What is Dance Therapy
Dance therapy also known as dance movement therapy, movement therapy, dance movement psychotherapy or movement psychotherapy, is a treatment method to assist the physical, emotional, and cognitive recovery of an individual or a group by using dance movements 1). Dance therapy has many differences compared to general dance. Dance movement therapy participants are encouraged to engage in movement initiation and cessation, rhythmic variation and a range of speeds, they are encouraged to engage in movement that is primarily creative and takes place within an embodied therapeutic relationship, rather than learning steps to music 2). Dance movement therapy is the psychotherapeutic use of movement, based on the assumption of the interconnection of body and mind, and the healing power of dance 3). The American Dance Therapy Association defines dance therapy as “the psychotherapeutic use of movement to promote emotional, social, cognitive, and physical integration of the individual, for the purpose of improving health and well-being” 4); the European Association Dance Movement Therapy adds the “spiritual integration” to this list 5). Dance movement therapy is thus a form of psychotherapy, which uses as its basis the creative movement process 6). The creative movement process has been described by Meekums 7) as involving two key components: the movement metaphor as the central tool; and a creative change process within which this tool is used. A movement metaphor is “a symbol encapsulated in either a movement or posture”. The creative change process occurs within the context of a psychotherapeutic relationship and is conceptualized by Meekums as incorporating four key stages: preparation, incubation, illumination, and verification. These stages may be repeated in cyclical fashion. In addition, Payne et al. 8) outline that in dance movement therapy, the emphasis is on improvised, imaginative, creative, aesthetic, and interpersonal engagement in movement. Karkou 9) argues that in dance movement therapy, dance is considered widely to include breathing, rhythm, pedestrian movement or gesturing and posturing, with a particular emphasis on imagery, symbolism and metaphors. Dance therapy tends to focus on non‐verbal communication (with some verbal processing of issues and insights), while support is offered for the development of therapeutic relationships through movement and dance.
Dance therapy or dance movement therapy is 10):
- Focused on movement behavior as it emerges in the therapeutic relationship. Expressive, communicative, and adaptive behaviors are all considered for group and individual treatment. Body movement, as the core component of dance, simultaneously provides the means of assessment and the mode of intervention for dance/movement therapy.
- Practiced in mental health, rehabilitation, medical, educational and forensic settings, and in nursing homes, day care centers, disease prevention, health promotion programs and in private practice.
- Effective for individuals with developmental, medical, social, physical and psychological impairments.
- Used with people of all ages, races and ethnic backgrounds in individual, couples, family and group therapy formats.
Dance therapy is also defined as a multi-layered and complex treatment program in which the therapist composes different body movements and determines the tempo of music, the therapist then observes and diagnoses the patient’s emotions and physical condition 11). Dance therapy differentiates itself from other forms of art therapy through its increased ability to create mind-body connections and improve physical and aerobic health 12).
Dance movement therapy was originally developed in the 1940s and 1950s, in the USA by notable pioneers including Marian Chace 13). Chace was an American dancer who developed methods still in widespread use today. Aspects of practice developed by her include an emphasis on the development of a therapeutic relationship through the empathic reflection of expressive movement qualities (‘mirroring’), and supporting group social cohesion through rhythmic group synchrony. In the UK, a ‘first wave’ of dance movement therapy was developing around the same time, independently of American developments, but was superseded by a second, more psychotherapeutic approach which developed from the 1970s onwards 14). Meekums 15) suggests that what marks out contemporary dance movement therapy practice is the emphasis on it as a form of psychotherapy. For many therapists, theories relating to psychoanalytic and psychodynamic principles are used to guide practice 16). For example, the practice of ‘Authentic Movement’ 17) is associated with Jungian psychology. For others, humanistic, developmental, behavioral or eclectic and integrative models are valued 18). Meekums 1991 19), for example, in her work with mothers and young children used a behaviorist approach combined with attachment theory. More recently, Meekums 2002 20) has suggested an integrative framework based on the symbolic power of the ‘movement metaphor’, which transcends such theoretical divisions.
Dance movement therapy has been posited as an appropriate intervention for patients with a range of diagnoses and presenting problems, including those for whom words may be difficult either because of cognitive impairment or because the emotions being explored and expressed are too painful, pre‐verbal in their origin, or too complex to readily express in words 21). A narrative literature review commissioned by the Dutch Federation of Arts Therapies 22) concluded that dance movement therapy could reduce symptoms related to depression, anxiety, and stress in clients with a personality disorder 23). Dance movement therapy could also help build a therapeutic alliance and play a role in emotion regulation and experiencing new interactions for these clients 24).
Session lengths vary from 30 to 90 minutes and often take place on a weekly basis, at the same place and time to assist emotional security. Interventions may last from a few weeks to several months depending on client needs and the treatment context.
Benefits of dance therapy
As a form of psychological therapy, dance movement therapy is very likely to work primarily because of non‐specific factors, notably the therapeutic relationship which has been shown across many forms of therapy to be a key determinant of outcome. A meta‐analysis completed by Ritter 25) provided evidence for a mild to moderate effect size of dance movement therapy for a wide range of different client groups and for an array of symptoms including reduction of symptoms of anxiety and depression. More recently, an updated meta‐analysis conducted by Koch 26) has demonstrated that dance movement therapy has a moderate effect for a range of disorders, including depression. They included controlled as well as randomized controlled trials in their analysis, and trials of both dance and dance movement therapy. As dance movement therapy combines the benefits of mild physical activity and specifically dance with psychological therapies, it may open up the options within non‐pharmaceutical therapy to people with depression who do not feel able or do not wish to focus exclusively on talking about their problems, or who prefer non‐medical approaches to treatment.
Norcross 27) identifies strong evidence for the importance of the therapeutic alliance, empathy and for group therapy cohesion in psychological therapies. Based on this finding, some of the specific effects of dance movement therapy can be attributed to the use of non‐verbal communication and kinesthetic (embodied) empathy in particular 28). Dance movement therapists use close attention to their own embodied responses, together with ‘mirroring’ of expressive movement on occasions, in order to attempt understanding of their clients’ feelings and experiences and communicate a level of empathic understanding.
Recent research in mirroring argues that when this technique is used within dance movement therapy it improves social competence, body‐awareness, self‐other distinction and well‐being for people with autism, and improves self experience, empathy and well‐being in people with schizophrenia 29). The degree to which these effects are transferable to people with depression remains unclear. One possibility is that mirroring might lead to a reduction in depression due to reduced social withdrawal, but this proposition awaits testing.
Some dance movement therapy literature 30) discusses a possible link with so‐called ‘mirror neurons’ 31). Mirror neurons are neurons that fire when individuals watch someone else performing an action or expressing emotion. The nature of the impulse mimics that which would occur, were the observer carrying out the observed action experiencing the emotional state. This occurs, provided that the observed state is broadly within the prior experience of the observer. The suggestion is made that empathic engagement associated with active ‘mirroring’ is in part mediated through the activation of mirror neurons. However, while echoing of movement qualities (that is, reproducing expressive qualities, shortly after the patient or client has done so) has long been associated with empathy and positive feelings towards the other in psychotherapeutic interactions 32), the precise role of mirror neurons in empathic engagement is not identified. It is likely that, while mirror neurons aid kinesthetic empathy, their activation is not sufficient in itself to explain the psychotherapeutic use of empathy, which includes a more sophisticated and holistic engagement than mere sensory‐motor activity 33).
Vitality was one of the healing processes identified by Schmais 34) in her foundational theoretical article concerning group dance movement therapy. She defines ‘vitalization’ 35) as “investing people with the power to live” and goes on to suggest that the ‘animation’ observed in infants is sometimes blocked or diverted during the process of maturation; thus, many patients seen by dance movement therapists lack this ‘vitality’. The blocking of energy (linked to Wilhelm Reich’s concept of chronic tension as body armor) results in a waste of energy: “distorted bodies and … awkward, inefficient movements” 36). Schmais argues that dance movement therapy can help release this armor and thus renew vitality. This proposition was given some support by Ehrhardt 37), who interviewed outpatients and asked them to watch video representations of each of Schmais’ healing processes within a dance movement therapy group in which they had participated, ranking them in terms of which they liked most and least. Vitalization was the most valued process. However, this does not necessarily mean that it was effective in reducing depression. More recently, Koch 38) claims to have demonstrated a statistically significant decrease in depression and increase in vitality within a group of people who had been clinically diagnosed as having depression and who participated in circle dances with jumping rhythms, as compared to exercise and music controls. Both circle dance forms and jumping rhythms are common ingredients of dance movement therapy sessions. Koch used a scale, the Heidelberger Befindlichkeitsskala, previously tested and shown to have internal consistency with a Cronbach’s alpha of 0.89 (mean of pre‐test to post‐test). The scale has a subscale for vitality (alpha = 0.89) in which the individual self rates on a scale of 1 to 9 from ‘lifeless, empty’ to ‘full of life’. Depression was similarly scored, from ‘depressive’ to ‘not depressive’, using the depression subscale (alpha = 0.72) of the same instrument. However, the statistical analysis was based on the differences from pre‐ to post‐testing. Taking their end results as the comparison, the depression and vitality scores are not significantly different at the end of study between the dance movement therapy and control groups, at 95% confidence interval. The proposed link between dance movement therapy, increased vitality and a reduction in depression thus remains unproven.
Schmais 39) also argued that symbolism is responsible for therapeutic change. Symbolism is often associated with movement‐based imagination and movement as metaphor, all integral components of the creative process 40). For example, as early as 1981 Dosamantes‐Alperson 41) argued for the value of activating imagination through movement in dance movement therapy. Karkou 42) argued that imagination can be manifested as a communicative expression in symbolic movement. Furthermore, working creatively with symbolic movement may enable participants to communicate difficult and distressing material which is difficult to communicate verbally 43), which can lead to a shift in cognitions and feelings (Meekums 2002). Meekums 2002 argues that ‘movement metaphor’ is a useful device since it serves both to decrease emotional distance between the therapist and client and to increase emotional distance from distressing memories and feelings; metaphors also inherently contain the potential for change and development.
Other healing processes referred to by Schmais 44) include synchrony, expression, rhythm, integration, cohesion and education, all echoing the therapeutic factors in group psychotherapy proposed by Yalom 45). It is possible that both Schmais’ healing processes in dance movement therapy and Yalom’s therapeutic factors are in complex and simultaneous operation during dance movement therapy. Embodiment literature 46) suggests that therapeutic factors are enhanced by sensory‐motor experiences.
For clients faced with depression or depressive symptoms, dance movement therapy may have positive effects for a number of other reasons. For example, mood may be elevated because the use of dance movement has an element of exercise (albeit often rather gentle) for which there is already evidence of an impact upon depressive symptoms, as reported in the exercise research literature 47). Many forms of dance movement therapy also involve the use of music. A 2008 Cochrane review of music therapy 48) suggests possible benefit, although it cannot be assumed that when music is used as part of another kind of therapy this finding will still be valid since music therapy uses music in a very specific way. Reviews of verbal psychological therapies indicate that there are benefits from the use of short‐term psychodynamic psychotherapy for common mental health problems 49); psychotherapy for older people with depression 50); and psychosocial and psychological therapies for antenatal and postpartum depression 51).
Does dance movement therapy work?
A 2013 Cochrane Review on dance movement therapy for schizophrenia by Ren 52) included just one study of moderate quality that suggested that there might be a positive effect by dance movement therapy on negative symptoms of schizophrenia; these symptoms are closely connected to low mood. Bradt 53) identified two studies with small sample sizes and judged them to be of very low methodological quality, in their Cochrane Review of dance movement therapy for people with cancer. Although they found no evidence for an impact of dance movement therapy on psychological or mood outcomes, one study, judged to be at a high risk of bias, claimed a positive effect on quality of life and fatigue. Finally, the Cochrane Review on depression 54) included a small subgroup analysis of adults that demonstrated an effect in favor of dance movement therapy. A large positive effect was observed for social functioning, but since this was from one study of low methodological quality the result was imprecise. In all cases the need for further studies with high quality and larger sample sizes is advocated before any conclusions can be drawn with clinical significance.
The results of Koch et al 55) meta-analysis investigating the effectiveness of dance movement therapy and dance interventions on health-related psychological outcomes on 2,374 participants, found encouraging results, which indicated that dance movement therapy and dance have positive effects on various health-related psychological outcomes. Most studies found evidence on the effectiveness of dance movement therapy on clinical outcomes (12 trials), followed by quality of life (10 trials) and cognitive skills (3 trials) 56). There was also a tendency that dance movement therapy improved interpersonal skills (6 trials) 57). They found empirical evidence that dance movement therapy consistently and with a high homogeneity improved affect-related psychological conditions by decreasing anxiety and depression levels, and increased quality of life and cognitive skills. The authors did not find enough studies on (psycho-)motor functioning, physiological changes, and positive symptoms of schizophrenia in the dance movement therapy cluster to draw conclusions 58). Dance interventions improved (psycho-)motor skills (8 trials), clinical outcomes (11 trials), and cognitive skills (7 trials) 59).
The systematic reviews by Guzmán‐García 60) and Beard 61) look at dance movement therapy within the context of dancing and arts therapies for dementia respectively. The review by Guzmán‐García 62) included four dance movement therapy studies of which only Hokkanen 2008 63) follows a randomized control trial design. The authors concluded that the reviewed studies suggest a decrease in difficult behavior and at the same time increased enjoyment and social interaction for both residents and staff 64). Beard study 65) includes, amongst others, nine studies in dance movement therapy with this population. Beard 2011 66) concluded that the emphasis of these studies is on the process of the work and in particular on encouraging quality of life, developing a sense of community and supporting interaction. It is therefore, “…far less biomedical…” 67) than for music therapy studies for example. The high variety of results, especially in the dance cluster, needs more investigation in future studies 68). Further research is needed that expands on the evidence of effects of dance movement therapy and dance interventions on health-related psychological outcomes.
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