research about dance movement therapy

SYSTEMATIC REVIEW article

Effectiveness of dance movement therapy in the treatment of adults with depression: a systematic review with meta-analyses.

• 1 Faculty of Health and Social Care, Faculty of Arts and Sciences, Edge Hill University, Ormskirk, United Kingdom
• 2 Department of Performing Arts, Faculty of Arts and Sciences, Edge Hill University, Ormskirk, United Kingdom
• 3 Division of Rural Health and Wellbeing, Institute for Health Research and Innovation, University of the Highlands and Islands, Inverness, United Kingdom
• 4 Independent researcher, Manchester, United Kingdom

Background: Depression is the largest cause of mental ill health worldwide. Although interventions such as Dance Movement Therapy (DMT) may offer interesting and acceptable treatment options, current clinical guidelines do not include these interventions in their recommendations mainly because of what is perceived as insufficient research evidence. The 2015 Cochrane review on DMT for depression includes only three studies leading to inconclusive results. In a small and underfunded field such as DMT, expensive multi-centered Randomized Controlled Trials (RCTs) are as yet rare. It is therefore, necessary to not only capture evidence from RCTs, but to also look beyond such designs in order to identify and assess the range of current evidence.

Methods: We therefore conducted a systematic review of studies that aimed to explore the effectiveness in the use of DMT with people with depression. This led to a qualitative narrative synthesis. We also performed meta-analyses that calculated the effect size for all included studies, studies with RCT designs only, followed by a subgroup analysis and a sensitivity analysis. In all meta-analyses a random effects model was used with Standardized Mean Differences (SMD) to accommodate for the heterogeneity of studies and outcome measures.

Results: From the 817 studies reviewed, eight studies were identified as meeting our inclusion criteria. Three hundred and fifty one people with depression (mild to severe) participated, 192 of whom attended DMT groups while receiving treatment as usual (TAU) and 159 received TAU only. Qualitative findings suggest there was a decrease in depression scores in favor of DMT groups in all studies. Subgroup analysis performed on depression scores before and 3 months after the completion of DMT groups suggested changes in favor of the DMT groups. When sensitivity analysis was performed, RCTs at high risk of bias were excluded, leaving only studies with adult clients up to the age of 65. In these studies, the highest effect size was found favoring DMT plus TAU for adults with depression, when compared to TAU only.

Conclusions: Based on studies with moderate to high quality, we concluded that DMT is an effective intervention in the treatment of adults with depression. Furthermore, by drawing on a wide range of designs with diverse quality, we were able to compile a comprehensive picture of relevant trends relating to the use of DMT in the treatment of depression. Despite the fact that there remains a paucity of high-quality studies, the results have relevance to both policy-making and clinical practice, and become a platform for further research.

Rationale: Why Is It Important to Do This Review

According to the World Federation for Mental Health ( WFMH, 2012 ), depression is the largest cause of mental ill health worldwide, described as a “global burden” ( Scott and Dickey, 2003 ) or a “global crisis” ( WFMH, 2012 ). Similarly, the World Health Organization ( WHO, 2017 ) indicated that more than 350 million people of all ages are faced with depression as a clinical diagnosis. This condition differs from just feeling “low” or experiencing mood swings in response to daily life events; serious depression can affect people in multiple ways and can be disabling to the individual and disruptive to family and whole communities. According to the American Psychiatric Association ( APA, 2000 ), for a diagnosis of major depression, five or more of the following symptoms are needed in the same 2 week period, causing significant distress or impairment of functioning: low mood, loss of interest or pleasure in most activities, sleep disturbances, changes in appetite or unintentional changes of weight, decreased energy, either slowed or agitated movement, decreased concentration and in some cases, feelings of guilt, worthlessness and thoughts of suicide.

In England and Wales, the current draft guideline from the National Institute for Health and Care Excellence ( NICE, 2018 ) for adults suggests that talking therapies and medication are the most effective treatment options. The Scottish Intercollegiate Guidelines Network ( SIGN, 2010 ), the Scottish equivalent to NICE, makes similar suggestions. Amongst the psychological treatment options for depression recommended by the new National Institute for Health and Care Excellence ( NICE, 2018 ) draft guideline, cognitive behavioral therapy, interpersonal psychodynamic psychotherapy, counseling for depression, short-term psychodynamic therapy and couples therapy are mentioned. Exercise has also made its way into the guidelines for less severe depression.

However, despite the prevalence of multiple and, often, body-based symptoms in depression, non-verbal and creative types of psychotherapy such as Dance Movement Therapy (DMT) 1 are not among the recommended treatment options. It is possible that this is because to date systematic reviews of research studies including Meekums et al. (2015) have not been able to draw confident conclusions of the effectiveness of this intervention for clients with depression; the low number and heterogeneity of studies available have been reported as reasons for inconclusive results. Reviews of research that allow for confident conclusions are increasingly required by policy makers in order to justify resource allocation. However, the question of whether limited research evidence should be taken to indicate limited effectiveness is highly debatable. Altman and Bland as early as ( 1995 ) argued that “When we are told that ‘there is no evidence that A causes B' we should first ask whether absence of evidence means simply that there is no information at all.” (p. 485). The same authors also suggest that when there is data, even non-significant results need to be considered for their clinical significance, especially for new treatment options.

This systematic review is, therefore, not just important for facilitating efficient integration of information into policy making in adult services; it is also necessary to demonstrate clearly and transparently where the effects of DMT are consistent and how they vary across contexts in order to translate research findings to clinical practice. Meta-analysis can provide more precise estimates than individual studies, minimizing bias and reducing chance effects. DMT is a relatively new intervention with an emerging evidence base. It is necessary to evaluate the wider range of available evidence stemming from different types of study designs alongside emerging new data, to allow for decision-making that is based on the totality of available evidence, whilst checking for consistency of results across designs.

A Critique of What Constitutes “Evidence”

The definition of what constitutes good evidence is debated at length, especially for psychotherapy. Randomized Controlled Trial (RCT) is the design that is generally perceived as the golden standard for establishing effectiveness ( Higgins et al., 2017 ). It has however been questioned if this is the only and an appropriately fitted design for research in psychotherapy ( Clay, 2010 ; Holttum and Huet, 2014 ). For example, in RCTs there is often an expectation that intervention groups will consist of participants with one set of diagnoses, who are randomly allocated to certain groups, a premise that clashes with regular psychotherapy practice. Participants with mixed diagnosis and other co-morbid characteristics are common amongst those receiving group psychotherapy. The overall group fit is an important concern in regular group psychotherapy. In contrast, pre-stated single-diagnosis inclusion criteria and randomization in RCTs tend to ignore these common group practices.

Furthermore, there have been arguments that studies in the field are not sufficiently powered to detect true differences ( Leichsenring et al., 2017 ). Calculating changes within groups, i.e., before and after therapy, may have limitations ( Eysenck, 1963 ; Cuijpers et al., 2016 ), but may also accommodate for the smaller power of the studies in the field.

According to Shean (2014) , RCT design favors treatment options that are simple and deal with uncomplicated symptoms. In contrast, most psychotherapists argue that they offer complex interventions to clients with complex needs. In the UK, the Medical Research Council (MRC) ( Craig et al., 2008 ) acknowledges that complex interventions present additional challenges when designing studies of effectiveness. They suggest that there are several phases in evaluating such interventions which do not need to be followed linearly. Although experimental and RCT designs are highly valued, practical applicability needs to be considered. In all cases, demonstration of an understanding of the process is important, as evidenced by a clear description of the intervention. The MRC report, while highlighting the importance of a focus on outcomes and attempts at standardization, recommends the adaptation of the study to local circumstances and context.

Without diminishing the importance of RCTs, the value of looking at a broad range of evidence and alternative research designs when it comes to policy making and evidence-based practice has been argued extensively ( Shadish et al., 2001 , 2008 ; Kazdin, 2010 ). Some researchers suggest that quasi experiments may provide useful information about the potential effectiveness of an intervention ( Colliver et al., 2008 ). Either way, the advantage of randomization is that it can prevent selection bias and reduce the difference between groups on both known and unknown confounding variables. Even without randomization, studies can still reflect many other aspects of therapy.

In all cases systematic reviews remain important and highly valued summaries of evidence of effectiveness, the most respected being reviews published by the Cochrane Collaboration ( Higgins et al., 2017 ).

Evidence in the Treatment of Depression

In the treatment of depression, existing evidence from Cochrane reviews covers both the effectiveness of anti-depressant medication, different types of talking therapies and cognitive behavioral therapy in particular. While there are systematic reviews that provide evidence for the value of these interventions ( Arroll et al., 2009 ; Hetrick et al., 2012 ; Rummel-Kluge et al., 2015 ; Davies et al., 2018 ), there are some that present a critical perspective on these prevalent approaches. For example, Arroll et al. (2009) , in their review of the use of anti-depressant medication, acknowledge that the side effects of medication are not sufficiently reported. Others, such as Shinohara et al. (2013) , report that the benefits and harms of behavioral therapy are not appropriately shared raising concerns around participant responses and withdrawal. Reviews on other forms of psychotherapy, for example from Abbass et al. (2014) , highlight the value of psychodynamic interventions, arguing that there are sustained benefits after 3 months and after 6 months. Furthermore, there is a growing body of research literature that provides evidence for the value of different psychotherapy and counseling approaches when compared to cognitive behavioral therapy including short term psychodynamic psychotherapy, generic counseling and counseling for depression ( Ward et al., 2000 ; Richards and Bower, 2011 ; Cuijpers et al., 2013 ; King et al., 2014 ; Freire et al., 2015 ; Pybis et al., 2017 ; Steinert et al., 2017 ).

Differences between types of client populations affected by depression have also been reported in the literature. For example, Dennis and Hodnett (2007) found that psychological and psychosocial interventions were more effective than usual care for women with postnatal depression. With children and adolescents, Cox et al. (2014) found it more difficult to establish a clear superiority of psychological interventions over antidepressant medication. They did however, raise high risk of suicidal thoughts in association with antidepressant medication, making psychological interventions potentially safer interventions to use. For older people with depression, the review by Wilson et al. (2008) concluded that cognitive behavioral and psychodynamic therapies were comparable and both potentially useful.

However, these approaches rely heavily on verbal interaction. Exercise, although not a form of psychotherapy, offers a non-verbal approach to the treatment of depression that is gaining popularity, finding its way into the 2018 draft guideline from NICE. Still, the Cochrane review of the literature on this topic by Cooney et al. (2013) suggests that the effect was small and did not seem to have long lasting effects. The same review also reported that attendance rates ranged from 50 to 100%, indicating the possibility of high attrition rates.

Given that available treatments may not be the treatment of choice for certain clients and/or client populations and there might be concerns about adverse effects as is the case with the use of medication, there is an urgent need to explore the evidence from diverse treatment options. DMT is one such option.

Dance Movement Therapy (DMT): Description of the Intervention

In the UK, DMT receives regulation via the UK Council of Psychotherapy (UKCP), one of the main regulatory bodies of psychotherapists. However, unlike verbal psychotherapy, and unlike the most prevalent forms of psychotherapy recommended for depression such as cognitive behavioral therapy, DMT does not require considerable cognitive and linguistic skills from the client/patient. Therefore, it can potentially bypass social or cultural barriers. Karkou and Sanderson (2006) argue that DMT, alongside other arts therapies (art therapy, drama therapy, and music therapy are the other arts therapies practiced in the UK) offers an attractive option for clients since it allows them to work through issues that are located at a non- and pre-verbal level. Thus, DMT may offer a way to work through issues that are difficult to articulate or are buried in the unconscious because they are painful, frightening, or simply difficult to access and address through cognitive means.

DMT as a form of psychotherapy is extensively discussed by authors such as Meekums (2002) , Karkou and Sanderson (2006) , Payne (1992) , Payne (2006) , and Levy (1988) . In particular, Meekums (2002) discusses DMT as a creative form of psychotherapy. Following on from her theory-generating doctoral research ( Meekums, 1998 ), Meekums (2002) argues that the therapeutic process follows the same pathway as the creative process. This process comprises the following phases: preparation, incubation, illumination, and evaluation. Moreover, she identifies the central importance of the movement metaphor within this process, including its links to body memory, body language, and mediation of the therapeutic relationship.

DMT has also been researched as one of the arts therapies by Karkou and Sanderson (2006) for example, who reported on survey results ( Karkou, 1998 ) that explored similarities and differences between DMT and the other arts therapies. This study argued, amongst other things, that DMT shares with the other arts therapies similar overall therapeutic approaches, namely humanistic, psychodynamic, developmental, artistic/creative, active/directive, and eclectic/integrative therapeutic approaches. An updated survey 17 years later ( Zubala, 2013 ; Zubala et al., 2013 ; Zubala and Karkou, 2015 ) suggests that these trends remain largely unchanged. However, similar to the work by Meekums (1998 , 2002 ), these studies focus on defining the field and identifying relevant processes and do not attempt to answer questions of effectiveness.

With regards to effectiveness, Cochrane reviews in DMT with different client groups are available, albeit often with a small number of studies included. For example, next to the Cochrane review on depression mentioned above ( Meekums et al., 2015 ), there are Cochrane reviews on DMT for schizophrenia ( Ren and Xia, 2013 ), cancer care ( Bradt et al., 2015 ), and dementia ( Karkou and Meekums, 2017 ), none of which had more than three studies included due to the strict inclusion criteria posed by the Cochrane Collaboration. The difficulty in capturing the effectiveness of this field with different client populations when the included studies were limited to designs of RCTs is apparent in these highly stringent systematic reviews.

In contrast, a larger number of studies was included in the meta-analysis by Koch et al. (2014) not confined to RCTs. Of the total 23 studies included, ten studies with RCT and controlled trials included measures of depression (total scores or subscales). A moderate effect of DMT and dance on depression was reported. However, in addition to the diverse research designs, populations were equally diverse (not confined to depression), and interventions included any form of dance practice (not solely DMT).

DMT and Depression: How the Intervention Might Work

Following an early scoping review of the literature ( Mala et al., 2012 ) that identified a number of empirical research studies on the effectiveness of DMT for depression, the Cochrane review on this topic was completed ( Meekums et al., 2015 ). The Cochrane review identified three studies that met the criteria for inclusion (147 participants). A sub-group analysis suggested that for adults, there was evidence of a positive effect for DMT in reducing depression. However, the evidence was too thin to allow any firm conclusions due to the low number of studies (and associated number of participants) and the varying, generally low, quality.

Another important contribution of this Cochrane review was that it hypothesized on the reasons of why this intervention could be useful for depression and identified several “active ingredients” as follows:

Participating in Dance as an Art Form and as Exercise

The authors discussed the potential contribution of dance as a central component of DMT to generate vitality, even joy, for clients who, due to their depression, lacked animation. They supported this claim with reference to a seminal theoretical article by Schmais (1985) and recent empirical studies including Koch et al. (2007) . Further arguments can be made regarding dance participation due to physiological responses associated with exercise such as the excretion of endorphins, the enhancement of chemical neurotransmitters ( Jola and Calmeiro, 2017 ) and the active engagement of almost every part of the brain ( Bläsing, 2017 ).

The positive contribution of music and music therapy in decreasing levels of depression has already been demonstrated ( Aalbers et al., 2017 ). Although music is not an essential component of dance practice in a DMT context, its regular use may act as a supporting component to the central active ingredient of dance with this client population.

Building the Therapeutic Relationship/s Through Mirroring

The presence of a therapeutic relationship is a key difference between dance as a sensitive form of teaching or community practice on the one hand and DMT as a form of psychotherapy on the other ( Karkou and Sanderson, 2000 , 2001 , 2006 ; Meekums, 2002 ). This relationship is also highly valued as an agent of change for clients with depression who often experience isolation and loneliness. Literature in humanistic and existential approaches to psychotherapy (e.g., Yalom, 1980 ; Rogers, 1995 ) suggests that a meaningful interaction is central to the therapeutic process. In more recent years several psychotherapists argue that this relationship is also the main agent of therapeutic change and directly linked with therapeutic outcomes ( Ardito and Rabellino, 2011 ; Stamoulos et al., 2016 ).

In DMT, the therapeutic connection can take the shape of an embodied relationship, particularly present in the model developed by Chace ( Chaiklin and Schmais, 1986 ). The technique of mirroring 2 is frequently used in this practice as a way of enhancing embodied relationships ( McGarry and Russo, 2011 ; Fischman, 2015 ) and discussed with regards to studies in neuroscience ( Meekums, 2002 ; Berrol, 2006 ; Rova, 2017 ). The sensori-motor mirroring system ( Rizzolatti et al., 1996 ; Gazzola et al., 2006 ) for example, appears to be particularly relevant, offering an additional explanation of the mechanism behind the technique of mirroring, though neuroscience does not fully explain the psychological processes behind this complex practice.

Accessing Unconscious Material Through Imagination, Symbolism, and Metaphor

Another reason why DMT might be an effective intervention is its capacity to tap into unconscious, hard to reach or taboo feelings and thoughts. Imagery, symbolism and metaphors are important DMT tools in this process. Activating imagination is a component of DMT that was discussed as early as Dosamantes-Alperson (1981) in the context of the approach known as Authentic Movement 3 ( Whitehouse, 1979 ; Pallaro, 2007 ; Chodorow, 2013 ). Active imagination allows access to difficult feelings, and anger in particular, which for people with depression may be internalized, attacking one's own self ( Freud, 1917 ). With this psychodynamic explanation of depression in mind, it is therefore possible that imagination might act as a vehicle to express difficult emotions and, through symbolism and metaphor, to process them in a safe way, finding resolutions to one's underlying difficulties ( Meekums, 2002 ; Karkou and Sanderson, 2006 ). This proposition suggests that DMT could have profound and long-lasting effects that are not present for interventions that do not address the underlying reasons for depression.

Achieving Integration Through Reflection, Creativity, and Movement Narratives

As early as 1985 , Schmais argued that integration between mind and body is a key therapeutic factor for DMT. Integration is still a term used in the ADMP UK (2013) definition of the discipline as the overall aim of the work. In practice integration can happen through reflecting on movement material that may or may not be congruent with one's own thoughts and feelings. Exploring new and unexpected connections between known things, i.e., engaging in a creative process ( Karkou and Sanderson, 2006 ), can also have an integrative character. Finally, summarizing one's experience of therapy in a movement sequence or a symbolic posture or gesture can act as an essential and potent reference back to the process of therapy. Movement material can therefore, act as a form of story-telling, a movement and embodied narrative of key moments in the therapeutic journey ( Karkou, 2015 ).

The formation of links between body, thoughts and feelings becomes important for people with depression who may experience a disconnect between what they feel, think and/or do. Integration, an important outcome for a number of different forms of psychotherapy including integrative psychotherapists such as Norcross and Goldfried (2005) , may therefore, be another important “active ingredient,” which can be relevant to and responsible for therapeutic change.

Researching DMT Practice

These “active ingredients” presented above appear to respond and add to therapists' views on the topic as explored by the survey of practitioners by Zubala et al. (2013) and clients' experiences of the DMT process ( Genetti, 2011 ). While there is growing research evidence in the field ( Zubala and Karkou, 2018 ), DMT remains largely under-funded and thus, under-researched. RCTs, the gold standard for assessing the effectiveness of an intervention ( Higgins et al., 2017 ), require resources that are often beyond the reach of many researchers in the field, including those associated with time, money, access to large numbers of clients, specialist clinical trials support, and control over the environment in which a study can take place. Furthermore, as discussed above, RCTs pose limitations when applied to complex interventions. Since DMT is indeed a complex intervention, other research approaches need to also be considered. Quasi-experimentation, a predominant approach adopted in DMT research, may reveal important information that is typically overlooked and omitted from many systematic reviews. In this review we attempt to change this.

Overall Aim

To explore evidence of effectiveness in the use of DMT with people with a diagnosis of depression.

Research Questions

The main research question we asked for this study was:

• Is DMT effective for clients with a diagnosis of depression?

We were also interested in the following sub-questions:

1. What patterns emerge from the collected evidence relating to the severity of depression, the setting and overall context, the length, duration or type of intervention?

2. Is there evidence of effectiveness for DMT in decreasing levels of depression when pre and post-treatment scores of depression are compared?

3. Is there evidence of long-lasting effects of DMT on scores of depression?

4. Is there evidence of effectiveness when DMT is compared with no treatment, treatment as usual (TAU) or another treatment?

5. Is there evidence of effectiveness of DMT in the treatment of depression based on studies with high quality, i.e., low risk of bias?

a. To synthesize results from all studies of effectiveness of DMT for clients with depression

b. To establish effect sizes within groups, comparing pre and post scores on depression immediately after treatment and at the time of follow up

c. To establish effects sizes between groups, comparing end scores between the experimental and control groups for all RCT designs and for those with low risk of bias.

A systematic literature review was chosen as the best way to answer the main research question and as the most highly valued methodology of synthesizing evidence from different studies. According to Higgins et al. (2017) , a systematic review offers a high level of evidence regarding the effectiveness of an intervention.

In this review, conventions and processes used in Cochrane reviews ( Higgins et al., 2017 ) were adopted; the study by Meekums et al. (2015) in particular was an important reference point. However, unlike the restrictive inclusion criteria of Cochrane reviews, a more open approach to the choice of studies was followed, aiming to offer a more comprehensive picture of available evidence on the topic. In this review, both a qualitative meta-synthesis and a quantitative meta-analysis of the reviewed studies are provided. While the former retains a narrative character, the latter involves the use of statistical calculations that enable a quantitative synthesis of data from several studies.

The analytic framework and its alignment with the main and sub-questions of this review is presented in Figure 1 .

Figure 1 . Analytic framework.

As indicated in this diagram, a qualitative meta-synthesis was conducted (see no. 1 in Figure 1 ) to answer the first sub-question of the study (i.e., “What patterns emerge from the collected evidence relating to the severity of depression, the setting and overall context, the length, duration or type of intervention?”).

As an exploratory study, a few meta-analyses were also performed to answer the four remaining sub-questions as follows:

The first meta-analysis was conducted in response to the second question (i.e., “Is there evidence of effectiveness for DMT in decreasing levels of depression before and after treatment?”) and focused on pre/post treatment scores of depression for all the studies identified by the systematic review process and synthesized through the qualitative meta-synthesis (see no. 2 in Figure 1 ). Long lasting effects were considered through a subgroup analysis of this initial set of studies in which only studies with follow up scores on depression were included (see no. 3 in Figure 1 ). The third sub-question was considered in this calculation (i.e., “Is there evidence of long-lasting effects of DMT on scores of depression?”).

The third meta-analysis summarized the effect size for RCTs only (i.e., “Is there evidence of effectiveness when DMT is compared with no treatment, TAU or another treatment?” no. 4), while the final calculation involved sensitivity analysis of this last set of studies, retaining only RCTs with low risk of bias (no. 5). Results from this analysis answered the final question of the study which was “Is there evidence of effectiveness of DMT in the treatment of depression based on studies with high quality, i.e., low risk of bias?”

Criteria for Considering Studies for This Review

Study design.

All RCTs were considered as well as studies with quasi-randomization or systematic methods of allocation. Unlike the Cochrane review on DMT for depression ( Meekums et al., 2015 ) however, in this review, controlled trials and studies with pre- post-testing were also included. Qualitative studies were excluded because they were perceived as providing information about process rather than outcome; the latter being the main focus of this review.

Participants

Included studies offered interventions to people with symptoms of depression as defined by the trialist and assessed through diagnostic means such as ICD-10 or DSM or through using a standardized measure such as Becks Depression Inventory, the Symptom Check List-90-Revision or the Hamilton Rating Scale. There was no restriction in terms of severity of depression, age, gender or ethnicity. Studies with participants whose primary diagnosis was something other than depression and/or individual symptoms of depression (e.g., low mood) in the absence of sufficient evidence to form a firm diagnosis of depression were excluded.

Intervention

The intervention was facilitated by a practitioner who had received formal training, was a dance movement therapist in training or was otherwise accredited in the country in which the study was conducted. In countries where professional accreditation was not available, the available description of the intervention was examined to establish that it demonstrated key relevant characteristics of DMT practice. DMT practice was defined as an active engagement of participants in dance movement in the presence of a therapist. All DMT approaches were considered, but in all cases the intervention had a clear psychotherapeutic intent and fostered a psychotherapeutic relationship. Dance classes with therapeutic benefit were therefore excluded.

Comparators

Studies with all types of comparators to DMT as a main intervention were included such as waiting list, TAU, another psychological therapy, pharmacological interventions, physical interventions or different types of DMT. In this review, and unlike the Meekums et al. (2015) review, studies without a comparator were also included.

Outcome Measures

Scores on levels of depression were seen as the primary outcome measure. Both self-rated standardized measurements (e.g., the Beck Depression Inventory, Beck et al., 1961 ; the Symptom Check List-90-Revision, SCL-90-R, Derogatis, 1977 ) as well as observational tools (e.g., the Hamilton Rating Scale for Depression, HAM-D, Hamilton, 1960 ) were considered. Attrition rates, where available, were also considered as a sign of acceptability of the intervention.

Secondary outcomes included social and occupational functioning, quality of life, self-esteem, body image, cost effectiveness and adverse events. In this paper however, only results from primary outcomes are reported.

Systematic Review Protocol

According to Uman (2011) , the presence of a protocol offers a rigorous a priori process that minimizes selection bias. The protocol for the completed Cochrane review on the topic was published by the Cochrane Collaboration ( Meekums et al., 2012 ). As indicated before, there were a few differences from this protocol, the main being in the inclusion of types of study design. In a departure from the initial protocol ( Meekums et al., 2012 ) that was used to guide the subsequent Cochrane review ( Meekums et al., 2015 ), the current review included all studies with randomized, controlled and pre/post quasi experimental designs. A revised protocol was therefore prepared.

Search Strategy

The search took place in two phases. The first was part of the Meekums et al. (2015) Cochrane review and was up to date on the 2nd October 2014.

A new search was completed between 2nd October 2014 and 1st March 2018 using the same key words and databases as the first search (see Table 1 ). In this second search the online package Covidence ( www.covidence.org ) was used which was not available at the time of the first search.

Table 1 . Databases and search terms.

In the first instance, all known DMT professional associations were contacted through the use of a standardized letter with a request to provide any studies known to them. During the second search, key researchers in the field were contacted to provide any additional new research studies completed since October 2014.

Data Screening, Eligibility and Data Extraction

With regards to the first set of studies identified during the Cochrane review process we revisited all studies that were excluded on the basis of the study design as indicated on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) diagram of this original review ( Meekums et al., 2015 ).

During the second phase, all new studies found since the 2nd October 2014 were screened at a title and abstract level and then at a full text level.

As for the first phase, two reviewers were involved simultaneously while a third reviewer was on call in case of disagreements 4 . The process and the number of included studies were recorded on a new PRISMA diagram that collated both the original and the new search (see Figure 1 ).

In consultation with the review team, a spreadsheet was created in the Covidence software to collect and organize all the relevant information from the studies. The first two authors (VK and SA) extracted data independently from all included studies on the characteristics of the design, the population, intervention and outcomes. Effect size data (mean, SD, and number of participants) for the calculation of meta-analysis was also extracted. Any mismatches between the two sets of data-extractions and discrepancies were resolved through consensus after jointly checking the full-text papers. In case of missing data or incomplete information, VK contacted the authors via email. Permission to include one of the studies that was still unpublished at the time of the review was sought from the authors. Additional information was also requested in order to provide clarification on the methods and procedures followed and complete the assessment of risk of bias.

Assessment of Risk of Bias

The risk of bias for all the reviewed studies was assessed using Cochrane criteria ( Higgins et al., 2017 ): (i) random sequence generation (ii) allocation concealment (iii) blinding of participants and personnel (iv) blinding of outcome assessment (v) incomplete outcome data (vi) selective reporting and (vii) other sources of bias.

Data Analysis and Synthesis

In the present study, careful qualitative synthesis was conducted for all studies that met the inclusion criteria. The key areas of interest for this qualitative meta-synthesis were: the severity of depression, the setting and overall context, the length, duration or type of intervention.

The quantitative meta-analyses were conducted using the Review Manager software (RevMan 5.3). The first included all studies and a within-groups calculation. The second involved studies with follow up measures. They were sub-grouped and effect size was calculated considering any long-lasting effects for DMT with this client population. The third calculation included only studies with RCT designs and between-groups scores. Finally, studies with low risk of bias were included in the last calculation that involved a sensitivity analysis.

Because of the outcome measures of depression used, the data collected was continuous. For this reason, and assuming that they measured the same construct, outcome measures of depression, such as BDI and HAM-D, were brought together for the calculation of our meta-analysis. Still, given that there were different scales used in each case, Standardized Mean Differences (SMD) were chosen over Mean Differences (MD). The SMD was calculated using Hedges' g method. This method can accommodate for the danger of a small sample size bias ( Deeks and Higgins, 2010 ).

A random effects model ( DerSimonian and Kacker, 2007 ) was considered as an appropriate approach for this meta-analysis. Its selection was based on the assumption that the data for meta-analysis was drawn from a hierarchy or variety of population whose differences influenced the analysis. The random effects model assumes that the included studies are not identical, and the true effect size varies between studies or there is a random distribution of true effects. This is unlike the fixed effects model which presupposes that the effects are identical ( Borenstein et al., 2010 ).

Although there was heterogeneity, the studies reviewed in this study were reasonably comparable as all participants had a common diagnosis of depression and received the same intervention. Still, if one were to ignore methodological heterogeneity, there would be a risk of an overly precise or too narrow confidence interval summary result which may wrongly imply that a common treatment effect exists when actually there are real differences in treatment effectiveness across studies ( Thompson and Sharp, 1999 ). Hence, to allow for unobserved heterogeneity (differences in instruments or across units being studied), a random effects meta-analysis appeared to be the appropriate analytic choice.

The overall mean or pooled estimate was calculated as a weighted average. In a random effects model, the weight is the inverse of the variance capturing the two sources of variance, within study variance and between study variance, which depends on the distribution of the true effects across studies (tau square).

Although data from secondary outcomes were also measured in some of the included studies such as anxiety, quality of life and body image, in this paper our focus remained on results from the primary outcome only.

For this paper we also considered the type of subgroup analysis performed in the Meekums et al. (2015) study based on age, but chose not to pursue this mainly due to the fact that only one study survived scrutiny that did not involve adults; this one study was also assessed as having high risk of bias. Subgroup analysis for the type of intervention was not performed either because there were no obvious differences between DMT practices used in the reviewed studies. Finally, although there were differences in the severity of depression at the start of the study, subgroup analysis on the level of depression was not performed because of the limited number of studies; differences were discussed in the narrative meta-synthesis.

Study Characteristics and Qualitative Meta-Synthesis

As the PRISMA diagram indicates (see Figure 2 ), 803 records were identified through searching electronic databases (595 were identified in the initial Cochrane review search and 208 in the newest search), whilst 14 were found through personal contact (13 during the first stage of the search and 1 in the second search), taking the total number of records identified to N = 817. From these records, 63 were duplicates and were taken out, leaving 760 records to screen at a title and abstract level. From these, 57 records were examined as full text articles, excluding 51 studies due to: the study design ( n = 10), the population ( n = 21), and the intervention ( n = 16).

Figure 2 . PRISMA 2009 flow diagram.

From the six studies that met the inclusion criteria, one by Hyvönen et al. (2018) was considered as three separate studies for the purposes of both the qualitative meta-synthesis and the quantitative meta-analysis because the researchers had adopted three different research designs, namely RCT, non-RCT (controlled trial) and pre- post-testing (see Figure 2 and Table 2 ). This study, the most recent and largest of the studies included in this review, was still unpublished at the time of writing this paper. Information about the methodology and preliminary results were supplied directly by the researchers.

Table 2 . Study characteristics.

Similarly, there was more than one reference associated with some of the studies included, e.g., Pylvänäinen et al. (2015) , Röhricht et al. (2013) and Punkanen et al. (2014) leading to the inclusion of eight studies from 817 records identified ( Table 2 ).

Sample Size

A total of 351 participants were involved in all the studies included in this review ( Table 2 ). From those participants, 192 attended DMT groups and 159 were part of control groups.

Methodologically the eight studies ranged from pilot studies with pre/post testing ( Punkanen et al., 2014 ), to a controlled trial ( Pylvänäinen et al., 2015 ), three small RCTs in one location and with one therapist in each ( Jeong et al., 2005 ; Xiong et al., 2009 ; Röhricht et al., 2013 ) and a triple multi-centered study involving several therapists that followed three types of designs: randomization in some locations, non-randomization in some others and pre/post testing in a third ( Hyvönen et al., 2018 ). Both the Röhricht et al. (2013) and the Hyvönen et al. (2018) RCT strand had a cross over design.

Although the studies came from different parts of the world such as Korea, China, and the UK, it is worth noting the increased research activity in Finland with three studies completed there, one of which ( Hyvönen et al., 2018 ) had three different strands that were conducted in different settings and different cities across Finland. The other two studies from Finland ( Punkanen et al., 2014 ; Pylvänäinen et al., 2015 ) were conducted in an outpatient psychiatric clinic and in a private center. Two of the remaining studies took place in a psychiatric/mental health hospital either as inpatient provision ( Xiong et al., 2009 ) or as an outpatient community service ( Röhricht et al., 2013 ). The oldest of the reviewed studies took place in a middle school in Korea ( Jeong et al., 2005 ).

There were 68 male and 283 female participants, the latter being 81 percent of the total population. One study, the Korean ( Jeong et al., 2005 ), recruited exclusively female participants. The studies in Finland were mixed but involved more women than men. In two of the included studies, the Chinese ( Xiong et al., 2009 ) and the UK ( Röhricht et al., 2013 ) studies, the ratio between men and women was balanced with 51 men and 56 women participating in the two studies.

With the exception of the study by Jeong et al. (2005) which involved adolescents, all of the included studies addressed adults with depression. The age range for the studies with adults was 18–65 with an average of 40.6 years of age. The average age for the Korean study was 16 ( Jeong et al., 2005 ).

Interventions

As Table 2 shows, the number of sessions varied from 12 in the Pylvänäinen et al. (2015) study to 36 in the Jeong et al. (2005) study with all the remaining studies offering 20 sessions. DMT groups were offered once, twice, three times and, in the case of the Chinese study, five times per week. The duration of each session also varied from 45 min in the Korean study that took place in a school to 120 min in the Chinese study that took place in an inpatient psychiatric hospital. The studies conducted in Europe included sessions that lasted from 60 to 90 min each.

In three of the studies reviewed here, the models of DMT adopted were named, and to varying degree described, as a combination of the interactive model by Chace with influences from Authentic Movement and analytic psychology ( Xiong et al., 2009 ; Pylvänäinen et al., 2015 ; Hyvönen et al., 2018 ). From the remaining studies, one offered a description of themes that resembled a Chacian approach to DMT practice ( Jeong et al., 2005 ), another conceptualized the intervention with strong influences from solution-focused and resource-based to reflect the additional training of the therapists involved in the study ( Punkanen et al., 2014 ), while the last labeled the intervention as Body Psychotherapy and offered a detailed description of the intervention that resembled a manualized version of DMT practice ( Röhricht et al., 2013 ). This last study was also delivered by an experienced DMT practitioner.

From the included studies, there are several detailed descriptions of the intervention offered through separate publications ( Papadopoulos and Röhricht, 2014 ; Punkanen et al., 2017 ; Pylvänäinen, 2018 ).

In the studies where there was a control group, DMT groups were added to existing TAU and were compared with TAU alone. The only exception to this was the Korean study, for which the control group was a waiting list. TAU often included medication and some brief contact with a mental health professional. Participants in all the studies included did not receive another form of regular and weekly psychotherapy.

In all studies the primary outcomes were the severity of depression measured through SCL, BDI, and HAM-D. Two different versions of BDI were used (the first one published in 1961 and the other a revised version BDI II published in 1996). BDI and SCL are self-reported inventories, while HAM-D is observational. Despite their differences, these tools are regarded as sensitive to capture mood, body image, health anxiety, sleep loss, appetite and many other factors related to the diagnostic criteria of depression.

As shown on Figure 3 , all the included studies showed a decrease in the severity of depression. Two studies ( Xiong et al., 2009 and Röhricht et al., 2013 ) involved participants with very severe depression and the majority of the other studies (all five Finnish studies) involved participants with moderate depression at the beginning. Only the Jeong et al. (2005) participants had mild depression at baseline assessment. Toward the end of the DMT intervention, all the studies with moderate severity of depression at baseline showed a reduction to either mild ( Punkanen et al., 2014 ; Hyvönen et al., 2018 ) or minimal depression ( Pylvänäinen et al., 2015 ). Results from the randomized and well-controlled Röhricht et al. (2013) study indicate a gradual shift from severe depression to moderate depression. Xiong et al. (2009) report a drastic improvement and a sharp shift from severe depression to mild depression. Pylvänäinen et al. (2015) is the only study which resulted in participants having minimal depression after the DMT intervention, i.e., appearing to present full recovery.

Figure 3 . Depression outcome scores before and after DMT groups.

Risk of Bias

Figures 4 , 5 shows the risk of bias of the studies assessed against Cochrane criteria ( Higgins et al., 2017 ). An emphasis on randomization and blinding is included in the risk of bias assessment. However, in three of the eight studies, randomization had not taken place resulting in high risk of bias ( Punkanen et al., 2014 ; Pylvänäinen et al., 2015 ; Hyvönen et al., 2018 disability pension group). Furthermore, blinding for participants and personnel, as for all studies in psychotherapy, was not possible. For this reason, this criterion was omitted from the assessment of quality as suggested by Schünemann et al. (2013) .

Figure 4 . Risk of bias across all included studies.

Figure 5 . Risk of bias for each included study.

As Figure 5 shows, the earliest included publication, the study by Jeong et al. (2005) had quality limitations, even though an RCT design was followed. Only one of the risk of bias criteria was scored as low, namely selective reporting (see green color). Most of the remaining criteria were scored as high risk (red color) or uncertain risk (empty box).

The study from China, Xiong et al. (2009) , was of moderate quality, presenting concerns due to insufficient information around random sequence generation, allocation concealment and blinding of outcome assessment. Attempts to contact the authors to clarify these were unsuccessful. Since this study was the only study not published in English 5 , it is possible that the language created a barrier that we did not manage to overcome.

The study by Röhricht et al. (2013) was assessed as the study with the highest quality (the lowest risk of bias). Both the design and a thorough reporting against all criteria of risk of bias added to the quality of study.

In contrast, the study by Punkanen et al. (2014) had methodological limitations mainly due to the fact that it did not have a control group and thus, there was no randomization. In addition, since this was a small pilot study the researchers tried different methods, the outcomes for all of which were not reported, including results from measurements of attachment styles. From the findings presented, it was not clear whether outcome assessors were blinded for all outcomes. It was not clear either how many participants were involved, and information concerning attrition was omitted. However, this was a multi-faceted study presenting rigor and clarity of roles between the research team from the University of Jyväskylä and the team of therapists involved. The first phase of the study reported in Punkanen et al. (2017) also adds to the DMT literature in that through the use of the technology “motion capture” it outlined movement characteristics particular to people with depression; comparisons were made between a group of people with depression and a group of people with no depression identifying important movement differences between the two groups.

The study by Pylvänäinen et al. (2015) is a study “in the real world.” The limitations that our risk assessment highlights are compensated for the fact that the study was conducted in a clinical environment and as part of regular work. The findings are thus potentially directly applicable to clinical work.

The value placed on randomization in the conventional hierarchy of evidence ( Higgins et al., 2017 ) is at odds with the prevalent culture in a clinical setting that prioritizes client choice. While the Cochrane criteria concerning risk of bias imply that the therapist should be a different person from the researcher, the dual role in practice might add an element of trust, rigor and depth both for the development and delivery of the intervention and for an insightful interpretation of results ( Meekums, 1998 ).

Finally, in the design of the study by Hyvönen et al. (2018) there is strong potential to compensate for the risks of bias in all previous studies without limiting the quality of the intervention. However, since this study had three different strands with different designs (RCTs, controlled trials and pre/post testing), the risk of bias in these strands was different. Furthermore, given that findings were still being processed at the time of writing this review, we were unable to include information for all the criteria each study was assessed as indicated on Figure 5 .

To summarize our findings, as indicated in Figure 4 , 75% of the included studies had low risk of attrition bias. This is the only criterion which most of the studies met. The next lowest risk of bias criterion was detection bias. Whilst as for all types of psychotherapy, it is impossible to blind participants to the type of intervention, it appears from our results to be less challenging to blind for the outcome assessment. The type of measuring tools used in the study (observational/self-reports) might have played a role in allowing (e.g., in the case of observational measures) or hindering (e.g., in the case of self-rating scales) the possibility for blinding for the outcome measure. Since, we have included quasi-experimental designs it is obvious that only 25% of the included studies had low risk of bias in sequence generation and allocation concealment and the majority (75%) of the studies were therefore, of high risk.

Quantitative Meta-Analyses

Meta-analyses were performed as a way of synthesizing quantitative evidence of effect size across studies. Although studies varied in their designs, they all addressed the same fundamental question around the effectiveness of DMT. These different designs were therefore grouped in different ways in order to identify the direction of effect and effect size. The analyses performed were based on four different data sets as follows:

• Studies with before and after DMT scores; all the reviewed studies were included

• Studies with 3 months follow up data (pre DMT vs. 3 months follow up) as a sub-group analysis

• Studies with RCT designs only (post DMT experimental vs. post TAU or no care)

• Studies with RCT designs with lower risk of bias through sensitivity analysis.

As per our protocol, only scores until the point of the crossover were considered. In all four cases the effect of DMT in decreasing scores on depression was evaluated. As shown in the forest plots ( Figures 6 – 9 ), each study included for the analysis was represented by its point estimate with 95% confidence interval. It is noticeable from the plots that the size of the square between the studies varied based on the allocated weight associated with the calculation of each power estimate. The larger studies with less variance and more precise results were given larger weight. The overall measure of effect and the direction of effect is visually represented on the forest plots by the location of the diamond.

Figure 6 . Within DMT groups (pre DMT vs. post DMT).

The first analysis (see Figure 6 ) in which all reviewed studies were included unsurprisingly had the largest total number of participants ( N = 188). The SMD using a random effects model was 1.10 (95% CI 0.40, 1.80). As the confidence interval did not contain zero, there was strong evidence of a positive treatment effect. The I 2 was calculated which is a measure of heterogeneity amongst studies indicating the percentage of variance amongst studies ( Higgins et al., 2003 ). In this calculation I 2 was 89%, suggesting 89% of the variability in treatment effect estimates was due to real study differences (heterogeneity) and only 11% due to chance. This is visually evident from the wide scatter of effect estimates with little overlap in their confidence intervals ( Figure 6 ). Xiong et al. (2009) showed greater effect estimate than all the other studies, appearing further apart from these other studies.

A subgroup analysis was performed on this initial set of data as shown in Figure 7 . Only studies with a follow up depression score were included in order to assess any lasting effects of DMT. This calculation had the smallest number of participants ( N = 98). The random effects model provided an estimate of the average treatment effect. It revealed 0.69 SMD with 95% confidence interval (0.37, 1.02). Using Cohen's rule of thumb ( Lipsey and Wilson, 2001 ), a SMD of 0.69 was considered to be of medium effect. Although the confidence interval depicts uncertainty around this estimate, since the confidence interval does not cross the zero line, it shows positive effect of the treatment even 3 months after completion of the intervention.

Figure 7 . Subgroup analysis for within DMT groups (pre DMT vs. 3 months follow up).

In this calculation, the I 2 was 14%, suggesting that variability in treatment effect was mainly due to chance. Regardless of treatment, people may recover in time on their own, but some may do so at a slower rate than others. The rate of their recovery may be to a great extent influenced by their baseline characteristics or condition. Thus, patient characteristics need to be considered and the findings should be interpreted with caution.

When the SMDs were compared as end scores between the groups that received DMT and the control groups, an effect size of −0.64 favoring DMT treatment was found (see Figure 8 ). This third calculation included all the RCTs that were found in our included studies. The total number of 131 participants were involved in four studies. The confidence interval ranging between −1.10 to −0.18 did not cross zero. This supported the effect direction favoring the DMT group. In terms of heterogeneity, ~67% of the variability in treatment effect estimates was due to real study differences among the studies and only ~33% was due to chance. Figure 8 shows that there is wide scatter of effect estimates with little overlap in their confidence intervals. Among these four RCTs, the study by Jeong et al. (2005) was the weakest study as indicated by the number of negative red marks in the risk of bias table ( Figure 5 ), suggesting very low methodological quality. Hence, a “crude sensitivity analysis” was carried out (see Figure 9 ).

Figure 8 . Between Groups—RCTs (post DMT vs. control).

Figure 9 . Sensitivity analysis for between groups—RCTs only with moderate to low risk (post DMT vs. control).

As shown on Figure 9 , only three RCTs with moderate to low risks were included in this last calculation that included end scores from 111 participants, all of whom were adults. Our meta-analysis showed a SMD of −0.82 suggesting a large effect size according to Cohens rule of thumb ( Lipsey and Wilson, 2001 ), favoring the DMT intervention. The confidence interval was −1.20–0.43. Since it did not contain zero, there is limited uncertainty around the average treatment effect estimate. We can therefore say with confidence that DMT has an impact in reducing scores of depression. The confidence interval depicts the uncertainty around the average treatment effect estimate. In this analysis, as the confidence interval does not contain zero, there is strong evidence that, on average, the DMT effect is beneficial to the participants.

A heterogeneity analysis with I 2 calculation demonstrates that 42% of the variability in treatment effect estimates was due to between study variations and the rest due to chance. Although there were only three studies, all three were of moderate to low risk of bias and there was consistency in the findings.

Results from this final calculation demonstrate the highest level of effectiveness of DMT in treating depression amongst adults. Since we used a random effects model we have not ignored heterogeneity and thus, we have a precise confidence interval ( Brockwell and Gordon, 2001 ; Borenstein et al., 2010 ). So, it is less likely that our summary result may wrongly imply that a treatment effect exists when actually there are real differences in the effectiveness of treatment across studies.

Summary of Main Results

This review gathered evidence from eight studies that involved 351 participants. Unlike the Cochrane review of DMT for depression ( Meekums et al., 2015 ), in this new review we were able to be quite conclusive concerning the effects of DMT on depression: when we conducted a sensitivity analysis on three studies of moderate to high quality involving 111 participants, we found that DMT offered in addition to TAU had the highest impact on decreasing levels of depression compared to TAU. This result is in accordance with a previous but differently focused meta-analysis that suggested dance and DMT can be potentially effective in decreasing symptoms for depression ( Koch et al., 2014 ). Through this review, we can now say with confidence that DMT exclusively (that is, without combining results of dance and DMT studies together) can have a positive impact on patients with a primary diagnosis of depression.

Interestingly, when scores from all RCT designs were considered in our calculations, including studies with high risk of bias, a smaller (i.e., moderate) effect size was found, suggesting that the lower quality studies dropped the calculated effect size.

The meta-analysis performed with all studies and with all designs on scores of depression before and after the DMT interventions also indicate a favorable trend for DMT groups since scores of depression were decreased in all cases. Since scores from control groups were not considered in this calculation, it is not possible to know whether this change took place due to what Eysenck (1963) termed “spontaneous remission.” We therefore, do not know whether participants simply recovered because time passed as opposed to the beneficial effect of DMT.

Similarly, following from arguments in the literature that DMT is not simply a form of dance and/or exercise that provides temporary relief only ( Karkou and Sanderson, 2006 ; Meekums et al., 2015 ), we explored whether any long-lasting effects could be found. Calculations with studies that had included follow up measures resulted in a moderate effect size, which however was not conclusive due to different baseline characteristics of the participants and other variables influencing the results. The heterogeneity found in these studies was majorly due to chance, suggesting the need for further research attention in this direction.

Although on the basis of both of these two last calculations, we are not able to draw firm conclusions, we can see certain trends which can have useful clinical and research implications. For example, in all cases we can see that the scores on depression decreased, and this decrease continued several months after the completion of DMT.

Another important trend relates to the gender of participants. The fact that 81 percent of the participants were women may reflect the fact that dance is seen as an art form that stereotypically attracts women. Research bias can be seen in studies such as Jeong et al. (2005) that involved adolescent girls only. When choice was offered as was the case with most of the remaining studies, most studies, with the exception of Xiong et al. (2009) and Röhricht et al. (2013) , did not accommodate for gender diversity resulting in samples with a large number of women (see all the Finnish studies for example). This skewed sample limits our capacity to draw firm conclusions that DMT can be of equal value to both men and women, especially since there is research literature to suggest that men and women respond differently to the use of psychotherapy ( Ogrodniczuk, 2006 ).

Unlike gender, the age of our sample was widely ranging from 16 to 65 years of age. However, all studies but one ( Jeong et al., 2005 ) did include adults with depression only. Although it was not our intention to focus solely on adults, the evidence we found related to the effectiveness of DMT mainly with this age group. Nevertheless, as reported in several publications before ( Karkou and Sanderson, 2006 ; Karkou, 2010 ; Karkou et al., 2010 ), dance movement therapists work extensively with children and adolescents. However, Zubala and Karkou (2018) argue that depression is rarely diagnosed amongst children and adolescents. This could explain why we only have one study included in this review that involved a non-adult population.

Similarly, studies with people older than 65 who may be struggling with depression were also missing despite the increased research activity relating to people in this age group ( Karkou and Meekums, 2017 ; McHitarian et al., 2017 ). Co-morbid medical conditions such as dementia, Parkinson's, heart disease, strokes and so on might explain why studies with depression as a primary diagnosis were not found.

Severity of Depression

As indicated in our qualitative narrative synthesis and our first meta-analysis, all the studies included in this review demonstrated a decrease in the levels of depression for the intervention with participants with a range of levels of depression. As Zubala and Karkou (2015) suggest, dance movement therapists work with clients with depression extensively, some of whom are fairly unwell, presenting moderate or severe levels of depression. As expected, when the work took place in hospitals and in psychiatric units, the severity of depression was higher than in other settings as we see in the different baseline scores in studies by Xiong et al. (2009) and Röhricht et al. (2013) . Most of the participants on average had moderate depression (in 5 out of 8 studies) at baseline which was reduced to mild in most of the cases. The only study where participants had mild depression at baseline was in the Korean study that took place in a mainstream school and involved adolescent girls ( Jeong et al., 2005 ).

As presented in our qualitative narrative meta-synthesis, the most common trend amongst the reviewed studies was two sessions per week across 10 weeks. The only Chinese study ( Xiong et al., 2009 ) offered five sessions per week for 120 min each time for 4 weeks, in an inpatient hospital setting. Another study with high DMT dosage was the study by Jeong et al. (2005) that offered three sessions per week. This latter study was the only study that was conducted in a school setting. It is possible that in a school environment, and in inpatient hospital environments as was the case with the Chinese study by Xiong et al. (2009) , it is more feasible to have frequent sessions when compared to community-based settings. It is also worth noting that the two studies with the higher frequency of sessions were from Korea and China. It is therefore, possible that culture may have a role to play on the high treatment dosage in these two studies.

The length of the sessions ranged from 45 to 120 min. On average, and in all the European studies, sessions lasted from 60 to 90 min. The shortest sessions were available in the Korean study by Jeong et al. (2005) that offered 45 min-long sessions. The age of the participants and plans around fitting to the school timetable might be reasons to explain this choice. The study with the longest sessions was the Chinese study ( Xiong et al., 2009 ) that offered 120 min each time; a fairly unusual length of time for a DMT session in Europe and the USA. This might be associated with either the cultural context and/or the severity of depression of the participants in this study.

On the whole, it is worth considering whether high therapy “dosage” was associated with higher level of severity of depression. In the Chinese study ( Xiong et al., 2009 ) for example, participants with severe depression received high overall DMT dosage. There was also a dramatic decrease on the levels of depression post DMT. Although in the literature we can find arguments for the need for longer term interventions for clients with higher levels of distress ( Lutz et al., 2015 ), the intensity of sessions in this study of five sessions per week, as far as we know, has only been seen in Freudian analysis ( Freud, 1917 ). In DMT, and given the physical engagement of participants, it is possible that such intensity may lead to fatigue. Furthermore, given that length of this intervention was only 4 weeks, it was not clear whether underlying issues were sufficiently processed, a practice that may also lead to relapse, a common feature of cognitive behavioral therapy ( Ali et al., 2017 ) and exercise ( Sullum et al., 2000 ).

Another study that involved participants with similar levels of severity of depression at the baseline was the study by Röhricht et al. (2013) . Even with a lower dosage, the severity of depression was still reduced, albeit less dramatically than in the Chinese study. Given the successful results from both of these studies in reducing depression to either mild or moderate, it is worth considering whether a more intense dosage of DMT is needed with severe depression.

With the exception of the study by Pylvänäinen et al. (2015) , most studies that involved participants with moderate depression offered DMT groups twice a week for 20 sessions. The Pylvänäinen et al. (2015) study offered only one session per week for 12 weeks, but still demonstrated substantial changes on levels of depression. Follow up scores also indicated that the low level of depression remained 3 months after the completion of the intervention, with the participants in the study not returning to the clinic for at least 3 years after the completion of the intervention. Based on this, we speculate that a degree of time between sessions might be needed to allow for processing some of the deeper work that can take place in sessions ( Karkou and Sanderson, 2006 ). It is also worth considering whether more frequent sessions are needed initially as in the Xiong et al. (2009) study. Once severity is reduced, the dosage of therapy might need to be gradually reduced offering DMT over a longer period, as in the Pylvänäinen et al. (2015) study, consolidating and stabilizing any acquired changes.

All the studies except for Punkanen et al. (2014) showed a shift in the level of depression. In the Punkanen et al. study (2014) , there was a decrease in the scores of depression post DMT, but the level of depression did not drop from moderate to mild. Since this was a small pilot study, researchers and therapists might have tried different DMT methods and processes in the sessions.

Type of Intervention

On the whole, the studies included in this review used integrative models that combined the interactive model by Chace ( Chaiklin and Schmais, 1986 ) with in-depth methods developed by Whitehouse (1979) . Variations to these can be found in the study by Jeong et al. (2005) , where the description of the intervention is thin and relevant references are not included even if the brief description does resemble DMT practice. Similarly, the Chinese study ( Xiong et al., 2009 ) offered thin descriptions around the intervention but named Chace and Jungian psychology as strong influences in the intervention used. Although in these two studies dance movement therapists were not used, the studies were included because the discipline in these two countries at the time the studies took place was still in the process of development and professionalization and the descriptions of the intervention included in these two studies met our DMT definition.

The DMT approaches used in the Finnish studies is worth looking at carefully. The Pylvänäinen et al. (2015) study presented a very comprehensive treatment protocol and a significant decrease in scores of depression ( Pylvänäinen, 2018 ). Key principles from this study were also used to inform the intervention used for the large multi-centered study completed by Hyvönen et al. (2018) . In both cases Chace ( Chaiklin and Schmais, 1986 ) and Whitehouse (1979) were mentioned as important influences in the work. The third of the Finnish studies (and the first of the included studies that was conducted in Finland) by Punkanen et al. (2014) was the only study that named solution-focused and resource model as the basis for this intervention ( Punkanen et al., 2017 ). Similarly, the UK study by Röhricht et al. (2013) indicated strong influences from Body Psychotherapy, a form of psychotherapy linked to DMT practice but less often discussed amongst DMT practitioners ( Payne et al., 2014 ).

In all the studies conducted in Finland and the study in the UK, qualified and registered dance movement therapists delivered the intervention. Due to their training, it is possible that similar methods were used and an overall integrative model of DMT practice was adopted reflecting similar trends in psychotherapy in general ( Norcross and Goldfried, 2005 ). This integrative approach limited our capacity to comment on whether one type of DMT practice was more relevant to depression than another or whether certain active ingredients were more “potent” than others; the whole “package” appeared to contribute to decreasing levels of depression.

Quality of Studies

The study with the highest quality at the time of writing up this review was the UK study by Röhricht et al. (2013) . This was led by a psychiatrist who offered important support to a new intervention such as DMT. It may also be significant that this study was conducted in the UK, a country where DMT has been practiced in hospitals since the 1970s; the profession is relatively established ( ADMP UK, 2013 ) and recognized as a form of psychotherapy.

In contrast, the first review study by Jeong et al. (2005) remained of low quality and was subsequently dropped from our final calculation. Its low quality could reflect both the historical period during which the study was conducted and the professional development of DMT in that country at that time.

All three of the most recent studies came from Finland, a country with particular interest in identifying appropriate treatment for depression due to its high rate of depression and Seasonal Affective Disorder (SAD— Saarijärvi et al., 1999 ; Magnusson, 2000 ); also a country with high quality in health provision ( Afonso and Aubyn, 2006 ). In addition, it appears that the team of the Finnish DMT researchers gradually built on evidence from a preliminary pilot stage to a large, well-funded study supported by the Finnish Social Insurance Institution (KELA), which is responsible for funding health interventions. It is possible that this last study by Hyvönen et al. (2018) benefitted from the knowledge gradually accumulated in the field and within the particular research team. Furthermore, as a multi-centered study, it was delivered by different therapists in different locations in both large and smaller studies. Because of the presence of different therapists, we can argue that significant results in decreasing the scores of depression were not based on the particular skills and/or charisma of the therapist but on the intervention itself, supporting our confidence on the beneficial impact of DMT on the treatment of depression.

Conclusions

During this systematic review we were able to explore evidence of effectiveness around the role of DMT in the treatment of depression and answer our main research question concerning whether DMT is an effective treatment for clients with a diagnosis of depression. We conclude that there is evidence from high quality studies of a positive effect for DMT in reducing depression in adults. Our positive conclusion offers additional and stronger support to existing evidence from previous reviews of DMT for depression (e.g., Meekums et al., 2015 ) and dance/DMT for symptoms of depression ( Koch et al., 2014 ). Furthermore, we have found that moderate to high quality studies demonstrate strong impact, the strongest possible, when a summary result of the effect size of an intervention is calculated. Additional results, albeit tentative, support the overall conclusion that DMT is a useful intervention in the treatment of depression and offer information about useful trends.

Still, studies that involved children, adolescents and older people were generally missing from this review, confining our positive conclusions to adults with depression only. We were not able to conclude with any confidence whether DMT is beneficial for both men and women. Similarly, in this review, although there were findings relating to secondary outcomes, we did not look at them. Future studies should consider both younger and older populations, men and women and, where available the impact of DMT on secondary outcomes such as anxiety, quality of life, self-esteem and body image next to other clinically relevant outcomes including potentially physiological or neurocognitive changes. Further research attention is also needed on the degree to which positive results, indicated in some of our calculations, can be sustained at a follow up stage and what is the impact of the process of therapy on levels of depression through, for example, mid assessments.

The use of dance, the embodied therapeutic relationship, unearthing and working through difficult issues non-verbally and integrating possible discoveries and solutions creatively may be some reasons for the positive impact of DMT. However, further research on the active ingredients of DMT is needed that can offer further confidence about whether these are indeed helpful factors in the treatment of depression. In-depth study of the manuals of the different types of DMT practice used can result in further refinement of what we think is currently responsible for the significant effects of DMT on reducing depression. A new project called “Arts for the Blues” ( Haslam et al., 2019 ; Karkou et al., 2019 ; Parsons et al., in press ) may offer relevant support in this direction for DMT as well as the other arts therapies.

Furthermore, we propose that studies need to take place where DMT is not simply added to TAU and compared to TAU alone, but it is also compared with other, regularly available, treatment options. Controlling for other forms of psychotherapy such as counseling, art forms such as dance and music, and either group work or recreational activities will also be of considerable benefit as a way of both narrowing down the active ingredients of the intervention and providing comparable results with other, widely used treatments. A new study recently funded by the UK National Health Service might act as a response to this need where DMT, next to art therapy and music therapy, is compared with person-centered counseling ( Carr, 2018 ). This new study, the largest in the field that we know of, will not focus on depression only but on diverse mental health diagnoses to reflect the mixed groups present in regular practice. Still, data extracted from this study for DMT for people with depression will be of particular interest, making a substantial contribution to field.

Finally, the type of approach used, its frequency and overall dosage need to be further explored leading to an associated clinical guideline that takes into account the severity of depression. Such guidelines are currently available for psychological treatment options and exercise (see NICE, 2018 ), but information about the contribution of DMT is still missing, as are calculations around the cost and cost effectiveness of this intervention. Future developments in this direction are now urgently needed, especially given the positive results of this review.

Author Contributions

VK was responsible for organizing, drafting, and finalizing the current paper. She also completed the systematic search with BM for the Cochrane review, i.e., the first search, and with SA during the second search. She also guided the statistical analysis for the current review. SA contributed to the systematic review, performed the statistical analyses, and contributed to the writing and editing of the text. BM led the Cochrane review, acted as a referee for the current review and edited the final paper. AZ contributed to revisions and edits of the paper.

Conflict of Interest Statement

VK and BM are dance movement therapists registered with ADMP UK and as such may be seen as having invested interest in demonstrating the effectiveness of the intervention. SA, originally a speech and language therapist and a dancer, is completing her doctoral studies on DMT. AZ is a psychologist who has been researching arts therapies in her doctoral and post-doctoral work. The submitted work was not carried out in the presence of any other personal, professional, or financial relationships that could potentially be construed as a conflict of interest.

Acknowledgments

We would like to acknowledge the support we received from the research office and our statistician from Edge Hill University.

1. ^ The discipline in the UK is formally called Dance Movement Psychotherapy to reflect the fact that it is regarded as a form of psychotherapy. It is defined as “…a relational process in which client/s and therapist engage creatively using body movement and dance to assist integration of emotional, cognitive, physical, social and spiritual aspects of self.” (Association of Dance Movement Psychotherapy UK – ADMP UK, 2013 , p.1). The discipline is also known under other names: in the USA is known as Dance/Movement Therapy, in Australia as Dance-Movement Therapy, in Germany as Dance Therapy. Other terms used interchangeably are: Dance Psychotherapy, Movement Psychotherapy and Movement Therapy. We will use the term Dance Movement Therapy (DMT) as a term with international recognition to refer to all of these different names for the same profession.

2. ^ Mirroring: a technique in which the dance movement therapist attempts to find ways of experiencing the feelings of clients by taking on and reflecting back to the client some of their expressive movements.

3. ^ In Authentic movement, internal sensations are focused upon as they give rise to associated movement.

4. ^ VK and BM were the reviewers in the first search; VK and SA were the reviewers in the second review and BM acted as a referee.

5. ^ It was published in Chinese and translated with support from the Cochrane Collaboration by Dr Li Weixiao.

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Keywords: dance movement therapy, depression, effectiveness, systematic review, meta-analysis

Citation: Karkou V, Aithal S, Zubala A and Meekums B (2019) Effectiveness of Dance Movement Therapy in the Treatment of Adults With Depression: A Systematic Review With Meta-Analyses. Front. Psychol . 10:936. doi: 10.3389/fpsyg.2019.00936

Received: 29 December 2018; Accepted: 08 April 2019; Published: 03 May 2019.

Reviewed by:

Copyright © 2019 Karkou, Aithal, Zubala and Meekums. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Vicky Karkou, [email protected]

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Life-long music and dance relationships inform impressions of music- and dance-based movement therapies in individuals with and without mild cognitive impairment

• PMID: 38798436
• PMCID: PMC11118554
• DOI: 10.1101/2024.05.09.24307114

Background: No effective therapies exist to prevent degeneration from Mild Cognitive Impairment (MCI) to Alzheimer's disease. Therapies integrating music and/or dance are promising as effective, non-pharmacological options to mitigate cognitive decline.

Objective: To deepen our understanding of individuals' relationships (i.e., histories, experiences and attitudes) with music and dance that are not often incorporated into music- and dance-based therapeutic design, yet may affect therapeutic outcomes.

Methods: Eleven older adults with MCI and five of their care partners/spouses participated (4M/12F; Black: n=4, White: n=10, Hispanic/Latino: n=2; Age: 71.4±9.6). We conducted focus groups and administered questionnaires that captured aspects of participants' music and dance relationships. We extracted emergent themes from four major topics, including: (1) experience and history, (2) enjoyment and preferences, (3) confidence and barriers, and (4) impressions of music and dance as therapeutic tools.

Results: Thematic analysis revealed participants' positive impressions of music and dance as potential therapeutic tools, citing perceived neuropsychological, emotional, and physical benefits. Participants viewed music and dance as integral to their lives, histories, and identities within a culture, family, and/or community. Participants also identified lifelong engagement barriers that, in conjunction with negative feedback, instilled persistent low self-efficacy regarding dancing and active music engagement. Questionnaires verified individuals' moderately-strong music and dance relationships, strongest in passive forms of music engagement (e.g., listening).

Conclusions: Our findings support that individuals' music and dance relationships and the associated perceptions toward music and dance therapy may be valuable considerations in enhancing therapy efficacy, participant engagement and satisfaction for individuals with MCI.

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What is therapy, who needs therapy, how to choose a therapist, publish an article on therapyroute, the therapeutic wellness with movement based therapy.

Mrs Pooja Biyani

Dance Movement Therapist

Ranchi, India

Dance Movement Therapy works with the body/mind connection. Our conscious and unconscious movements affect their total control, and reflect their personality and inner life.

Dance has always been in my life. Whenever music starts, my body tends to swing, and I move rhythmically. Last year while I was exploring to find what else I could do with dance in my life, I found out about dance movement therapy and approached to study more.

I chose dance movement therapy at the age of 41yrs when I found that my passion for dance would lead to learning and a therapeutic experience. I would be able to explore a diverse population of society and get them connected with mind and creative body movements.

I am a graduate of business administration and have been an entrepreneur since 15yrs. I did not know psychology and therapy until I jumped into dance movement therapy. Becoming a student again was a great challenge. Putting on the student hat, even though I am an entrepreneur and a mother of two, was a challenge.

But I choose it, so I made it, and I am a Dance Movement Therapist today.

Hence let me tell you what Dance Movement Therapy (DMT) is!

Based on the belief that the body, the mind and the spirit are interconnected, dance/movement therapy is defined by the American Dance Therapy as “the psychotherapeutic use of movement as a process that furthers the emotional, cognitive, social and physical integration of the individual”. Dance/movement therapy, a creative arts therapy, is rooted in the expressive nature of dance itself. Dance is the most fundamental of the arts, involving a direct expression and experience of oneself through the body. It is a basic form of authentic communication, and as such, it is an especially effective medium for therapy.

DMT is very different from technique-based dance in that it creates a safe and non-judgmental space for people to express themselves through movement. Some participants may have never had any formal training in dance as we know it; the difference here is that we encourage all movements as equal and respected. DMT starts with expressing through physical body movements, but as that progress, it also addresses the emotional, cognitive and social well-being of the participants. It works to address emotional wounds that affect the day-to-day functioning of a human being. The premise is that all human memory is stored in the body, and negative memories and experiences, if not released, will also manifest themselves in negative ways in the person’s life. We work at identifying the root issues of the problem that often express itself in anger, fear, depression, suicide, low self-esteem, identity issues and sexuality. Based on the needs and assessment of the client/group at the start of the programme, key issues will emerge. I would then customise sessions to address these needs so that the client benefits from the process.

While dance itself is effective in activating happy hormones in the body, like when serotonin is released, it makes the individual “feel good”, DMT goes a step deeper to address core issues that an individual may be struggling with emotions. DMT looks different for everyone depending on a sense of safety, access to the body, and personal familiarity with an authentic expression of the body. The process may range from mostly verbal or speaking to mostly nonverbal or movement.

I can assure you that nothing feels better sometimes than just moving our bodies. The joy of expressing ourselves through movement, giving voice to inner attitudes and feelings can, at its peak, enhance our sense of self and foster new growth, and even minimally, give us a sense that our mind and body are connected. We can experience how our mind responds to our body – for example, if we slump our shoulders and put our heads down. After being in this position for a few minutes, one’s mind begins to feel the emotional repercussions of this body position, not to mention the muscle aches and pains that may come with it. As Dance Movement Therapists, the basic belief is that a person has the ability to alter their inner life and enhance their quality of life by expanding their movement possibilities.

Dance therapy session treats several physical and mental health issues:

It helps to explore and make meaning of the connection between movement and emotions, encourages tracking of bodily sensations and breath, guides through self-expressive and improvisational movements, and offers specific movement or verbal therapeutic interventions to promote healing and the feelings evoked by the movement.

It helps to build feelings of empathy, self-awareness, body awareness, mindfulness, self-expression, relief of stress, self-esteem, confidence, physical fitness, gross motor skills coordination, imagination and creativity. It provides the space for individuals to experience an invitation, a sense of choice, validation, and to tolerate internal sensations. Thus, it offers compassionate and supportive ways to feel a sense of control and autonomy within your body!

As quoted by Judith Lynne Hanna, “Dance therapy provides an outlet for energy and a safe and playful environment in which many areas of conflict can be identified and worked through, and appropriate adult roles and behaviour tried out.”

“Dance Therapy is not about dance, but about using movement as a tool of communication. It is about connecting movement to psychological processes.” – Erica Hornthal

Pooja Biyani | Dance Movement Therapist

About the Author: Mrs Biyani is a qualified Dance Movement Therapist , based in Ranchi, India, holding a Diploma in dance movement therapy from Artsphere, St Mira's University Pune.

Click here to schedule a session with Mrs Biyani .

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Patients “dance, dance, dance” in this therapy session

Occupational therapist Renee Callahan led two girls with cerebral palsy in a six-month dance/movement program that she hopes to expand to more patients in the future.

By Maureen Gilmer, Riley Children’s Health senior writer, [email protected]

The girls are 6 and 13, both with cerebral palsy and both ready to rock it out in their wheelchairs at Riley Hospital for Children’s rehab gym on a Monday evening.

Riley outpatient occupational therapist Renee Callahan is leading a group therapy program on a trial basis that incorporates a passion of hers – dance.

Since December, she has been working with Micaiah Flory and Isabelle Jones weekly to put together a performance for parents and family on the last day of the program.

The goal is to combine music and dance in warmups, games and routines to improve visual motor skills, motor coordination, muscular endurance, strength and internal rhyming and timing, Callahan said.

Added benefits include improved self-expression, confidence and social-emotional skills.

“I have danced my whole life,” said Callahan, who developed a dance-fitness program for Special Olympics Indiana during her OT doctoral capstone. “It has been my goal to incorporate dance with my OT practice because dance has several physiological and psychological benefits.”

Doing it in a group setting is new within Riley rehab, she said, and it’s something she hopes to expand in the next session to more patients with an occupational and physical therapy plan of care. The program doesn’t replace traditional therapy; it complements it.

“It brings me joy to watch these children achieve their OT goals through the modality of dance,” Callahan said.

Isabelle and Micaiah didn’t know each other before the program started six months ago, but they’ve become fast friends during these Monday sessions.

“Nervous? Or excited,” an onlooker asks the girls before the show begins.

“Both,” says Isabelle, as she waits for her parents and grandmother to take their seats.

Meanwhile, Micaiah resists her dad’s attempt to fix her ponytail, ready to get her groove on as only she can.

The one-hour session begins with warmups set to a lively beat.

“We start with marches,” Callahan directs the girls. “Get those knees up. Now together, raise the roof, arms up!”

As one song ends, another begins, and the group moves into stretches.

“Look up, look down, to the side, switch. Shoulders up, down, alternate. Hands on hips, show me some sass, stretch to the side … “

As Callahan leads the class with a joyful energy that the girls match, the therapist takes time to help Micaiah follow along with her arm movements while the little girl bounces in her chair.

After warmups come games, also set to music, followed by the dance portion of the program.

To the beat of Taylor Swift’s “Shake It Off,” the girls incorporate several of the movements they practiced in warmups – rolling their shoulders, clapping, twisting, reaching high and low and freestyle.

Justin Timberlake’s “Can’t Stop the Feeling” sets the mood for more “dance, dance, dance” as the girls move to the beat, stretching and giggling throughout.

The cool-down taps into some of those same muscles, from their heads to their toes, this time to the tune of “Love Story,” by Swift.

Philip Flory said he learned the dance and exercise movements himself early on in the sessions just to get his daughter engaged in the program, but Micaiah has come a long way.

“I’ve seen an improvement in her strength and coordination but also just in her ability to participate and work with another child, to stretch out and have some fun,” he said. “Also, Isabelle has been there to encourage her and help her out.”

While this session has come to an end, Callahan said the goal is to get more kids and more therapists involved and to expand to a larger open space.

“I’ve seen a lot of improvement with these two, and it’s been a lot of fun,” she said. “I hope this provides an opportunity for kids with motor challenges to be involved in a dance movement-based class and also help with the socialization aspect and achieve their therapy goals, too.”

Photos and video by Mike Dickbernd, IU Health visual journalist, [email protected]

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Exploring the Concept of Social Reconciliation Through the Experience of a Dance/Movement Therapy Group of Migrant Women in Spain

• Open access
• Published: 29 May 2024

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• Catherine Sophia Castellanos-Montenegro   ORCID: orcid.org/0009-0006-9314-4434 1 &
• Margaret Hills de Zárate   ORCID: orcid.org/0000-0003-1040-0959 2  

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This paper explores the potential of Dance/Movement Therapy (DMT) as a means of contributing to social reconciliation processes. The study, conducted through a group process with migrant women living in Spain, suggests that the relationships developed between participants in the DMT group reflect some of the key elements underpinning theories of social reconciliation. The elements of trust, empathy, and a willingness to coexist with others can be understood as the return to a sense of community and belonging. Furthermore, working with migrant women appeared as an opportunity to explore the concept of social reconciliation beyond national borders as an initial step to understanding this phenomenon through DMT. In summary, it is proposed that Dance Movement Therapy, oriented towards the configuration of new forms of relationship, has the potential to contribute to the modification of polarization frameworks in group and community relationships, particularly in areas affected by conflict or social marginalization experienced by migrants and refugees.

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Introduction

As human beings, we are in an ongoing relationship with our environment. We construct our subjective reality, but we also influence and are influenced by that reality which transcends our corporeality. It is in the human relationship that cultural codes, and socio-political practices are defined. However, in contexts of violence, there is a violation of human rights that can paralyse and cause suffering, undermine communities’ beliefs and ways of life, and generate mistrust, isolation, and low self-esteem (Centro Nacional de Memoria Histórica, 2014 ). Furthermore, a loss of power calls into question human agency. In these scenarios, healing wounds and rebuilding the social network becomes necessary.

In response to this need, social reconciliation is aimed at promoting and improving social relations (Rettberg & Ugarriza, 2016 ). Reconciliation, conceptualised as a collective process of deep transformation, implies a voluntary rapprochement of the parties previously in conflict, who seek to connect again (Bloomfield et al., 2015), re-establishing their social ties and maintaining stability in the territory (Alzate & Dono, 2017 ). However, having an approach to this concept through a dance/movement therapy (DMT) group process with migrant women raised the question of how we can understand a reconciliation process between people who have never or no longer share the same territory and were unknown to each other prior to joining the group.

It could be said that reconciliation within migrant populations poses a two-way challenge. On the one hand, the necessity to heal wounds with a social reality from which they have migrated, and on the other hand, keeping in mind the experience of arriving at a different place with little or no knowledge of the culture and no strong or even pre-existing relationship. This situation involves the role of host societies and the importance of their perceptions of migrants. It requires meaningful interaction between migrants and the receiving society in a two-way process, in which it will not only change the migrant’s perspective and way of life, but also effect structural change in the receiving society (Rudiger & Spencer, 2003 ).

This project focuses on the experience of a Latin-American group of women in Spain, who have migrated primarily for economic or personal reasons. Upon arrival, they faced the difficulties of relating to a different culture, where they may be mistrusted and stigmatised, resulting in experiences of uprootedness and not-belonging. Working with them was an opportunity to explore the intersections between DMT and social reconciliation, considering this research as an initial step in developing an approach to understanding the concept of social reconciliation through dance/movement therapy.

Social Reconciliation: An Overview

Etymologically, reconciliation means to become part of a relationship again, and to return to being a community (Cano et al., 2022 ). In broad terms, social reconciliation is understood as a deep dimension of peacebuilding, related to ending processes of violence and restoring relationships (Fernández, 2015 ), so that they can negotiate the realities and commitments of a new shared socio-political reality (Bloomfield et al., 2015 ).

In transitional contexts, reconciliation is a term that is used to encompass a broad range of peacebuilding. However, according to Rettberg and Ugarriza ( 2016 ), certain incentives and public discourses emphasising the need to involve all members of society in building sustainable peace have resulted in a marked tendency to label all sorts of activities as synonymous with or conducive to reconciliation thus depriving the term of any stable meaning or shared definition. Appropriation has resulted in the term being used diffusely, ranging from narrow and subjective to more expansive definitions and approaches.

The findings of this small pilot study are based on the understanding of reconciliation as a psychological and political process, which involves a change of individual and collective attitudes. Examples of this outcome are shifts from denial and resentment to acceptance and trust, enabling communities to re-establish the social fabric, non-violent daily relationships and the ability to work together (Cano et al., 2020 ). Reconciliation is thus conceived as an integrative process that involves multiple interdependent layers of interaction, from the individual and personal to the interpersonal through to the collective level, which encompasses social norms and representations.

This research focuses on the interpersonal dimension of reconciliation, oriented towards constructing and transforming human relationships. At the interpersonal level, this involves “deep transitions of personal interaction that focus on emotions, acknowledgement, apologies, forgiveness, healing, and the creation of shared personal bonds” (Bloomfield, 2015 , p. 23). According to Huyse ( 2003 ), there are three stages to making a reconciliation scenario possible. The first is non-violent coexistence, the second is trust building, and the third is mobilisation towards empathy.

Coexistence is seen as the possibility of peaceful connivance between antagonistic individuals and groups (Huyse, 2003 ). A model based on coexistence emphasises interpersonal similarities and cultural commonalities, as well as supporting notions of unity and cooperation (Silbaq & Belinky, 2020 ). Coexisting implies the right of each group to exist (Worchel & Coutant, 2008 ).

Trust can be defined as a psychological mechanism that aims to overcome uncertain social situations through benign assumptions about the behaviour of others (Kollock, 1994 ). Thus, the basis of mutual trust lies in believing that humanity is present in each person (Huyse, 2003 ). This element facilitates the modification of polarisation frameworks in interpersonal and group relationships and is a recurring variable in various works on constructive conflict transformation (Alzate et al., 2015 ). Polarisation can be described as the presence of separated groups in society with opposing attitudes (Jung et al., 2019 ). As Albada et al. ( 2021 ) point out, individual characteristics and group affiliations are key factors in attitudinal polarisation. “How people perceive their position and that of their in-group in society can influence how accepting they are of out-groups, especially refugees and migrants” (p. 629).

Empathy allows a person to take another’s viewpoint to understand the intentions behind their actions more fully; in other words, ‘feeling what they feel’ (McGarry & Russo, 2011 ). It is the attempt to experience another person’s inner life and resonate with what they are experiencing, living, and feeling; to have information about their situation and act accordingly (Fischman, 2013 ).

These three concepts are also key principles in a DMT process. That is why they are taken as central axis for the research, to enable a dialogue between the concept of social reconciliation and DMT as a discipline.

The Relevance of Dance/Movement Therapy

One way of promoting change and repairing damage is through the expression of the body in movement (Maralia, 2007 ) because the body reflects the most intimate part of the person. Working with the body connects us with an emotional and symbolic level that makes it possible to give voice and express that which cannot be expressed through words (Rodríguez & Dueso, 2016 ). It also allows reinterpreting and deconstructing symbols, giving new readings, and transforming meanings. Therefore, increasingly, the focus has turned to listening to and understanding bodies as channels for self-expression, places of recognition and connection between thought and emotion (Rodríguez, 2011 ).

Defined as the ‘psychotherapeutic use of movement to promote the emotional, social, cognitive and physical integration of the individual, with the purpose of improving their health and well-being’ (American Dance Therapy Association, n.d.), Dance/movement therapy becomes a psychotherapeutic technique that is based on creative processes using the body, its non-verbal expressions, and dance (Rodríguez, 2009 ). Its objectives revolve around allowing the exploration of new ways of relating, promoting greater integration of the self, increasing awareness, and enhancing the development of social skills that can lead, through movement, to changes in the psyche, thus promoting well-being and personal growth (Rodríguez & Dueso, 2016 ).

One of the main purposes of DMT is to strengthen people’s mental health. The World Health Organization (WHO) conceptualizes mental health as a ‘state of well-being in which the individual realizes their own capabilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community’ (World Health Organization, n.d.). It is a concept that encompasses all dimensions of human nature and is the basis for the well-being and effective functioning of individuals and societies that favour dignified living conditions and humanization (Cano et al., 2020 ).

Therefore, mental health requires not only material factors such as employment, housing, or road infrastructure but also immaterial aspects such as equity, security, hope, respect for difference, and strengthened social capital, such as peaceful possibilities for coexistence and social solidarity (Mukashema & Mullet, 2013 ). Consequently, the daily dynamics of violence can have grave consequences on mental health, as they can generate suffering, trauma, depression, anxiety, breaks in social bonds, destroy action of life projects, also sowing hopelessness, mistrust, indifference, and isolation (Cano et al., 2020 ). Promoting reconciliation, as ‘working through’ these issues in DMT, is a way to heal wounds and improve the mental health of those who have experienced multiple forms of violence. Especially when the need of social reconciliation goes beyond conflict-affected societies and includes different forms of violence reflected on daily lives. Political as well as other chronic forms of violence undermine social relations, contributing to societal divisions and grievances, adversely affecting people´s well-being, and the ability to share social space (Oettler & Rettberg, 2019 ).

Migration: I’m (Not) Here, and I’m (Not) There

Migration is understood as the movement of a person or a group of people from one place of residence to another, either within a country or across an international border, temporarily or permanently (International Organization for Migration & United Nations, n.d.). It is a complex and multifaceted phenomenon that encompasses economic, political, psychological, social, and cultural factors. It involves migrants and the receiving society (Cano et al., 2020 ) since it implies a change of culture and, therefore, a change in social codes and ways of interacting with the environment.

While it is an opportunity to exchange cultural values, learn new habits and lose the fear of the unknown and difference; migration is experienced as a traumatic process that highlights our vulnerability and challenges our mental health (Cano et al., 2020 ). Migration implies an identity crisis due to the loss of home, family, and friends on the one hand, and the loss of how one’s existence had been configured up to that point on the other hand (Romero, 2020 ). Even by assuming the body as the home of identity, one could speak of a third loss in cases of dissociation, when there is a disconnection and an uprooting from one’s body.

Wars, poverty, and political conflicts are some of the most important causes that push millions worldwide to leave their country (Garcia, 2018 ). In doing so, migrants face arriving in a society with different norms, values, rhythms, and relationships. This constitutes an attack on one’s own cultural identity and will only cease to represent a problem to the extent which people integrate the new set of meanings (Garcia, 2018 ). However, according to the conference ‘The Economic and Social aspects of Migration’ organised by The European Commission and the OECD in 2003, in the European Union many migrants suffer economic and social disadvantages, even some after decades of settlement. As a result, they are excluded from civic and political participation and face discrimination, racism, and xenophobia (Rudiger & Spencer, 2003 ). Their marginalisation makes them easy targets for scapegoating by far-right parties, which have gained increasing support throughout Europe by exploiting fears and inciting resentment (Rudiger & Spencer, 2003 ). Based on a report published by the European Council on Foreign Relations in 2019, there is evidence that electoral support in Spain for anti-immigration policies has grown lately even when the country has some of the fastest-growing immigration numbers globally (Fine & Torreblanca, 2019 ). Attitudes are not the same towards every migrant. Nationality, ethnicity, and other visible characteristics influence the local neighbourhood response. In Spain, there may be differences between the reception that people arriving the Global South receive from that extended to those arriving from Northern countries. Therefore, it is not taken for granted that the invasion anxiety felt in host societies, often prompted by the media, evokes images of flimsy boats crowded with determined irregular migrants making their way towards Spanish shores or by large-scale jumps at the border-crossings at Ceuta and Melilla (Fine & Torreblanca, 2019 ).

Public attitudes tend to turn against migrants, especially when social welfare provisions are rolled back, and exclusion emerges as a real threat for many. The ensuing polarisation of some groups of the population signals a process of social fragmentation. In the context of economic, social, and even physical insecurities, appreciating diversity and learning to manage differences appear particularly challenging (Rudiger & Spencer, 2003 ).

When people move from one place to another, they need to establish new relationships with those who were there before them, they need to negotiate their place (Celestina, 2015 ). In this process of recognising and integrating new practices and meanings, social reconciliation means restoring divisions between migrants and the communities in which they arrive. In such contexts, Dance Movement Therapy can provide a temporary home -a safe space- which facilitates recovery and integration (Dieterich-Hartwell & Koch, 2018 ), improving the relationship of migrants with their unfamiliar environment and providing tools to face new challenges (Romero, 2020 ).

Artistic Research as a Methodology

Working with migrants implies a scenario characterised by low regularity of attendance and complex, changing, and uncertain life situations. In response to this, the methodology must be highly reflexive, sensitive, and flexible enough to follow and elaborate on different themes as they emerge (Hills de Zárate, 2012).

Artistic research can contribute to knowledge generation by using artistic methods in collecting, analysing data, and presenting results (Mateos, 2011 ). This research process is characterized by an inductive approach in which the researcher has an open mind, allowing the theory to emerge from the data and, thus, a dialectical and integral path is proposed to understand human beings in their complexity (Wall, 2018 ). This methodology makes it possible to discover our inner landscape, making room for lived experiences, and validating emotions as sources of information and knowledge of a process that is weaving itself (Rojas, 2016 ).

In a DMT context, the objectives and methodology used in the psychotherapeutic process must be differentiated from the questions and methodology applied for the research; even more so when they fall on the same person, therapist and researcher. The therapeutic results takes priority over the research objectives (Mateos, 2011 ). Consequently, the DMT group process’ objectives were the priority. In contrast, the research process focused on an open and reflective approach, collecting data and information from diverse sources, including participants’ experiences.

Design and Participants:

As García ( 2018 ) points out, the framing that is built in the therapeutic relationship of DMT, especially in group sessions, can offer migrants a safe space to explore new referents and meanings. In addition, group sessions provide cohesion, promote trust, and help reduce prejudice. Thus, a group of participants was defined who voluntarily undertook a DMT psychotherapeutic process of 19 sessions, each of 90 min. In the beginning, there were five women. After several sessions, two more women joined the group. However, in the middle of the process, three decided to withdraw for various reasons. Ultimately, the DMT sessions culminated with four women, although not all of them participated in the first session.

Data Collection :

To develop a comprehensive understanding of the phenomena and to test validity, it was decided to converge information from multiple data sources. Mixed qualitative data collection methods allowed for and facilitated the expression of different perspectives that may have been overlooked (Carter et al., 2014 ). Information was collected through:

An initial semi-structured interview conducted before commencing the DMT sessions to collect information about each participant’s background, migration experience and expectations of the research process.

The researcher’s reflexive diary.

Movement videos of the researcher/therapist recorded after each session, based on her bodily experience of the session.

Participants’ drawings and writings which recorded what they had worked on during the sessions.

A final semi-structured interview, which sought to delve more deeply into what was experienced during the research process and gather participants’ final reflections.

Triangulation

Method triangulation promotes using several data collection methods and is frequently used in qualitative studies. The study also draws upon theory triangulation which encourages several theoretical schemes to enable the interpretation of phenomenon (Carter et al., 2014 ).

Reflexivity and Positionality

Reflexivity in research refers to the thoughtful, self-aware analysis of the inter-subjective dynamics between the researcher and the researched (Finlay & Gough, 2003 ). Practising reflexivity requires an ongoing critical self-reflection of how the researcher’s social background can impact the research process, particularly the collection and analysis of the data (Wall, 2018 ). In addition, it requires openness and an acceptance that the researcher is part of the research (Finlay, 1998 ; Finlay & Gough, 2003 ). It has also been proposed that “reflexivity is a helpful conceptual tool for understanding both the nature of ethics in qualitative research and how ethical practice can be achieved” (Guillemin & Gillam, 2004 , p. 262–263). With these considerations in mind, the researcher kept a reflexive diary, from which extracts are interspersed at key points in the account of the research process.

Positionality is related to reflexivity and describes one’s worldview and the position one adopts about research and its social and political content (Holmes, 2020 ). Qualitative researchers consider the positionality of the researcher and the researched as core aspects of inquiry in understanding how knowledge and experience are situated, co-constructed, and socio-historically located. “This methodological expectation for reflexivity does not just allow for richer data, but also requires researchers to consider power within and around the research process to employ an ethic of care for their subjects and for the overall work of qualitative research” (Reich, 2021 , p. 575).

The Researcher’s Positionality

The research represents a shared space shaped by both researcher and participants. The identities of the researchers and participants impact the research process and come into play via our perceptions of others and how we expect others to perceive us (Bourke, 2014 ). In this case, the therapist-researcher who carried out the fieldwork, shared many feelings with these women. Castellanos-Montenegro, as a migrant woman from Latin America, became aware of her identification in this context.

I was genuinely excited to carry out this research in an organisation that a group of Colombian women created. I felt recognised and welcomed from the first day because my cultural and historical background connected me to this familiar place. I was seen as an equal, and this implied that I had to assume a reflexive position to be seen as a migrant woman without this affecting my role in the group as a dance-movement therapist. It was fundamental to cultivate my therapeutic presence even before the therapeutic process began to be able to perceive what was internal or external to me as a researcher-therapist. (Extract Researcher’s Reflective Diary, 10/09/2021)

Therapeutic presence combines two types of disposition: the readiness to adapt our approach in the encounter with the participant while avoiding the risk of fusion, thanks to the maintenance of a constant relationship with the capacity to think (Robbins, 1998 ). To achieve this, it was necessary to promote the maintenance of a lucid internal observer of our own experiences, which also allowed us to think and elaborate hypotheses about the therapeutic process (García, 2007 ).

The Research Process

Before starting the group process, a four months’ observation process was carried out in the organisation where we did the research. During that time, Castellanos-Montenegro observed recurrent bodily expressions with closed postures in the women who arrived at this institution. Not only did they have a small kinesphere Footnote 1 reflected in their gaze on the floor, their legs and arms crossed, and a soft, almost inaudible voice. They also appeared nervous, touching their fingers or with stereotypical leg movements, slow and hesitant or sudden and heavy movements. They verbalised feelings of helplessness, indignation, frustration, and anger.

These bodily expressions reflect how the migration experience is embodied in their daily lives. These experiences include not being recognized as citizens, not having the same rights as EU nationals, not feeling in a safe place, and being at constant risk of exclusion, of carrying the system’s weight on their shoulders, and trying to survive in an asymmetrical reality of power in which they lose out.

Migrants often have higher levels of stress, anxiety, mistrust, irritability, depression, isolation, poor concentration, or a deterioration of the immune system than non-migrants (García & Panhofer, 2019 ). To be a migrant is to live daily with significant vulnerability and uncertainty about the present and the future. There is a sense of anguish connected to the lack of a sense of belonging, of not finding a home anywhere, feeling disconnected from both the past and the present, and not knowing what will become of the future (Aranda et al., 2020 ). Therefore, migrants often accept precarious jobs and are willing to take risks to fit into the new social reality. According to a report on the social integration of the immigrant population in Spain in 2020, 73 out of every 100 employed migrants fall outside the Social Employment Standard (ESS). Moreover, migrant women suffer more intensely than men from job insecurity and devaluation. This greater precariousness is related to asymmetrical gender patterns that have a decisive influence on the institutional organisation of the labour market in Spain, producing worse working conditions for women in general, and for migrant women, in particular (Iglesias et al., 2020 ).

The Dance/Movement Therapy Sessions

First approach.

As a general characterization of the seven women who participated in the DMT group, three had left their country for economic reasons, two to reunite with family, and the youngest two, to change their lives. Currently, most of them live with a relative (daughter, sister, mother); the two youngest live in shared flats, and another in a foundation for non-profit organization for women.

As migrants, they commented that the greatest difficulties they face are finding a job that meets their basic needs, especially for those who do not have a resident permit. They also mentioned racism as a problem that increases the difficulties of living together in a community with a different culture. During the DMT process, there was also evidence of the grief and a sense of being uprooted, reflected in the drawings made by participants in which they represented themselves without feet, with light and almost imperceptible strokes. Emigrating involves the elaboration of mourning, migratory mourning, understood as the process of reorganisation of the personality that occurs when something significant for the subject is lost: their origin (Aranda et al., 2020 ).

Thus, the issue of identity appears, expressed as belonging to more than one place or not fitting into any of them. Despite this, participants have identified resources to cope with their difficulties. There are support networks and other tools that help them to be more resilient. Resilience is oriented to overcome difficulties and continue, connecting to those motivations that give meaning to their existence and keep hope alive (Wengrower, 2015 ).

Group Process

Group members moved within small kinesphere during sessions, inhabiting the middle level, which means that participants’ feet were on the ground, their knees were extended, and their gaze was forward. The participants hesitantly explored the limits of space and their bodies and preferred not to close their eyes. Their expressions were shy and superficial, with contained flow and reduced movements. There was stillness and difficulty in expressing themselves both in words and movement. A sense of restraint predominated, related to the previously mentioned closed-body expressions. In the somatic countertransference, this translates into a feeling of insecurity that presses on my body and contains energy that wants to get out but cannot find its way.

I felt a contained flow very present (…) this restricted flow, with these limits/weights/enclosures that suffocate, that immobilise, that do not allow the free exploration of the emotion and the visceral, of the most animal thing that we carry with us. Even in me, many times, compressed air in my sternum does not push the diaphragm that does not reach my centre. (Extract Researcher’s Reflective Diary, 24/03/2022).

We refer here to the framework of flow efforts as outlined by Laban ( 1984 ), who defines efforts as the inner impulses that are the origin of movement. These efforts are the external expression of the dancer’s inner vital energy, which can inspire the moods that accompany the movement, which is fundamental in the experience and expression of emotions. For example, a bounded flow often corresponds to inhibition, discontinuity, and danger-related emotions. In contrast, free flow corresponds to impulse facilitation, continuity and emotions which are usually related to a sense of freedom and safety (Loman & Sossin, 2013 ).

Furthermore, there was an instability in attendance, and three participants dropped out of the group process. This uncertain dynamic made it difficult to consolidate the group and sustain each session. Footnote 2 As the process progressed, participants’ explicit needs emerged, such as strengthening their support networks, relating to other women, changing routines, moving, and expressing emotions, being cared for, and feeling affection. In their non-verbal expressions, it was also perceived a need to heal and soothe, be listened to, be held, have safe spaces to release their flow, and allow themselves to open and let go.

In response to this, the group worked each session with a Chace structure: warm-up, theme development and closure (Levy, 1988 ), creating a routine that allowed for greater trust in the space. After each session, they expressed feelings of well-being and, above all, felt listened to, welcomed and able to share in a safe environment. In other words, they felt recognised as who they were, making possible the creation of a shared scenario based on unity and cooperation.

Over the sessions, Castellanos-Montenegro perceived changes in their range of movement as the group became more open, and they made new proposals to expand their bodies in different directions. There was also greater autonomy in the relationship and moments of integration of the experience. For example, one participant who used to draw her body as incomplete started to paint a full and more organic body. The relationship between participants was also strengthened. The role of social interaction was crucial in the process of integration. It is through social contacts and the climate created by the possibility of such contacts that people develop a sense of belonging in a particular social space (Rudiger & Spencer, 2003 ).

Towards the end of the process, the participants described the experience as positive. They concluded that they learned to relax, to be more open, to get to know each other and themselves better, to cooperate and realised that it is possible to learn and grow in a group, in a supportive environment. They also recognised how, through movement, it is easier to process and integrate emotions. We could also witness how they released the flow, allowing them to trust and relate to each other safely.

The Experience of Coexistence, Trust, and Empathy

As the participants interacted with each other, relationships based on complicity, respect and affection were created. They also did constant teamwork during the proposals, being aware of their differences and accepting them. They defined coexistence as the possibility of living together, knowing that everything is linked and that they are part of the same diverse unit.

Regarding trust, participants associated it with a feeling of security. For them, trust is a feeling of confidence in themselves and all the people around them. It is the conviction that everything is as it should be, being certain that there will be respect and confidentiality in human relations. In the group, trust was achieved through constant interaction and getting to know each other increasingly. Repeating the structure, creating routines, and proposing games in which the women felt they could trust each other. This trust-building was also made possible by establishing a safe place to express themselves and share their experiences with people in similar circumstances. Thus, participating in this DMT process enabled them, through movement, drawing and speaking, to establish a secure basis of trust (Hills de Zárate, 2012) from which a respectful and caring bonding process could take place.

As for empathy, the participants see it as the ability to put oneself through what another person is going through. It is seeing the other person as part of us and trying to feel what the other person feels. In that way, it also offers comfort and trust.

When asked about their experience regarding these three concepts, the participants agreed that they felt both trust and empathy and therefore felt that they were in a safe place where they could live with each other. In their words, they empathised with each other, got along well, were together, and created the group. They shared pleasant moments, knew their limitations, and yet motivated each other. They did what they could and expressed their feelings through music, dance, play and walking with different people.

Trust, empathy, and coexistence have been part of the group since day one. There has been, or rather, a space created and maintained where we can share what we want because we feel trust. The way we interact is empathetic (we listen, we smile), and we have been coexisting every day of the meeting. (Interview 7.2 MA).

Reconciliation is a key element in creating societies with better mental health (Alzate & Dono, 2017 ), just as Dance/Movement Therapy is presented as a useful working tool to promote human well-being among migrants, prioritising mental health by reducing symptoms such as depression, isolation, and anxiety (García & Panhofer, 2019 ). Furthermore, working from DMT with people and communities whose ties have been disrupted by some circumstance implies restoring relationships and promoting a process of reconciliation both internally and interpersonally.

The key aspects of social reconciliation, which are mutual recognition, acceptance and the development of peaceful relationships, trust, empathic experience, sensitivity and respect for the needs and interests of the other party (Alzate et al., 2015 ), are at the same time the basic principles of a DMT process, in which the emphasis is on the interpersonal and subjective connotations of emotions; sharing the objective of removing the barriers that block the way to rebuild a community.

This possible contribution of DMT to social reconciliation could be evidenced, among other things, in the participants’ liberation of the flow effort. This hypothesis arises from what was experienced during the DMT group process, where the contained flow of the participants reflected a restricted, controlled, restrained and tense image of movement. According to Rudolph Laban, there are four motion factors -efforts- common in each movement: Space, Time, Weight, and Flow. This last one is connected to continuity, emotions, control, and breathing (Laban, 1987 ); so, we could say that this effort of contained flow is the bodily expression of the participant’s emotional state and how the migration phenomenon is embedded in their realities. Therefore, releasing the flow was possible as we worked on the consolidation of a safe space, trusting relationships, empathic communication, and respect. In other words, the movement and presence of the participants were more fluid and lighter when working on the aspects of a reconciliation process. This phenomenon raises new questions and research interests around the premise that a free/released flow effort becomes possible when people feel reconciled with themselves, the space, and the people around them. Furthermore, this hypothesis arises from the observation of bodies and non-verbal language supported with the videos recorded. Once the process finished, the videos showed a systematic oscillation between expressions of a body with bound flow, close shape, heavy weight, hesitation, and slowness on one hand, and the need of opening the gaze and the movements, of expanding, growing, shaping, resting, and liberating on the other hand. In fact, it is during one of these moments when the researcher-therapist had an insight around the flow, remembering a past bodily memory:

The image that I worked in theatre (me on the water, keeping my balance while practicing windsurfing), I was not letting it flow because I was contained, tight, in tension, and that is not the feeling of really being on the waves out in the sea. There is a grounding work that implies firmness, direction, and focus, but this does not have to translate into containment (…) Free flow is also (perhaps, and above all it is) internal. The pleasant sensation I remember from windsurfing, rather than firm weight, direct space, and sustained time, is free flow. Feeling the rippling of the water inside me, fluidly coursing through my veins, driving my movement. (Extract Researcher’s Reflective Diary, 24/03/2022).

The videos gave the researcher-therapist a record of her own movement, which testified to her process of tuning in with the bodily expression of participants while connecting, from her own experience, with their feelings, states, and dispositions. The above ratifies the importance of facilitating expression through alternative languages that stimulate the different senses because when the body participates in the process, the narrative is complemented and enriched, giving rise to new dimensions of the experience (Centro Nacional de Memoria Histórica & Fundación Prolongar, 2017 ).

A link between reconciliation principles and Yalom’s’ therapeutic factors was also seen. This DMT group experience was a psychotherapeutic process in which Group Cohesiveness, Universality, Catharsis, Self-Understanding, Interpersonal Learning Inputs and Outputs, among others were developed (Yalom, 2005 ). These factors imply the creation of relationships based on co-existence, trust, and empathy. This reinforces the purpose of developing DMT interventions oriented to social reconciliation processes, with a practical but also theoretical basis about linkages between these concepts.

Another reflection is the necessity to build our work with an intersectional perspective. Likewise, migration cannot be defined as a monolithic phenomenon. Factors like class, citizenship, ability, age, race, sexual orientation, gender, religion, among others, affect the way we see and interpret the world around us, but also how the world sees and interprets us (Jacobson & Mustafa, 2019 ). Therefore, migration -as other social phenomenon- is based on complexity of political, cultural, economic, and historical contexts. Working with women from Latin-American countries is different from working with women from Spain, or any other region. There are substantial differences between a 24-year-old woman who came here looking for better life options and a 64-year-old woman who migrated to take care of her grandchildren. So, even when there are rich gains in a female gender multi-aged experience, there is also a responsibility to have a differential framework that recognises each reality and allows an accompaniment without causing damage, re-victimisation, or invisibility with our actions.

Finally, we want to make visible the figure of the space that arises from the participants’ non-attendance at the sessions.

I ask them how they feel with so many empty chairs. We talk about the emptiness that produces sadness but also understanding because, at some point, they have been the ones to leave the chairs empty ... one of the women comments how in breathing exercises, it is more difficult for her the act of holding when she is without air and empty- than when she has air and full . (Extract Researcher’s Reflective Diary, 12/05/2022).

What emerges with this image is the conclusion reached by the participants. Holding a group and engaging is more difficult when there are empty chairs, and the absence is more tangible than when people are present. Holding ‘emptiness’ is more difficult than holding’ fullness.’ In other words, it is in the power of the group that community is built and, therefore, being in community makes possible the creation of conditions and social agreements based on human dignity and peaceful relationships.

Conclusions and Recommendations

Following Lederach’s invitation, we want to assume the construction of peace as the opening of spaces to recompose human relationships (Leredach, 1997 ). This, added to the potentially transformative capacity of the body, leads to a work proposal in which one’s own embodied experiences can be communicated and become known through creative processes and psychosocial accompaniment as offered by dance/movement therapy. Therefore, once the experience of the group process is over, the present research reaffirms DMT as a constructive approach in the support of migrants and, in a more general way, this exploration underscores the potential applicability of DMT in various social reconciliation and peacebuilding processes, due to it being intimately connected with the constant revision and construction of our relational intersubjective reality.

Hence, integrating dance/movement therapy into existing structures and institutional frameworks for migrants, including psychosocial support programs and first reception processes, appears not only fitting but also potentially impactful. This approach could yield valuable outcomes, as DMT is a proposal for the configuration of a form of citizenship based on trust, empathy, and human coexistence, that contributes to the creation of presents and futures where life becomes possible, which is the main purpose of social reconciliation.

Limitations

This research took place in Barcelona with migrant women who were participants of the host organization. They did not know each other prior to joining the group, so they did not share any type of previous experiences together. In this sense, it is not possible to say that they reconstructed their social relationships broken by violent conflicts, or they reconciled with each other after a shared disruptive experience. Nevertheless, the results of the DMT process shows how it was possible to work around the key factors of a social reconciliation process, according to the literature review. Furthermore, this research posed new questions on social reconciliation theories and how they could be understood in the context of people who have migrated. Regarding this experience, it is revealed the need of talking about the role of host communities and the need of also having a conciliation process, oriented to build new scenarios that did not exist before. Future research would focus on further broadening the concept of social reconciliation beyond national borders, and on proposing dance/movement therapy experiences with heterogeneous groups that include migrants and host communities. As well as in contexts of chronic violence between antagonist parts who are in conflict, to explore how trust, empathy, and coexistence processes could be built and extended as a contribution to social reconciliation processes which are priority in some socio-political and communitarian scenarios.

The kinesphere is the imaginary bubble that surrounds our body and our movements. It is the space used around the body by the limbs, whether standing still or moving (Ros, 2008 ). Is the sum of all the points and forms a volumetric area inside which the body moves (Queyquep, 2013 ).

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Castellanos-Montenegro, C.S., de Zárate, M.H. Exploring the Concept of Social Reconciliation Through the Experience of a Dance/Movement Therapy Group of Migrant Women in Spain. Am J Dance Ther (2024). https://doi.org/10.1007/s10465-024-09402-2

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What Is Dance Movement Therapy (& Can It Really Help with Anxiety and Depression)?

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When it comes to therapy , we often envision sitting down with a therapist—maybe over Zoom, perhaps in a cozy office—to work through the challenges we’re facing. But what if you incorporated movement into the session? Enter dance/movement therapy (DMT), a practice that uses a more holistic approach to mental wellness that focuses on the integration of the physical being with the emotions. The practice can be used to help treat a variety of diagnoses, such as trauma, depression , autism , eating disorders and psychosis. We spoke with two therapists about what it is, who it’s for, the conditions that it can help manage and the benefits of participating in the practice.

Meet the Experts

7 Life-Changing Lessons I Learned After 20 Years in Therapy

What Is Dance/Movement Therapy (DMT)?

According to the American Dance Therapy Association , dance/movement therapy can be defined “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.” Sterling likes to describe it more as therapy that takes the entire individual into account. 

“We’ll talk, but we’ll also get curious about what’s happening in your body and the ways we can use your body as a resource for emotional expression, emotional regulation and healing,” she says.

Hornthal adds that DMT is “a somatic psychotherapy that focuses on all communication, including nonverbal, as well as body awareness, mindfulness and verbal processing as it emerges in the therapeutic relationship.”

DMT can be beneficial to anyone wanting to take a holistic approach to therapy, with Sterling noting that it can be effective for various ages and diagnoses, from depression to autism and dementia.

Dance vs. Dance/Movement Therapy: How Are They Different?

This isn’t your average dance class, where you come to learn the choreography for a tap or jazz sequence. Instead, DMT sessions focus on organic movement and movement patterns that support a person’s emotional regulation and behavior change. Sessions are always facilitated by a registered and/or board-certified therapist, shares Sterling. There are also regulations: Practitioners must abide by state counseling laws and a professional code of ethics.

“It considers the individual’s cognitive, emotional, spiritual and physical abilities and needs regarding mental and emotional wellbeing,” Hornthal elaborates. “DMTs are trained to work with a myriad of mental health diagnoses as well as provide therapeutic movement goals designed to support mental health. Therapeutic techniques include but are not limited to kinesthetic empathy, mirroring, attuning to the client’s psychosomatic symptoms, rhythmic body movement, improvisation, play and guided movement interventions designed to regulate the nervous system and widen the individual's emotional window of tolerance.”

Sterling goes on to add that there is an emphasis on mindfulness in DMT. “We pay attention to breathing and other involuntary movements and rhythms in the body, like the beat of our hearts. There may also be opportunities to use movement (big, small and in between) to express emotions. For example, how might you demonstrate anger with your hands, feet or whole body?”

What Conditions Can Dance/Movement Therapy Help With?

Hornthal and Sterling note that DMT can be effective in helping to manage a variety of conditions, including, but not limited to:

“We work with the body using a spectrum of movement—from metabolic movement to tone, reflexes, motor planning, non-verbal communication and creative movement,” Sterling says. “Addressing each of these aspects allows dance/movement therapists to impact different systems in the body. We invite clients to speak and notice thoughts, like other forms of therapy, but we're also making the connection between the brain and the body which allows us to get to the root cause of behavior patterns and support the folks we work with in creating sustainable changes and/or move toward sustainable healing and recovery.”

Benefits of Dance/Movement Therapy

DMT marries physical and mental wellness by inviting practitioners to engage with physiological processes that might not be explored in other types of therapy, Sterling says. Doing DMT can help you understand how your body is responding to your environment, which can reveal the impact it has on your behavioral patterns. Sterling also notes that it has been shown to improve mood, support positive body image, increase feelings of vitality, coordination and mobility and reduce stress.

Hornthal adds that other benefits can include increased self-identity, awareness and confidence, enhanced resilience, compassion and better body awareness.

How to Access Dance/Movement Therapy

Like other types of therapy, DMT is offered in one-on-one settings but is also frequently done in groups. To find a registered, board-certified therapist, Sterling suggests looking through the directory on the American Dance Therapy website . There, you can filter results to find therapists by specialization, which range from eating disorders to autism and palliative care.

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Dance/Movement Therapy: A Whole Person Approach to Working with Trauma and Building Resilience

Ilene a. serlin.

Union Street Health Associates, 2084 Union Street, San Francisco, CA 94123 USA

This paper explores the use of dance/movement therapy, as a Whole Person approach to working with trauma and building resilience, to effect individual and community change around the world. The arts are a particularly effective way for people who cannot express themselves verbally to find symbolic and embodied expression of their suffering and hopes for the future. Dance/movement therapy can draw on folk dance and specific cultural forms to address universal themes. The content of this paper was presented as a workshop at the American Dance Therapy Association convention in San Diego, 2015.

Introduction: How Does Art Heal?

The arts heal from the basic human need to create, communicate, create coherence, and symbolize. They are symbolic representations of human experience, usually visual, kinesthetic (dance), verbal (poetry), or musical (song, music). They are transcultural, expressing archetypal symbols that are universal throughout history and across cultures. In an age of increased interconnectedness, we are challenged by natural and manmade disasters from around the globe. The clash of cultures brings misunderstandings and conflict. The arts can “help us search again not only for the meaning of life but also the purpose of our individual and collective experience…for ways we might re-create ourselves anew as a human species, so that we may end at last the cycle of violence that has marred our history “(Walsh, 2001 , p. 17).

The arts provide symbolic nonverbal ways to work with unspeakable trauma, natural and manmade disasters, dislocation and caregiver burnout. Building on creativity, they facilitate posttraumatic growth (Tedeschi & Calhoun, 1996 ; Serlin & Cannon 2004 ), growth through adversity (Joseph & Linley, 2008 ), hardiness (Maddi & Hightower, 1999 ), optimism and resilience (Antonovsky, 1979 ; Epel et al, 1998 ) and self-efficacy. Used to build resiliency in a Whole Person context (Serlin, 2007a , 2010a , b , c ), they bring together body, speech, mind and spirit.

The arts heal by improving immune functioning and reducing stress and health complaints, and help people live longer (Pennebaker, 1990 ). Increasingly, studies have demonstrated the relationship between stress and the body, including the relationship between negative emotions and the fight/flight response, cortisol levels, hypertension and Type A personalities (Babette, 2006 ; Schore, 1994 ). Positive emotions also impact wellness including hope, curiosity, and a positive expectation about the future. Finally, stress is not the same for all people, but is individually and subjectively mediated by perceptions, beliefs and cognitions (Serlin, 2006 a).

The arts provide access to multiple modes of intelligence (Gardner, 1982 ), thinking, communicating, and problem solving (Briere & Spinazzola, 2005 ), connecting us to the imagination (McNiff, 1981 ), and bridging the conscious and the unconscious. They take us into expanded states of consciousness, helping us understand our waking reality, mindfulness, altered states and dreamtime. And, in many cultures, art takes us into the realm of ritual and the sacred (Graham-Pole, 1997 ; Marcow Speiser, 1995 , 1998 ; Marcow Speiser and Speiser, 2005 , 2007 ; Serlin, 1993 , 1996a , 2012a ; Sonke-Henderson, 2007 ). Facilitating creativity, compassion and connectedness, new contexts and new frames of reference, the arts help each person to discover his or her personal strengths and preferred channel of communication (Carey, 2006 ; Haen, 2009 ; Harris, 2007 ; Levine, 2009 ; Serlin, 2007b , 2010a ).

Stories of death and rebirth descend into sadness and ascend to joy. Disconnection and reconnection are ancient themes reflected in the myths common to all humankind (Serlin, 1993 ). With the courage to create (May, 1975 ), new narratives move the self from deconstruction to reconstruction (Feinstein & Krippner, 1988 ; Gergen, 1991 ; McAdams et al, 1997 ; Sarbin, 1986 ). These healing narratives are experienced as coherent and meaningful and have been gaining attention in many areas of clinical practice, including family therapy (Epston & White,  1992 ; Howard, 1991 ; Lieblich & Josselson, 1997 ; Omer & Alon, 1997 ; Polkinghorne, 1988 ). The act of telling stories has always helped humans deal with the threat of nonbeing, and sometimes the expressive act itself has a healing effect (Pennebaker, 1990 ; Serlin, 2012a , b , c ). It expresses not only the individual person, but also the collective unconscious and universal states of the human condition (Jung, 1966 ).

Art heals by helping us transcend our stuck places and imagine a future or a different situation. The arts are used in rituals around the world for individual and communal healing. Spiritually based rituals have been shown to be effective coping strategies for dealing with life stresses (Pargament, 1997 ; Marcow Speiser, 1995 , 1998 ) and serious trauma (Frankl, 1959 ). Art opens doors to the religious and spiritual dimensions of human nature and human fate, which are ultimate questions that are central to an integrative whole person healthcare (Sue, Bingham, Porche-Burke, & Vasquez, 1999 ).

Art helps us create in the face of these ultimate questions. Rollo May reminds us that the creative act is a courageous affirmation of life in face of the void of death (Maslow, 1962 ; May, 1975 ; Serlin & Hansen, 2015 ). Trauma brings a confrontation with mortality that can lead to the creation of a new identity, sense of meaning, beliefs, existential choice and a renewed will to live (Serlin, 2002 ; Stolorow, 2007 ). Through art, through the telling and re-telling of their stories, people can rediscover meaning, gain a sense of efficacy and re-create themselves (Paulson & Krippner, 2007 ; Yalom, 1980 ).

From Destruction to Reconstruction: The Path of Resilience

What is resilience? Resilience is the capacity to bounce back after stress and trauma, to rebuild a life even after devastating tragedy. Being resilient doesn’t mean going through life without experiencing stress and pain. Grief, sadness, and pain are natural after adversity and loss (Herman, 1992 ). The road to resilience lies in working through the emotions and effects of stress and painful events and learning from them. Reflecting on adversity can increase a sense of meaning, purpose and compassion in life. Meeting challenges with creativity can widen horizons and possibilities.

Resiliency includes many dimensions. The arts and narrative methods express and record life stories (Gergen, 1991 ; May, 1975 , 1989; Sarbin, 1986 ) and facilitate healing (Pennebaker, 1990 ) within a community of witnesses (Marcow Speiser, 2014 ). Qualities that build resiliency include optimism, joy and compassion. The use of the arts and particularly dance/movement, builds resilience at the body level.

What brings resiliency? Resiliency grows with enhanced self-management skills and more wisdom. It is helped by supportive relationships with parents, peers and others, as well as through cultural beliefs and spiritual traditions. Developed across the lifespan, resiliency is marked by close relationship with family and friends, a positive view of oneself and confidence in one’s strengths and abilities, the ability to manage strong feelings and impulses, and good problem-solving and communication skills. Additionally, the ability to seek help and find resources, seeing oneself as resilient rather than as a victim, coping with stress in healthy ways and avoiding harmful coping strategies, helping others, and finding positive meaning in life despite difficult or traumatic events is helpful.

Domains of Resiliency

For an online support group used in workshops in Silicon Valley and with youth groups for high school students going into healthcare professions, Dr. Laleh Shahidi, Dan Esbensen and this author developed the following four domains of resiliency as composite descriptions from many definitions of resiliency ( www.selfresiliency.com ) :

Kinaesthetic intelligence includes the ability to keep one’s balance, to clarify boundaries, to read the messages from one’s body, to take stretch breaks while working, and to be aware of one’s nonverbal communication to others.

Psychological

From a cognitive perspective, resiliency means the ability to see the glass as half full, and to know deeply who one is. From an emotional perspective, it means the ability to support and love oneself, to be able to self-soothe and self-regulate, and to feel and express one’s emotions.

The social domain of resiliency includes the relational ability of forming and sustaining attachments, enjoying satisfying intimate relationships, and creating a healthy support system. Also included are the environmental aspects of respecting and enjoying nature and one’s community.

Meaning and Purpose

The existential aspect of meaning and purpose includes the ability to confront mortality and to live a life of commitment and authenticity. The spiritual aspect can mean having a “calling”, and a sense of meaning and belonging larger than oneself. The transcendent aspect is the ability to feel at home in the universe (Serlin, 2010 , summer).

Resilience from a Whole Person Perspective

A Whole Person (Serlin, 2001 –2002, 2007a , b , c ) perspective on resiliency brings together mind, body and spirit in an integrated healthcare model with a focus on meaning and purpose, wellness, strengths, creativity and humor.

Whole Person Healthcare is built on a new vision of a fully-actualizing person first articulated by Abraham Maslow, former president of APA: “There is now emerging over the horizon a new conception of human sickness and of human health…Perhaps we shall soon be able to use as our guide and model the fully growing and self-fulfilling human being, the one in whom all his potentialities are coming to full development, the one whose inner nature expresses itself freely.” In 2001, the American Psychological Association added “health” to its mission statement, and this author convened a panel at the APA convention on the subject (De Leon et al, 1998 ). In 2004, she was part of an APA Task Force on Health Care for the Whole Person, and in 2006 part of one from Division 42 of APA. The question of what it means to be human can be understood from the Humanistic Psychology perspective on identity, beliefs, and existential issues; from the creative arts therapy perspective of imagery, art, dance music drama, poetry, and journaling; from a somatic psychology perspective including qigong, tai chi, aikido, Feldenkrais, movement, EMDR, EFT and yoga, and a spiritual perspective that includes meditation, mindfulness awareness, stress reduction and prayer.

A Whole Person psychotherapy embraces diverse approaches that include non-verbal and multi-modal modalities such as expressive therapies and mindfulness meditation (Shapiro & Walsh, 1984 ), cultural beliefs about living and dying (Sue et al, 1999 ), opening healthcare to diverse, disabled, and marginalized populations. A Whole Person model offers new ways of cultivating resourcefulness and nurturing a growth mindset.

Whole Person approaches to psychotherapy include: can be grouped into three areas: (1) Meditation or mindfulness (Shapiro & Walsh, 1984 ); (2) Imagery including guided imagery, KinAesthetic imagery (Serlin, 1996 ), and verbal imagery (Serlin, Rockefeller & Fox, 2007 ); (3) Movement including dance movement therapy (Serlin, 2010a , b , c ), qigong, yoga, Feldenkrais, Alexander, and somatic therapies.

Movement is a whole person approach that helps clarify and release the stress, countertransference and burnout carried by both caregiver and the person in need of care. The kind of approach used by this author is a process of dance/movement therapy called Kinaesthetic Imagining. Kinaesthetic imagery comes from the Greek word “kinaesthesia” (Gr.), the sensations and expressions arising from bodily movement that become a nonverbal expressive text (Serlin, 1996 ). By learning to listen to our bodily signals, we can understand better how to care for ourselves and others. Kinaesthetic Imagery has three basic components: Warm-up and check-in, using breath, sound, stretching and circle dance movements to warm up the body and mobilize the healing energies; Body Language includes the development of the themes to explore images and emotions that arise from the movement, individually, in dyads, and in the group so that participants have an opportunity to develop their own personal healing images, stories, and mythologies; and Reflection (Action Hermeneutics) as a time to wind down, internalize the imagery, and reflect on its meaning in order to make a transition into real life.

Posttraumatic Growth

Without a bit of sadness a beautiful samba cannot be made (Vinicius de Morais & Baden Powell)

The concept of resilience is closely tied to a new theory called Posttraumatic growth (PTG) (Calhoun & Tedeschi, 2006 ). Instead of focusing on restoring personal and communal functioning to premorbid levels of functioning, as is done in traditional trauma recovery, the theory of posttraumatic growth suggests that from the break-down of trauma can come break-through, and that further growth is possible (Lev-Weisel & Amir, 2006 ; Rosner & Poswell, 2006 ).

Reflecting on the fact that posttraumatic growth might seem too positive, Stephen Joseph and Alex Linley from proposed a theory called “Growth Following Adversity” ( 2008 ). Proponents of this theory value the learning that comes from adversity and bring this dimension into the therapy.

Both Posttraumatic Growth and Growth following Adversity support an approach that builds resiliency by going through stages of destruction to reconstruction. The arts have an important role to play here as they help people re-imagine and re-energize their lives.

Secondary Trauma

The arts can also play a large role to help with secondary trauma; the trauma that caregivers experience after prolonged exhaustion from caregiving. Caregivers also experience what psychologist Charles Figley called “compassion fatigue” ( 1995 ). Even in non-combat situations such as families living with elders who have dementia or Alzheimer’s, these caregivers need help. The arts can facilitate resilience, self-care, care-giver satisfaction and compassion regeneration from a whole person relational and client-centered perspective. This toolkit, that includes mindfulness, imagery and movement, was developed by the author to help caregivers with a form of burnout called “Compassion Fatigue” (Serlin, 2012b ) (Fig.  1 ).

Compassion fatigue and regeneration

Whole Person Approaches to Trauma and PTSD

Whole Person approaches to working with trauma and building resilience include all dimensions: existential, embodied, creative and mindful. Recent research tells us that trauma is in the body (Levine, 1997 ; Ogden et al, 2006 ). Trauma has been called by Bessel Van der Kolk “speechless terror;” therefore, approaches need to utilize nonverbal, symbolic methods (Van der Kolk, 2014 ; Serlin, 2015 ). Trauma is a crisis of mortality, meaning and identity; therefore, approaches need to cover existential and spiritual perspectives. Trauma is about “stuckness” and “numbness” and the inability to play; therefore, approaches that are creative, imaginal, moving and emotional are important. Finally, trauma is about fragmentation; therefore, approaches that support connection, integration and transitions can be helpful.

Resilience in Regional Contexts

These tools of arts have been brought into the American Psychological Association to help psychologists develop better self-care. Last year, a collaboration between the San Francisco and the Los Angeles Psychological Association explored the role of the arts in self-care (Fig.  2 ).

Dance therapy, creativity, and self-care workshop

Global Applications of Trauma and Resilience

In Israel, this author did workshops with staff on resiliency and learned from site visits to Natal, Israeli Trauma Center for Victims of Terror and War; SELAH, Israeli Crisis Management Center; the Casualty Division of the Israeli Defense Forces (IDF), and The Israel Center for the Treatment of Psychotrauma (ICTP). All of these use Whole Person approaches, including the arts and movement (Serlin, 2006b , 2007a , 2014 ). Pathways to resiliency developed at Selah include control, commitment, challenge, connectedness, courage, compassion, confidence, contribution, and creativity (Pardess, 2004 , 2005 ). Below is a photo of a session at SELAH, a culturally sensitive trauma center that specializes in the needs of Ethiopian and Ukrainian immigrants.

For a workshop with the caregivers (Casualty Division) of the Israeli Defense Forces (IDF), we worked with young officers whose movements and drawings reflected their level of stress (Fig.  3 ).

Calm on the outside, chaos inside. When the mess is inside it’s difficult to see

The stresses included losses such as loss of innocence, missing their own beds at home, and loss of what made them feel “human and whole.”

Casualty division of the Israeli defense forces

In Natal, the Israel Trauma Center for Victims of Terror and War, we used movement and art to work with staff at the center to help them with burnout (Fig.  4 )

Natal: training staff

One participant’s drawing was called: The Tree of Life, White Bird. In her description, she said: “I really enjoyed the movement to let go a little, the passing from the floor felt good, the tree turned into a White Bird.”

In 2006, during the war in Lebanon, an extraordinary conference was organized by Lesley University called “Imagine: Expression in the Service of Humanity.” There, Israeli, Palestinian and Bedouin caregivers presented and co-presented their work on the ground caring for the wounded in an intercultural exchange (Serlin & Speiser, 2007 ) (Fig.  5 ).

Imagine: Expression in the service of humanity

We explored the use of movement to amplify dreams as a way to work with trauma. The following words were written by an Israeli student during the 2006 war in Lebanon:

The State of Israel—war in the north—I had a dream; I dreamt I lose all that is nearest to me, Arabs seize my home and take it under their control, into my sister’s kindergarten bursts a strange man who proceeds to pack all the children’s belongings into boxes; in one box he places all the childrens’ handiwork of butterflies.

One small room, Lots of boxes One box, Lots of butterflies A struggle The man closes the box A woman tries to open it The butterflies in the box struggle to fly and be freed of the box…. One small room…. lots of boxes…

She recited the dream as the class was in a relaxation state, receptive to the images arising from the bodily sensations and the words. As she chanted and walked around the room, the class began to move around her. They draped themselves in fabric, slowly moving around the room, creating a dreamlike atmosphere.

Describing this class, the student wrote:

By means of the movement, by means of my participation in the movement therapy course, I searched for the center part of my body and equilibrium: within my emotions, movement and thoughts… what is the center of me or what is the place from which my movements evolve, from where come the things I say; I felt that words and movements are connected as if they are one; sometimes there was no need for words to understand about others or what I do… Due to its processes we are able to turn our attention to another, to “feel” him, to touch him and enable him to touch us emotionally, spiritually and even physically…The amazing bond was between the personal dream and the group dream, in which each one could be in a place of her choice… It was wonderful how group members supported each other; joining together without words and I, in the background, used the words as mantra, repeating the words that strengthened the support of the group’s physical movements. ..Upon my observation of the others’ support, I felt I was floating with the mantra that I had created for the group and myself; finally, I too, once a captive within, was freed…I felt that the dream told the story of the little spirits of the entire group and the butterflies in the box desiring to fly to freedom are a metaphor of each one of the group members’ hurt spirits. This same hurt spirit of each one that desires to be free from its soul and to feel better, happier in life after the burden is released from its heart. I felt that through the dream and the movement, joint and individual, we had advanced one additional and small step towards our joint task – to reach happiness.

In her paper, the student reflected (Fig.  6 ):

I understood that this connection probably came from my strong unconscious thought of my connection with the Holocaust and the fear that enveloped me during the period of the war that we experienced recently, if so why a butterfly?

In the Lochamei HaGettaot Memorial Museum, a special building in memory of the million and a half children lost in the Holocaust, was built. Engraved on the metal flooring are the words: “There are no butterflies in the Ghetto”… in the museum you lift up your eyes to see a huge stained glass window illuminated by incoming rays of the sun and it depicts a colored butterfly surrounded by flowers. This expresses the memory of the million and a half little spirits lost in the Holocaust; this picture is deeply engraved within me from my visits to the museum and I continually connect the butterfly with a hurt spirit wanting to be freed. Through the experience of our group process I also succeeded in becoming released from the visions of the little children and their spirits in the Holocaust. When I accompany a group of school pupils to Poland this will surely assist me in dealing with the difficult journey. I understood that in the group we had succeeded in sensing the great curative strength that exists in the connection of body and soul.

The butterfly is trapped behind bars the sun illuminates with hope, this is the hope that I found during the war through the experiencing of realization of a dream by means of movement therapy.

Through the process of KinAesthetic Imagining, this student was able to enact a dream image of grief and loss, use group support to develop its themes and feelings, and discover its meaning for her life.

Stained glass window in the roof of the ‘hand-to-hand’ museum, Lochamei HaGettaot

Developing Resilience: Using KinAesthetic Imagining to Explore Lived Experience

Some psychological descriptions of resilience are abstract and don’t convey its lived experience. If we understand the lived experience, perhaps it will be easier to teach skill to develop the capacity for resilience. In classes through Lesley University in Israel, we explored the physicality of resiliency, using rubber bouncing dolls and props, and by sinking down to the floor and rising again in an archetypal pattern of death and rebirth. We experienced the weight of our bodies as we rolled, using the earth for support to rise again. We understood resilience in Laban terms of space, rhythm, and time. We identified four existential elements of regeneration: Death/Rebirth, Down/Up, Dark/Light, and Transitions. Seven elements were related to time: Rhythm, Rest and Renewal, Recuperation, Recovery, Breath and Heartbeat. Eight elements related to space were: In/Out, Big/Small, Boundaries/Borders, Opening/Closing, Yes/No, Here/There, Entrance/Exit, and Coming Home. These elements are related to existential themes of facing mortality, freedom versus constriction, connection and attachment versus disconnection, and meaning expressed as mindful and committed actions in the world (Fig.  7 ).

Developing resiliency

Students co-created final projects based on the existential themes. These themes often brought out deep emotions that were both personal and cultural.

Themes of resilience were similar in other global contexts. For example, in China one group worked with the theme of “Freedom and Fate”. For their project, they staged a re-enactment of Chinese version of Romeo and Juliet. Not only did the music sound different than the traditional Western romantic music, but the ending changed significantly. After both Romeo and Juliet die, they are re-incarnated as butterflies and their whole family flies beautifully away.

In Istanbul, the embodiment of the “Life and Death” theme triggered deep feelings and existential inquiries among group members. Two days after their group performance for the class occurred a tragic event in Turkey, May 13th, 2014: the Soma coalmine disaster where hundreds of workers died. Their class papers wrote about how the “courage to move” could facilitate expression and awareness on a deeper level as a part of the transformation process: “It functions to remind us; keep moving since life is movement and also a never-ending journey of transformation”. One student wrote:

… as I was dancing to the life and death theme, freezing one moment and moving the other.. I realized that when I freeze, I can see only one part of the reality, I couldn’t see the people behind or out of my sight zone..it translates for me, seeing one side of the reality is death!! that death means all my preconceived ideas, judgments, belief systems, attitudes that inhibit me to move ahead, make me stuck…as I shared in our small group ‘we can be dead while we physical are living’ as living deads....

In many ways, their re-enactment of death and rebirth echoed early initiation rituals for women, as expressed in the myth of Inanna’s descent to the underworld, dismemberment and “re”memberment (Perera, 1981 ).

The death and rebirth theme was also the one chosen by Irmgard Bartenieff when she led a group of us in her first movement choir in the US at the ADTA conference in 1976. It is not only a visual archetype (an image of Inanna going to the underworld), but it is an experiential and existential archetype, in this case expressed in the movements of sinking down and rising up.

Another Turkish student wrote:

I am also so deeply touched and feel sorry and terrified about all happened in Soma. Not only the disaster or massacre in many ways, but things that happened afterwards have shaken me a lot, as most others would share. Still I feel the pain for those whose bodies are still locked in that darkness in order to hide and cover the real scope of the event and the attitude towards the community who are not allowed to grieve and express their feelings … There is lot to scream. On, death and rebirth theme now, there is so much death around us…but still need to feel the hope for the rebirth of a new potential life or era.

In Istanbul, we trained healthcare professionals at Safir Institute, a training program that is now at Mimar Sinan University. Students have begun applying The Art of Embodiment training to work in psychiatric hospitals, nursing homes, with breast cancer and hematology units in general hospitals (Fig.  8 ).

Resilience in Istanbul

The training in Beijing took place at the China Institute of Psychology, where students are taking the training back to their hometowns. In Hong Kong, the training took place at the University of Hong Kong in a master’s program in Expressive Therapies at the Centre on Behavioural Health. Masters students in the program work with situations of child abuse, domestic violence, and life-threatening illnesses (Fig.  9 ).

Resilience in Hong Kong

The world is increasingly interconnected, and in need of powerful healing responses to trauma and human suffering. Dance Movement Therapy is one trauma approach that can address this suffering. Reaching across cultures, it can be shared in global training settings.

Ph.D, BC-DMT is a licensed psychologist and registered dance/movement therapist in practice in San Francisco and Marin county. She is the past president of the San Francisco Psychological Association, a Fellow of the American Psychological Association, past-president of the Division of Humanistic Psychology. Ilene Serlin is Associated Distinguished Professor of Psychology at the California Institute of Integral Studies, has taught at Saybrook University, Lesley University, UCLA, the NY Gestalt Institute and the C.G. Jung Institute in Zurich. She is the editor of Whole Person Healthcare (2007, 3 vol., Praeger), over 100 chapters and articles on body, art and psychotherapy, and is on the editorial boards of PsycCritiques , the American Dance Therapy Journal, the Journal of Humanistic Psychology , Arts & Health: An International Journal of Research, Policy and Practice, Journal of Applied Arts and Health, and The Humanistic Psychologist. In 2019, she received the Rollo May award from APA’s Society for Humanistic Studies, and the California Psychological Association Distinguished Humanitarian Contribution award.

Compliance with Ethical Standards

The author declares that the author has no conflict of interest

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