Dance movement therapy group improves social functioning and increases positive embodied experiences in social situations

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY-NC-ND 4.0 https://creativecommons.org/licenses/by-nc-nd/4.0/ Dance movement therapy group improves social functioning and increases positive embodied experiences in social situations © 2022 Informa UK Limited, trading as Taylor & Francis Group Accepted version (Final draft) Veid, Natalia; Pollari, Annukka; Hyvönen, Katriina; Pylvänäinen, Päivi Veid, N., Pollari, A., Hyvönen, K., & Pylvänäinen, P. (2023). Dance movement therapy group improves social functioning and increases positive embodied experiences in social situations. Body, Movement and Dance in Psychotherapy: An International Journal for Theory, Research and Practice, 18(3), 201-217. https://doi.org/10.1080/17432979.2022.2122563 2023 Dance movement therapy group improves social functioning and increases positive embodied experiences in social situations Natalia Veida,b, Annukka Pollaria,b, Katriina Hyvönenc, & Päivi Pylvänäinend aDepartment of Psychology, University of Jyväskylä, Jyväskylä, Finland bEducation Division department, City of Helsinki, Student Welfare Service Unit, Helsinki, Finland c Institute of Rehabilitation, JAMK University of Applied Sciences, Jyväskylä, Finland d Tampere University Hospital, Mood disorder Unit, Tampere, Finland Corresponding author: Natalia Veid E-mail-address: [email protected] Abstract This Finnish study examined the impacts of a group-form dance movement therapy intervention on the social functioning, attachment styles, and embodied experiences during social situations of its participants. The sample consisted of Finnish working-age adults with diagnosed depression who were randomised into intervention and control groups. Participants responded to surveys at three measurement points: pre- and post-intervention, and a follow-up 3 months later. The quantitative results showed that social functioning increased in the intervention group between the pre-intervention and follow-up measurement points but there was no change in attachment styles. The embodied experiences of participants during social situations were analysed qualitatively. The prevalence of avoidant reactions and insecurity decreased between the pre-intervention and follow-up measurement points. This study deepens understanding of the embodied experiences depression sufferers encounter in social situations, and provides insight into the ways in which dance movement therapy may be effective in decreasing depressive symptoms. Keywords: Dance movement therapy; DMT; social functioning; group intervention; CORE-OM; attachment Introduction Over 300 million people are suffering from depression worldwide (World Health Organization, 2017). Within the Finnish population, it is estimated that around 5–7% have depression (Isometsä et al., 2021), and the World Health Organization (2017) suggests that depression is the single largest cause of disability globally. Depression impacts people’s ability to function in multiple ways. These can include negative perceptions and beliefs regarding one’s own body (Papadopoulos & Röhricht, 2014), and impairments in social functioning (Szanto et al., 2012). The potential of dance movement therapy (DMT) to positively affect social functioning in depression sufferers has not previously been widely studied, and this paper aims to investigate this phenomenon. DMT is a form of creative arts psychotherapy based on movement and embodied experience, focussing on the connection between physical movement and emotional expression (Chaiklin & Wengrower, 2009; Meekums, 2002; Schmais, 1974). In the therapeutic process of movement, the body expresses emotions, and the thoughts and feelings of the participant can be changed through the movement of the body. In DMT, movement and dance are methods to connect with oneself to improve personal strengths, recognise and process emotions, and practice social interaction with others (Meekums, 2002). In group-form, DMT participants have an opportunity to be part of a community and share their experiences with others, which can result in receiving approval, support, and validation from other group members (Chaiklin & Wengrower, 2009). The healing power of group-form DMT is attributed to a combination of social activity, synchronous movement, and vitality of experience (Hanna, 1988). DMT has had positive outcomes in the treatment of depression (see e.g. Karkou et al., 2019). Previous studies have found that DMT led to increases in the consciousness of one’s body, and greater body-mind integration. The main objectives in treating depression with DMT are to create and support a more positive body image through the embodied expression of emotions and movement (Pylvänäinen, 2003; Pylvänäinen & Lappalainen, 2018), and the development of a more secure attachment style (Punkanen et al., 2014). The social aspect of DMT could also be relevant in the treatment of depression. Previous negative social experiences could lead to negative predictions regarding future social situations (Kirmayer Ramstead, 2017). Consequently, one might avoid social situations as a coping mechanism (Goossens, 2014). Social isolation could lead to the development or deepening, of depression, and avoiding social situations can also lead to a lack of opportunity to develop social skills. This, in turn, could lead to an inability to function in relationships and solve the interactional difficulties that arise in them (Joiner & Timmons, 2009; Trew, 2011; Wai & Bond, 2004). According to Joiner and Timmons (2009), depression can decrease the ability to take part in social interaction and to be in intimate relationships. It can also result in a lack of social support systems, poor social skills, insecurity, constant ensuring, and overall suffering in relationships, instead of them being positive resources. Previous research has indicated that DMT can increase feelings of social belonging (Cantrick et al., 2018; Hanna, 1988) and trust in others (Levaniemi & Maaskola, 2019). Problems in social interaction can be observed through attachment styles, and different attachment styles can be used to predict depressive symptoms (Mikulincer & Shaver, 2012). People with insecure attachment styles are likely to have dysfunctional beliefs of themselves such as interpretations of being worthless and thus have an over-codependency of other people’s approval. Insecure people are also likely to have problems with emotion regulation. Consequently, they are prone to depressive symptoms. One cause for the emergence of depressive symptoms in individuals with insecure attachments is the interpretation of inner experiences as being worthless and inadequate. In Punkanen et al. (2014), DMT intervention significantly increased participants’ secure attachment to others, and the authors’ assumptions were that shared positive and creative embodied experiences in a DMT setting could strengthen secure attachment styles, which, in turn, would decrease depression. Based on the findings of these studies it would be beneficial to investigate the effects of DMT on attachment styles. Research questions DMT has shown positive results as a treatment for depression (e.g., Hyvönen et al., 2020; Karkou et al., 2019), but not enough research has been done to ascertain why DMT is effective. DMT is often performed in groups, but the role of this social interaction has not been widely studied. The research questions we aim to answer in this study are: 1. Is there a difference in the social functioning and attachment styles of participants after receiving group-form DMT, compared to participants who do not? 2. What kind of embodied experiences do participants report in social situations before and after group-form DMT, and is there a change? Based on the findings of previous studies, we hypothesise that group-form DMT intervention will increase participants’ social functioning and secure attachment styles (Pylvänäinen & Lappalainen, 2018). It is also hypothesised that group-form DMT intervention will lead to positive changes in embodied experiences in social situations (Pylvänäinen, 2010). Methods Recruitment of participants This study is part of a project conducted by the University of Jyväskylä Department of Psychology and funded by The Social Insurance Institution of Finland, which aimed to investigate the effectiveness of group-form DMT in the treatment of depression. Participants were recruited from all over Finland in cooperation with mental health services. The inclusion criteria for participation were diagnosed depression, severe enough to affect the ability to study or work, a minimum of 3 months of treatment before the DMT intervention, and a written appraisal from mental health services, indicating that an intervention could be beneficial for the participant. Participants could not have suicidal ideation, psychotic symptoms, or substance abuse problems. Pregnant women or persons with severe pain that restricted their movement could not be included in the study. After the pre-evaluation, 157 participants were recruited, and 109 were taken forward into the study. In cities where the number of participants was small, only non-randomised groups were formed (n = 43). Participants who were on disability pension (n = 5) had their own separate groups in one city. Altogether, groups were held in 11 different cities in Finland between 2017 and 2018 and were led by 12 therapists. Data were collected at three measurement points, where participants responded to surveys regarding their depression symptoms, functioning, body image, and attachment styles. At the pre-intervention measurement (P1), comprising data gathered after participants were recruited but before the intervention began, all 109 participants (100%) responded. At the postintervention measurement (P2), gathered immediately after the intervention, 92 participants (84%) responded. At the three-month follow-up measurement (P3), 77 participants (71%) responded. In an attrition analysis of the study, participants who only took part in P1were compared to those who responded at P1 and P2. In addition, those who responded at all points were compared to participants who did not respond to some of the later points. A Little MCAR test showed that attrition was arbitrary (x2 (21) = 12.884, p =. 913). Attrition analysis showed that participants who had secondary education were overrepresented among those who did not answer the body image questionnaire at P2 and/or P3 (47.1%/22.9%). In turn, participants with a university degree were overrepresented among those who answered the body image questionnaire at those points (28.6%/5.9%). Otherwise, there were no significant differences, in terms of background variables, between those who answered at all points compared to those who did not. Participants’ demographic data Participants (n = 109) were randomised to an intervention group (IG) (n = 52) and a control group (CG) (n = 57). Demographic data for all participants are presented in Table 1. Baseline demographics were age, educational level, and medication because these variables had been shown to affect the outcome of measures that estimate depression or physical symptoms (Hyvönen et al., 2020; Pylvänäinen et al., 2015). Participants in the IG continued their treatment as usual, which consisted of group support once a week (8%), or discussion support every or every second week (31%), every third or fourth (37%), or every fifth week or more rarely (19%). Intervention The intervention was led by trained dance movement therapists who took part in a 12-day training program to prepare. The therapists also attended supervision groups regularly during the intervention delivery period. The DMT intervention consisted of 20 sessions of 75 minutes each, held twice a week for 10 weeks. Group sizes varied from 4 to 10 participants. The intervention evolved with certain themes: a sense of safety in the body, exploration of one’s body boundaries, somatic resources, pleasant and unpleasant feelings, mindfulness, and body awareness. The main methods used to examine these themes were dance and movement exercises based on structured improvisation, body awareness exercises, and reflection through drawing, writing, and verbalisation. Table 1. Participants’ Demographic Data. Groups IG (n=52) CG (n=57) All (n=109) Gender (%) Female/male 98.1/1.9 94.7/5.3 96.3/3.7 Age (years) Mean 41.8 36.5 39.0 Min 18 18 18 Max 63 64 64 Education (%) Comprehensive school or equivalent 7.7 5.3 6.4 Upper secondary school 30.8 36.8 33.9 Vocational adult education 11.5 10.5 11.0 Bachelor’s degree 26.9 22.8 24.8 Master’s degree 21.2 17.5 19.3 Other¹ 1.9 7.0 4.6 Medication (%) yes/no 65.4/34.6 47.4/52.6 56.0/44.0 ¹ e.g. doctorate, double degree, degree unfinished Outcome measures Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) was used in this research to investigate the social functioning of the participants. CORE-OM is a measurement tool that examines one’s psychological functioning. It consists of 34 items, relating to four domains: well-being, symptoms, functioning, and risk (Barkham et al., 2005; Connell et al., 2007). The participants choose an answer on a 5-point Likert scale that ranges from 0 (not at all) to 4 (mostly or all the time), reflecting their latest week. The higher the score, the more difficulties are present in that specific area of psychological functioning (Barkham people suffering from depression have had negative experiences in previous social situations. These experiences, which can include sexual abuse and domestic violence (Pylvänäinen et al., 2020), might lead one to feel excluded, unaccepted, and invalidated. Previous negative experiences might lead to negative predictions about the self in social situations that are formed cognitively but are also stored at the embodied level. Kirmayer Ramstead (2017) suggests that the brain’s main function is to predict the world through sensory information that impinges on its receptors. The brain system acts to minimise the differences between prediction and actual sensory input, either by changing the embodied experience to equate to the predicted world or by changing the statistical models that create the predictions in various neural networks (Kirmayer Ramstead, 2017). Avoiding social situations can be a coping mechanism, but might also lead to developing depressive symptoms. In turn, depression might provoke further distancing of oneself in social situations (Joiner & Timmons, 2009; Trew, 2011), which creates a situation where one has less opportunity to strengthen social skills. Despite the high incidence of mentions of anxiety and avoidant reactions, shame and insecurity were less frequent themes. The lower incidence of responses in these themes might be because they were treated separately. It is plausible that insecurity could be linked to shame, and observing these as a unified theme would give a better representation of the experiences. Humans have a basic need to connect with others and shame could be caused by not being able to connect in an expected manner, leading to insecurity in social situations. Despite a significant increase in social functioning, DMT did not affect the experience of shame. This could be explained by the intervention being only 10 weeks long and shame and negative attachment styles being deeply rooted coping mechanisms. Change in these aspects might not be possible in such a short amount of time. However, the decrease in avoidant reactions and insecurity shows that, during DMT, it might be possible to experience the self and one’s own body positively in relation to others. This could lead to a decrease in shame and a positive change in attachment styles in the longer term. That participants’ attachment styles did not change is at odds with the findings of a previous study that showed an increase in secure attachment styles following DMT (Punkanen et al., 2014). This difference could be related to slow neural changes in negative predictions related to social attachments (Kirmayer Ramstead, 2017). Decreased insecurity and avoidant reactions could exemplify the attachment toward one’s own body. Acceptance of one’s own body is a requirement for positive change in the attachment style – to be more secure in social situations. In this study, however, shame and anxiety did not decrease. It is possible that the DMT intervention began the process of accepting one’s own body, and over a longer period we might observe attachment styles changing as well. The nothing special theme can be interpreted as a positive, neutral, or negative experience. Considering the heightened negative self-observation that is common in depression, it might be seen as a positive to reach a neutral evaluation of the self. On the other hand, a nothing special experience might express difficulties in feeling positive in the body. In depression, the predictions in sub-cortical and conscious levels are usually negative because of previous experiences (Kirmayer Ramstead, 2017). These might lead to negativity bias in our evaluation of ourselves and our environment. In addition, negative experiences in social situations can cause a coping mechanism to develop, where embodied experiences and emotions are avoided. In this study, the nothing special theme might reflect this phenomenon. Positive embodied experiences In addition to the high number of responses to the themes of anxiety and avoidant reaction, one of the most common themes was positive experiences, which were frequently described in relation to close relationships. The number of reported positive experiences was broadly consistent across the measurement points. Having a close relationship could increase the possibility of positive experiences in social situations. The ability to feel positive experiences could also be a beneficial starting point for the DMT process. Group-form DMT can offer an opportunity for social interaction, which can enable positive experiences (Chaiklin & Wengrower, 2009). In DMT, rhythmic dance in a group setting can help create connections with other group members. Social interactions are also made visible in a new way through movement (Payne, 2003). The participant can experience being appreciated and accepted as part of the group (Chaiklin & Wengrower, 2009). Thus, the participants can take part in social interaction, which can strengthen the sense of agency, and, through that strengthening, support social connections in other areas of life. Increased connectedness to others can decrease the symptoms of depression and social isolation. This is supported by the findings of previous studies where DMT intervention increased participants’ sense of agency (Mills & Daniluk, 2002; Pylvänäinen et al., 2020), trust in others, freedom of emotional expression (Levaniemi & Maaskola, 2019), and extroversion (Punkanen et al., 2014). Body awareness in DMT Processing emotions, and exploring social interaction through movement, could be explanations for increased social functioning following DMT. DMT can create a safe environment in which to increase body awareness and offer a corrective experience where one can be accepted as they are. In the IG, participants’ acceptance of their own bodies improved and, as found in other studies, this greater acceptance can lead to greater self-expression and easier interpretation of others’ emotions (Punkanen et al., 2014; Roberts, 2016). Participants learn to give greater attention to bodily experiences when relating to others. This learned awareness can also create a curious and flexible intrapersonal way of relating to one’s own body (Pylvänäinen, 2010). This can create the conditions for an individual to settle into and more easily sense their own body, which, in turn, could lead to increased social functioning. Decreased insecurity could be explained by the positive change in body image as awareness of the body increases (Pylvänäinen, 2003; Pylvänäinen et al., 2020; Pylvänäinen & Lappalainen, 2018). In this study, insecurity decreased from P1 to P3, but there was a slight increase from P2 to P3. Decreased insecurity following DMT could decrease participants’ dependency on reassuring feedback from others regarding their acceptance, as the person learns to trust their own embodied perceptions. This could lead to further decreases in insecurity in social situations outside the IG and reinforce positive emotions instead of negative ones. In addition to insecurity, avoidant behaviour decreased significantly from P1 to P3. People tend to avoid situations that they find difficult or unpleasant, or where they consider their own agency insufficient. DMT offers a safe space in which to practice being in one’s own body with a sense of comfort and safety, and interact with others from this position (Payne, 2003), thus decreasing the need to avoid social situations. Limitations and further research The strengths of the current study were the randomised and controlled design and the followup measurement. The combination of quantitative and qualitative data provided a broader understanding of the changes occurring in social functioning after group-form DMT. This study also had a larger sample than previous randomised trials. In a further study, we suggest that it could be beneficial to make the follow-up time longer to better estimate the reliability of changes over time. In the current study, there was bias in gender distribution because the majority of the participants were female. In a further study, it would be useful to study these phenomena with wider gender representation in the data. There are also concerns over the validity of the qualitative analysis because of the small sample size and the missing data at some measurement points. In this study, changes in attachment style were measured using only one instrument: a question taken from the RQ. It would be useful to use the full RQ or another instrument that could perhaps offer a broader, yet more precise, way to measure attachment styles and the changes in them. The increase in social functioning, and decrease in anxiety and avoidant reactions found in this study support further investigation of the effects of DMT on attachment styles. It could also be beneficial to examine the social functionality and atmosphere within each of the DMT groups because each group is unique and differences in these aspects may impact participants’ individual changes in social functioning and body image. There were missing data from the embodied experiences questionnaire at later measurement points, consequently, the results could not include the whole sample. P1 data was gathered face-to-face whereas P2 and P3 data were gathered remotely using a paper questionnaire sent to participants’ homes. This might account for lower participation rates in the later measurement points. Finally, because this study organised the answers to the body image into different themes, it could be beneficial to explore the causes and background underlying each theme. In addition, the small sample size prevented statistical observation of the qualitative findings. Conclusions Our results showed that group-form DMT can improve participants’ social functioning and embodied experiences. They also brought depth to our understanding of the diversity of embodied experiences participants had in social situations. This study’s results complement the findings of previous studies and highlight one of the ways in which DMT may be effective in decreasing depressive symptoms. Disclosure statement No potential conflict of interest was reported by the author(s). Data availability statement The datasets used in this study are available, upon request, from the corresponding author. Funding This article is based on data collected for a research project funded by KELA, the Social Insurance Institution of Finland in 2017–2019. Notes on contributors Natalia Veid, works as a clinical psychologist at the City of Helsinki. Her work focuses on promoting well-being and treating mild to moderate mental health issues among students of vocational school. She conducted this research while studying at the University of Jyväskylä. Annukka Pollari, is a clinical psychologist and a practical nurse. She works in the student welfare services at elementary schools in Helsinki. Her work focuses on psychological interventions and assessments. She conducted this research while studying at the University of Jyväskylä. Katriina Hyvönen, works as a Senior Researcher at the JAMK University of Applied Sciences in Jyväskylä and in private practice as a Dance Movement Therapist and Psychotherapist. Her research focuses on psychological and therapeutic interventions in promoting well-being and in the treatment of depression. Päivi Pylvänäinen, a clinical psychologist, dance movement therapist (MA in CAT) and researcher. She has researched the use of dance movement therapy in the treatment of adults with depression and the body image of depressed patients. She is the president of the Finnish Dance Therapy Association. References 1. Barkham, M., Gilbert, N., Connell, J., Marshall, C., & Twigg, E. (2005). Suitability and utility of the CORE-OM and CORE-A for assessing severity of presenting problems in psychological therapy services based in primary and secondary care settings. The British Journal of Psychiatry: The Journal of Mental Science, 186, 239– 246. https://doi.org/10.1192/bjp.186.3.239 [Crossref], [PubMed], [Web of Science ®], [Google Scholar] 2. Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226–244. https://doi.org/10.1037//0022- 3514.61.2.226 [Crossref], [PubMed], [Web of Science ®], [Google Scholar] 3. Cantrick, M., Anderson, T., Leighton, L. B., & Warning, M. (2018). Embodying activism: Reconciling injustice through dance/movement therapy. American Journal of Dance Therapy, 40(2), 191–201. https://doi.org/10.1007/s10465-018-9288-2 4. Chaiklin, S., & Wengrower, H. (eds.) (2009). The art and science of dance/movement therapy: Life is dance. Routledge. 5. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Erlbaum. https://doi.org/10.4324/9780203771587 6. Connell, J., Barkham, M., Stiles, W. B., Twigg, E., Singleton, N., Evans, O., & Miles, J. N. V. (2007). Distribution of CORE-OM scores in a general population, clinical cut-off points and comparison with the CIS-R. The British Journal of Psychiatry: The Journal of Mental Science, 190, 69– 74. https://doi.org/10.1192/bjp.bp.105.017657 7. De Swert, K. (2012). Calculating inter-coder reliability in media content analysis using Krippendorff’s Alpha. (Vol. 15). Center for Politics and Communication. 8. Goossens, L. (2014). Affinity for aloneness in adolescence and preference for solitude in childhood. In Coplan, R.J., & Bowker, J.C. (Eds.), The handbook of solitude: Psychological perspectives on social isolation, social withdrawal, and being alone. (pp.150–166). Wiley. https://doi.org/10.1007/s10826-017-0916-0 9. Hanna, J. L. (1988). Dance and stress: Resistance, reduction, and euphoria. AMS Press Inc. 10. Hyvönen, K., Pylvänäinen, P., Muotka, J. S., & Lappalainen, R. (2020). The effects of dance movement therapy in the treatment of depression: A multi-centre, randomised controlled trial in Finland. Frontiers in Psychology, 11, 1687. https://doi.org/10.3389/fpsyg.2020.01687 11. Isometsä, I., Kinnunen, E., Koponen, H., Lappalainen, J., Lindfors, O., Marttunen, M., Pirkola, S., Raaska, K., Stenberg, J.-H., & Tuunainen, A. (2021). The working committee of The Finnish Doctor Association and Finnish Psychiatric Association. In: Depression. Duodecim. 12. Joiner, T. E., & Timmons, K. A. (2009). Depression in its interpersonal context. In Gotlib, I.H., & Hammen, C. L. (Eds.), Handbook of depression (pp.322– 339). Guilford Press. https://doi.org/10.1097/NMD.0b013e31829db5ed 13. Karkou, V., Aithal, S., Zubala, A., & Meekums, B. (2019). Effectiveness of dance movement therapy in the treatment of adults with depression: A systematic review with meta-analyses. Frontiers in Psychology, 10, 936. https://doi.org/10.3389/fpsyg.2019.00936 14. Kirmayer Ramstead. (2017). Embodiment and enactment in cultural psychiatry. In Durt, C., Fuchs, T., & Tewes, C. (Eds.), Embodiment, enaction, and culture: Investigating the constitution of the shared world. (pp. 397–422). MIT Press. 15. Levaniemi, A., & Maaskola, N. (2019). “When arms became wings”: Effectiveness of dance/movement group therapy and embodied memories of depressed patients. “Kun käsistä tuli siivet": Ryhmämuotoisen tanssiliiketerapiaintervention vaikuttavuus ja masennuskuntoutujien ruumiilliset muistot ryhmästä. University of Jyväskylä. 16. Meekums, B. (2002). Dance movement therapy: A creative psychotherapeutic approach. SAGE Publications Ltd. 17. Mills, L., & Daniluk, J. (2002). Her body speaks: The experience of dance therapy for women survivors of childhood sexual abuse. Journal of Counseling & Development, 80(1), 77–85. https://doi.org/10.1002/j.1556-6678.2002.tb00169.x 18. Mikulincer, M., & Shaver, P. R. (2012). An attachment perspective on psychopathology. World Psychiatry, 11(1), 11– 15. https://doi.org/10.1016/j.wpsyc.2012.01.003 19. Papadopoulos, N. L., & Röhricht, F. (2014). An investigation into the application and processes of manualised group body psychotherapy for depressive disorder in a clinical trial. Body, Movement and Dance in Psychotherapy, 9(3), 167– 180. https://doi.org/10.1080/17432979.2013.847499 20. Payne, H. (2003). Dance movement therapy: Theory and practice. Routledge. 21. Punkanen, M., Saarikallio, S., & Luck, G. (2014). Emotions in motion: short-term group form Ladance/movement therapy in the treatment of depression: A pilot study. The Arts in Psychotherapy, 41(5), 493– 497. https://doi.org/10.1016/j.aip.2014.07.001 22. Pylvänäinen, P. (2003). Body image: A tripartite model for use in dance/movement therapy. American Journal of Dance Therapy, 25(1), 39– 55. https://doi.org/10.1023/A:1025517232383