The majority of the studies reviewed by the authors concluded that boxing reduced stress and was able to improve mood, self-esteem and perceived quality of life. Furthermore, a reduction in the amount of substances consumed (in the study: alcohol, methadone, cannabis, codeine, benzodiazepine) (Morton et al., 2019) was observed. Perceived physical skills improved (Gammage et al., 2021). Furthermore, improved school behaviour in students (Shultz et al., 2014; Woodhead et al., 2019) and improved mental health (e.g. Lyon et al., 2020; Shultz, et al., 2014) were observed. Three studies (van Ingen, 2011; Lyon et al., 2020; Gammage et al., 2021) focused on trauma-sensitive non-contact boxing for women with traumatic or violent experiences: participants felt encouraged to "let out their pent-up energy or anger" in a traditionally "more masculinely-associated sport", "in a safe and healthy way" (van Ingen, 2011). Participants learned that anger is an appropriate response to trauma. Benefits of a movement-based (therapeutic) programme were emphasised, which, compared to conventional talk therapy, focuses on using "the body as a source of power and strength" (van Ingen, 2011). In an interview, one participant in the therapeutic boxing programme stated: "At the end of the boxing training session, I am completely exhausted, but the sadness, the trauma, feels so much further away than it did at the beginning" (cf. van Ingen, 2011). The following case report explicitly addresses the aspect of re-integrating (legitimate, justified) anger and aggression, as well as 'new' experiences of self-efficacy and an increased sense of the victim's sovereignty (see below).
Although the authors of the scoping review emphasise the limitations of their work (including the lack of peer reviewing in a number of the papers they analysed), they conclude that preliminary evidence shows that non-contact boxing (author's note: the term "therapeutic boxing", which recently became established in Germany is not yet commonly used in English language literature) appears to be beneficial for mental health regarding depression, anxiety (disorders), PTSD, and negative symptoms of schizophrenia (Bozdarov et al, 2022). Evidence also appears to exist regarding the benefits of integrating mindfulness aspects into therapeutic boxing (Bozdarov et al., 2022). Further evidence can be found in relation to the improvement of parameters associated with somatic diseases such as diabetes mellitus (Zheng et al., 2015), cardiovascular diseases (Yli-Piipari et al., 2018; Sánchez-Lastra et al. 2020) and obesity (Cheema et al., 2015). Beneficial effects of “adapted boxing” on various health complaints were also demonstrated in one systematic review (Sánchez-Lastra et al., 2020).

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