JYVÄSKYLÄ STUDIES IN EDUCATION, PSYCHOLOGY AND SOCIAL RESEARCH

621

Päivi Pylvänäinen

Dance Movement Therapy

in the Treatment of Depression
Change in Body Image and Mood
- A Clinical Practice Based Study
 JYVÄSKYLÄ STUDIES IN EDUCATION, PSYCHOLOGY AND SOCIAL RESEARCH 621

Päivi Pylvänäinen

Dance Movement Therapy

in the Treatment of Depression
Change in Body Image and Mood
- A Clinical Practice Based Study

Esitetään Jyväskylän yliopiston kasvatustieteiden ja psykologian tiedekunnan suostumuksella

julkisesti tarkastettavaksi yliopiston vanhassa juhlasalissa S212
elokuun 7. päivänä 2018 kello 12.

Academic dissertation to be publicly discussed, by permission of

the Faculty of Education and Psychology of the University of Jyväskylä,
in building Seminarium, auditorium S212, on August 7, 2018 at 12 o’clock noon.

UNIVERSITY OF JYVÄSKYLÄ

JYVÄSKYLÄ 2018
 Dance Movement Therapy
in the Treatment of Depression
Change in Body Image and Mood
- A Clinical Practice Based Study
JYVÄSKYLÄ STUDIES IN EDUCATION, PSYCHOLOGY AND SOCIAL RESEARCH 621

Päivi Pylvänäinen

Dance Movement Therapy

in the Treatment of Depression
Change in Body Image and Mood
- A Clinical Practice Based Study

UNIVERSITY OF JYVÄSKYLÄ

JYVÄSKYLÄ 2018
Editors
Noona Kiuru
Department of Psychology, University of Jyväskylä
Ville Korkiakangas
Publishing Unit, University Library of Jyväskylä

Cover picture by Päivi Pylvänäinen and Sari Heikkilä.

Permanent link to this publication: http://urn.fi/URN:ISBN:978-951-39-7503-6

URN:ISBN:978-951-39-7503-6
ISBN 978-951-39-7503-6 (PDF)

ISBN 978-951-39-7502-9 (nid.)

ISSN 0075-4625

Copyright © 2018, by University of Jyväskylä

Jyväskylä University Printing House, Jyväskylä 2018

“We are essentially and fundamentally animate beings. In more specifically dy-
namic terms, we are animate forms who are alive to and in the world, and who,
in being alive to and in the world make sense of it. We do so most fundamental-
ly through movement.” – Sheets-Johnstone, M. (2012)
ABSTRACT

Pylvänäinen, Päivi
Dance movement therapy in the treatment of depression: Change in body
image and mood - A clinical practice based study
Jyväskylä: University of Jyväskylä, 2018, 92 p.
(Jyväskylä Studies in Education, Psychology and Social Research
ISSN 0075-4625; 621)
ISBN 978-951-39-7502-9 (nid.)
ISBN 978-951-39-7503-6 (PDF)

This dissertation includes four studies of the use of dance movement therapy
(DMT) in a group form in the treatment of depression at a psychiatric
outpatient clinic. DMT is based on exploring the embodied experience in the
here and now in the encounter between patient(s), therapist and the
dance/movement. DMT is a method to develop awareness of embodiment. This
dissertation presents data from ten DMT groups, involving 62 patients who
participated in and completed DMT groups during the years 2007-2013 at one
psychiatric outpatient clinic. The age range of the participants was 21-61 years.
To allow comparisons between DMT and treatment as usual (TAU), a control
group of 12 patients was part of the quasi-experimental design in one substudy.
The studies utilised qualitative and quantitative research material. The aim was
to offer interpretations of meanings about the phenomenon of body image and
the particular group of patients with depression in outpatient psychiatric care.
A tri-partite model of body image was applied in this study. It perceives the
body image to consist of the body self, image properties, and body memory. To
assess the body image contents, a verbal Body Image Assessment (BIA) was
developed. Depressed patients’ body image reflects difficulties in intra-personal
and interpersonal relating. Pre- and post-intervention BIA’s showed, that a 12 x
90 mins DMT group treatment produced change for the positive in the body
image of the patients with depression. DMT group treatment also reduced
depressive symptoms. DMT vs. TAU comparison yielded Effect sizes of d = 0.60
– 0.97, depending on a measurement tool (BDI, HADS, SCL-90, CORE-OM), and
in favor of the DMT group. The results of this study support the view that DMT
is beneficial in the treatment of depressed patients. For the individual, DMT
provides tools for creating, enhancing, and maintaining a sufficient sense of
safety in one’s presence and action, and developing flexibility in responding.
This dissertation demonstrates the possibilities for applying movement and
various practices of dance in an interactional process to support the patient’s
wellbeing.

Keywords: dance movement therapy, body image, depression, group therapy,

psychiatric outpatient care
Author’s address Päivi Pylvänäinen
Department of Psychology
PO Box 35
FI-40014 University of Jyväskylä
Paivi.m.pylvanainen@juy.fi
paivi.pylvanainen@tanssiterapia.fi

Supervisors Professor Raimo Lappalainen

Department of Psychology
University of Jyväskylä

Professor Sabine S. Koch

Research Institut for Creative Arts Therapies
Alanus University Alfter/Bonn
SHR University Heidelberg

Professor Vicky Karkou

Faculty of Arts and Sciences
Faculty of Health and Social Care
Edge Hill University

Reviewers Professor Sherry W. Goodill

Department of Creative Arts Therapies
Drexel University

PhD, senior researcher Iris Bräuninger

HfH – University of Applied Sciences of Special Needs
Education
HFH – Institute for Behavior, Socio-Emotional and
Psychomotor Development

Opponent Professor Sherry W. Goodill

Department of Creative Arts Therapies
Drexel University
TIIVISTELMÄ (FINNISH ABSTRACT)

Pylvänäinen, Päivi
Tanssi-liiketerapia masennuksen hoidossa: Muutosta kehonkuvassa ja
mielialassa – Kliiniseen käytäntöön pohjautuva tutkimus
Jyväskylä: University of Jyväskylä, 2018, 92 p.
(Jyväskylä Studies in Education, Psychology and Social Research
ISSN 0075-4625; 621)
ISBN 978-951-39-7502-9 (nid.)
ISBN 978-951-39-7503-6 (PDF)

Väitöskirja koostuu neljästä osatutkimuksesta, joissa on tutkittu tanssi-

liiketerapian (TLT) ryhmämuotoista käyttöä masennuksen hoidossa aikuisten
avomielenterveyspalveluissa. TLT perustuu kehollisen kokemuksen tutkimi-
seen tässä ja nyt hetkessä, vuorovaikutustilanteessa mikä syntyy poti-
laan/potilaiden, terapeutin ja liikkeen välille. TLT on menetelmä, jolla kehittää
tietoisuutta kehollisesta kokemuksesta. Tämä väitöskirja käsittelee kymmenen
TLT-ryhmän kokemuksista karttunutta aineistoa. Yhdessä osatutkimuksessa
tietoa koottiin 21 TLT-ryhmäläisestä sekä 12 potilaan kontrolliryhmästä, joka sai
tavanomaista hoitoa. Kaikkiaan TLT-ryhmiin osallistui 62 potilasta vuosien
2007-2013 aikana erikoissairaanhoidon avomielenterveyspalveluissa. Tutki-
mushenkilöiden ikä oli 21-61 vuotta. Tutkimuksessa käytettiin laadullista ja
määrällistä tutkimusaineistoa. Tavoitteena oli nostaa aineistosta esiin tulkinta
siitä, mitä merkityksiä kehonkuvalla ilmiönä on masennuksesta kärsiville poti-
laille, jotka saavat hoitoa avomielenterveyspalveluissa. Tutkimus sovelsi keho-
kuvan kolmiosaista jäsennystä. Tässä jäsennyksessä kehonkuvan osarakenteiksi
tunnistetaan kehoitseys, olemusseikat sekä kehomuisti. Kehonkuvan sisältöjen
tutkimista varten luotiin haastatteluun pohjautuva kehonkuvakysely (Body
Image Assessment, BIA). Masentuneen potilaan kehonkuva heijastelee vaikeuk-
sia siinä, kuinka on suhteessa itseensä ja kuinka on osallisena vuorovaikutuk-
sessa toisten kanssa. Kehonkuvan alku- ja jälkimittaukset osoittivat, että 12 x 90
min TLT-ryhmäjakso tuotti masennuspotilaille myönteisiä muutoksia kehon-
kuvaan. TLT-ryhmäjakso vähensi myös masennusoireilua. TLT-ryhmäjakson ja
tavanomaisen hoidon vaikutusta vertailtaessa efektikoot vaihtelivat d = 0.60 –
0.97, riippuen mittausvälineestä (BDI, HADS, SCL-90, CORE-OM). Suotuisampi
muutos tapahtui TLT-ryhmiin osallistuneille. Tämän väitöskirjatutkimuksen
tulokset osoittavat, että TLT on hyödyllinen hoitomuoto masennuksesta kärsi-
ville potilaille. Yksilölle TLT tarjoaa keinoja luoda, vahvistaa ja ylläpitää riittä-
vää turvallisuuden tunnetta omassa läsnäolossa ja toiminnassa, sekä kehittää
joustavuutta siinä, miten tilanteisiin vastaa omalla toiminnallaan. Tämä tutki-
mus kuvaa mahdollisuuksia käyttää liikettä ja tanssia vuorovaikutusprosessissa,
joka tukee potilaan hyvinvoinnin vahvistumista.

Asiasanat: tanssi-liiketerapia, kehonkuva, masennus, ryhmäterapia, psykiatrinen

avohoito
PREFACE

My interest in body image begun during my Dance Movement Therapy Mas-

ter’s studies during 1997-1999 in Philadelphia, at MCP Hahnemann/Drexel
University Creative Arts in Therapy program. Having studied DMT for a year
in Finland – the very first Finnish DMT basic course at the Theatre Academy
continuing education center – and having danced since I was a child, it deeply
annoyed me to face the implication, that an image should be so relevant for a
person’s well being. As if one’s reflection in a mirror or the images in photos
would be so essential that improving body image would be a valuable thera-
peutic goal and a desirable therapeutic outcome. In common sense it is under-
standable, that feeling content with what you see in the mirror is better than
feeling discontent with it, but it did not make sense to me, that just seeing the
body’s image would be so crucial. My experiential knowledge, and the readings
on non-verbal communication, developmental psychology, attachment and re-
lational theories pointed to a much richer, deeper, and multi-sensory connect-
edness to one’s own body and between the bodies we encounter in daily life. So,
in my Master’s Thesis I took up this topic, went back to study Schilder, the fa-
ther of the concept of body image. I found out, that he actually was talking
about a much richer sphere of experiences that link ourselves to the body, than
just a mere image. Needing to clarify what he was describing, I organized the
concept in to the tri-partite model of body image. That has been one important
source for this dissertation project.
The years of clinical practice as a psychologist and a dance movement
therapist have strengthended my understanding that safety in moving, safety in
space, and safety in relationships are essential. I want to thank my patients for
the collaboration, which has shaped this understanding. I thank Tampere City
Mental Healths Services, i.e. my bosses Päivi Kiviniemi, Ulla Ilveskoski, and
Eija Stengård, and the colleagues over the years, for welcoming DMT in the
clinical practice. The learnings in dance and movement have been an essential
backbone in my work: I want to thank my dance teachers, particularly Tarja
Sara, Elwa Molin, Leena Gustafson, Marcia Plevin (authentic movement), Yo-
shito Ohno (butoh), and Osku Leinonen (butoh and qigong). In learning about
dance, with you I also learnt about being in life and expressing one-self in life.
Collaborating with my Finnish DMT colleagues has been inspiring, and has
given me boost to complete this long project. I thank my parents, my family,
and my friends. The gentleness and support in life comes often in unexpected
ways, and they do stay with you. In the body.
Dissertation is a project of several years. Thank you for taking on with this,
going through and staying along, my team of supervisors, Raimo Lappalainen,
Vicky Karkou, and Sabine Koch. And with Sabine, I think warmly of our shared
DMT roots at Hahnemann/Drexel University in Philadelphia.

Tampere 08.06.2018
Päivi Pylvänäinen
LIST OF ORIGINAL PUBLICATIONS

I Pylvänäinen, P. (2010). The dance/movement therapy group in a psychi-

atric outpatient clinic: Explorations in body image and interaction. Body,
Movement and Dance in Psychotherapy, 5, 219–230.

II Pylvänäinen, P. (2012). Body memory as a part of the body image. In S. C.

Koch, T. Fuchs, M. Summa, & C. Müller (Eds.), Body, metaphor and move-
ment. Advances in Consciousness Research 84 (pp. 289–306). Amsterdam:
John Benjamins Publishing Company.

III Pylvänäinen, P., Muotka, J., & Lappalainen, R. (2015). A dance move-
ment therapy group for depressed adult patients in a psychiatric outpa-
tient clinic: Effects of the treatment. Frontiers in Psychology, 6:980. doi:
10.3389/fpsyg.2015.00980.

IV Pylvänäinen, P. & Lappalainen, R. (2018). Change in body image among

depressed adult outpatients after a dance movement therapy group
treatment. Arts in Psychotherapy, 59, 34–45.

The author of this thesis is the first author of all the articles. She created the
study design, formulated the research questions, the tri-partite model of body
image, and the related Body Image Assessment. She structured the treatment
interventions and was the facilitator of the DMT-groups. She collected the data
and did the analyses. In study III the collaboration with M. Muotka focused on
statistical analysis with MPlus. R. Lappalainen contributed quality check for the
statistical analyses and provided critical comments, which aided in
communicating the findings more clearly.

This research was supported by the Department of Psychology, University of

Jyväskylä, with a 3-month study grant in 1.1.-31.3.2015.
FIGURES

FIGURE 1 The level of rationale behind the chosen DMT method:

Summary of the literature review on the DMT practice aiming
at treating depression in the context of embodiment. ...................... 34
FIGURE 2 The differences in outcome with-in DMT and TAU groups as
expressed in d values of the change between pre- and post
measurement in the scores of the self-evaluation
questionnaires. ....................................................................................... 53

TABLES

TABLE 1 Compilation of the research on the use of DMT in group

format in the treatment of depression ................................................ 29
TABLE 2 The research questions of this dissertation. ....................................... 38
TABLE 3 Body Image Assessment (BIA) structure ............................................ 43
TABLE 4 Methods summary for the Studies 1-4 ................................................ 46
ABBREVIATIONS

ACC anterior cingulate cortex

BDI Beck Depression Inventory
BIA Body Image Assessment
CADS complex adaptive dynamic system
CBT cognitive behavioral therapy
CORE-OM Clinical Outcomes in Routine Evaluation – Outcome Measure
EADMT European Association Dance Movement Therapy
HADS Hospital Anxiety and Depression Scale
ICD-10 International Statistical Classification of Diseases and Related
Health Problems
DMT dance movement therapy
KELA Kansaneläkelaitos/ National Social Insurance Institution
MUS medically unexplained symptoms
SCL-90 Symptoms Check List -90
TAU treatment as usual
WHO World Health Organization
CONTENTS

ABSTRACT
TIIVISTELMÄ (FINNISH ABSTRACT)
PREFACE
LIST OF ORIGINAL PUBLICATIONS
FIGURES AND TABLES
ABBREVIATIONS
CONTENTS

1 INTRODUCTION .................................................................................................. 13
1.1 Embodiment ............................................................................................... 14
1.2 Depression .................................................................................................. 16
1.2.1 Neuroscientific findings on depression ..................................... 17
1.2.2 Relational problems and depression .......................................... 20
1.2.3 Depression in the view of phenomenologically oriented
psychiatry ....................................................................................... 21
1.3 Body image................................................................................................. 22
1.3.1 Body image in depression ............................................................ 25
1.3.2 Embodied mindfulness ................................................................ 26
1.4 Dance movement therapy (DMT) in the treatment of depression ..... 27
1.4.1 DMT methods in the treatment of depression .......................... 31

2 METHODS .............................................................................................................. 36
2.1 Aims of the research ................................................................................. 36
2.2 Research questions .................................................................................... 38
2.3 Chrystallization ......................................................................................... 39
2.4 Participants................................................................................................. 40
2.5 DMT group treatment .............................................................................. 41
2.6 Data collection tools .................................................................................. 42
2.7 Analysis methods ...................................................................................... 44
2.8 Ethical questions and trustworthiness ................................................... 46

3 OVERVIEW OF THE ORIGINAL STUDIES ...................................................... 48

3.1 Study 1: The dance/movement therapy group in a psychiatric
outpatient clinic......................................................................................... 48
3.2 Study 2: Body memory as a part of body image................................... 50
3.3 Study 3: A dance movement therapy group for depressed adult
outpatients in psychiatric clinic: Effects of the treatment .................. 51
3.4 Study 4: Change in body image among depressed adult
outpatients after a dance movement therapy group treatment ......... 54

4 DISCUSSION .......................................................................................................... 58
4.1 Conclusions answering the research questions .................................... 58
 4.2 The relevant aspects of DMT in the treatment of depression:
Modulating stress, safety, interaction, dialogue, and creativity ........ 61
4.3 Promoting secure attachment qualities promotes change in the
mood ........................................................................................................... 64
4.4 Body image as a tool for understanding depression ........................... 66
4.5 Clinical implications ................................................................................. 68
4.6 Limitations ................................................................................................. 71
4.7 Research aspirations for the future ......................................................... 72

SUMMARY ................................................................................................................... 75

YHTEENVETO (FINNISH SUMMARY) .................................................................. 79

REFERENCES............................................................................................................... 83

ORIGINAL PAPERS
1 INTRODUCTION

This is the first dissertation in Finland related to Dance Movement Therapy

(DMT) and to treating depression with DMT. Dance Movement Therapy is a
creative form of therapy which uses movement and various practices of dance
in an interactional process, which aims to support the client’s or patient’s well-
being and his/her coping with the issues that are identified as the reasons for
the person to seek therapy (EADMT, 2017; Cappello, 2009; Meekums, 2002).
DMT practice in Finland has developed gradually. The earliest explora-
tions of applying dance therapeutically appeared in the 1960’s. First DMT cour-
ses in Finland became available in the mid 1990’s. By the end of the decade
DMT was offered as one specialization in the Bachelor in Social Services trai-
ning in North Carelian Municipal Training Consortium. By the beginning
2000’s, providing DMT training as a professional specialization for profes-
sionals from the suitable fields of social and health care, culture and education
professionals, had started in the Continuing Education Center of the Theatre
Academy. At the present, the structure for DMT training consists of one year
basic course and a 3-year specializing training. The Theatre Academy (Helsinki)
via its continuing education sections and Eino Roiha Institute (Jyväskylä) have
provided these programs. Finnish DMT training echoes the DMT programs in
the Netherlands, the US (Philadelphia), the UK, and Sweden. DMT in Finland is
based on the basic DMT tradition of expressive dance, developmental move-
ment, Laban Movement Analysis, movement interaction, and creativity. In Fin-
land the DMT training has been informed by attachment and object relations
theories, trauma therapy, and cognitive psychotherapy. The tools for body and
movement work have been strengthened by kinesiology and anatomy studies
and by particular movement practices such as Feldenkreis and Authentic Mo-
vement. The Finnish Dance Therapy Association was founded in 2000 as a pro-
fessional association for dance movement therapists. It currently has approxi-
mately 120 members.
This study explores the treatment of depression from the perspective of
DMT. It scrutinises clinical work, perceiving the human situatedness in an
interacting and responsive body. Starting with the concept of embodiment, the
14

symptoms of depression appear in a new light, which offers a new perspective

to the treatment of depression. The goal is to present to the reader, why and
how embodiment is so crucial in human being and in depression, and how
embodiment and depression can be addressed in DMT.

1.1 Embodiment

Embodiment as a concept takes the attention to human embeddedness in a sen-

sing, responding, and active body (Aphosyan, 1999; Foolen, 2012; Tschacher &
Bergomi, 2011; Ziemke, 2016). This is quite a fundamental notion. When this
recognition is the base for observations and thinking of the humans, the view of
human beings is shaped differently than when embodiment is ignored. In this
study, embodiment sets the epistemological and ontological starting point for
the work.
Embodiment begins already during the prenatal development. The deve-
lopment of the embryo is created from a nourishing mother’s body, by the ge-
netic information inherent in the embryo’s material and by the sensory stimula-
tion that is available in the womb. For the newborn, this creates the embodied
predisposition for functioning in the world.
Essentially, the interaction with the environment and others is sensory and
emotional (Foolen, 2012; Frank & La Barre, 2011; Stern, 1985). The input from
the external environment is captured by the body – tactile, kinetic, olfactory,
auditory, and visual sensory information. The responses are created by the bo-
dy – tensions, release, different kinds of breathing, opening towards, withdra-
wing, reaching, grasping, pulling and pushing, smiling, crying, sounding. The-
se physical responses begin to build the relatedness to the environment, sha-
ping the neuronal patterns, constructing the repertoire of expectations and ac-
tions.
In neurosciences the Hebbian theory proposes that ”the neurons that fire
together wire together” (Cozolino, 2002). Hebbian theory explains the plasticity
of the brain, i.e. the brain’s ability to shape itself by its responses. Also, it ex-
plains how connections once learnt continue to have an impact on the activity
and responses the individual produces. Bucci (2011) proposes that a human
being is a multi-format information processor. The information has two basic
formats: symbolic and subsymbolic. Both of these can function within or outsi-
de awareness, incorporating both non-verbal and verbal components. When
considering embodiment, also in adulthood, the subsymbolic system is one way
to comprehend the characteristics of embodiment:

“Technically, subsymbolic processing, distinguishing it from symbolic forms, is the

continuous flow; the felt similarities and relationships are known through patterning
and analogy rather than generated from discrete elements. Subsybolic systems
operate in sensory, motoric and somatic systems, as sounds, smells, feelings of many
different sorts. They contribute to verbal processing as well, in forms such as prosody,
speech rhythm patterns and modulation of intensity and pitch” (Bucci, 2011, 211).
 15

Thus, embodiment is subsymbolic information processing in the body, accor-

ding to the learnt patterns. Based on research on affective neuroscience, embo-
died communication, and cognitive science, Bucci (2011) outlines a model of a
recursive sequence of events in the embodied information processing. There is
perception (action mirroring), activation of motoric and emotion circuitry, anti-
cipating the action of the other, preparing a response and anticipating the con-
sequences of alternative responses. The repetition of these sequences from the
beginning of life shape the individual’s response patterns, which hold the rep-
resentation of one-self in relation to one’s interpersonal world. It is embodied.
The representation may include symbolic and verbal contents as well, but its
core and essence are embodied.
Embodiment is a phenomenon within everyday experiences. The study of
embodiment refers to understanding of the role of an individual’s own body in
its everyday, situated cognition; how persons’ subjective, felt experiences of
their bodies in action provide the fundamental grounding for human behavior,
cognition, and language (Gibbs, 2005). Observing and consciously regocnizing
movement and embodied sensations can be a challenging task, as they are tran-
sient but yet constantly present in human existence (Moore & Yamamoto, 2012).
It appears, that humans collectively and individually are often poorly conscious
about the body’s role in perceptions, responses, and interactions. Often, what is
described as unconscious in human behavior (Schore, 2012), is actually body
responses and implicit, procedural memory impacting the behavior. Movement
can be seen as our “royal road to the unconscious” (Penfield, 2006). Bodily re-
sponses and movement patterns are phenomena, which allow explicit presenta-
tion of that what we have not yet reached consciousness of.
We essentially perceive our body via internal, kinesthetic proprioception.
For our development, we need interactional movement, responses, and feed-
back from the other and from the environment. Attachment theory, initially de-
veloped by Bowlby and Ainsworth, has recognized the quality of the interac-
tion between the child and the caregiver to be the central phenomenon, which
shapes the relational patterns the child begins to learn (Schore, 2000; Slade,
2014). The security vs. insecurity in the ways of relating are embodied. Especial-
ly, to reflect on our emotional, responsive and interactional body-self, we need
other human beings. It is in the interaction, where we develop and discover
what we are and can be.
From the perspective of systems theory, which is one of the foundations of
embodied cognition, the human body can be perceived as Complex Adaptive
Dynamic System, CADS (Claxton, 2015). A system is a constellation of subsys-
tems. Its processes are in constant interaction and reciprocal shaping. Consider-
ing humans, whatever the level of the subsystem is, ranging from cells to whole
bodies of the persons to nations, the boundaries between subsystems, are sites
of vital interaction. Claxton (2015) points out, that from systems perspective,
human body is not a noun, it is a verb. It is constantly in interaction with its
context. “The coherence of bodily structure and behaviour reflects the constant
16

internal resonance of all their ingredients with each other – and with the wider
set of Systems within which they are embedded” (Claxton, 2015, 55).

1.2 Depression

In Finland, 5% of the population suffers from depression yearly (Käypähoito,

2016). According to the National Institute of Health and Welfare (THL), every
fifth Finn gets depression during the lifetime, and for half of them, it becomes
recurrent, at least once. In Finland, in 2015, there were 51 072 patients treated
for depression in specialized health care, i.e. in psychiatry (THL, 2017) for dep-
ression (F32 in the ICD-10, International Statistical Classification of Diseases
and Related Health Problems) or recurrent depression (F33 in the ICD-10). Mild
depression is typically treated in primary health care, and those cases are not
included in these statistics of psychiatry. Considering that the depressed per-
sons’ relatives, friends, and colleagues may also encounter the ramifications of
depression, there is a substantial group of people, who is influenced by depres-
sion every year. Depression as a major psychiatric diagnosis is a cause of early
retirement with a frequency that is considered alarming and a substantial finan-
cial strain in the Finnish society. The statistics show that the mental health rea-
sons, including depression, have been the main cause for the work disability
pension since the 2000 in Finland (Findikaattori, 2018). At the same time, the
statistics show the levels double in the use of antidepressants (Kalliokoski, Voi-
pio, & Ruokoniemi, 2015). Approximately half of the adult population engages
in physical activity for 1.5 hrs per week, and the habit of commuting by physi-
cal excercise (biking, walking) has been decreasing. Thus there is a large portion
of population for whom physical activity is not part of their daily life (THL,
2015). The studies on the use of physical excercise in the treatment of depressi-
on have shown it as effective as medication and psychological therapies (Her-
ring, Pruetz, O’Connor, & Dishman, 2012; Rimer et al., 2012).
Efforts to improve the treatment of depression have been made: the treat-
ment of depression has been given more resources in the primary health care,
and a special project (MASTO-project) was carried out in 2008-2011 to improve
the handling of depressed patients in the health care and to clarify the proce-
dures and benefits the employers and the National Social Insurance Institution
(KELA) can offer to support the rehabilitation of a depressed patient. In the cas-
es of moderate or severe depression the patient frequently requires treatment at
the level of specialized health care: the public outpatient psychiatric clinics, day
hospital units and and inpatient periods at the psychiatric units of hospitals.
Those patients who can benefit from psychotherapy can apply for 1-2 years of
psychotherapy, which expenses are substituted by KELA. The choice of psycho-
therapy forms reimbursed by KELA is limited to psychoanalytic, cognitive-
behavioral, and family therapy. Art therapy and music therapy are also availa-
ble options with expenses substituded by KELA, but not DMT.
 17

Currently in Finland, the Current Care Guidelines for depression (Käypä-

hoito, 2016) include the combination of psychopharmacological medication and
counseling or psychotherapy. It is acknowledged that physical exercise can be
beneficial, but cannot act as a substitute for medication and therapy. Treatment
programs at inpatient hospital units, day hospitals, and outpatient psychiatric
clinics may provide some physical activity and/or psycho-physical physiother-
apy, sometimes DMT is also used.
Interestingly, in the 1600’s, in the earliest descriptions of ilness, which later
became named depression, a set of symptoms was presented: 1) fatigue, 2) mild
anxiety, 3) low mood, anhedonia, 4) somatic complaints and 5) obsessive
thoughts (Shorter, 2013). The same set of symptoms is common today as well.
In the early days the symptoms were understood as a problem of nerves. The
struggle to understand the reasons for these symptoms and their cure continues.
It has been challenging to find fully satisfying treatment options for depression,
particularly for the most severe type, major depressive disorder (Kupfer, Frank,
& Phillips, 2012).
The Finnish Current Care Guidelines perceive depression as a bio-psycho-
social disorder. The present study recognizes the lived and experienced phe-
nomena of the biology of the human body, and builds on the embodied nature
of psychological and social phenomena. This study holds a view that depres-
sion is a state of systemic distress and it usually involves an experience of a loss
of agency and reduced energy level. This produces the identified symptoms of
depression: low mood, loss of interest and enjoyment, anxiety, disturbed sleep
and appetite, feelings of guilt or low self-appreciation, and also medically un-
explained somatic symptoms (WHO, 2012; ICD-10, 2016).

1.2.1 Neuroscientific findings on depression

Neuroscientific studies on depression and the patterns of neurological function-

ing and networking that relate to depression offer one Complex Adaptive Dy-
namic Systems (CADS) perspective on persons suffering from depression. Pun-
kanen (2011) presents a summary of recent findings on the neurological phe-
nomena that have been found relating to depression. By neuroimaging tech-
niques, it has been discovered, that in the brain of a depressed person, it is typi-
cal that there is an increased activity of limbic brain regions and in the Anterior
Cingulate Cortex (ACC). Also, there is decreased connectivity between limbic
regions and ACC during negative emotional stimuli. There is asymmetry, i.e.
unbalanced activity in the frontal lobes of the right and left frontal hemisphere.
EEG-studies have shown that in the brain of a depressed person, there is hypo-
activation of the left frontal lobe and hyperactivation of the right frontal lobe.
To what functions do these brain areas relate to? Limbic brain channels
sensory information coming to the brain and it is essential in processing emo-
tional information. Limbic brain (amygdala and hippocampus) is connected to
the anterior cingulate and Orbitofrontal cortex (Ofc), which together create the
brain areas that are called the social brain (Cozolino, 2002). Thus, in the de-
pressed person’s brain, there are depression-typical functional patterns in the
18

social brain. There is increased activity in the limbic brain and anterior cingu-
late - metaphorically speaking there is stress or pressure. Anterior cingulate is
an association area of visceral, motor, tactile, autonomic, and emotional infor-
mation. Anterior cingulate is involved with attention, reward-based learning,
maternal behavior (nurturing, care), and autonomic arousal (Cozolino, 2002). It
is known, that when handling negative stimuli, the depressed person’s brain
has a lack of connectivity between the limbic brain, that detects threat and safe-
ty and is involved with the initiation of the stress response, and anterior cingu-
late, which is involved with the autonomic arousal, attention and maternal be-
havior, which could be offering options for responding.
Also, in the brain of a depressed person the asymmetry in the activity be-
tween right and left frontal lobes may relate to lack of connectivity between
them. The right hemisphere is involved with processing information in a global
way, closely connected to the limbic system and information stemming from
the body (Schore, 2012). The left hemisphere is less connected to the direct
body-information and more involved with processing information via language
related functions. Essentially, the task of the left hemisphere is to synthesize
information and produce a coherent narrative of it (Cozolino, 2002). Left hemi-
sphere does not have information on which to build the narrative, if there is
poor connectivity to the right hemisphere, which would provide the essential
information about the state of the body and sensory systems.
Regarding the limbic system, Cozolino (2002) discusses also the interac-
tion between amygdala and hippocampus. Amygdala is an old, primitive – or
rather, primary - brain structure that develops early and is available already at
birth. Hippocampus matures more slowly, and its cortical-hippocampal connec-
tions myelinate till late adolescence. Hippocampus is vital for conscious, logical,
and cooperative social functioning. Amygdala is involved in the emotional and
somatic organization of an experience. Amygdala is geared toward right hemi-
spheric and down systems in the brain. Hippocampus is biased toward left and
up systems in the brain. For an individual to function well, the proper function-
ing of amygdala and hippocampus and their mutual regulation is needed. In
depression, however, there is decreased density or volume of the hippocampus.
Hözel et al. propose the following perspectives for decreased volume of the
hippocampus:

… “neuronal loss through chronic hypercortisolemia, glial cell loss, stress-induced

reduction in neurotrophic factors, or stress-induced reduction in neurogenesis may
contribute to this (Sheline, 2000). Furthermore, smaller hippocampi have also been
shown to constitute a risk factor for the development of stress-related
psychopathology (Gilbertson et al., 2002). However, the hippocampus is a region
well known for its ability to remodel synapses and generate new neurons (Gage,
2002), and volume loss in this region seems to be reversible (Gould et al., 2000; Jacobs
et al., 2000)” (Hözel et al., 2011, 40-41).

An interesting perspective to the decreased hippocampal volume is also the

question, whether the lack of connectivity to the “right and down” systems, i.e.
those neuronal systems that process sensory information in and from the body,
 19

feeds to a situation, where the hippocampus eventually receives less infor-

mation to process, and consequently becomes decreased in volume.
Hözel et al. (2011) refer also to stress as one possible reason for the mal-
functions that have been discovered to be associated with the brains of de-
pressed persons. Stress causes the individual to reduce attention to internal in-
formation and focus on the external information instead (Cloninger, 2004; Fogel,
2013). According to Fogel (2013), the interoceptive information, i.e. information
about internal sensations in the body and arousal are transmitted in the nervous
system through the non-myelinated axons and thus the transmission of infor-
mation is slower. The information from the external environment and from the
proprioceptive system (stretching of muscles and ligaments, balance, movement
coordination) travels through a fast lane in the spinal cord and is thus dominat-
ing. This phenomenon may be one factor that enhances the lack of connectivity
between the right and left hemisphere of the brain, and the limbic system and
anterior cingulate, when the individual encounters stress. Interestingly, neu-
roimagining studies have shown, depressed persons’ brain activation presents
difficulty in segregating emotional processing from cognitive and sensorimotor
processing (Epstein et al., 2010).
Studies have also shown, that depressed patients have disturbed autono-
mous nervous system arousal patterns, particularly apparent in the heart rate
and heart rate variability (Birkhofer, Schmidt, & Förstl, 2005; Campbell-Sills,
Barlow, Brown, & Hofmann, 2006; Shinba, 2014;). Heart rate has multiple de-
terminants: present somatic activity, mental effort, emotional arousal, and/or
orientation to stimuli. Heart rate is an idex of sympathetic and parasympathetic
arousal. The abnormalities in the autonomous nervous system arousal in de-
pressed patients may be linked to the acquired stress response patterns and to
social coping styles. There is evidence linking emotion suppression to more
negative affect and sympathetic autonomous nervous system arousal (Camp-
bell-Sills et al., 2006). For recuperation after arousal, the activation of the para-
sympathetic system and calming and restoring activity in the body and nerv-
oussystem would be needed.
The brain has a particular set of activation when at rest from demanding
cognitive tasks, and this mode of activation has been identified as default sys-
tem. Affective neuroscience studies have found out, that the default system is
activated in tasks related to the formation of self-representation and self-
projections, i.e. mentally imagining one-self to the future or to the past, and in
recognizing one-self from the perspectives of others. It has been found out, that
patients with depression have abnormalities in the resting state activation of the
brain. Messina, Bianco, Cusinato, Calvo, et. Sambin (2016) discuss this abnormal
functioning of default system in depressed patients and connect it with the
shaping of the attachment style during early childhood. They propose that the
representations formed in early interactions resonate in the brain functioning.
Also, they see this as relavat to the emotion regulation skills a person has.
20

1.2.2 Relational problems and depression

There are research findings showing that persons with depression have experi-
enced stress, particularly familial and relational stress. Kuhlman (2013) studied
51 depressed persons and their marital couples in a couple therapy context. At
the start of the study the participants’ marital satisfaction was measured by Dy-
adic Adjustment Scale (DAS). The score 95 was taken to indicate marital dissat-
isfaction. The mean DAS for the depressed patients’ was 104 and for their
spouses 108 (higher scores indicate more marital dissatisfaction). Participants
had also experienced unemployment, the average time among the subjects was
2.25 months. On the average, their depression had lasted for 42 months at the
start of the study.
Heikkinen (2014) studied patients suffering from severe mental health
problems, collecting data on their life satisfaction. The total sample consisted of
87 participants and 63 of them had a diagnosis in a mood disorder range. In the
whole sample 65% of the subjects were discontent with their occupational situa-
tion (the participants had low income level), 50% were discontent with the situ-
ation in their family of origin, 44% were dissatisfied with their current family
situation and 17% were unsatisfied with their social relations. The majority of
the participants were living alone (64%).
In earlier, international studies (Andrews & Thomson, 2009; Kendler et al.,
1999; Major et al., 1997) there have been findings that depressive symptoms are
often present in relational problems, and depression is more severe, if there is a
conflict between people close to each other. The risk of severe depression is in-
creased, if the person has recently experienced severe marital or relational prob-
lems, has divorced, had conflicts with close ones or friends, or has been assault-
ed physically. A conflict between persons, that earlier had been in a collabora-
tive and mutually supportive relationship, causes more depressive symptoms.
Depression has been linked to underactivation of the approach system and
the loss of perception of intensives (Carver, 2001). Hayes et al. (2004) found that
higher levels of experiential avoidance were associated with higher levels of
general psychopathology, depression, anxiety, a variety of specific fears, trauma,
and a lower quality of life. Experiential avoidance refers to unwillingness to
experience negatively evaluated feelings, physical sensations, and thoughts.
These characteristics can be understood as behavioral patterns that are pro-
duced by the difficult social and interactional situations, and by neurological
characteristics discussed in the section 1.2.1. At the same time, these behavioral
patterns enhance such neurological characteristics.
Behavioral patterns appear also on the basis of the attachment style the
individual has acquired through his/her interactional experiences. Research
indicates that insecure, i.e. avoidant/dismissing or ambiva-
lent/anxious/preoccupied attachment style characteristically can be observed
in patients with depression (Siegel, 1999). Insecurity in the attachment style
produces difficulties in behavioral self-regulation and also in interpersonal reg-
ulation (Mikulincer & Shaver, 2007; Schore, 2012). There are interesting research
 21

findings on the emotional processing characteristic to patients with depression

(see Punkanen, 2011). Discoveries include negative attentional bias in recogniz-
ing facial emotions, whether the stimulus faces are emotionally neutral, sad,
happy, or subtly changing; more negative interpretation of prosodic infor-
mation than in healthy controls; significantly fewer happy facial expressions
when observing a film; prolonged involuntary processing of negative emotional
information; and rumination of negative emotional material. These characteris-
tics of emotional information processing match with the insecure attachment
environment and stress.

1.2.3 Depression in the view of phenomenologically oriented psychiatry

In the Finnish discourse on mental health and psychiatry, phenomenologically

oriented psychiatry is less known. However, for clinical practice, phenomeno-
logically oriented psychiatry offers insightful views, which can provide a valu-
able perspective. It perceives depression (melancholia) as as unitary phenome-
non that transforms and deforms all dimensions of experience in a coherent
way. This touches the individual’s experience of embodiment and intersubjec-
tivity. Micali for example proposes, that

“regarding the disturbances of embodiment in melancholia, it is possible to introduce

a distinction of three different dimensions: a) disturbances mainly concurring the re-
lation of the body with the surrounding environment; b) disorders mainly related to
the way in which the body feels itself, c) disturbances mainly concerning the relation
between my body and the other's body (intersubjectivity). These dimensions are
closely interdependent in experience” (Micali, 2013, 204).

Micali (2013.) describes, that the feeling of the body in depression is distor-
ted in the sense of gravity, namely there is a sense that everything appears to be
heavy, falling down. There is trouble in unification of one’s lived body, and a
sense of a gap between one-self and one’s own body. The melancholic person
conceives his relation to the body in instrumental terms, not as a responsive nor
affective living being, not in the context of a relationship. Micali also notes that
people withe depression feel pains, and he has found it an emblematic characte-
ristic that depressed persons feel pain in the upper part of the throat/chest and
stomach.
In recognition that the body is the medium through which humans per-
ceive and interact with the world, and our understanding of the world is based
on the tacit, bodily knowledge of the world, the concept of corporealization sig-
nifies an alteration of the transparency and mediality of the lived body (Fuchs,
2005; Micali, 2013). Phenomenologically oriented psychiatry holds a view that
in (severe) depression the corporealization is altered. The body is no loger a
transparent, communicative site, but an obstacle and a block on the way be-
tween the individual and the environment. There is a withdrawal away from
the external environment into the closed, subjective immanent sphere and a
vanishing of intersubjective reciprocity in the encounter with the other (Micali,
2013; Ratcliffe, 2013). The body ceases to respond to the affordances of the sur-
22

rounding environment. Micali (2013) describes the person with depression

identifying him/herself only with the void that is created in the middle of his
existence, as he has lost the ability to feel him/herself, and thus there is nothing
to activate the kinesthetic reactions and responses. Consequently the body be-
comes more rigid and heavier, which makes the individual less sensitive to the
surrounding world. A spiral of diminishing affectability and weakening sense
of self develops. Ratcliffe (2013) also makes a point that when a sense of inter-
personal connection is gone from the experience, the world no longer incorpo-
rates the potential that would be inherent in the experience of the world. The
network of others as a dynamic space of significant possibilities by virtue of our
potential and actual relations with them ceases to have impact on the person’s
experience.
The value of this view on depression is that it brings together on the level
of experience, what happens when the interactions with the environment are
loaded with stress and insecure relating patterns. It offers a phenomenological
description of the sense of self and world relations that are built when the com-
plex system (CADS) is lacking integration of the brain networks, and lacking
integration of the mind and body.

1.3 Body image

The mainstream of body image literature and research focuses on the question
of the body dissatisfaction or satisfaction in normal population and in various
pathologies, whether physical or psychiatric (Cash & Pruzinsky, 2002). How-
ever, there are broader and phenomenologically oriented approaches to body
image, which make the concept more systemic (in the sense of complex adap-
tive dynamic systems) and involved with the lived body (Bermúdez et al., 1995;
Gallagher, 2005, 2011; Koch et al., 2012; Sheets-Johnstone, 2009). Within this ori-
entation to body image, the concept refers to the multilayered experiential total-
ity we perceive within our body, about our body, and by our body. Historically,
when Schilder begun to study body image, he argued for a bio-psycho-social
approach to body image and recognized the need to study its neurological, psy-
chological, and sociocultural elements (Pruzinsky & Cash, 2002). The concept of
body image has had an elusive nature in literature and research, as it has been
perceived to address a range of phenomena and terms. Early body image re-
search was struggling to clarify body schema, and proposed neural mechanism
whereby changes in body posture and movement were centrally coordinated.
For decades the study of body image evoled around questions about appear-
ance satisfaction and appearance evaluation, body esteem and body concern.
Now recently, a new focus on positive body image has emerged. Tylka &
Wood-Barkalow (2015) posit positive body image is multifaceted, including
body appreciation, body acceptance/love, conceptualizing beauty broadly,
adaptive investment in appearance, inner positivity, and interpreting infor-
mation in a body-protective manner.
 23

The present work is built on a tri-partite model of body image, which ini-
tially is based on Schilder’s (1950) view on body image. Body image consists of
three elements: body-self, body memory, and image properties (Pylvänäinen,
2003). Body-self refers to the interacting body: how body is sensing and re-
sponding in a moment and how the individual experiences this. Body-self
communicates and responds in a physical way, i.e. by movement, by gestures
and postures, by tensions and releases, by activating or calming down in the
present moment. Body-self responses are sensory-motor and often emotional.
The features of emotional responding in a moment can be understood as ex-
pressions of body-self. The continuous connectedness to the body-self is essen-
tial for mental health (see also Lumsden, 2010).
Body-self actualizes the individual’s relatedness to the internal and exter-
nal environment in the present moment. Body-self shapes the responses in close
connection to body memory. Body memory is procedural, sensory, and mostly
implicit memory. Casey (1987) proposed the body memory holds three types of
memories: habitual body memories, traumatic body memories, and erotic body
memories, which relate to interactional memories of pleasure. Habitual body
memory refers to the learnt movement patterns, schemas and skills, which
build the base for the everyday functioning. Fuchs (2012; also Koch et al., 2013)
has structured the body memory in a more detailed way and proposes a de-
scriptive taxonomy with six forms of body memory:

• Habitual or procedural body memory: skill memory for motor pro-

cesses
• Situational body memory: memory of the spatio-temporal situation
• Inter-corporeal body memory: bodily knowing of how to deal with
others
• Incorporative body memory: socio-cultural habits and manners ob-
tained by bodily imitation and identification
• Pain memory: the impact that painful experiences of the past con-
tinue to have to the present moment
• Traumatic memory: the impact psychologically traumatic experi-
ences have on the present moment

Body memory functions by activating and simulating the past experiences

in the body responses in the now, and to varying extent, in the consciousness.
When body memory is activated, the past experience is echoed in the present
body felt moment. Body memory is a dimension of the lived body, functioning
as a continuous background for present, subjective experiences.
Image properties are the set of beliefs, attitudes, and values the individual
associates with his/her body and its looks. These are culturally shaped and ob-
tained in a social setting. These thoughts may elicit feelings towards the body,
for example they can impact how much the person likes or values his/her bodi-
ly appearances. Image properties are typically easily described in words. In im-
24

age properties the body and its characteristics are viewed as something the per-
son owns, can shape, and manipulate.
Body image, in those contents just described, contains the individual’s re-
latedness to the physical/spatial and social environment. It portrays the body
as a subject, the body as an object, and the body for others, i.e. an interactional
and relating body, a body in togetherness. In the sphere of social relations, the
attachment style, i.e. the secure or insecure response patterns and expectations,
are ingrained in body image (Bentzen, 2015; Schachner, Shaver & Mikulincer,
2005). These patterns are embodied, learnt early in life and imprinted in com-
munication, where the non-verbal content is central: gestures, gazes, touches,
distances, the matching and mismatching of timing and movement qualities.
Affordances, which refer to an individual’s perception of possibilities for action
provided by environment (Gibson, 1966; Rietveld 2008; Rietveld, 2013) are also
essentially rooted in the body image. For example, when a person sees a door
nob, there is a readiness in the hand to reach and shape around the knob, and to
pull the door open. The door nob calls for some action. The physical and motor
abilities in the body construct, how the person can relate to this potential in the
external environment. The situation for the individual is quite different, if there
is a door without a knob; if the joints in the person’s hand are sore and moving
is painful; if the hand is strong and flexible; if the individual feels secure or in-
secure in his/her body at the moment of taking the action; or if reaching for the
door knob reminds him/her of a traumatic event.
Body image holds embodied behavioral and emotional patterns. The re-
sponses created in the present moment can influence how the patterns develop
and how the individual perceives himself/herself in the present moment. Body
feedback experiments show, that body-self responses create emotional states
within the body. For example, Koch (2011) studied the kinesthetic movement
feedback in normal, healthy individuals (n = 66), and found that participants
perceive their emotional state differently depending on the movement rhythms
(smooth or sharp rhythm) and movement shapes (approach or avoidance
movement) they used in their behavior. Rhythms and movement shapes,
whether indulgent or fighting, were linked to the affect system. Approach
movements produced a more relaxed, peaceful affect independent of the
rhythm quality. Avoidance movement made the participants feel more tense. In
the task of assessing neutral stimuli (Chinese ideographs presented to non-
Chinese speaking persons) the indulgent/smooth rhythm produced more posi-
tive assessment of the stimuli. The combinations of indulgent vs. fighting quali-
ty had an impact as well: a clashing combination of shape and rhythm (e.g. ap-
proach shape/indulgent combined with sharp rhythm/fighting) produced
negative, aversive reactions and a congruent combination (e.g. approach
movement, palm open and smooth rhythm) produced a positive affect. These
experiments demonstrate how the concrete, identifiable qualities of movement
response influence the quality of the experience of one-self and the external
stimuli in the present moment. Body actions and body image are constantly in a
 25

responsive, dynamic process with the environment. As long as the body is alive,
the responding and motion never cease.
What is a healthy body image like? It is sufficiently integrated, it enables
flexible and realistically responsive behavioral patterns, and it supports the ex-
perience of well-being, ability, and security. This is created in the interactional
relating experiences with others and environment (Pylvänäinen, 2003; Sandel,
Chaiklin & Lohn, 1993). Secure attachment promotes these qualities (Siegel,
1999).

1.3.1 Body image in depression

What is known about the characteristics of the body image of patients with de-
pression? There is not much research on this topic. Fuchs & Schlimme (2009)
recognize that the embodiment of depression has an impact on the prereflective,
embodied sense of self, i.e. on body image and body-self in particular. Papado-
poulos and Röhricht (2014) studied chronically depressed patients ( n= 31) in
the UK in a body psychotherapy context. Their study provides some descrip-
tion of the typical features of the depressed patients’ bodily experience and re-
sponse patterns. The patients with depression showed a poor body satisfaction
and feelings of being detached and distant from own body. They found it diffi-
cult to be grounded, and were cut-off from experiences in their bodies. The de-
pressed patients experienced high permeability in their body boundaries. Their
body posture typically included a sunken chest, hunched shoulders, narrow
body stance and downcast eye line gaze with an internal and withdrawn focus.
Their breathing was typically shallow and mainly involved upper chest region.
The core characteristic in their movement and bodily presence was bound flow.
They felt fatigue and pains in the body. Michalak, Burg, & Heidenreich (2012)
report a finding that depressed patients walk more slowly than healthy controls.
In their walk, the persons with depression have smaller arm swings and have
pronounced swaying, lateral movements of the upper body. The gait of de-
pressed patients is characterized by a slumped posture and reduced vertical up-
and-down movements of the upper body. Punkanen et al. (2017) report that in
emotionally expressive motion, patients with depression move more slowly,
use less acceleration, use less open postures, and move generally less than
healthy controls.
The totality of body image holds an embodied, experiential, lived experi-
ence of the self and the body and the relatedness to the environment. The limi-
tation of the descriptions just reviewed is, that they mostly present what can be
observed of the body, posture, and movement by an external observer. They
report about the visible characteristic movement patterns actualized by the
body-self and accessed from the habitual body memory. How the depressed
person experiences these patterns in him-/herself remains somewhat hidden;
the few descriptive words on the experience were fatigue, pain, and feeling de-
tached from the body.
26

1.3.2 Embodied mindfulness

Embodied mindfulness is a process to gain more conscious awareness of the

body image contents. Mindfulness is a way for connecting with the base of ex-
periencing, developing the skill to be more clearly aware of the present sensory
contents and the responses they evoke in the body and mind. Mindfulness is a
tool to develop the ability to be more connected of the right brain and low brain
information. Mindfulness skills relate to observation skills, affect modulation,
and stress-level management (Siegel, 2007). Mindfulness invites to develop
awareness, sensing and observing with a non-demanding, neutral attitude
(Kabat-Zinn, 2003). This essentially develops body awareness, which is needed
for understanding one’s responses to one’s body. This provides the grounding
of one’s understanding of one’s feelings and thought based interpretations of
the situation (Grogan et al., 2014). Mindfulness is a skill of embracing the senso-
ry responses with non-judgmental awareness and naming, thus creating an op-
tion for choice making regarding how to relate to these responses in one’s in-
ternal environment (Odgen, 2010). Mindfulness promotes qualities of presence,
which actually echo secure attachment related qualities of presence and action
(see Fosha, 2010).
Originally, mindfulness essentially refers to introspective awareness of
one’s physical and psychological experiences (Keng et al., 2011). Framed in
simple questions, this would refer to what you sense, what is the feeling, what
is the emotion, what is the imagery, and what is the thought related to per-
ceived experience (sensation). Developing mindfulness skills develops also the
reflective skills and the inner observer (Adler, 2002; Weiss, 2009). The inner ob-
server can be strengthened by directing it at something to observe. The sensory
system offers a constant flow of perception, and the body action, i.e. breathing,
posture, and movement create a clear flow of events to observe. The best way to
start to develop mindfulness is to engage the body and to develop breath
awareness.
Michalak et al. (2012) present a summary of the reasons, why body is rele-
vant in mindfulness:

• The body functions as an anchor of mindfulness.

• Mindfulness of one’s emotional bodily responses supports early de-
tection of one’s emotion.
• Intuitive insight into the interplay between the body and emotional
processes enables better tracking.
• Mindful body-awareness functions as an antitode to emotional
avoidance (quit rumination, separate from identification with
thoughts/emotions, reduce avoidance behaviors).
• Embodied compassion and the body as the place of bliss (comfort,
compassion towards one-self).
• Contact with organismic needs and limits (hunger, thirst, tiredness
etc.).
 27

• More vivid contact with the other persons in interactions (better

tracking, responsiveness).

The health benefits of mindfulness have been reported in several studies.

Keng et al. (2011) present a review article on the effects of mindfulness on psy-
chological health and provide an extensive array of studies showing the bene-
fits of mindfulness training and gained mindfulness trait. Depression, anxiety,
stress, anger, and rumination are reduced; emotional regulation, cognitive flex-
ibility, and attentional functioning are improved. An accepting attitude towards
internal experiences, gained by mindfulness training, supports the recovery
from dysthymic mood and eases the level of emotional reactivity to aversive
stimuli.
Naturally, mindfulness can also be applied in the context of interaction
and relationships, and in therapy relationship context in particular. Horst et al.
(2013) studied the experience of mindfulness practice in psychotherapy by in-
terviewing five therapist-client dyads, which applied mindfulness practices in
the therapy process. The patients were suffering from depression, anxiety, rela-
tional problems, and stress. Mindfulness exercises - breathing meditation and
body-scan - were a shared activity in the therapy session. The client and the
therapist discussed the exercises together before doing them, interacted togeth-
er in doing the exercise and reflected together on the experience after the exer-
cise. They valued this sharing and togetherness in the session, and found it
helpful in transitions, in focusing on the therapy. Mindfulness exercises sup-
ported slowing down, calming, and working in a thoughtful way in the therapy.
The use of mindfulness exercises was more fluent, if the therapist was engaged
in practicing mindfulness and was familiar with the approach.
In the field of therapy, mindfulness has been applied in mindfulness based
stress reduction (MBSR), in mindfulness based cognitive therapy (MBCT), dia-
lectic behavioral therapy (DBT) and acceptance and commitment therapy (ACT).
In dance movement therapy (DMT) mindfulness, i.e. being attentive of the body
sensations and breath, and describing the experiences in a non-judgmental and
observant way, is an essential element in how the therapist approaches the in-
teraction and how the patient and his/her bodily responses are received. In
DMT, however, the array of movement activities is much richer compared to
what is used in mindfulness based therapies rooted in the cognitive behavioral
psychotherapies.

1.4 Dance movement therapy (DMT) in the treatment of depres-

sion

The joint exploration of physical action, mindfulness, and social interaction

creates a integrative and interactive creative space, that enables the understan-
ding of oneself and the development of better ways of coping. DMT integrates
28

the physical, emotional, cognitive, and social aspects in the treatment (Chaiklin
and Wengrower, 2009; Meekums, 2002; Payne, 2006; Stanton-Jones, 1992). To
clarify the contribution of each, here are the three key topics:

• Physical action – how to use body, how the body moves, connect
with the core of self; presence and agency, creativity
• Social interaction – trust, actual space, real responses, expectations,
attachment styles, communication, attunement; environment
• Mindfulness – how you use your awareness and cognition; connec-
tedness with inner observer, connectedness with the lived body;
embodiment

The focus in DMT is partly in engaging with movement, getting concretely

involved in movement activity in the here and now. The other locus of activity
is to be attentive to the movement experiences and to develop the skills to be
conscious and reflective of them and to communicate about them in words. The
relevant effective elements in DMT are the engagement of moving body, crea-
tivity, the development of body awareness and mindfulness, and the verbal ex-
ploration of the movement experiences, which focuses on the qualities of the
experience. This makes the dialogue to unfold the experience more from the
perspective of the right hemispheric contents, and this enables the patient to
connect with the emotional core of his/her experience. The discussion about the
movement experiences fosters interhemispheric connectedness.
DMT is also known as dance therapy, movement therapy, dance move-
ment psychotherapy, movement psychotherapy, dance/movement therapy or
dance-movement therapy (Meekums, Karkou, & Nelson, 2015; Payne,
Warnecke, Karkou, & Westland, 2016). DMT in the treatment of depression has
been found helpful, but the amount of studies on the topic is not large. See Tab-
le 1, which summarises the studies on the use of DMT in the treatment of dep-
ression.
TABLE 1 Compilation of the research on the use of DMT in group format in the treatment of depression

Author Title of publication N Age range Context Duration and Control group Outcome
frequency of activity
DMT treat-
ment
Steward Movement therapy with 12 adults Inpatient 2 weeks, eve- No CG Depressive symptoms (DACL) re-
et al. depressed inpatients; a psychiatric ry other day, duced on the intervention days for 5
1994 randomized multiple single unit total of 7 ses- pts out of 12.
case design sions
Jeong et Dance Movement Therapy 40 Adolescents Students 12 weeks, 3 No interventi- Negative psychological symptoms
al. improves emotional res- (mean age 16 sessions per on of distress had improved (BDI, SCL-
2005 ponses and modulates neu- yrs) week, total of (n= 20) 90), plasma serotonin concentration
rohormones in adolescents 36 sessions increased, dopamine concentration
with mild depression. (n = 20) decreased in the treatment group
but not in the control group.
Koch et The joy of dance: specific 31 21-66 years Clinical One session, Home ergo- Depressive symptoms (HSI) alle-
al. effects of a single dance up-beat circle meter training viated more for DMT intervention
2007 intervention on psychiatric dance, 20 min or music participants compared to the music
patients with depression. (n = 11) (n = 20) group or ergometer trainers. Vitality
increased more immediately after
the DMT intervention compared to
music intervention.
29


TABLE 1 continued 30

Author Title of publication N Age Context Duration and Control group Outcome
range frequency of activity
DMT treat-
ment
Röhricht An exploratory randomized 31 35-59 Clinical; com- 10 weeks, 2 Treatment as At the end of treatment patients
& al. * controlled trial of body years munity mental sessions per usual in com- in the treatment group had signi-
2013 psychotherapy for patients health service week, total 20 munity ficantly lower depressive symp-
with chronic depression users sessions psychiatric ser- tom scores than the waiting group
(n = 16) vices (mean difference 8.7, 95% confi-
(n =15) dence interval -0.71 to
–16.76)
Punkanen Emotions in motion: Short- 21 18-60 Clinical; com- 10 weeks, 2 No CG BDI score decreased significantly
et al. term group form Dan- munity mental times a week, from the pre- (M = 21.67, SD =
2014 ce/Movement Therapy in the health service total of 20 5.26) to post-measurement (M =
treatment of depression: A users sessions 10.50, SD = 5.50), t(17) = 10.40, p
pilot study. < .001.
* Results from the same study are presented also in Papadopoulos & Röhricht (2014)
 31

A Cochrane review of the effects of DMT on depression by Meekums,

Karkou, & Nelson (2015) examined the effects of DMT for depression compared
to no treatment or to standard care, to psychological interventions, drug treat-
ment, or other physical interventions. Only three studies met the Cochrane re-
view inclusion criteria, totaling 99 adult subjects and 40 teenager subjects.
When the authors compared group DMT to standard treatment in adults with
depression, DMT reduced symptoms of depression at follow-up measure, as
indicated by clinical observation using the HAM-D. Due to low methodological
quality of the studies and small sample size, the findings of the effectiveness of
DMT could not be considered conclusive.
A meta-analysis of the effects of DMT and dance on health-related psycho-
logical outcomes included the evidence of 23 primary studies (Koch, Kunz,
Lykou, & Cruz, 2014). The meta-analysis showed moderate effects for quality of
life and for depression and anxiety.
In a Finnish study (Punkanen, Saarikallio, & Luck, 2014; Punkanen et al.,
2017) DMT short-term group intervention produced a positive outcome, indi-
cated by the statistically significant decrease in the BDI scores of the 21 partici-
pants. Assessed on the basis of their BDI scores mean, the participants’ moder-
ate depression alleviated to the level of normal mood.
In the treatment of depression, DMT can be identified as an option within
non-pharmaceutical therapy to patients, who do not feel able or do not wish to
focus exclusively on talking about their problems. The research on the use of
DMT in the treatment of depression has consistently shown positive and en-
couraging results, but all the research has been done with small groups of sub-
jects. The field needs more high quality research.

1.4.1 DMT methods in the treatment of depression

Zubala (2013) found in her dissertation ”Arts therapies in the treatment of dep-
ression”, that disconnection is an essential feature of depresssion. In arts thera-
py (DMT included as one of the modalities), the essential factors were reconnec-
ting with 1) self, 2) others, and 3) environment. This aim also can cause anxiety
and threat to the patient, and consequently it may evoke a tendency to retreat.
In therapy it is essential to balance this. Engagement, in Zubala’s study, was
understood as increased awareness of one-self and the other. Engagement was
found to be a positive change for depressed patients participating in arts group
therapy.
Gentle physical exercise, music, the therapeutic relationship, the use of
imagery, symbolism and methaphors, creativity and the use of non-verbal
communication and kinaesthetic empathy in particular have been considered as
the elements that enable the positive outcome of DMT for persons with depres-
sion (Meekums et al., 2015).
However, movement can be applied in multiple ways, and the methods of
DMT are varied and diverse. Thus a relevant question is, what specific DMT
methods have been found useful in the treatment of depression. Papadopoulos
& Röhricht (2014) report a successful use of manualised group body psycho-
32

therapy for depressive disorder. This manualised treatment consisted of 20 ses-

sions, bi-weekly, and the flow through the process was structured to four phas-
es: 1) creating a safe containing environment, 2) recognition, widening and di-
versifying the experience of emotion through movement and body experience
and 3) physical and cognitive re-evaluation in respect of individual’s life history
(conflicts, developmental needs, traumatic experiences) and 4) closure and inte-
gration of the perceptive, emotional and cognitive aspects of depressive disor-
der. The components for the activities during these sessions were movement
exercises and sensory awareness procedures that addressed self-awareness and
psychomotor activity level; exploring of psycho-motor activity, enacting and
transforming affective modulation; interventions focusing on bodily strength
and capabilities, working against gravity; and body-oriented psychological
work for processing individual life background and unmet needs in particular.
The group intervention for patients with depression presented by Pun-
kanen et al. (2014; 2017) also consisted of 20 bi-weekly sessions, 60 minutes long.
Each therapy session was structured with three phases: warm-up, thematic
work, and closure. The main DMT methods were dance-movement improvisa-
tions, body awareness exercises, and reflection through drawing/painting,
writing, and verbalization. There was orientation to personal space and body
awareness, interaction in pairs, and interaction in the whole group. Each thera-
py session began with a brief verbal discussion about the theme of the session;
participants reflected it through art picture selection and eventually in move-
ment. The themes were chosen on the basis of earlier clinical experience with
this population, and included exploration of boundaries, somatic resources
(core and periphery of the body), symbols, pleasant and unpleasant emotions,
mindfulness and body awareness, enriched movement experiences, and safety
and touch.
Lin & Payne (2014) present a structured method, The Body Mind Ap-
proach, TBMA™, which is an application based on DMT and was used for the
treatment of medically unexplained symptoms (MUS; a somatic symptom di-
sorder in DSM-V). These patients frequently have also depression and anxiety
symptoms. The rationale behind this treatment, which appeared beneficial in
the pilot study, is that the MUS symptoms are produced by dissociation and
conversion, as the patient cannot be sufficiently aware of some embodied, typi-
cally trauma related events in his/her life. The treatment consists of three pha-
ses: 1) connecting the body and mind through (gentle) physical activity and re-
laxation, 2) raising the level of awareness of the body, and of the inner and ou-
ter world by the application of authentic movement practice, and 3) finding ex-
planation for the body symptoms as the patients are verbalizing their experien-
ces through talking and writing in an interactional setting.
Depression and stress are often related in the individual’s experience.
Bräuninger (2014) found in her study that the improvement of quality of life
and reduction of stress were related with the use of psychodynamic-oriented
DMT, the Chace approach (shared, interactional movement improvisation in a
circular formation; allowing the synchronization of rhythm, space, and Effort),
 33

the combination of directive and non-directive leadership styles, and interper-

sonal closure. Also, those clients who performed dance improvisation, spatial
synchrony, synchrony in Effort and who received focused treatment sessions
during their participation in DMT, exhibited improved daily life and decreased
somatization symptoms. ‘Focused treatment sessions’ refers to the dance thera-
pist’s choice to focus on specific themes, emotions, or associations elicited by
the client or by the therapist’s response to their interaction.
Even though this present study focuses on adult depressed patients,
Bräuninger’s study (2014b) on the elderly is also relevant, as the elderly clients
in various treatment settings and structured therapy activities often suffer from
depression, anxiety, and suicidality. Dance movement therapists (n = 113) in
Germany, Austria, and Switzerland responded to a survey on the use of DMT
with the elderly population. Anxiety and depression were most frequently
treated with improvisation, everyday movements, guided exercises focusing on
grounding and breathing, Chace approach, and Circle Dances. Lack of energy
was treated by developing body awareness and by focusing on a movement’s
quality rather than its quantity. Awareness exercises were considered also to
lead to inner calmness, thus increasing energy levels. The limitation of this sur-
vey is that the usefulness of the intervention was only assessed by the therapists,
as no data was collected from the participants.
All the interventions mentioned above were grounded on the basic DMT
assumption, that body movement and psycho-emotional state are closely inter-
twined. Central features of a depressed condition are low energy level and fa-
tigue, bound body posture, experience of easily permeable body boundaries
and often pains in the body. Bräuninger (2014b) reports dance movement thera-
pists’ practise-based understanding on what movement activities to use in or-
der to address those aspects:

• sense of body-boundaries: visualization can encourage self-perception.

Linking dysfunctional body parts to the rest of the body can create
a sense of wholeness. It is therefore argued that focusing on the
whole body helps to update self-image (body image) and strength-
ens the body boundaries.
• increase energy level / sense of self-efficacy: grounding exercises can
provide security. Furthermore, deepening movement impulses can
strengthen autonomy. As a result, Bräuninger (2014b) argues, crea-
tive dance and improvisation have the potential to expand personal
skills and independence. Expressive movement work can support
coping mechanisms. Using physical strength and resistance in a
concrete and playful way enables expressions of power and con-
structive aggression, stimulating resilience in a positive way.
• ease the body / release flow in the body: activities such as self-massage
can promote self-acceptance, while gradual movement flow can in-
vite relaxation.
34

These practices were reported as useful with the elderly population.

These research findings up to date portray the rationale for a DMT meth-
od choices as multilayered. The choice always happens in the context of embod-
iment and the unique therapy process of each group (or individual). The levels
for DMT intervention method choices can be perceived as body level, interac-
tional level and meta level. The Figure 1 summarises these levels.

METALEVEL
Integration
Mindfulness skills
Interconnectedness of the internal and
external world
Verbal reflection of experiences

INTERACTIONAL LEVEL
Safety
Engagement (re-connection)
Responsiveness
Attunement – to oneself and between per-
sons

BODY LEVEL
Grounding excercises
Sensing the body and sensory perceptions in
it; sensing breath
Body boundaries
Movement improvisation
Expressive movement

FIGURE 1 The level of rationale behind the chosen DMT method: Summary of the litera-
ture review on the DMT practice aiming at treating depression in the context of
embodiment.

Even though DMT is frequently practiced in individual sessions (see Zu-

bala & Karkou, 2015), all the studies found in the literature on the use of DMT
in the treatment of patients with depression were applying DMT in group for-
mat. This may link to the reality that by case studies of individual therapy it is
hard to present outcome results that are generalizable and carry strong validity
in scientific view. Another reason behind this phenomenon can be that in prac-
tice, DMT is often provided in a group form. Dance originally has been a com-
munal and social activity (Fralegih, 1987; Halprin, 2003; Hanna, 1987; LaMothe,
2015), which naturally emerged in interaction with others, in a group. When
 35

practicing DMT in a group, the impact of the therapy is not only in the move-
ment interventions or the therapist-client interactions, but it is the group that
also influences the participants’ experience and the outcomes of the therapy. In
group therapy, the central therapeutic features include instillation of hope, uni-
versality, corrective recapitulation of primary family group, developing sociali-
zig techniques, and interpersonal learning in the social microcosmos that emer-
ges in the group (Schmais, 1985; Yalom & Leszcz, 2005). DMT creates a setting
where participants can gather around the movement practice, and can create a
group that enables them to have an access to the therapeutic qualities of a
group and to explore social connectivity while attending to the embodied expe-
riences this environment elicits in them.


2 METHODS

2.1 Aims of the research

This research is practice-oriented therapy research. It was carried out by a clini-

cian, in a clinical setting, and the questions that gave impetus to the study had
their root in the practice of the treatment offered at a psychiatric outpatient cli-
nic, in the treatment of depression, and in the practice of DMT. In general, very
little of the clinical practice in health care has actually been explored by robust
clinical study (Newell & Burnard, 2011). There are two characteristic ap-
proaches of practice oriented research, namely patient-focused research and
practice-based evidence research (Castonguay, Barkham, Lutz, & McAlevey,
2013), and they are echoed in this study.

• Patient-focused research aims to produce knowledge for improve-

ment of the actual treatment as implemented and to develop tools
for achieving that task. The interest is at outcomes and the im-
provement of actual clinical practice. This often involves a focus on
particular diagnostic subgroup.
• Practice-based evidence refers to rooting the research into actual
clinical practice, and using the knowledge produced in that setting,
to guide the treatment choices and organizational policies.

There is also a concept of evidence-based practice (Gilroy, 2006). Evidence-

based practice is a political and social phenomenon, which origin and devel-
opment is related to government policies in health services. It is characterised
by a cycle of activities that seek to guarantee that interventions are effective and
based on rigorous research and to make certain that services are delivered in
the most efficient and economic way. Evidence-based practice evolves through
many cycles of activities, beginning initially directly from clinical work, via sys-
tematic observations of particular phenomena, which then can be accompanied
by development of associated theory. This should be followed by inductive,
 37

small-scale research projects on the treatment/practice, and finally, on the basis

of these, research with larger samples and more focused research questions can
be conducted. This dissertation serves the early stages in the development of
the evidence-based practice of DMT in the treatment of depression in Finland.
Both of patient-focused research and practice-based evidence have their
primary focus on the patient. Even when the research assesses the therapist, the
attention is at the therapist’s efficacy in delivering the treatment and promoting
positive change in the patient. This dissertation focuses on the experiences of
the patient by studying patients’ experiences of the DMT process, their expres-
sions of their body image, and their own assessment of their mood.
Treatment efficacy is not the only relevant question. As depression has
such a wide occurrence in the population, it is highly important to enrich the
choices of effective treatments available to persons with depression. The health
care system has to be able to offer deep understanding of the phenomenon of
depression and to be able to respond to different kinds of treatment needs ac-
cording to the individual, the severity of depression, and phase of depression
recovery. This dissertation aims to contribute to these efforts. In a broader view,
it is important, that research in mental health not only studies treatment outco-
me, but also contributes to understanding mental health problems and explores
them in a social, cultural, and political context (Gilroy, 2006). Embodiment, tak-
en as a base in this study, creates a view to social, cultural, and even political
context of depression.
This dissertation brings into attention and under study a fairly new treat-
ment method in Finland. DMT has been developing since the 1940's in the USA
and Europe. In Finland it has been appearing since 1960's and it has been in the
years of 2000 that the profession of DMT in Finland has been developing with
increased volume. Research in DMT is much needed for the development of the
method, for developing its applications in Finnish health care, and for develo-
ping the professional identity of dance movement therapists. Also, research on
DMT is paramount to the profession’s participation in the interdiciplinary dia-
logue in the fields of mental health, therapy, and psychiatry.
When body, moving, and human embodiment are approached from the
perspective of DMT, the psychological, interactional, and emotional significance
of body is acknowledged. Culturally, it is pertinent to begin to recognize and
understand these aspects of embodiment, because they have great potential for
supporting human well-being, development, and health. Collectively, with this
information, the attitudes towards one's body could lead to more understan-
ding, acceptance, and collaboration, which would encourage a more positive
relationship to one-self. On a community level this information and these quali-
ties in relating to one’s body would be an essential support for mood and men-
tal health – a cost-effective way to tackle the challenge of depression through an
early intervention and supportive mental health attitudes. Thus, deepening our
understanding of depression can also be useful in the preventive mental health
work and in educating the genearal public on how to manage the risk factors of
depression and to promote supportive everyday life habits and interactions.
38

2.2 Research questions

The general goal of this dissertation is to develop the understanding of the met-
hod of DMT in the treatment of depression. Specifically, this is done through
the concept of body image: by exploring the concept theoretically and observing
how body image is appearing in the movement experiences of the patients. The
body image concept serves as a tool for organizing information and clarifying
focus on the available literature and research material. Understanding the con-
cept of body image builds the theoretical basis for understanding the changes
DMT treatment may elicit in a patient.
Broadly speaking, this research evolves around the research questions of 1)
what are the contents of the body image for the patients suffering from depres-
sion, and 2) what are the emergent themes in the DMT group process with pa-
tients with depression? Table 2 summarizes the research questions linked spe-
cifically to each substudy.

TABLE 2 The research questions of this dissertation.

Study Title of the research Research questions

1. The dance/movement therapy A qualitative pilot study: In the therapist’s ob-
group in a psychiatric outpa- servations, what are the general themes that
tient clinic emerge in DMT group processes with de-
pressed patients?
2. Body memory as a part of body Are the concepts of body image and body
image memory valid and applicable in studying the
embodied experiences and DMT process expe-
riences of the patients with depression?
3. A dance movement therapy Does the DMT group treatment alleviate the
group for depressed adult out- symptoms of depression when quantitatively
patients in psychiatric care: assessed by self-evaluation measurement tools?
Effects of the treatment
4. Change in body image among What is the body image of patients with depres-
depressed adult outpatients sion like and does the DMT treatment produce
after a dance movement therapy changes in their body image?
group treatment What are the patients’ experiences of the DMT
group intervention? What features in the DMT
interaction are relevant to their experience?

The Study 1 begun the work by seeking to capture the general themes that
emerge in the DMT group processes with patients with depression. This was a
stage of familiarizing with the phenomena through the observations the thera-
pist had done while working with the DMT groups. The Study 2 utilized the
concept of body image and sought to find out, how it appears in DMT group
participants’ experience. These two studies prepared the way for the Studies 3
and 4, where the research subjects, participating in DMT groups, provided data
on their body image, symptom change, and feedback about the experience of
the DMT group. The goal was to find out, with the same subjects, does the DMT
 39

treatment alleviate the symptoms of depression, and how this is portrayed in

their body image. The participants’ personal experience of the DMT groups was
studied in order to find out, what appears as relevant in the participants’ expe-
rience, as this probably is shaping their change.
The root question underpinning this study has been, what is responsible
for therapeutic change amongst the patients with depression participating in
the DMT groups. This is a broad systemic question, and this study can provide
answers, which are incomplete but still, the answers may help in developing
better treatment for patients with depression.

2.3 Chrystallization

The choice of the research method is based on the research topic: a method that
best contours the topic, is chosen (Berrol, 2004). The general reseach traditions
of quantitative and qualitative research can be seen as traditions that can mutu-
ally enhance each other in mixed methods research. Mixed methods (Bergman,
2008), simply put, mean the combination of at least one qualitative and at least
one quantitative component in a single research project, i.e. in this dissertation.
Research can be interested in what happens, or interested in why something
happens and how something happens, exploring the underlying events. Re-
search can be utilizing measurable, observable phenomena to demonstrate the hu-
man experience. Research can seek to explore the internal process of experien-
cing via making it observable by some demonstrating tools. Berrol (2004) pro-
poses the shared goal in research, regardless of the paradigm, is to enrich the
body of knowledge by credible investigative research, through creative problem
solving and discovery. In this dissertation, the researcher aims to make a pro-
ductive blending of the arts of dance and therapy with science and to reach in-
novative ways of making sense and offering representation of the research topic.
This dissertation pursues to offer thickly described, complexly rendered inter-
pretations of meanings about a phenomenon (body image) and a particular
group (outpatients with diagnosis of depression). More than one genre of wri-
ting is utilized in the substudies: theoretical analysis, narratives/vignettes and
reporting.
Triangulation is a central aspect behind the use of mixed methods. Trian-
gulation sets the different data sources and different methods of analyzing
them as means for validity checking, for recognizing the differences in the
construction of the experiences, and for finding complementary data (Ham-
mersley, 2008). In this dissertation, the substudies serve the triangulation.
Triangulation in this dissertation is adviced by the qualitative research
method of crystallization (Ellingson, 2009). Chrystallization is a qualitative re-
search method that acknowledges the embodied nature of knowledge, recogni-
zes the interactive role of the researcher in the process of knowledge production,
and aims to produce a thick description of the chosen phenomenon, covering it
from different angles. Chrystallization was originally introduced by a social
40

scientist Laurel Richardson, and the method has been used in the fields of edu-
cation, nursing, social work/human services, medicine, sociology, psychology,
and the humanities. Chrystallization encourages the view that science and art
are not separate opposites, but can be fruitfully integrated for the purpose of
creating more understanding of humans, of ourselves, and the world. Truth is
understood as partial, but at the same time, concrete, particular, and sensuous.
Truth is constantly in creation in the interactions.
As this present study is involved with the body and body experience,
chrystallization as a method fits the topic. In chrystallization, the body is not
considered neutral. Ellingson (2009) in her introduction to chrystallization
quotes Laurel Richardson: "Crystals are prisms that reflect externalities and re-
fract within themselves, creating different colors, patterns, and arrays, casting
off in different directions. " She was using this description as means to describe
the research method of chrystallization, but the same description applies to
body. Body also reflects externalities and refracts within itself in its responses
and the behavioral patterns that are shaped. Also, non-neutrality refers to the
relatedness of body; there is no unmediated experience, bodies reflect the rela-
tions between the individual and the environment, and we socially construct
our perceptions.
In this study, the central site of the data collection has been the setting of a
DMT group, where the researcher has been a participant as a therapist. The par-
ticipants/subjects have also been involved with their body and embodied re-
sponses, and the therapist-researcher and the participant subjects have pro-
duced verbal expressions of these experiences. This interactional situation cre-
ated an embodied practice, which influenced the creation of the therapeutic ex-
perience, representations, and the responses to the DMT-group intervention; i.e.
the outcome (Johnson, 2014). Chrystallization perceives knowledge production
always as a mind/body/spirit enterprise; this is a key characteristic of this
study as well.

2.4 Participants

All the substudies of this dissertation have their root in clinical, embodied DMT
practice. The four studies were completed at the same public health care outpa-
tient psychiatric clinic. The articles presented in this dissertation are based on
interactions with a total of 74 adult patients, out of which 62 participated in and
completed DMT groups during the years 2007-2013 at the psychiatric outpatient
clinic. The age range of the participants was 21-61 years.
Study 1 explores the therapist’s observations of the processes of five DMT
groups with 33 patients. Study 2 describes the experiences gained from one
DMT group process of eight patients. Study 3 presents data from 21 patients
who participated in DMT groups, and 12 patients who were in a control group.
Study 4 deepens the scope of study of the same 21 patients whose data as DMT
group participants was presented in the Study 3. In these ten DMT groups, the-
 41

re were 13 patients who dropped out from the group at the beginning or in the
middle of the process. In the Study 1, in the first five groups, there were three
patients who participated in several group periods.
All the patients participated in the DMT groups voluntarily. The subjects
for the Studies 2-4 gave their written concent for participating in the research.
For the Study 1 no concent from the patients was obtained, as the idea to study
the group processes arose after the five therapy processes were completed. The
therapist’s notes of the therapy sessions had been written with the focus on faci-
litating the therapy process, not considering research intentions. Study 1 explo-
res in retrospect the observations from the therapist’s view and shares her theo-
retical and reflective understanding of the therapy processes. As no concent
was obtained from the participants afterwards, particular attention is placed on
keeping the patients’ protected, and filtering the information, which could
promote therapy work, through the therapist’s experience.

2.5 DMT group treatment

The same therapist facilitated all the DMT groups this research is based on.
There was no other dance movement therapist working at the clinic. The
ground rules for the group facilitation were confidentiality, respect for the body
and experience, and no harming of one-self or others. The basic principles the
therapist followed in the group facilitation were:

• supporting the safety in the body by paying attention to grounding in the

movement, body boundaries (personal space and contact of the body
with the environment via its surface), the respect for personal space, and
the mover's position as a modulator of his/her own movement
• supporting the sense of agency by emphasizing the choices made in move-
ment, paying attention to the ways one uses one's body in movement
and interaction, recognizing the resources the body offers
• supporting mindfulness skills by paying attention to the experience of the
body sensations, movements, and states, fostering the ability to verbalize
these as well as the emotions and imagery relating to the body sensations
• being attentive to interaction by paying attention to body responses in the
group interaction situations, acknowledging the impact of expectations
and anticipation on the body responses
• fostering the interaction by being present and attentive to others, seeing
and hearing them as they are, respecting the body experience, and en-
countering via shared movement qualities

The DMT groups were not manualized, i.e. there was no definite pre-set
task for each therapy session. However, as the facilitator was the same therapist
in all the groups, the way of working and the selection of DMT techniques was
similar through out the processes. She utilized the same session structure- and
42

themeplans she had used in the earlier groups, and modified them in accordan-
ce with the particularities of the present group, i.e. according to the themes and
needs the group expressed in the session.
In Study 1 the group processes for five groups were 10 x 90 mins. In the
Study 2 the group process was 15 x 90 mins. In the Studies 3 and 4, the group
processes for four groups were 12 x 90 mins. The groups had their sessions once
a week. The variations in the amount of sessions were due to the clinical practi-
ce. Initially the 10-sessions period was provided, but it begun to seem short for
the group process to evolve. Thus a longer 15-session group was offered. This
was a good structure, but it was difficult to continuously actualize it in the time
pressures of the clinic. A 12-sessions structure was a practical compromise.
On the average, in these ten DMT groups 7-8 patients started in a group
and six patients completed it. The drop out rate was on the average 1, ranging
from 0-3 patients. The number of sessions the patient was participating in the
group was on the average 8/10, 13/15 and 11/12, when counting the partici-
pation of those patients who completed the group.

2.6 Data collection tools

Chrystallization promotes the use of various approaches to the topic. This re-
search utilized qualitative and quantitative data collection tools as follows:

• Study 1: the therapist’s notes of therapy processes

• Study 2: the therapist’s notes and the patients’ written feedback
• Study 3: the self-evaluation measurement tools
• Study 4: the body image assessment in a dialogue and written format,
the patients’ poems, and written feedback

The notes of the therapy processes were the central data source in the Study 1
and also relevant in Study 2. After the lived moments of a DMT group session,
the responses in the practice have been stored in a verbal and written form. No
videorecording was used in this research, because video was not part of the
usual clinical practice. The therapist always wrote notes on the therapy process
after each session. She desrcribed the group’s activity and interaction, partici-
pants’ responses, narratives and metaphors, her perceptions of the energy level
and mood of the group.
The feedback was one data collection tool in the Studies 2 and 4. The feed-
back was requested by a questionnaire and the participants provided their ref-
lections of the process in a written form. These texts are valuable, because they
store the participants’ experiences and their explicit expressions of their expe-
rience. This gives a voice to the participants and expresses their expectations of
the therapy process, their meaning making, their challenges, and resolutions
(McLeod, 2013). The feedback questions were:
 43

• What were your main expectations of the DMT group?

• Did the DMT group meet your expectations?
• During the process, did something change in your experiences, your
condition or in your relation to the group?
• What was important and meaningful in the group?
• What was difficult?
• What felt irrelevant?
• What was given too little space or attention in the group?
• Any other comments?

The poem was one more qualitative data collection tool in the Study 4. The
poem was a home assignment between the second last and last DMT session.
The participants were invited to write a poem with the following instructi-
on: ”In your own way, please write a poem of your own experiences in the
DMT group; what was important and central for you.” The poems were discus-
sed and responded to in movement in the last therapy session.
Body Image Assessment (BIA), utilized in the Study 4, is a body image as-
sessment tool based on the tri-partite model of body image (Pylvänäinen, 2003;
2010). Table 3 presents the BIA structure. BIA was developed during the years
of this dissertation project in the clinical practice while seeking for efficient
ways to gain an understanding of the patient’s relationship to his/her body,
his/her interactional characteristics and his/her body memory. The findings
and understanding that emerged from the Studies 1 and 2 quided the structu-
ring of BIA as well. The information BIA provides is relevant in understanding
the patient’s current situation, his/her problems, and the central needs and
goals in the treatment. This is useful information in the patient’s treatment in
general, and in planning his/her participation in a DMT group in particular.

TABLE 3 Body Image Assessment (BIA) structure

Question Tri-partite model aspect

A. How do you perceive your body and its appearances? image properties
B. What is it like for you to take physical action? body-self
C. In your body, how do you typically sense or feel your body-self
everyday interactions with others?
D. What is the basic mood like in your body when you body-self
are by yourself?
E. Do you have bodily memories of moments, when you body memory
have suffered or felt ill at ease? Please give an example
of such a memory.
F. Do you have bodily memories of moments when you body memory
have felt good and enjoyed? Please give an example of
such a memory.
G. What is important for you in your body? integrative personal evalua-
tion; relationship to the
body image
44

The application of BIA can happen in an interview dialogue with the pa-
tient or s/he can respond to the questions in writing. In a dialogue, with the
interviewer’s further questions, the responses are richer. When responding in
writing, patients typically are shorter in their expressions. BIA responses can be
analyzed both qualitatively and quantitatively. Quantitative analysis is based
on the negativity-neutrality-positivity of a response, and it provides a score
range from 0-2 for each of the questions A-D and a sumABCD score ranging
from 0-8. The questions regarding body memory and the integrative evaluation
of one’s relationship to one's body were omitted from this scoring system. Body
memory naturally contains positive and negative contents, and these contents
change gradually over the years, thus scoring body memory contents by a nega-
tivity-positivity scale does not produce relevant information and change cannot
be detected in short measurement intervals. Question G, ”What is important
for you in your body?”, inquires about the person’s beliefs and opinions, and
specifically those, which the person finds important. This biases the responses
towards positive contents, and thus the negativity-positivity scale is not appli-
cable on it.
The Study 3 focused on research material from a quasi-experimental de-
sign (Kazdin, 2003) on 21 DMT participating subjects and 12 treatment-as-usual
subjects, who replied to self-evaluation measurements three times: before the
intervention, 12 weeks later i.e. after the intervention, and after 12 weeks fol-
low-up period. The self-evaluation measurements were:

• BDI-II – Beck Depression Inventory II (depression), score range 0-63

• HADS – Hospital Anxiety and Depression Scale (depression and
anxiety), total score range 0-42
• SCL-90 - Symptoms Check List- 90 (general psychiatric, physical
and psychological symptoms); GSI (general severity index) was
used and its range is 0-4
• CORE-OM – Clinical Outcomes in Routine Evaluation – Outcome
Measurement (global distress), score range 0-40

These self-evaluation measurements have been used in earlier research on dep-

ression, psychotherapy outcome, and DMT (Jeong, 2005; Punkanen et al., 2014).
They are also often used in the clinical practice.

2.7 Analysis methods

In the Study 1, the analysis of the therapist’s therapy notes was thematic: the
therapist-researcher read and re-read the texts in order to recognize central
themes that they presented regarding the body image and the therapy expe-
rience. Initially, the guiding questions were:
 45

• what did the therapist record from the patients’ description of their
experience of their body?
• how was the body image reflected in the experiences and expres-
sions?
• what did the DMT group offer to the participating patient?
• what was relevant in a DMT process – what goals/ the-
mes/issues/patterns seem to emerge again and again?

The same thematic analysis on the therapy process notes was applied in
the Study 2, emphasizing on the observations on body image and body memo-
ry. In the Study 2, also the participants’ feedback was qualitatively analyzed
from the view point of body image and body-memory: did the feedback reflect
these contents, and what the patients had experienced as relevant in the therapy
process?
In the Study 3, presenting a quasi-experimental design with DMT and
treatment as usual (TAU) groups, the quantitative data from self-evaluation
measurements was analyzed with the statistical softwares SPSS and MPlus. The
guiding questions for the analysis were: indicated by the self-evaluation scores,
what was the level of distress and depression in the sample before and after the
intervention period, and at the follow-up; and how significant the change was
statistically and clinically? The number of subjects (DMT n = 21, TAU n = 12)
was small, and thus the statistical analysis was limited to measuring the statisti-
cal significance of the differences between the DMT and TAU groups (Wald test)
and effect sizes (d).
With the DMT-group participants in the Study 3, it was also possible to
analyze the correlations between self-evaluation assessment scores and Body
Image Assessment scores. This analysis allows to respond to the reasearch ques-
tions whether there are any changes in the symptoms of depression after a
DMT-group treatment, and how the body image is relevant in depression. This
analysis was part of the data reported in the Study 4.
In the Study 4 the Body Image Assessment (BIA) was the primary data
collection tool. Qualitatively, the analysis of responses aimed to find the central
themes emerging, portraying what is typical to the body image of the patient
with depression. In both dialogue and written format it was possible to detect
whether the BIA response reflected a negative - neutral- positive content. Utili-
zing the scoring for the questions A-D, it was possible to calculate statistical
averages (i.e. means), statistical significance of the differences between pre- and
post-intervention assessments, and correlations of BIA scores with other as-
sessment measuremets, i.e. the self-evaluation measurements. With the qualita-
tive and quantitative analysis of of BIA, it was possible to respond to the re-
search questions, identify the contents of the body image concept and speculate
on the causes of therapeutic change in DMT group, if change was discovered.
In the Study 4, analyzing the poems was organized by utilizing creatively
the Laban Movement Analysis for the text material. This choice was motivated
by the need to maintain connectedness to a movement based approach as the
46

poems arose from embodied movement experiences. The Laban Movement

Analysis Efforts, i.e. the elements of Flow, Space, Weight, and Time (Bartenieff,
1980; Hackney, 2002) provided a vocabulary, which was applicable both on the
embodied experiences and the verbal contents of the poem-texts. To the aut-
hor’s knowledge, this application of the Laban Movement Analysis is new.
Finally, in the Study 4, the DMT group participants’ feedback was ana-
lysed question by question (see 2.6 Data collection tools). Particularly, informa-
tion about participants’ experiences of the participation in the group and of the
outcome of the group was sought after, and reflected with the information that
emerged from the poems and BIA responses.

TABLE 4 Methods summary for the Studies 1-4

Name Subjects Lenght of Data collecti- Analysis met-

N intervention on tools hods
age
1. The dance/movement 33 10 x 90 min Therapist’s Qualitative
therapy group in a psychiat- process notes thematic
ric outpatient clinic 21-61 5 groups
2. Body memory as a part of 8 15 x 90 min Patients’ Qualitative
body image feedback, thematic
20-59 1 group therapist’s
process notes
3. A dance/movement ther- 21 12 x 90 min BDI-II, Quantitative:
apy group for depressed (DMT) SCL-90, Wald test
adult outpatients in psychi- 20-59 4 groups HADS, Effect size
atric care: 12 CORE-OM
Effects of the treatment (TAU)
22-55
4. Change in body image 21 12 x 90 min Body Image Qualitative
among (DMT) Assessment thematic
depressed adult outpatients (BIA), Quantitative:
after a dance movement 20-59 poem, correlations of
therapy group treatment 4 groups patients’ scores
feedback

2.8 Ethical questions and trustworthiness

This is a practice-based research. The substudies 3 and 4 received an ethical ap-

proval the City of Tampere Research Board. The plan for the Study 2 was con-
sidered as a development project for the clinical practice. It was assessed and
accepted by the board Psychiatric Clinic of Tampere City. Study 1, focusing on
the therapist’s experience, was initiated and created after the clinical encounters,
and at that point the approval for presenting the work was requested from the
clinical supervisor.
 47

Due to its grounding in clinical practice, the study has certain limitations.
There was no randomization of the subjects into research groups and the num-
ber of research subjects was small in each study. The researcher was also the
therapist. The research subjects were real patients seeking treatment for their
depression, and the data was collected from DMT groups that essentially aimed
to respond to the patients’ treatment needs, not to the needs of the study. Thus
there is variation in the exact contents of the group processes: the length of the
treatment interventions ranges from 10 to 15 (90 mins sessions), and the actual
themes and practices in the sessions resonated the group process.
Ethical treatment requires that the patient has privacy in the therapy pro-
cess, and yet at the same time, research demands detailed, systematic data col-
lection and attention to the therapy process. A research project in a clinical prac-
tice required balancing between these. A central balancing tool was time: collec-
ting the data in the clinical practice in a systematic way and analyzing it only
after the therapy process was over. The author took first on a therapist role, la-
ter a researcher role. This was the feature in all the studies, but especially in the
Study 1 as the research idea arose after the clinical work was completed.
In the Studies 2-4, patients were informed about the research prior their
commitment to the DMT group. They received a written information sheet
about the study in question, and in the DMT group intake interview they re-
search was discussed. Patients knew they could withdraw from the study and
the DMT group if they felt a need to do so, and their treatment would continue
otherwise. The patients signed a written concent to participate. The intake in-
terview content and the summary after the DMT group were written in the pa-
tient records. For research purposes, the therapist kept the group process notes
of all the DMT groups, body image assessments, the patients feedback (Study 2
and 4) and poems in locked storage, and without social security numbers.
When the body image assessments, feedback, and poems (Study 4) were trans-
ferred into electrical form (doc-files), the patients received a pseudonym in the
Study 2 and a research subject number in Study 4. The same research subject
number was used in the Study 3 when scoring the participants responses to
self-evaluation measurement questionnaires. The electrical files are kept protec-
ted data storage spaces, and are only in the researcher’s use.
Subjective perspective in this study is present in how the patients describe
their experiences, and it is also present in how the therapist observed the thera-
py process. It is also present in scientific thinking in that subjectivity directs the
attention of the researcher. Reflectivity and the effort to promote neutral obser-
vation and clear desrciption of the experiences is cultivated in DMT process and
in qualitative research. The transparency this brings can make the subjectivity
more openly expressed and thus known.
The selection of literature that is studied and referred to in the research
constitutes one aspect of the quality and ethicalness of the research. The choices
for literature are shaped by relevance, applicability, availability, coherence, and
limitations of time in a sense that it is not possible to review all the published
information, which is linked to the research topic.


3 OVERVIEW OF THE ORIGINAL STUDIES

3.1 Study 1: The dance/movement therapy group in a psychiatric

outpatient clinic

This study presents clinical experiences gained in the practice of DMT at the
psychiatric outpatient clinic. It summarizes the essential process themes from
five different DMT group processes, 10 x 90 min, which involved 33 patients
who suffered from depression, anxiety, and pain problems. This study was a
pilot: it explored the first five DMT groups provided at the outpatient clinic,
focusing on how the patients experience their body (body image) and the DMT
group.
The theoretical grounding for applying DMT was searched from interper-
sonal neurobiology. In DMT, the limbic system and right hemisphere processes
are naturally activated and connected with, as the focus is on non-verbal affec-
tive signals, facial expressions, gestures, and observing body states. The integra-
tion of the information processing in the right hemisphere of the brain and in its
networking to the left hemisphere shape the intersubjective relationships the
individual creates. DMT is perceived as a method that works from “bottom-up”:
eliciting interaction on the body-centered level creates an interactional space,
which allows right brain to right brain communication between the interacting
persons. Right brain focused connection means connectedness through move-
ment and body sensitivity, and it is essential in creating an intersubjective at-
tachment bond. The bodily-based and often implicit communication is seen as
the core of the change mechanism at the unconscious level in the therapeutic
alliance (Schore, 2007; 2012). DMT, promoting movement experiences, internal
attunement, and enhancing the body-self, allows a creative method to explore
and integrate the contents of the right hemisphere.
The attentiveness and sensitivity to movement experiences in the DMT is
similar to mindfulness; it is one practice of mindfulness. Mindfulness consists of
three streams of awareness (Siegel 2007):
 49

• direct sensory experience – i.e. the sensation of one’s body and per-
ceptions
• the conceptual stream – i.e. thoughts, words
• the observer – the inner observer, inner witness that stays present
to what is happening

This is also a practice of internal ‘being-with-the Self’. It promotes connected-

ness to the body-self. It is proposed it can have similar beneficial effects on the
person as the attuned interpersonal interaction has. From a state of resting,
yielding, and connecting with the body-self and in a relationship, a creative
reaching-out can emerge.
The therapist-researcher’s notes of the therapy processes revealed a three-
phase pattern in the therapy process. The basic phases of 1) beginning, 2) mid-
dle process and 3) end could also be characterized as 1) positive expecta-
tions/experiences, 2) shadow and 3) resolution.
At the beginning, in this outpatient psychiatric clinic, the groups ex-
pressed a wish to experience safety and belonging into the group, sharing
movement and thoughts, playfulness, integration of mood and body, observing
one’s body, learning to relax while others are around, coping with pain, reliev-
ing anxiety and tension, finding a calm mind and joy of dance, discharging
emotions, and discovering one’s femininity in a positive way.
The process phase, shadow, presented the uncomfortable, unpleasant sen-
sations, discomfort and anguish that related to body and movement experiences.
The themes included tiredness, lack of energy, anxiety, emotional and physical
pain, a sense of difficulty in being in the group and interaction, aggression, de-
mands and feelings of guilt, memories of troublesome past interactions and re-
lationships, and negative and critical image of one-self. The groups needed to
work their way through these themes in movement and words, eventually cre-
ating some resolutions with them. The movement work often was oriented to-
wards moderating the movement qualities, searching for a more neutral and
safer experience of the body or searching for a movement based transformation
of the emotional state. This was done in a mindful way, essentially holding a
sense of acceptance: there was an intention to be open to perceive without
judgement whatever arises in the experience and awareness, to simply explore
and observe. This is one way to release suffering.
Regarding the relationship to one’s body, the central themes in the group
processes were sensitivity and threat vs. safety. At the core of the trouble in be-
ing in one’s body, being one-self, appeared to be the question of body sensitivi-
ty and difficulties in coping with it. The body was overly sensitive or its oppo-
site, numbed. The trouble was two-fold: how one was willing to encounter
one’s sensitivity and what the sensitivity brought up for the individual.
Sensitivity related to the issue of threat vs. safety in the being-in-the-body.
The groups needed to work through questions such as: what brings safety,
what movements can a group member experience as safe to herself, what quali-
ties of space create safety, what distance feels safe, what sounds feel safe. The
50

group needed to learn about the safety and how it was maintained in order to
be able to tolerate to observe also the sensations, emotions, and imagery that the
individual in the group perceived as suggesting threat. This work was essential-
ly done on the body level, as it was the embodied experience that was attended
to and supported towards sufficient sense of safety.

3.2 Study 2: Body memory as a part of body image

To theoretically better comprehed the psychological significance of embodied

experiences, the concepts of body image and body memory in particular were
the topic of this study. The manifestation of body image related expressions
was studied in one clinical DMT group of eight female patients, who participa-
ted in a DMT group of 15 x 90 mins (once a week). This study served three dif-
ferent purposes:

• Exploring the validity of the body image and body memory concepts by
studying how their contents can be perceived in individuals’ experiences.
• Using body image and body memory as concepts with which to organize
and clarify the significance of a participant’s experiences.
• Using body image and body memory as concepts with which to organize
and clarify the group process.

Body memory is a bodily resonance in relation to some lived experience.

In this study, Kandel’s (2007) neuroscientific findings were applied as a theore-
tical basis for the body memory. Kandel has studied implicit, procedural me-
mory: habituation, sensitization, classical conditioning, perceptual, and motor
skills. The response patterns, that are created by a living body, begin by sensory
information received by the sensory neurons, which is then combined with ac-
tion execution by the kinesthetic, motor neurons. Between the sensory and mo-
tor neurons are modulatory interneurons, which transmit the information from
sensory neurons to motor neurons. The learning experiences modulate the func-
tioning and connections of the modulatory interneurons. Fundamentally, this is
integration of sensory, tactile, proprioceptive, and motor (efferent) information,
which is the essence for an organism’s ability for intelligent action. This action
can be modulated by information from the environment and the organism’s
own state. The body-self responds and acts in the here and now, building on the
information from body memory: the habits, the learnt thresholds and response
patterns. For example, tension patterns are one way for the body memory to
shape the state and responses of the body-self.
In the DMT participants’ experiences the body memory related themes
were reflected as narratives about their embodied sensations and emotions,
about their lived experiences. The more we – the group participants and me as a
therapist - moved and observed ourselves in movement, the more information
 51

we had, which opened the access to the body memory contents. This process
elicited different kinds of responses, emotions, and thoughts.
For the individual participant, the body memory related material was eli-
cited by different stimuli: by a movement pattern (e.g. rolling), by a movement
quality (e.g. a quality of tempo in the interactional movement), by an interac-
tional response which was related to coping (e.g. how a tempo was a means to
adjust to others), and by emotional responses in an interactional situation. Often
body memory emerged in a subtle way, intertwined with the body-self in the
present, reflecting the life history and the way of being in one’s body; it was
presented in the habitual patterns of sensing, mood, and bodily state.
At the end of the DMT group process, participants’ verbal, written feed-
back reflected how they explicitly recognized and embodied their changes. The
release of tension from the body, a need to also talk about the lived experiences,
recognition of one’s typical social interactional roles and responses such as
withdrawal vs. engagement or different ways of expressing emotions were is-
sues that the participants had observed and also changed during the process.
Consciously connecting with the contents of the body memory supported body-
self to create new patterns and ways of relating with the environment.
The work around these body memory related themes was an organic part
of the therapy process. For this to happen, the therapy process needed a safe
space. The group presented already at the start of the process, what they would
welcome in the group, what they perceived as a goal for the group, and what
would the good space be like. The good space would provide sense of safety,
physicality, emotion, gratifying interaction, tolerance of difference, acceptance
and change, and adventuring into something unknown which could be nou-
rishing. All this relates to secure and attuned interaction, which enables the in-
dividual to explore and integrate the experiences.

3.3 Study 3: A dance movement therapy group for depressed

adult outpatients in psychiatric clinic: Effects of the treat-
ment

This study focused on the question, does a DMT group alleviate the symptoms
of depression. The research design was quasi-experimental. There was no ran-
domization of the participants. Four DMT group processes of 10 x 90 mins, in-
volving 21 patients, produced the data for the study. Also 12 patients who re-
ceived treatment as usual (TAU) at the psychiatric clinic, responded to the set of
self-evaluation questionnaires, which were used in the study: BDI-II, SCL-90,
HADS and CORE-OM. The measurements were applied at the start (pre-
measurement), after the 12-weeks intervention time (post-measurement) and 3
months after the end of the intervention (follow-up measurement).
The participants of the study were adult patients at an outpatient
psychiatric clinic. The majority of the patients suffered from moderate or severe
52

depression, according to the doctor’s assesment. Their depression was recurrent

and/or chronic type: for the majority of the participants, four or more years had
passed since the first episode of depression. Most patients participated in the
study at a point where their current treatment period had lasted less than a year,
typically less than 6 months. All the patients in the TAU group used antidep-
ressive medication. In the DMT group, 57% of the patients used antidepressants
and 43% did not. Patients in the TAU group typically had participated in a
psychoeducational group during their treatment but not in psychotherapy. In
the DMT group, it was characteristic that the patient had earlier gone through
psychotherapy (57% of the DMT participants), but had no experience of a
psychoeducational group (81% of the DMT participants). All the patients (97%)
had experienced significant relational stress either in their past (childhood) or in
their current life situation.
The questions for the data analysis were: indicated by the self-evaluation
scores, what was the level of distress and depression in the sample before and
after the intervention period, and at the follow-up; and how significant the
change was statistically and clinically. At the pre-measurement, the TAU group
had statistically significantly more severe depressive symptoms in BDI-II and
CORE. There was no statistically significant difference between the TAU and
DMT groups in the SCL-90 and HADS scores at the pre-measurement.
Symptoms (SCL-90) decreased more in the DMT group than in the TAU
group during the study period (Wald test = 8.73, df = 2, p = 0.013). SCL-90
scores changed statistically significantly differently in the DMT and TAU
groups during the intervention time (Estimate = -0.425, p= 0.011) but not during
the follow-up (Estimate = 0.031, p = 0.086). In the HADS scores, during the in-
tervention time the scores changed statistically significantly differently between
the DMT and TAU groups (Estimate = -6.295, p = 0.024), but not during the fol-
low-up (Estimate = 0.741, p = 0.714).
The self-evaluation scores indicated, that DMT group produced more dec-
rease in the depressive symptoms than the treatment as usual (TAU) (see Figure
2). With-in DMT group the effect size range was d = 0.57- 0.92. With-in TAU
group the range was d = 0.02 - 0.47. DMT vs. TAU comparison yielded values d
= 0.60 – 0.97. In with-in group comparison, effect size was considered small
when d = 0.50, medium 0.8 and large when d = 1.1. In between-group compari-
son, effect size of 0.2 was considered small, 0.5 medium and 0.8 large. Effect size
indicates the clinical significance of the change. In this study, the effect sizes of
the DMT group ranged from small to medium, indicating clinically favorable
outcome from DMT. For TAU group the effect size range indicated small or
very small change.
 53

1 DMT
DMT
0,8 DMT

0,6 DMT
TAU
0,4
TAU TAU
0,2
TAU
0
BDI-II HADS SCL-90 CORE
FIGURE 2 The differences in outcome with-in DMT and TAU groups as expressed in d
values of the change between pre- and post measurement in the scores of the
self-evaluation questionnaires.

There was no statistically significant difference between the score changes

of the DMT-no-medication and DMT-with-medication subgroups. Thus DMT
appears to be effective whether the patient was under antidepressive medica-
tion or not. At the post-measurement, assessing the clinical significance of the
changes after the intervention period, the best improvements in the condition
appeared in the group of DMT participants who were without antidepressant
medication. In this group, the effect sizes ranged from d = 0.56 to d = 1.07, i.e.
from small to large. The effect sizes in the pre- follow–up measurements com-
parison ranged also from small to large, d = 0.62 - 1.10. The condition of the
DMT-participants using antidepressants had also clearly improved, but not so
close to a normal condition as for the DMT-participants without antidepres-
sants.
The results of the self-evaluation inquiries indicated that DMT is beneficial
in the treatment of depressed patients. The analysis of the results encourages
the use of creative, interactive, psycho-physical therapy intervention of the
treatment of depression. This study gives evidence that DMT offers a suitable
social structure to be utilized in health care for promoting interaction, the expe-
rience of relatedness, and learning through experience. The patterns of score
changes of individual patients show, that promoting positive change and recu-
peration in milder depression happens more likely. Thus, an effective and
committed treatment of depression as early as possible, i.e. responding to mild-
er, early signs of depression, is wise. The relevant element of the treatment is
supporting the connectedness to the lived body.
54

3.4 Study 4: Change in body image among depressed adult out-

patients after a dance movement therapy group treatment

The view on depression, taken in this study, holds the assumption that the total
body-mind condition, the embodied response patterns and the implicit, proce-
dural information individuals use in their behavior, attachment and affordances,
are relevant in depression and its rehabilitation. The study of the body image
contents and their change by a DMT process was expected to demonstrate,
what is the quality of the body image in a depressed patient and how it can
change. This study aimed to answer to the research question, what the body
image of patients with depression is like, and what is the impact a short-term
group form DMT treatment can have on their body image.
Grogan (2008, 3) defines body image as “a person’s perceptions, thoughts
and feelings about his or her body”. Study 4 was applying the tri-partite model
of body image. Body image refers to the lived experience contained in the body
and the psychological significance of the body. Body image holds our intercon-
nectedness in an embodied way. Body image is the umbrella concept for our
implicit, procedural information, which relates to our motor, social, and emo-
tional response patterns and the beliefs we have about our body. Attachment
and affordances are embodied and learnt predispositions to responding.
Mindfulness is an attentional skill that supports the connectedness to the
body image. Mindfulness promotes being present, aware, and open to the expe-
rience in a non-judgemental way. It is based on the awareness of one’s body,
and breath in particular (Michalak et al., 2012). In DMT a central locus of action
is to be attentive to the movement experiences and to develop the skills to be
conscious and reflective of them – i.e. to develop mindfulness - and to narrate
about them in words.
Safety of the DMT setting relates essentially to the possibility of fostering
interoseption and self-aware consciousness. When the interactional situation is
safe, it welcomes the orientation to one’s own bodily sensations and experiences.
When the interactional situation presents non-judgemental interest towards
these, body-awareness and self-aware consciousness in the present can develop.
This is the core of mindfulness as well.
In earlier studies, it has been observed that certain body image characteris-
tics are typical to persons with depression. Rosenström et al. (2013) found a link
between chronically elevated dysphoria and body image dissatisfaction. De-
pressed individuals characteristically show muscular tension, shallow breath-
ing, lack of energy, a predisposition of exhaustion and loss of sensory aware-
ness (Papadopoulos and Röhricht, 2014; Stötter et al., 2013). When early child-
hood attachment experiences have been marked by insecurity, and the individ-
ual suffers from depression, it has been observed that these persons are typical-
ly lacking mindful body awareness (Segal, Williams, & Teasdale, 2002).
This study focused on the patients who participated in DMT group inter-
vention (n = 21) and the qualitative material produced by them during the ther-
 55

apy process (12 x 90 mins). The participants had a Body Image Assessment (BIA)
(50-60 min) at the intake to the group, replied to the same body image related
questions after the intervention, wrote a poem at the closure phase of the thera-
py process, and completed a feedback form at the end of the therapy process.
To inquire the research questions of this study, the qualitative text materi-
al was organized according to the themes that emerged from the responses.
Positive, negative, or neutral perception regarding the body image was detected.
The words in the poems were associated to Effort (Flow, Space, Weight and
Time) elements’ themes, and this enabled a movement-oriented reflection of the
content of the poems, allowing an indirect access to recognition of the relevant
elements of therapy process and change.
In the Body Image Assessment (BIA), prior the DMT intervention, experi-
encing lack of energy, encountering the environment as difficult, and lacking
direction in one’s action describe the qualities of the patient’s relationship with
the environment as experienced in the body-self. The fragmentation of the body
image and shallow consciousness of one’s body reflect difficulty within one-self
and in one’s body, i.e. difficulty in an intra-personal relationship. Pain and dif-
ficulty to have a repose reflect the strain and stress the patient experiences cur-
rently, or has learned and is habituated to by his/her earlier experiences. This
also relates to an imbalance in the autonomous nervous system. Worry about
weight can reflect the social norms and expectations related to the image prop-
erties aspect of body image. Weight concerns can also relate to a stress state in
the body, as stress causes dysfunction in the systems modulating appetite and
digestion.
After the DMT-group intervention, the changes in the body image could
be observed in the participants’ responses. The acceptance of one’s body had
improved. The positive valence of physical activity was strengthened. The par-
ticipants were better able to consciously identify something positive in their
embodied experiences of interaction with others. The majority of the partici-
pants were able to relate something positive in their embodied mood when
alone. This can be seen as a reflection of more comfortable settling into one’s
own body. Participants were better able to relate in a validating way to their
body memories. Regarding the pleasurable body memories, half of the recol-
lected moments of pleasure related to the other and the experience of related-
ness, proximity and connectedness with him/her. After the DMT-intervention,
the participants valued in their body:

• Health: balance, strength, ability to function, well-being

• Ability to listen to one’s body: ability to perceive the body state, the situ-
atedness and condition of the body
• Respect of the body: allowing the body to be expressive, having the op-
portunity to interact with the environment by one’s body, carrying out
actions in a way that enables well-being in the body
• Peace: relaxedness, balanced being, free breathing, inner calm
56

Utilising a scoring system on the BIA, based on the negativity-neutrality-

positivity of the responses relating to body-self and image-properties, it was
possible to convert the responses into numeric score. BIA -scores indicated large
effect sizes in the change between pre- and post-intervention assessments. Also,
after the intervention, the structured self-evaluation inquiries (BDI, SCL-90,
HADS, CORE-OM) indicated alleviation in the symptoms and improvement in
the condition in this group of subjects. Statistically, the positive body image
change had on the average a predictive power of 33% on the symptom scores
improvement. Change for the better in body image predicted fewer depressive
symptoms at the follow-up measurement.
In their feedback, the participants’ own assessment of the significance of
the changes during the therapy process revealed that four (21%) patients con-
sidered the changes insignificant. Three patients (16%) considered something
relevant had changed but they continued to lack some aspect of change; for ex-
ample the group felt safe but the participant did not perceive change in his/her
mood. The majority of the patients, twelve (63%) felt that there had been posi-
tive changes during the process. These positive changes were:

• Improvement in condition: less sleeping problems, more positive percep-

tion of one’s body, decrease or cessation of anxiety, improved activity
level
• Lessening of tension
• Strengthening of feeling safe
• Recognition of one-self and one’s state: finding one-self, recognizing
physical experience and its influence, strengthening of trust in one’s
body, modulating one’s action on the basis of observations from the
body
• Strengthening of interaction: better tolerance for other people, courage to
approach others and to be more active in interaction, positive experience
of peer support

In their feedback on the process of the DMT group, participants consid-

ered the presence, peer support, encounters, and non-judgmental attitude to be
important. According to the written feedback, focusing on the body, an oppor-
tunity to share and discuss one’s experiences, and the development of the skill
to observe the body were the wise approaches the group promoted.
The DMT group also presented challenges to the participants. At times,
they had found it difficult to focus on the other or in one-self in the interaction.
Pair work, sharing experiences verbally and telling about one-self (in the con-
text of the present experiences) felt difficult especially at the beginning of the
group process. In verbal expression, it was particularly effortful to speak about
what one perceived in the body and how one felt in the body. Finding and cre-
ating own movement felt troublesome at times. These challenging aspects were
also the aspects in which or through which the participants developed during
the therapy process.
 57

Rehabilitation of depression, healing and personality development in-

volves an increase in self-awareness, which can occur in a state of sufficient
safety and acceptance. The focus on the body, the interaction and sharing in a
safe group created a sufficiently supporting and enabling space for the partici-
pants in this study. The non-judgmental approach and the interest towards the
embodied experiences offered a validation of the participant’s presence and
commitment. Essentially, this was a validation of the body-self. This kind of
validation constructs the base for trusting one’s body, perceptions, and assess-
ment. It can develop the person’s ability to be conscious of his or her way of
perceiving the internal and external environment and relating with it. Essential-
ly, the therapeutic space of a DMT group aims to promote qualities of secure
attachment (Siegel, 1999; 2007): presence, attunement, responsiveness, modula-
tion of emotions, communication, and reflection. This can enable the change in
the body image. The body image itself begins to have more of the characteristics
of secure attachment.
Analyzing this research material elicited a notion that attachment style is
not only applied on external relationships, it is also applied in the ways the in-
dividual relates to his/her body and the internal environment the body consti-
tutes. It seems, the style of relating to the external and internal world enhance
each other and also can extravagate the strains caused by an insecure attach-
ment style. The attachment style is embodied; it is also coded in the body re-
sponses and sensory patterns. The site for change is the present moment and
the body; awakening the notion that one can make choices about how one re-
lates to the information from the body.


4 DISCUSSION

4.1 Conclusions answering the research questions

This research project had two broad questions: 1) what are the contents of the
body image for the patients suffering from depression, and 2) what emerges in
the DMT group process with patients with depression. These questions were
used as tools to explore the therapeutic change in the DMT group, if change is
discovered.
Regarding the body image, patients with depression expressed tiredness,
lack of energy, anxiety, emotional and physical pain, a sense of difficulty in be-
ing in the group and interaction, aggression, demands and feelings of guilt,
memories of troublesome past interactions and relationships, and negative and
critical image of one-self. Before the DMT intervention, the patients’ body im-
age presented the encountering with the environment as difficult and lacking
direction in one’s action. These qualities resonate the patient’s relationship with
the environment as experienced in the body-self. The fragmentation of the body
image and shallow consciousness of one’s body reflect difficulty within one-self
and in one’s body, i.e. difficulty in an intra-personal relationship. Pain and dif-
ficulty to have a rest reflect the stress the patient experiences currently, or has
learned and is habituated to by his/her earlier experiences. Chronic stress re-
sponses also relate to an imbalance in the autonomous nervous system.
On the basis of the four substudies, what were the general themes that
emerged in DMT group processes with depressed patients? The studies showed
that the patients recognize a need for constructive and reciprocal interaction, as
they expected the DMT group to offer safety and belonging in the group, shar-
ing movement and thoughts, playfulness, integration of mood and body, learn-
ing to relax while others are around, and finding a calm mind and a joy of
dance.
In the DMT process, the essential themes were body sensitivity and threat
vs. safety. At the core of the trouble in being in one’s body, being one-self, ap-
peared to be the question of body sensitivity and difficulties in coping with it.
 59

This was connected to the issue of threat vs. safety in the being-in-the-body. The
body was overly sensitive or its opposite, numbed. The trouble was two-fold:
how one was willing to encounter one’s sensitivity and what the sensitivity
brought up for the individual. This feature of the therapy processes connects
with the body image issues, i.e. how one relates to the embodied experiences.
Fundamentally, the integration of sensory, tactile, proprioceptive, and mo-
tor (efferent) information, is the essence for an organism’s ability for intelligent
action. This action can be modulated by information from the environment and
the organism’s own state. The body-self responds and acts in the here and now,
building on the information from body memory: the habits, the learnt
thresholds, and response patterns. Tension patterns are one way for the body
memory to shape the state and responses of the body-self. These phenomena
are explored in the DMT process.
In the DMT participants’ experiences of the body memory related themes
were encountered in movement and reflected in narratives about their embo-
died sensations and emotions, about their lived experiences. Consciously con-
necting with the contents of the body memory supported the body-self to create
new patterns and ways of relating with the environment. The concepts of body
image and body memory as one aspect in body image were useful in the DMT
process. They clarified the recognition of relevant information from the pa-
tient’s experience and from the therapy process. Frequently, the patients reflec-
tions of their experiences of the therapy process pointed at interactional needs
and patterns. For example, many expressions in the patients’ poems expressed
the transitioning from the initial strain in the lived body to a better oriented and
better connected relation with one’s embodiment, which then produced a more
positive tone to one’s mood and being. After DMT group process, participants
were better able to relate in a validating way to their body memories. Regarding
the pleasurable body memories, half of the recollected moments of pleasure in
body and life related to the other and the experience of relatedness, proximity
and connectedness with him/her. These are features that are associated with
secure attachment.
At the end of the DMT group process, participants’ feedback reflected
how they had recognized and embodied their changes. The release of tension
from the body, a need to also talk about the lived experiences, recognition of
one’s typical social interactional roles and responses such as withdrawal vs.
engagement or different ways of expressing emotions were issues that the par-
ticipants had observed and also changed during the process.
After the DMT intervention, the patients’ body image contained more pos-
itive contents intra- and interpersonally. Intra-personally, the acceptance of
one’s body had improved. They had begun to appreciate the ability to perceive
the body state. They recognized more the situatedness and condition of the
body. The majority of the participants were able to relate something positive in
their embodied mood when alone. This can be seen as a reflection of more com-
fortable settling into one’s own body. The positive valence of physical activity
was strengthened. Interpersonally, the participants were better able to con-
60

sciously identify something positive in their embodied experiences of interac-

tion with others. They expressed certain respect and valuing of the body in in-
teractional situations: allowing the body to be expressive and appreciating the
opportunity to interact with the environment by one’s body. In these ways, the
participants’ sense of agency had improved.
DMT elicited change in the depressed person’s mood. It was evident in the
self-evaluation score change patterns: the symptoms alleviated. The self-
evaluation scores indicated, that DMT group produced more decrease in the
depressive symptoms than the treatment as usual (TAU). With-in DMT group
the effect size range was d = 0.57- 0.92 (small to medium). With-in TAU group
the range was d = 0.02 - 0.47 (very small – small). DMT vs. TAU comparison
yielded values d = 0.60 – 0.97, depending on a measurement tool, and in favor
of the DMT group. To compare to earlier studies, in the Koch et al. (2007) study,
where the intervention was a sigle DMT session, the effect size was small (d =
0.46), when measured by a HBS/HSI subscale of depression. In the Röchricht et
al. (2013) study the intervention was 20 bi-weekly sessions, and the outcome
was measured by HAMD total score. The effect size was medium (d = 0.96). A
comparison to Cognitive Behavioral Therapy (CBT): Hoffmann et al. (2013) con-
cluded in their meta-analysis, that CBT for depression was more effective than
control conditions such as waiting list or no treatment, with a medium effect
size. Cuijpers et al. (2010) published a meta-analysis on the use of CBT and oth-
er psychological treatments in the treatment of adult depression, assessing the
publication bias on the efficacy results. In this meta-analysis the result was, the
mean effect size was 0.67, which was reduced after adjustment for publication
bias to 0.42 (51 imputed studies). A meta-analysis by van Straten et al. (2010),
studied the depressed patients with medical conditions, and with this popula-
tion the CBT treatment produced a small effect size (d = 0.42).
The question, what features in the DMT interaction were relevant to the
participants, brings together the questions about the body image and the thera-
py process. At the end of the treatment period, participants reported positive
changes: less sleeping problems, more positive perception of one’s body, de-
crease or cessation of anxiety, lessening of overtension, strengthening of feeling
safe, improved activity level. Participants described a better ability to recognize
physical experience and its impact, an increase in trust in one’s body, and expe-
riences of modulating one’s action on the basis of observations from the body.
Simultaneously, the participants found better tolerance for other people, cour-
age to approach others and to be more active in interaction. Also, there was a
positive experience of peer support, which was important to the participants.
The poems echoed the positive interactional experiences the participants had
had in the DMT group. Overall, when the quality of body image improved, the
psychiatric symptoms tended to decrease. Positive change in body image at the
at the end of the DMT group treatment predicted a reduction in symptom sco-
res from pre-measurement to three-month follow-up.
 61

4.2 The relevant aspects of DMT in the treatment of depression:

Modulating stress, safety, interaction, dialogue, and creativity

As a clinical practice-based research, one of the aims of this research project was
to understand better, clarify, and improve treatment that can be provided to the
patients with depression. Doing this research has shaped a practical-theoretical
view on humans, DMT, and depression. Individual is an idivicible dual, a
complex, dynamic, and adaptive mind-body system, which is engaged in an
exchange between the internal and external world. DMT aims for a practical
application of human embodiment for the goal of improving well-being and
integration. DMT methods relate to the body itself, to individual’s awareness
(mindfulness), to interaction, and to knowledge the individual has about
his/her situation. Essentially, DMT methods work around initiating and
strengthening safety within the body and in the interactional situation. If dep-
ression is understood as a state of systemic distress arising from the overload of
difficulties and stressors in the exchanges between internal and external world,
then addressing the embodied responses that are created, offers a path to work
on the central phenomena in the individual’s depressed condition. DMT pro-
vides an experiential setting for interactions that activate in the individual’s be-
havioral patterns - which also are neurological patterns - and allow their re-
shaping and modulation.
Earlier studies (Andrew & Thomson, 2009; Carver, 2001; Gross, 2006;
Kuhlman, 2013) have shown that patients with depression have experienced
relational stress and embody behavioral coping mechanisms, which do not alle-
viate the relational stress. Also, the patients participating in the substudies of
this dissertation have expressed difficulty, anxiety, and embodied experiences
of tension in interactional situations in their everyday lives. Stress response in-
volves embodied reactions and autonomous nervous system activation. Coping
with stress calls for managing embodied stress response, which essentially re-
quires behaviors that support the body, produce change in the body state, and
change in how the person relates to his/her embodied state. Increasing
knowledge and awareness of the characteristics of the information processing in
stress response can also support the individual in coping with stress response.
The recognition, that stress response in not the only option in responding, but
instead, there is also the option of playful exploration and social connecting (see
Panksepp, 1998), which is concretely practiced in DMT, can provide the indi-
vidual with more behavioral choices in everyday life.
Stress causes a condition where the individual's self-organization becomes
challenged. If the challenge can be managed, the self-organization develops fu-
ther and coping improves (Cozolino, 2002; Huether, 1998). If the stress exceeds
the capacities the person has for coping, the person eventually may begin to
loose his/her ability to self-organize and thus the actions with the environment
and relatedness to self deteriorate (Fogel, 2013). DMT introduces activities to
reduce stress, i.e. to calm the body, and to calm the autonomous nervous sys-
62

tem, essentially, to create safety. This enables the path from distinction into par-
ticipation. Safety makes participation more possible, thus the sense of agency
and body image begin to have a chance to change towards integration.
DMT elicits interaction on the body-centered level and creates an interac-
tional space, which means opportunity for connectedness through movement
and body sensitivity, which is essential in creating an intersubjective attach-
ment bond. The bodily-based and often implicit communication is seen as the
core of the change mechanism at the unconscious level in the therapeutic alli-
ance (Schore, 2012). DMT, promoting movement experiences, internal attune-
ment, and enhancing the body-self, allows a creative method to explore the con-
tents of this body-based, implicit communication and to integrate the contents
of the right hemisphere. Also, movement is a broad channel to use, as a very
large part of the human nervous system is specialized to process sensorial and
kinesthetic information (Cozolino, 2002; Medina, 2008). What is needed, is the
development of coordinated and integrated connections in the nervous system
through experiences.
The playful exploration is possible only in safety and in sufficiently safe
interaction (Winnicott, 1971). Thus in DMT, safety is essentially important.
There needs to be a sufficient sense of physical, emotional and psychological
safety. The therapist’s task is to communicate safety on all levels:

• to guard the safety of the therapy room (privacy, comfortableness,

commitment to accurate therapy time),
• to verbally express the ground rules that create safety, namely con-
fidentiality, respect of the body experience, non-harming, and each
participant’s right to move the way that is suitable to him/her,
• to express and model non-judgementality, acceptance, and respect
of the participant and, in particular, his/her embodied experiences
and movement; this is reflected in the non-verbal behavior as well
• to allow space to be and support grounding
• to be capabable in sufficiently supporting the patient in the mutual
affect regulation; attunement

Safety and interaction are interconnected; they mutually enhance each

other. In safety there is a possibility for freedom and exploration, which allows
a richer, more flexible information processing and action possibilities with the
other and environment. Thus the individual’s experience of affordances gains a
more positive tone. In DMT this is learnt through experiences - bodily activities,
interactional responses, settling into the body and self – and thus the process
creates new embodied learning for the participant. The process allows the par-
ticipant to discover his/her relationship to the sensitivity of the body. Also, in
safety the behavioral responses and patterns can become explicit, and thus ex-
plored and understood in integrating and more conscious ways.
Interaction is about action in the present, and dialogue is a specific form of
interaction as it also can involve reflection of what has happened a moment ago.
 63

Sufficient safety makes dialogue possible. In DMT group, there is interpersonal

dialogue, which particularly gives attention to sensory experiences and bodily
responses: movements and their qualities, body shapes, distances, and the feel-
ings, images, and memories relating to those. The participant learns to use this
kind of dialogue also in intra-personal dialogue, which increases his/her
awareness of what his/her embodied responses and state are. This awareness
decouples automaticity (Siegel, 2007) and allows space for choice making, for
example making subtle changes in movement pattern, body position, tempo or
other movement quality, which will then impact the individual’s experience in
the interaction.
Dialogue in the DMT context has an integrative nature; it integrates expe-
rience and information, emotion and cognition, sensory events and verbal ex-
pression, unconscious and conscious contents, inner and external world. Dia-
logue enables sharing, validation, and recognition of phenomena. When the
dialogue is rooted in the embodied experiences, it offers a practice to strengthen
the consciousness and connectedness to the self, to develop mindfulness skills.
All this is very much rooted in implicit information processing, i.e. body re-
sponses in perception, being, and action. In DMT body responses - movement,
changes in arousal, tensions in the body - are central in the interaction, and
skills to observe them, relate to them, and to communicate about them verbally
are developed.
Creativity is inherent in DMT. Creativity means the ability to see through
the tacit assumptions gained via implicit learning (Nachmanovitch, 1990). Crea-
tivity is learning to translate your sensations. Creativity arises from working
with what you have at hand, responding to it in new ways. Creativity is part of
improvisation, and improvisation is acceptance; what arises in the moment is
accepted and responded to. The moments of relaxation and quietude, that may
take place in a DMT session, allow space for creative insights to emerge, as crea-
tive insights and surprises often arise at moments of surrender and repose.
Nachmanovitch (1990) identifies the prerequisites of creation: playfulness, love,
concentration, practice, skill, using the power of limits, using the power of mis-
takes, risk, surrender, patience, courage, and trust. These are also present in the
creation of a therapy process.
Validation is one important aspect of interaction and dialogue. Validation
shapes interactional patterns. If an individual has not learned to perceive con-
sciously and validate his bodily responses, what are the consequneces? Embod-
iment continues even if one is not conscious about it. Thus, a lot of information
will be omitted from conscious attention. Like Nachmanovitch (1990, p. 174)
says, “we are beings of little consciousness and a lot of unconsciousness.” In
order to validate an experience, response or sensation, one has to become aware
of it. The sphere of consciousness enlarges as one becomes better able to stay
present to embodied responses.
64

4.3 Promoting secure attachment qualities promotes change in

the mood

After exploring the literature and the findings of the substudies, the conclusion
is that on many levels, change for the mood evolves around promoting the
characteristics of secure attachment. Some very relevant observations on at-
tachment arose during the studies included in this dissertation. Firstly, learning
is embodied (Kandel, 2006). Secondly, people’s experience of movement is more
positive when the movement quality combinations are congruent with attach-
ment-based actions (Koch, 2007; Pylvänäinen, 2012). Thirdly, depressed patients
are well able to identify what kind of interaction would be desired and support-
ive to them, and what they describe, is an interactional space characteristic to
secure attachment (Pylvänäinen, 2010). Fourthly, an intervention that includes
embodied action and characteristics of secure attachment based interaction does
produce positive change in the body-image and mood (Pylvänäinen et al., 2015;
Pylvänäinen & Lappalainen, 2018).
In practice and in action, a dance movement therapist is conscious of
his/her aim of using gestures and elements of non-verbal communication,
which support the connection and attunement in interaction. This begins al-
ready at the intake interview. The interview also cognitively prepares way for
the work as the relationship to the body is discussed through the questions re-
lating to body image and the central issues of the DMT group. The central
themes in the group are: strengthening the safety of the body, supporting agen-
cy, mindfulness skills, supporting and attending to interaction, and learning
about the body image. Initially, the question is, how the patient feels and thinks
about these themes. Beginning to discuss these issues helps the patient to cogni-
tively orient to the body and movement in ways that are new to him/her in or-
der to support his/her motivation and personally connecting with the group,
and moving in ways that s/he finds meaningful. A sense of meaningfulness
builds safety.
In the therapy process, the phases can be characterized as 1) positive ex-
pectations/experiences, 2) shadow and 3) resolution. The movement work often
is oriented towards modulating the movement qualities, searching for a more
neutral and safer experience of the body or searching for a movement based
transformation of the emotional state. This is a way to tolerate and modulate
the affect together. Mindfulness is a relevant quality in this, holding a sense of
acceptance: there is an intention to be open to perceive without judgement
whatever arises in the experience and awareness, to simply explore and observe.
This is one way to release suffering. Staying safely present is a feature of secure
attachment as well.
For the individual, DMT provides tools for creating, enhancing, and main-
taining a sufficient sense of safety in one’s presence and action, i.e. embodied
actions, which can actualize the secure attachment features. These tools are: giv-
ing consciously attention to space and one’s relating to the environment; distin-
 65

guishing the internal and external space and stimuli that arise from these; ex-
ploring grounding by sensing the body in movement and developing attention
to yielding (i.e. giving in, connecting with the supporting ground) as a part of
preparation for moving. Finetuning the sensing of the perceptions, which arrive
through different sensory systems, and sensing the different (movement) quali-
ties in responses, thus knowing the situation more cleary, can support safety. To
an individual, an experience of space can bring a sense of spacioucness and a
sense of having an accepting space to be, which can support the sense of safety.
Space can be related to distances to the other, and to setting boundaries. Experi-
ence of space can relate to direction in movement: suggested direction, self-
chosen direction, clarifying direction. Individual can discover options for direc-
tion, i.e. direct-indirect, expanding–shrinking, rising-lowering, expanding–
narrowing, opening–closing, retreating–proceeding (Bartenieff, 1980; Fernandez,
2015; Hackney, 2002). Learning to use these options in movement, learning to
consciously do them when needed, provides the individual with tools to man-
age one’s emotional state, stress, and actions in relation with the environment.
Also, naming the experience is a way to modulate the pressure a bodily sensa-
tion or bodily affect evokes (Block, 2007; Siegel, 2007). Returning to attending to
the bodily sensations can help cessate looping, ruminative thought processes.
A therapy situation is never free from anxiety. The challenges arise in how
to modulate and tolerate anxiety and discomfot so that the presence, explora-
tion, and responding can begin and continue – so that the interaction can begin
and continue. In therapy the aim is to develop this safety, but the challenges
come with the reality that people often have had a lifetime learning of insecuri-
ty. Individuals’ experience of safety in a same, shared situation can be different.
It may be, that at the same time as we work towards the security, we also need
to develop the tolerance and resilience towards insecurity, whether it is in the
internal or external world. That is a place where we need compassion. Using
attunement brings the qualities of secure attachment and compassion into the
interaction: orienting towards the other, opening towards him/her, respecting
personal space, kind facial expressions, synchronizing the tempo, and mirroring
the movement qualities. Yet there is a fine line: mirroring the patient is one way
to communicate attunement, but if the depressed qualities of the posture, ges-
turing, and movements are fully mirrored back, this tends to maintain the de-
presssed state. Therapist needs to neutralize the mirroring: communicate the
interest and orietedness towards the patient, but subsume the depressive quali-
ties. Therapist presents ”titered mirroring”, which aims to bring the secure at-
tachment qualities to the interactional moment, while at the same time creating
sufficient matching, sufficient attunement with the patient’s embodied de-
pressed state to promote interactional connectedness. When depression allevi-
ates, the therapist can increase the matching in mirroring.
66

4.4 Body image as a tool for understanding depression

When understanding and treating depression, body image is a relevant concept.

It can be used to clarify the patient’s condition and the relevant events in the
therapy process. Body image concept integrates the experiential contents of the
body and thus offers a view to the dynamic, bio-psycho-social, affective reality
of the individual. When systematically studying the body image of a person
with depression, it is possible to gain an understanding of depression that takes
into account the embodiment and interrelatedness of a human being, and how
these are altered in depression.
A cognition (a thought, a belief, a value), an affect, or a body response are
all phenomena of relating to something. Thus, the interest in body image con-
tents focuses the therapy, exploration, and learning on the patterns of being in
relation with the external and internal environment. This study showed, the
depressed patient’s body image is characterized by a sense of difficulty in rela-
ting with the environment, a sense of lacking direction, and lacking energy. The
depressed patient’s body image is fragmented, i.e. attention is given to particu-
lar body parts (e.g. head) or painful areas of the body or just one feature of the
body such as weight. There often is a shallow consciousness of one’s body, for
example the patient is not interested in noticing the body sensations or does not
have a habit of attending to them. Patients find it difficult to settle and have res-
toring rest. This is in line with the few earlier descriptions of the depressed pa-
tients’ experiences of their body (Micali, 2013; Michalak, 2012; Papadopoulos &
Röhricht, 2014).
Micali (2013) differentiates the depressed patient’s trouble in embodiment
into three types: a) disturbances mainly concurring the relation of the body with
the surrounding environment; b) disorders mainly related to the way in which the
body feels itself, c) disturbances mainly concerning the relation between own body
and the other's body (intersubjectivity). The tri-partite model of the body image,
i.e. image properties, body-self, and body memory can resonate these difficul-
ties. Each part of the model offers a slightly differently tuned sounding of the
person’s situation. Image properties can reflect the thoughts, feelings and ideas
relating to the body appearances and the relation to the environment, which is
shaped to some extent by the physical appearances of the body. Body-self ech-
oes the present moment condition and state in how the individual senses the
body - how the body feels itself in its relatedness to the surrounding environ-
ment and others. Body memory, synonymous to implicit memory, contains the
embodied learning from the interactions with the environment and attachment
relationships. What can be observed in these contents, what the patient express-
es in his/her body and movement responses, and what s/he can verbally nar-
rate about his/her experiences, offer direct information about his/her experien-
tial world and its characteristic patterns.
The task in therapy is to create interaction where intersubjective com-
munication and regulation can happen in increasing safety and attunement,
 67

and where the individual’s internal working models of interactions with the
environment (implicit, procedural memory) can be brought into consciousness
and be explored and reassessed (Schore, 2012). The information on the patient’s
body image is thus used in enabling the creation of this kind of interactional
space. Body image concept helps the therapist to be sensitive and attentive to
the patient’s expressions in an organized way. The body image concept offers a
containing shape for the information.
Body image contains a lot of information that originates from the body
and body responses. This information is organized and processed particularly
in the right hemisphere of the brain (Cozolino, 2002). Recognizing that an
asymmetry of the activity between right and left hemisphere of the brain is ty-
pical to the depressed patient, as well as poor connectivity of the limbic system
and right brain (see Punkanen, 2011), it can be assumed that therapeutic activi-
ties, which engage the body and elicit a narrative about the embodied experien-
ces, promote activation and integration of the limbic system, right brain, and
the interconnectedness of the left and right hemispheres. Hippocampus is vital
for conscious, logical, and cooperative social functioning. Amygdala is involved
in the emotional and somatic organization of an experience. Amygdala is
geared toward right hemispheric and down systems in the brain. Hippocampus
is biased toward left and up systems in the brain. When a person moves, creat-
ing a movement experience probably with some emotional valence, and then
discusses about his/her experience of it, the person has to bring together infor-
mation from hippocampus and amygdala, from both left and right hemispehric
systems.
It can be speculated, that the social brain gets naturally activated in social
movement interactions, which the DMT group session offers. In this study the
participants offered clear guidelines what they would find helpful in alleviating
their condition. These are the interactional contents that they identified:

• Sense of safety
• Sense of belonging into the group
• Sharing movement and thoughts; interacting with one another
• Playfulness
• Relaxing, relieving anxiety and tension
• Finding calmness
• Ability to listen to one’s body – ability to perceive the body state
• Allowing the body to be expressive
• Breathing freely

These are the landmarks that orient the therapy process for the depressed pa-
tients. These landmarks are very similar to secure attachment features and safe
interactional situation, and they are needed for building a better body image.
To actualize these may take time and commitment. It requires compassion and
reflection; it is a mutual effort of the participant(s) and the therapist. Improving
68

the individual’s connectedness and consciousness to his/her body image sup-

ports the alleviation of depression and carries the process onwards.

4.5 Clinical implications

The clinical implications of this study are three fold: 1) what new understan-
ding on depression did this study produce, 2) what features of the DMT practi-
ce could be integrated into general practice in psychiatry and treatment of dep-
ression, and 3) what considerations regarding the clinical setting arose in the
study?
In this study, actively searching for information on the embodied ap-
proach to human beings - on our being, interacting and information processing,
and on depression - did reveal that there is a substantial field of literature dis-
cussing these topics. Sharing knowledge on the role of embodiment is becoming
possible. Approaching depression from the perspective of embodiment, interac-
tion and responding, offers a more systemic understanding of depression. In
the context of a complex adaptive dynamic system (CADS), the recognition of
depressive symptoms can lead into growth rather than impasse, if the clinician
and the patient can perceive, what phenomena in the patient’s systemic life situ-
ation strain the sense of safety, maintain stress in the mind-body system and
lead to fragmentation in the body image, i.e. weaken the connectedness to the
self and thus the coordination of one’s being and behavior.
The improvement and integration in body image appears to be related to
safe interaction. Clinically, this invites a consideration on the interrelatedness of
depression and sese of safety; and this relates to the sense of affordances and
the typical attachment styles the person has acquired. The experiential learning
and developing mindfulness appear clinically significant features of DMT, simi-
larly to what is discovered in contextual cognitive behavioral therapies (Hayes,
Villatte, Levin, & Hildebrandt, 2011). Including DMT in the treatment of dep-
ression offers the patient the opportunity to experientially work on embodied
responses, body image, and ways of relating to one-self and others. The fin-
dings of the substudies encourage the use of DMT in the treatment of depressi-
on.
Considering how the general clinical practice can be informed by DMT,
the primary questions are, how to include the view of embodiment into the cli-
nical encounter, and how to create safety in the meeting between the patient
and the clinician. Body image interview (BIA) can be used as a part of the clini-
cal interview and assessment. It is a dialogue-based tool, and by a brief training,
also clinicians who are not dance movement therapists, could adopt it for their
use. This would support the inclusion of the perspective of embodiment and
interactional and experiencing body in the treatment. It would give information
on the patient’s attachment style, and help clarifying the essential themes in the
patient’s treatment. Also, inquiring about the patient’s experience of his/her
being and physical experiencing in the current life situation offers a way to
 69

communicate interest and validation of his/her own knowledge if his/her situ-

ation. This begins to build safety as well.
Applying the basic qualities of embodied attunement in the therapy en-
counters is always cruicial for building safety in the interaction. Orienting and
opening towards the patient, reaching for the eye contact, matching patient’s
tempo, synchronizing the gesturing, and fitting the tone of voice are basic ele-
ments of an attuned interaction. Clinicians can support the patient and the en-
counter by utilizing these in a respectful, kind way. Observational skills sup-
port the clinician in relating and interacting.
Safety is deeply relevant, as depression arises in a condition where there is
not sufficient safety in intra- and interpersonal experience, thus the mood and
sense of agency becomes jeopardized. People have different resiliency in their
sense of safety. This study indicates a general guideline that the therapy for a
depressed patient should provide the patient with tools to improve the sense of
safety. It may be, that the mindfulness skills, that have been applied in many
therapeutic interventions, are effective because they actually provide cognitive
and experiential tools to practice a settling that is naturally characteristic to a
safe intra- and interpersonal setting, i.e. secure attachment patterns. The charac-
teristics of a secure and attuned interaction, first modeled in a good enough
mother-child interaction, are similar to the characteristics of the moment of
mindfulness: acceptance, presence, openness to the experience and a sense of
connectedness, which brings pleasure.
Safety arises also from finding meaningfulness. DMT, as it typically is a
new intervention for the participants, requires the dance movement therapist to
be sensitive to how to enable the patient to make sense of the view offered in
the treatment encounter. It is important to offer an affectively attuned encoun-
ter, but at the same time, patients need to be able to connect the information
offered and the questions elicited with their own stance, values, and unders-
tanding. For example, in discussing the patient’s joining in a DMT group, one
way to proceed is to invite the patient to reflect the guiding principles of a DMT
group, i.e. safety in the body, sense of agency, interest in mindfulness skills and
attentiveness to the body sensations in particular, and orientation towards in-
teraction. Considering these themes also cognitively, initially as questions, pro-
vides the patient more entries to connect with these issues, which supports
his/her experiential exploration in the treatment, if s/he chooses to proceed
into a DMT group.
In DMT the inherent features of the activity are play and creativity. The
roots of the clinical significance of play and creativity are in acceptance and suf-
ficiently safe relationship, which eventually support the venture into explorati-
on. Winnicott (1971) emphasized these aspects already decades ago, and creati-
ve therapists have continued to bring creativity into clinical settings. Creativity
and play are allowed by sufficient safety, but they not only echo the external
relatedness. Creativity and play also reflect the intra-personal relatedness, a
broader way of information processing, which is enabled by the safety and ac-
ceptance. It can be assumed this is a natural way to promote new coordinated
70

neural connectedness, and to enhance those neural connections that integrate

emotional and cognitive information. Thus it would be valuable to find more
ways for the creativity and play to be present in clinical settings. This can be
challenging, as the present culture in clinical settings tends to value quick and
focused, task and goal oriented information processing and interaction.
The considerations regarding the clinical setting evolve around the featu-
res of the structure of the group form, especially the length of the group process.
The structure needs to balance the participants’ motivation to commit to a
group, the reality of staff resources, and the findings on sufficient length of
treatment for eliciting a clinically significant result. In this study the duration of
the DMT-groups (in Studies 3 and 4) were 12 x 90 mins, and the results were
positive, but the recovery from depression was not complete. The differences in
the severity of depression, use of medication, and participant’s life situation
contribute to this as well, but considering the factor of the length of treatment is
also a relevant question. The research on group interventions to treat depresssi-
on documents interventions, that typically have been 10-12 sessions. The effec-
tiveness has been similar to the individual therapy (Burlingame, Strauss, &
Joyce, 2013). However, there are also findings suggesting, that the patients, who
were at a dysfunctional level before the beginning of the treatment, needed a
much longer intervention in order to reach a clinically significant change: in
order to bring 70% of these patients to a level of clinically significant change,
more than 35 sessions were necessary (Castonguay et al., 2013). Yet,
Castonguay et al. also refer to another result from clinical trials literature re-
view, reporting that approximately 55% of the patients improved within the
average of 12.7 sessions. They continue the discussion by pointing to the reality
of clinical practice: the treatment actually received in health care produces an
average of less than five sessions, and the rate of improvement at the level of
20%. In light of these research findings, it seems fairly reasonable to offer in
public health care a group intervention of 10-12 sessions. It would be most ben-
eficial to offer it before the patient reaches a dysfunctional level. Those paritici-
pants, who initially are at dysfunctional level, should be offered an opportunity
to participate in two or three group periods sequentially. Thus the initial com-
mitment would not be too entangling, and eventually these patients would
have a sufficient length of treatment.
In the clinical setting, the pre-group individual interview and a report of
the participant’s process in the group are important communication tools. It is
beneficial to provide the patient with these documents. They can clarify the
process for the participant, offer once again a response to and a validation of
his/her presence and participation. These documents can support the patient in
his/her meaning making and commitment to his/her own well-being.
 71

4.6 Limitations

This study is a practice-based clinical study, which has evolved over several
years. The substudies have had their particular nature, and the shape of the
whole project has emerged during the process. The project was not clear and
planned at the very beginning of the first substudy. The progress of the project
has informed the next phases: what becomes possible to actualize in the re-
search in the clinical setting. The research plan for the whole work was getting
clearer at the time of the Study 2, and for the Studies 3 and 4, a research plan
was written and accepted by the City of Tampere Research Board and by
University of Jyväskylä.
A central limitation through all the substudies is the relatively small
amount of participants. The small abount of subjects in each study can bias the
findings on the basis of individual features. If the number of research subjects
was larger, the findings would be better validated, more reliable, and more ge-
neralizable.
The lack of randomization of the participants is another limitation of all
the substudies. In all the substudies the patients self-selected to the groups and
entered on the basis on their own motivation, which naturally varied from low
to high, but was on a sufficient level to get the patients involved with the activi-
ty. Because of the lack of randomization, and due to self-selection, it is not pos-
sible to rule out, that the motivational state of the participants influenced the
results. In the Study 3, this may have influenced the differences in outcome
between the DMT and TAU groups. One possibly significant difference bet-
ween the DMT and TAU group participants of the Study 3 was, that in the DMT
group 57% of the patients had earlier experience of psychotherapy process,
where as in the TAU group 12% of the patients had had psychotherapy. This
may indicate differences in the type of depression, as well as difference in the
patients’ capacity to benefit from treatment that is based on interaction, self-
reflection, and psychological processing of information.
Even though it can be perceived as a strentght of the study, that it was ac-
tualized in the reality of clinical practice, it also brought vagueness and varian-
ce to the data collection. This is particularly apparent in the definition
of ”treatment as usual” (TAU) in the Study 3. The participants in the TAU
group did not participate in the DMT group, but instead, used medication, had
individual appointments with varying frequency (typically not weekly, but on-
ce in every 2-5 weeks) and/or participated in psychoeducational groups fo-
cusing on managing the symptoms of depression or the tendency to set high
demands on one-self. The participants in the DMT group actually had some
features of the TAU in their treatment: the use of medication, and individual
counceling appointments once every 3-5 weeks. The key difference between the
groups was, that at the time of data collection, the DMT group participats re-
ceived DMT and did not participate in a psychoeducational group, and the
TAU group participants did not receive any DMT.
72

In the Study 4 the data collection tool, Body Image Assessment (BIA) was
developed for the purposes of this study, on the basis of the tri-partite model of
body image. This assessment tool is a way to collect data of the person’s body
image, as she or he perceives it and is able to describe it in words. Clearly, it is a
limitation, that an established well known body image inquiry/questionnaire
was not used. The reason for this was, that the body image questionnaires used
in research typically are based on the body image dissatisfaction-satisfaction
dimension, and on the symptomology of eating disorders. This approach to bo-
dy image does not fit well with the tri-partite model of body image. Originally,
the tri-partite model was presented in 1999 by Pylvänäinen (unpublished mas-
ter’s thesis, MCP Hahnemann University), and in her paper in 2003. The appli-
cation of the model in the clinical work has been developing for about 20 years,
but research is needed to document the observations and to seminate the model
into broader professional and scientific use. The researcher developed the BIA-
questionnaire through the DMT intake interviews she had done over the years
at the psychiatric clinic, but it was not formally piloted as a data collection tool
before the Study 4. At the moment, one of the central limitations of the BIA is,
that there is no research on how persons without health problems would res-
pond to its questions. This information would help in contextualizing the res-
ponses of the patients with depression.
Finally, in the Study 4, the connections between body image and depressi-
on, and body image improvement and the alleviation of depression were obser-
ved as correlations between the BIA- and self-evaluation score changes. Corre-
lation does not mean causality. It is true that the patients verbally reported
changes in their body image, at the same point of time as they reported self-
assessed changes in their mood. It is possible to infer reasons why DMT could
have contributed to the positive changes, but inferred reasons are not yet scien-
tific facts. In order to claim causality between the body image and mood chan-
ges for better, more research is needed to document the systemic changes pa-
tients with depression experience when they participate in DMT.

4.7 Research aspirations for the future

There are ample research needs in order to better understand the systemic na-
ture of depression, to develop best fitting DMT interventions for depression,
and to develop further the knowledge on body image and its relation to at-
tachment styles in particular. Essentially, what is needed is a study of these
questions with a larger sample of research subjects. This study has already been
initiated in Finland, at the University of Jyväskylä, as a collaboration between
the Department of Psychology, National Social Insurance Institution (KELA)
and the Finnish Dance Therapy Association.
During this present dissertation project arose the observation that the
body image reflects the attachment styles that have been identified in the pat-
terns with which individuals relate to others. The attachment styles can be se-
 73

cure or insecure (Schachner et al., 2005). When insecure, they can be avoidant,
ambivalent or disorganized. There seems to be a similar variation in how indi-
viduals relate to their own body, their internal world, and their embodied inter-
connectedness to the environment. Keeping in mind, that body memory is a
part of body image, and body memory holds the implicit learning from inter-
personal and constitutional encounters, it becomes understandable, that similar
choices would be applied in relatedness to the external and internal environ-
ment. The roots of the similarities between body image contents and attachment
style are in the experiences of interactional safety or the lack of it. Usually indi-
viduals present a melange of attachment styles - it is context specific to some
extent – yet some attachment pattern may be dominant or more typical to a per-
son than some other. Knowing that attachment style creates predispositions to
mental health problems, for example the avoidant attachment style has been
linked to depression, it becomes very relevant to recognize the attachment qual-
ity that is echoed in the individual’s body image. In a fairly concise body image
interview, the attachment style can be recognized in descriptions on how one
relates to one’s body, how one interacts with others, and what are the contents
of body memory that the person most easily can access. Exploring in more de-
tail, how the patterns in attachment and body image co-emerge, could provide
valuable systemic understanding on human mind and body and the reciprocity
of relatedness to the environment. Furthermore, it would be valuable to study
these body image related phenomena in different cultures.
The antidepressant medication has a dominating role in current recom-
mended treatment guidelines. In the Study 3 in this dissertation project, with a
fairly small amount of research subjects (total n = 33), the finding was that the
best improvement in the patient’s condition happened when s/he was not
using antidepressive medication and participated in DMT. In the Study 3 the
best alleviation in the depression, measured by the self-evaluation scores, was
with the DMT patients who were not using antidepressant medication. This
subgroup was small (n = 9), but their score means closely reached the level of
normal mood in the post-treatment measurement. In this subgroup, the within-
group pre to post effect sizes ranged from d = 0.56 to d = 1.07, i.e., from small to
medium. The effect sizes in the pre- follow–up measurements comparison
ranged from small to large, d = 0.62–1.10. At the pre-measurement, the mean
score differences were small (ranging from 0.15 to 1.41 points, depending on the
measurement tool) between the DMT participants using antidepressive medica-
tion and not using antidepressants. However, the difference between these sub-
groups was, that the patients not using antidepressants had had their first de-
pressive episode on the average five years ago, and the patients using antide-
pressants had had the first depressive episode on the average 10 years ago. The
mean duration of the present treatment period was 10 months for patients not
using antidepressants and 17 months for patients using antidepressants. These
findings, even though based on the data of a small subgroup, elicit important
questions about the timing of interventions and the early accessibility of treat-
ment, which would seem beneficial for the patient. Also, it is important to con-
74

tinue to research the impact of antidepressants in the patient’s ability to benefit

from psychotherapeutic and interactional treatment.
DMT is a field that is an unexplored terrain compared to for example cog-
nitive behavioral therapies. To develop DMT and its applications, it is necessary
to research it. It is an inspiring field to research, as it invites explorations into
complex, living and interacting mind-body systems, which self-organize. This
offers tasks of studying coordination, integration, and patterns in the context of
human action, struggles, and well-being.
 75

SUMMARY

This clinical practice-based, mixed methods research evolved around the follo-
wing research questions: 1) what are the contents of the body image for the pa-
tients suffering from depression, and 2) what are the emergent themes in the
DMT group process with patients with depression? These questions were ex-
plored in more detail by asking, were there any changes in the symptoms of
depression after a DMT-group intervention, and how the body image is rele-
vant in depression and mood change.
As a concept, body image refers to the multilayered experiential totality
we perceive within our body, about our body, and by our body. Body image
refers to the lived experience contained in the body and the psychological sig-
nificance of the body. Body image holds our interconnectedness in an embodied
way. The ways of relating and interacting with the environment compile into an
attachment style and individual ways of relating with affordances; fundamen-
tally, these are embodied response patterns, which constitute body image.
Tri-partite model of body image consists of body-self, body memory, and
image properties (Pylvänäinen, 2003). Body-self communicates and responds in
a physical way, i.e. by movement, by gestures and postures, by tensions and
releases, by activation and calming down in the present moment. The features
of emotional responding in a moment can be understood as expressions of
body-self. The continuous connectedness to the body-self is essential for mental
health. Body-self actualizes the individual’s relatedness to the internal and ex-
ternal environment in the present moment. Body memory is procedural, senso-
ry, and mostly implicit memory. Body memory functions as a continuous back-
ground for present, subjective experiences. Image properties are the set of be-
liefs, attitudes, and values the individual associates with his/her body and its
looks. These are culturally shaped and obtained in a social setting.
The identified symptoms of depression are low mood, loss of interest and
enjoyment, anxiety, disturbed sleep and appetite, feelings of guilt or low self-
appreciation, and also medically unexplained somatic symptoms (WHO, 2012).
Typically, persons with depression have experienced stress, particularly famili-
al and relational stress (Andrews & Thomson, 2009; Heikkinen, 2014; Kendler et
al., 1999; Kuhlman, 2013; Major et al., 1997). Depression has been linked to un-
deractivation of the approach system (Carver, 2001). Hayes et al. (2004) found
that higher levels of experiential avoidance is also linked with depression. Re-
search indicates that insecure, i.e. avoidant/dismissing or ambiva-
lent/anxious/preoccupied attachment style characteristically can be observed
in patients with depression (Siegel, 1999). Depressed patients have also dis-
turbed autonomous nervous system arousal patterns (Birkhofer et al., 2005;
Campbell-Sills et al., 2006; Shinba, 2014) and present a difficulty in segregating
emotional processing from cognitive and sensorimotor processing (Epstein et
al., 2010).
In depression, there is trouble in unification of one’s lived body, and a
sense of a gap between one-self and one’s own body (Micali, 2013). The depres-
76

sed person conceives his relation to the body in instrumental terms, not as a
responsive nor affective lived being and as a relationship. The body is no loger
a transparent, communicative site, but rather, an obstacle and a block on the
way between the individual and the environment. There is a withdrawal away
from the external environment into the closed, subjective immanent sphere and
a vanishing of intersubjective reciprocity in the encounter with the other (Micali,
2013; Ratcliffe, 2013). The body ceases to respond to the affordances of the sur-
rounding environment.
It has been discovered, that the brains of depressed persons frequently
present asymmetry between the activation of left and right hemispheres, and
decreased hippocampal volume (see Hözel et al., 2011; Punkanen, 2011). Hözel
et al. (2011) refer to stress as one possible reason for these malfunctions in the
brain structure. Stress causes the individual to reduce attention to internal in-
formation and focus on the external information instead (Cloninger, 2004; Fogel,
2013). According to Fogel (2013), the interoceptive information, i.e. information
about internal sensations in the body and arousal are transmitted in the nervous
system through the non-myelinated axons and thus the transmission of infor-
mation is slower. The information from the external environment and from the
proprioceptive system (stretching of muscles and ligaments, balance, movement
coordination) travels through a fast lane in the spinal cord and is thus dominat-
ing. This phenomenon may be one factor that enhances the lack of connectivity
between the right and left hemisphere of the brain, and the limbic system and
anterior cingulate, when the individual encounters stress. However, practicing
non-judgemental and observing attention to the information of the propriocep-
tive system, can provide means to develop and broaden the attentive skills to
the internal sensations and arousal, thus improving the connectedness between
various brain networks. Experientially this means improving connectedness to
one’s embodiment.
In terms of body image, this study revealed the patients with depression
experience a lack of energy, encounter the environment as difficult and sense
lacking direction in one’s action. These features describe the qualities of the pa-
tient’s relationship with the environment as experienced in the body-self. The
fragmentation of the body image and shallow consciousness of one’s body re-
flect difficulty within one-self and in one’s body, i.e. difficulty in an intra-
personal relationship. Pain and difficulty to have a repose reflect the strain and
stress the patient experiences currently, or has learned and is habituated to by
his/her earlier experiences. Worry about weight was quite often mentioned.
DMT is interaction based: exploring the embodied experience in the here
and now in the encounter between patient(s), therapist and the
dance/movement. DMT is a method to develop awareness of embodiment. The
theoretical basis of DMT provides knowledge that improves understanding of
the phenomena of embodiment. The practice of DMT offers to an individual an
experiential space where to explore, learn about, and integrate the embodiment.
The aspiration is to provide the individual with more behavioral choices in eve-
ryday life. In DMT body responses - movement, changes in arousal, tensions in
 77

the body - are central in the interaction, and skills to observe them, relate to
them, and to communicate about them verbally are developed. The central fac-
tors in the DMT treatment of depression are the modulation of stress response,
safety, interaction and dialogue. This process is carried on in the context of em-
bodiment and fuelled by creativity.
In this study, the groups’ expectations of a DMT group were a wish to ex-
perience safety and belonging in the group, sharing movement and thoughts,
playfulness, integration of mood and body, observing one’s body, learning to
relax while others are around, coping with pain, relieving anxiety and tension,
finding a calm mind and joy of dance, and discharging emotions. A good DMT
group space would provide sense of safety, physicality, emotion, gratifying in-
teraction, tolerance of difference, acceptance and change, and eventually also
adventuring into something unknown, which can be nourishing. All this relates
to secure and attuned interaction, which enables the individual to explore and
integrate the experiences.
A DMT group intervention (12 x 90 min) resulted in an alleviation of de-
pressive symptoms, as measured by self-evaluation measures (BDI-II, SCL-90,
HADS, CORE-OM) and in improved, more positive body image. DMT vs. TAU
comparison yielded Effect sizes of d = 0.60 – 0.97, depending on a measurement
tool, and in favor of the DMT group.
The effect sizes of the DMT group ranged from small to medium, indicat-
ing clinically favorable outcome from DMT. For TAU group the effect size
range indicated very small change.
After the intervention, a positive change was observed in the Body Image
Assessment (BIA). The body image change explained 30% of the improvement
in the self-evaluation measures scores. The more positive the Body Image As-
sessment (BIA) score, the lower the symptoms scores were at the post-
measurement. Also, the more positive the BIA was at the post measurement,
the lower the symptom scores at the 3-months follow-up measurement.
In their feedback, patients described their experiences with their body
with more positive quality. They had a more positive perception of one’s body,
improved activity level, lessening of tension, strengthening of feeling safe. They
recognized more themselves: a feeling of finding one-self, recognizing physical
experience and its influence, strengthening of trust in one’s body. They felt
more able to modulate one’s action on the basis of observations from the body.
Interaction became more flexible as the patients felt a better tolerance for other
people, courage to approach others and to be more active in interaction. The
positive experience of peer support in the group was relevant.
People have different resiliency in their sense of safety. In therapy, there
needs to be a sufficient sense of physical, emotional, and psychological safety.
In safety there is a possibility for freedom and exploration, which allows a rich-
er, more flexible information processing and action possibilities with the other
and environment. Thus the individual’s experience of affordances gains a more
positive tone. In safety the behavioral responses and patterns can become ex-
plicit, and thus explored and understood in integrating and more conscious
78

ways. The participant learns to use this form of dialogue also in intrapersonal
dialogue, which increases his/her awareness of what his/her embodied re-
sponses and state are. This awareness allows space for choice making, for ex-
ample making subtle changes in movement pattern, body position, tempo or
other movement quality, which will then impact the individual’s experience in
the interaction.
In DMT, the inherent features of the activity are play and creativity. The
clinical significance of play and creativity is in acceptance and sufficiently safe
relationship, which eventually support the venture into exploration. Creativity
and play also reflect the intra-personal relatedness, a broader way of infor-
mation processing, which is enabled by the safety and acceptance.
DMT experience can result in a better ability to recognize physical experi-
ence and its impact, an increase in trust in one’s body, and experiences of mod-
ulating one’s action on the basis of observations from the body. Simultaneously,
the participants can find better tolerance for other people, courage to approach
others and to be more active in interaction. This improves mood and alleviates
depressive symptoms. To summarize, DMT seems to enhance psychological
flexibility as the person becomes better connected with the embodiment and
more aware of the patterns and options embodied responding.
In the future, it will important to continue to study the body image and
the use of DMT interventions with a larger sample of patients with depression.
BIA (Body Image Assessment) is a useful tool in this research, as well as in the
clinical practice, when assessing the patient’s body image, ways of relating to
one-self and others, and the goals for the therapy.
 79

YHTEENVETO (FINNISH SUMMARY)

Tämän kliiniseen potilastyöhön perustuvan monimentelmätutkimuksen tutki-

muskysymyksinä ovat olleet: 1) mikä on kehonkuvan käsitteen sisältö ja 2) mi-
kä on keskeistä masentuneiden potilaiden tanssi-liiketerapiaryhmien prosessis-
sa. Näitä kysymyksiä tutkittiin tarkemmin selvittämällä, tuottiko TLT-ryhmä
muutosta masennusoireiluun, ja hakemalla tietoa siitä, miten kehonkuva on
relevantti masennuksessa ja mielialan muutoksessa.
Käsitteenä kehonkuva viittaa monikerroksiseen kokemukselliseen koko-
naisuuteen, mikä havaitsemme kehossamme, kehoomme liittyen, kehollamme.
Kehonkuva viittaa elettyyn keholliseen kokemukseen, joka kehoon tallentuu, ja
joka on psykologisesti merkityksellinen. Kehonkuvassa on kehollisina koke-
muksina ja reaktiotaipumuksina tallentuneena meidän vuorovaikutteisuutem-
me ympäristön kanssa. Tavat olla suhteessa ja vuorovaikutuksessa ympäristön
kanssa rakentuvat kiintymyssuhdelaaduiksi ja yksilön tavoiksi olla suhteessa
ympäristön tarjoamiin toimintapotentiaaleihin (affordances); pohjimmiltaan
nämä ovat kehollistettuja toimintatapoja, joista kehonkuva rakentuu.
Kehonkuvan voidaan katsoa rakentuvan kolmesta elementistä: kehoitseys,
kehomuisti ja olemusseikat (Pylvänäinen, 2003). Kehoitseys kommunikoi ja vas-
taa tilanteissa fyysisellä tavalla, eli liikkeillä, eleillä ja asennoilla, kehon jänni-
tyksillä ja kehon vapautumisella, vireystason nousulla ja laskulla. Emotionaali-
sen responssin ilmiöt nyt-hetkessä voidaan ymmärtää kehoitseyden ilmauksina.
Jatkuva yhteys kehoitseyteen on mielenterveyden kannalta olennaista. Kehoit-
seys todellistaa yksilön yhteyden sekä sisäiseen kokemusmaailmaan että ulkoi-
seen ympäristöön nyt-hetkessä. Kehomuisti on proseduraalista, aistimuksellista
ja suurimmaksi osaksi implisiittistä muistia. Kehomuisti on jatkuvasti taustana
yksilön subjektiivisille kokemuksille nykyhetkessä. Olemusseikat ovat se us-
komusten, asenteiden ja arvojen joukko, minkä yksilö liittää oman olemukseen-
sa ja ulkonäköönsä. Nämä ovat kulttuurisesti muovautuneita ja omaksutaan
sosiaalisessa ympäristössä.
Masennuksen tunnistettuja oireita ovat mielialan mataluus, mielenkiinnon
ja mielihyvän menetys, ahdistuneisuus, uniongelmat ja ruokahalun häiriöt,
syyllisyyden tunteet ja itsearvostuksen vähäisyys, sekä lääketieteellisesti selit-
tämättömät somaattiset oireet (WHO, 2012). Tyypillistä on, että masennuksesta
kärsivät henkilöt ovat kokeneet stressiä, erityisesti perhesuhteissa ja ihmissuh-
teissa (Andrews & Thomson, 2009; Heikkinen, 2014; Kendler et al., 1999; Kuhl-
man, 2013; Major et al., 1997). Masennus on liitetty riittämättömään sosiaalisen
liittymisen järjestelmän aktivaatioon (Carver, 2001). Hayes ym. (2004) totesi,
että masennuksessa kokemuksellinen välttämiskäyttäytyminen on korkeam-
malla tasolla. Tutkimus myös osoittaa, että turvaton kiintymyssuhde, eli vältte-
levä tai ambivalentti, kaoottinen kiintymyssuhdelaatu on tyypillisesti havaitta-
vissa masentuneissa potilaissa (Siegel 1999). Masentuneiden potilaiden au-
tonomisen hermoston aktivaatiossa on häiriöitä verrattuna terveisiin henkilöi-
hin (Birkhofer et al., 2005; Campbell-Sills et al., 2006; Shinba, 2014). Aivokuvan-
tamistutkimukset ovat tuoneet esiin, että masentuneiden henkilöiden aivoissa
80

ilmenee vaikeus erotella emotionaalinen prosessointi kognitiivisesta ja senso-

motorisessa prosessoinnista (Epstein et al., 2010).
Masennuksessa henkilö kokee vaikeutta olla yhteydessä kokemukseen
omasta eletystä kehosta, ja henkilö kokee, että itseyden ja oman kehon välillä on
kuilu (Micali, 2013). Suhteessa omaan kehoonsa henkilö ei tunnista kehon res-
ponsiivisuutta eikä affektiivisuutta, eikä tunnista kokemuksellista suhdetta ke-
hoon ylipäätään. Keho ei ole enää informaatiota välittävä, kommunikoiva tila,
vaan pikemminkin este yksilön ja ympäristön välillä. Henkilö vetäyyty pois
yhteydestä ympäristöön, sulkeutuu subjektiiviiseen kehonsisäiseen tilaansa ja
katoaa vastavuoroisesta intersubjektiivisesta kohtaamisesta toisen kanssa (Mi-
cali, 2013; Ratcliffe, 2013). Keho ei enää vastaa ympäristön tarjoamiin toiminta-
potentiaaleihin (affordances).
On todettu, että masentuneiden potilaiden aivoissa on hyvin usein epä-
symmetriaa vasemman ja oikean hemisfäärin aktivaatiossa, ja supistunut hip-
pokampuksen tilavuus (ks. Hözel ym., 2011; Punkanen, 2011). Hözel ym. (2011)
olettavat stressin olevan yksi mahdollinen syy näihin aivojen toiminnallisen
rakenteen häiriöihin. Stressi saa yksilön kiinnittämään vähemmän huomiota
sisäiseen informatioon ja fokusoimaan ympäristöstä tulevaan informatioon
(Cloninger, 2004; Fogel, 2013). Fogelin (2013) mukaan interoseptiivinen infor-
maatio, eli informaatio kehon sisäisistä tuntemuksista sekä vireystilasta välitty-
vät hermostossa myelinisoitumattomia hermoratoja pitkin, ja siksi informaatio
kulkee hitaammin. Informaatio ulkoisesta ympäristöstä ja proprioseptiivisestä
systeemistä (lihasten ja ligamenttien venyminen, tasapaino, liikekoordinaatio)
kulkee selkäytimessä nopeita hermoratoja pitkin, ja on siksi dominoivaa. Kun
ihminen kohtaa stressiä, tämä em. ilmiö voi olla yksi tekijä, joka ruokkii yhteyk-
sien puuttumista oikean ja vasemman hemisfäärin sekä limbisen järjestelmän ja
anteriorisen cingulaatin välillä aivoissa. On mahdollista, että arvostelematto-
muuden ja havainnoivan tarkkaavuuden kohdentaminen proprioseptiiviseen
systeemiin voi tarjota keinoja, joilla kehittää ja laajentaa havainnointitaitoja
myös sisäisiin tuntemuksiin ja vireystilaan, mikä voisi kehittää monimuotoi-
sempia yhteyksiä aivojen toiminnallisten verkostojen välille. Kokemuksellisesti
tämä tarkoittaa sitä, että yksilö kehittää yhteyttään omaan kehollisuuteensa.
Tämä tutkimus toi esiin, että masennuspotilaiden kehonkuvassa ominaisia
piirteitä ovat kokemus energian vähyydestä ja siitä, että ympäristön kohtaami-
nen on vaikeaa, puuttuu suunta omalle tekemiselle. Nämä seikat kuvailevat
niitä laatuja, joilla masentunut kokee kehoitseytenään olevansa suhteessa ym-
päristöön. Kehonkuvassa on fragmentaatiota, eli osittuneisuutta, ja ohut tietoi-
suus omasta kehosta. Nämä heijastelevat vaikeutta olla suhteessa itseen. Kipu ja
vaikeus levätä heijastelevat rasittuneisuutta ja stressiä, jota potilas kokee nykyi-
sessä tilanteessaan, tai johon potilas on aiempien kokemustensa myötä oppinut
ja virittynyt. Huoli omasta painosta tuli myös melko usein mainituksi potilai-
den kehonkuvakokemuksessa.
Tanssi-liiketerapia (TLT) on vuorovaikutukseen perustuvaa: tutkitaan ke-
hollista kokemusta nyt-hetkessä siinä kohtaamisessa, mikä toteutu poti-
laan/potilaiden, terapeutin ja tanssi-liikkeen kesken. TLT on metodi, jolla kehit-
 81

tää tietoisuutta kehollisuudesta. TLTn teoreettinen perusta tarjoaa tietoa, joka

syventää ymmärrystä kehollisuuden ilmiöistä. TLTn toteutus tarjoaa yksilölle
kokemuksellisen tilan, jossa tutkia ja oppia kehollisuuden kokemuksia ja integ-
roida niitä. Pyrkimyksenä on tarjota yksilölle mahdollisuus laajempaan käyttäy-
tymisen vaihtoehtojen kirjoon arkielämässä. TLTssä keho reagoi ja vastaa – ta-
pahtuu liikettä, vireystilan muutoksia, jännitteet kehossa vaihtelevat – ja tämä
on keskeistä myös vuorovaikutuksen arkitodellisuudessa. Taidot havainnoida
näitä kehollisia tapahtumia, olla tietoinen niistä, ja osata kommunikoida niistä
myös sanoilla kehittyvät TLTssa. TLTn keskeiset tekijät masennuksen hoidossa
ovat stressireaktion säätely, turvallisuus, vuorovaikutus ja dialogi. TLTssa näi-
den tekijöiden prosessi tapahtuu kehollisuuden kontekstissa ja sen eteen päin
kuljettamisessa luovuudella on keskeinen sija.
Tässä tutkimuksessa ryhmien odotukset TLT-ryhmään liittyen olivat seu-
raavia: toive kokea turvallisuutta ja kokea kuuluvansa ryhmään, jakaa liikettä ja
ajatuksia, leikillisyyttä, mielialan ja kehon integraatiota, oman kehon havain-
nointia, oppia rentoutumaan toisten läsnäollessa, selviytyä kivun kanssa, hel-
pottaa ahdistusta ja jännittyneisyyttä, löytää mielenrauhaa ja tanssin iloa, ja va-
pauttaa tunteita. Hyvä tila TLT ryhmässä tarjoaa riittävän turvallisuuden ko-
kemuksen, fyysisyyttä, emootioita, tyydytystä tuottavaa vuorovaikutusta, eri-
laisuuden sietämistä, hyväksyntää, muutosta ja lopulta myös jotakin, joka on
ryhmässä olijalle tuntematonta, mutta mikä voi olla voimaannuttavaa. Nämä
kaikki seikat liittyvät turvalliseen, läsnäolevaan ja virittäytyneeseen vuorovai-
kutukseen, joka mahdollistaa yksilölle sen, että hän voi tutkia ja integroida ko-
kemuksiaan.
Tässä tutkimuksessa ryhmämuotoinen TLT-interventio (12 x 90 min) tuotti
potilaiden vointiin masennusoireiden vähentymistä, kun sitä mitattiin oiremit-
tarein, joilla potilas itse arvioi vointiaan (BDI-II, SCL-90, HADS, CORE-OM).
Vertailtaessa TLT- ja TAU-ryhmiä toisiinsa, TLT-intervention myönteisempää
vaikuttavuutta osoittava efektikoko oli d = 0.60 – 0.97, riippuen oiremittarista.
Kun vertailtiin TLT-intervention vaikutusta ennen ja jälkeen intervention, TLT-
ryhmäintervention efektikoot vaihtelivat pienestä keskisuureen, osoittaen TLTn
vaikuttavan kliinisesti suotuisasti. Kontrolliryhmässä, jossa potilaat saivat ta-
vanomaista hoitoa, efektikoot osoittivat hyvin pientä muutosta voinnissa.
TLT-intervention jälkeen oli havaittavissa positiivinen muutos kehonku-
vakyselyssä (Body Image Assessment BIA). Kehonkuvan muutos positiiviseen
suuntaan selitti 30% oiremittareiden pistemäärien myönteisestä muutoksesta.
Mitä positiivisempi oli kehonkuvakyselyn vastausten laatu jälkimittauksessa,
sitä matalampia pistemääriä ilmeni oiremittareissa seurantamittauksessa, joka
tehtiin 3 kuukautta TLT-jakson jälkeen.
Palautteessa, jota ryhmäläiset antoivat terapiakokemuksestaan, potilaat
kuvasivat kehoon liittyviä kokemuksiaan positiivisemmin laaduin. He havait-
sivat oman kehonsa positiivisemmalla tavalla, aktiivisuustaso oli kohentunut,
jännitys oli hellittänyt, oli turvallisempi olla. He tunnistivat ja havainnoivat it-
seään joustavammin: oli kokemus, että itsensä löysi, tunnisti fyysisiä kokemuk-
siaan ja niiden vaikutusta itseen, luotti omaan kehoonsa enemmän. Oman toi-
82

minnan säätelyyn oli tullut joustavuutta, kun osasi käyttää havaintoja oman
kehon olosta ja tilasta apuna. Vuorovaikutus tuli joustavammaksi, kun potilaat
kokivat jaksavansa toisia ihmisiä paremmin, uskalsivat lähestyä toisia ja olla
aktiivisempia vuorovaikutuksessa. Positiivinen vertaistuki ryhmässä oli merki-
tyksellinen, tärkeä kokemus osallistujille.
Ihmiset ovat eritavoin resilienttejä siinä, miten kokemus turvallisuudesta
säilyy. Terapiassa ensiarvoisen tärkeää on se, että potilas voi kokea riittävässä
määrin fyysistä, emotionaalista ja psyykkistä turvallisuutta. Turvallisuus mah-
dollistaa vapauden ja tutkimisen, mikä tuottaa rikkaampaa, joustavampaa in-
formation käsittelyä ja toimintamahdollisuuksia toisen kanssa ja ympäristön
kanssa. Näin yksilön kokemus toimintapotentiaaleista (affordances) alkaa saada
positiivisemman sävyn. Turvallisuudessa käyttäytymistä rakentavat responssit
ja toimintakuviot voivat tulla selvemmin ilmaistuiksi, ja siten niitä voi tutkia ja
ymmärtää tietoisemmin ja integroivalla tavalla. Osallistuja oppii käyttämään
tämän kaltaista dialogia myös itsensä sisäisessä dialogissa, mikä vahvistaa hä-
nen tietoisuuttaan siitä, mitä hänen keholliset vastauksensa ja kehollinen tilansa
kulloinkin ovat. Tämä tietoisuus rakentaa tilaa valintojen tekemiselle; yksilö voi
esim. tehdä hienovaraisia muutoksia liikemuotoon, kehon asentoon, tempoon
tai johonkin muuhun liikelaatuun, mikä sitten vaikuttaa yksilön kokemukseen
vuorovaikutustilanteesta.
TLTssa toiminnan sisäänrakennettuina ominaisuuksina ovat leikki ja luo-
vuus. Leikin ja luovuuden kliininen merkitys on siinä, että niiden juuret ovat
hyväksynnässä ja riittävän turvallisessa vuorovaikutussuhteessa, mikä viime-
kädessä tukee sitä, että yksilö voi uskaltautua tutkimaan asioita ja vuorovaiku-
tusta. Luovuus ja leikki heijastavat myös yksilön sisäistä suhteessa olemista,
laajempaa tapaa käsitellä informaatiota, ja myös tätä turvallisuus ja hyväksyntä
tukevat.
Kokemus TLTsta voi tuottaa parempaa kykyä tunnistaa fyysisiä koke-
muksia ja niiden vaikuutsta, vahvistunutta luottamusta omaa kehoa kohtaan, ja
kokemusta siitä, että omaa toimintaa voi säädellä omien kehohavaintojen pe-
rusteella. Samanaikaisesti osallistujat voivat löytää parempaa sietoa toisia ihmi-
siä kohtaan, rohkeutta lähestyä ja osallistua vuorovaikutukseen. Tämä korjaa
mielialaa ja helpottaa depressiivisiä oireita. Tiivistäen, TLT näyttää vahvistavan
psyykkistä joustavuutta sitä kautta, kun yksilö tulee parempaan yhteyteen
oman kehollistetun kokemuksensa kanssa, ja osaa olla tietoisempi kehollisen
vastaamisen toimintakuvioista ja niiden vaihtoehdoista.
Tulevaisuudessa on tärkeää jatkaa tutkimusta kehonkuvasta ja TLT-
interventioiden käytöstä laajemmalla masennuspotilaiden aineistolla. Kehon-
kuvakysely (Body Image Assessment, BIA) on käyttökelpoinen menetelmä täs-
sä tutkimuksessa, mutta myös kliiniesssä työssä, kun arvioidaan potilaan ke-
honkuvaa, potilaan tapoja olla suhteessa itseensä ja toisiin, sekä hänen tavoittei-
taan terapiassa.
 83

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 ORIGINAL PAPERS

THE DANCE/MOVEMENT THERAPY GROUP IN A PSYCHI-

ATRIC OUTPATIENT CLINIC: EXPLORATIONS IN BODY IM-
AGE AND INTERACTION

by

Päivi Pylvänäinen 2010

Body, Movement and Dance in Psychotherapy, 5, 219–230.

Reproduced with kind permission by Taylor & Francis.

The dance/movement therapy group in a psychiatric out-
patient clinic: explorations in body image and interaction

Absract
The clinical experiences gained in the use of dance/movement therapy group at
the Psychiatric Clinic of Tampere are discussed. The clinical work has been built
on the tradition of DMT and on the recent findings in neurobiology and interac-
tion. From DMT perspective it is essential that the experiences of the bodily,
true self are dominantly processed in right hemisphere of the brain, and the
right hemisphere is also essentially involved in emotional processes, nonverbal
communications, attachment, subjectivity and intersubjectivity, in empahty, in
the processing of non-conscious self images, threat detection, bodily-based
stress regulation and survival. Intersubjective relationships are essentially de-
pendent upon the information processing in the right hemisphere. The quality
of interpersonal interactions and relationships is influenced by nonverbal be-
havior and the sensitivity to it. DMT work, promoting movement experiences,
internal attunement and sensitivity to body-self allows a creative method to
explore and integrate right hemispheric contents.

Keywords: dance/movement therapy, group therapy, psychiatric outpatient

treatment, depression, anxiety, interpersonal neurobiology

Introduction

This paper, which is developed from an oral presentation at ‘Kinaesthesia and

Motion’ conference at the University of Tampere on 2–4 October 2008, discusses
the clinical experiences gained in the use of dance/movement therapy (DMT) at
the Psychiatric Clinic of Tampere City since 2007. This paper stems from the
clinical work: what is the rationale for choosing DMT as a treatment method,
how to understand the significance of movement experiences and what can be
learnt from the therapy processes that develop. This paper reflects on the pro-
cesses of the first five groups at the psychiatric clinic making reference to body-
based, kinesthetic experiences and then figuring out the essential patterns of the
group themes and processes.

At the psychiatric clinic, the DMT group was offered to adult psychiatric outpa-
tients, the majority of them females, in 10-sessions periods. It is meaningful to
offer DMT in a group, because dance and movement interaction are interactive
modes of being. The group interaction offers opportunities for peer interaction
and sharing. It enlarges the scope of experiencing and enriches the process and
the insights and understanding gained in it. Group format makes the treatment
available for several patients at a time, which improves the treatment availabil-
ity and reduces costs in public mental health services. DMT in a group form
allows the integrated use of therapeutic experiential work, reflection and psy-
choeducation.

The clinical work has been built on the tradition of DMT (Meekums, 2002;
Payne, 1992, 2006; Sandel, Chaiklin, & Lohn, 1993; Stanton-Jones, 1992) and on
the recent findings in neurobiology and interaction (Cozolino, 2002; Gallagher,
2005; Schore, 1994, 2003a, 2003b, 2007; Siegel, 1999, 2007). In the practice of
DMT there is variation in the applications of DMT. At the shared core of DMT
there is the grounding statement that DMT is a creative form of therapy, which
uses movement, dance and body experiences as the means of communication to
connect with the other and with oneself. DMT is a body/ mind-integrated ap-
proach to psychotherapy, which uses expressive dance and movement process-
es to encourage the integration of emotional, cognitive, social and physical
functioning. A lived experience is created in DMT, and some layers of this ex-
perience are conscious, some remain unconscious. This experience involves the
person’s body, emotional responses, expression, cognition and verbal commu-
nication in a relationship with the others in the group.

Attentiveness and mindfulness

The attentiveness and sensitivity to the movement experiences and expressions

are fundamental in the DMT process. It is a path to get connected with what ‘is’.
For those who engage with DMT, this conscious, deliberate and nonjudgmental
attentiveness to sensations and movement experiences in the body is often a
new approach to oneself and to others. It is new as an idea and it is new as an
act. Marian Chace (in Sandel et al., 1993), one of the pioneers of DMT, frequent-
ly proposed that if one can allow a change of perspective to oneself, and give
interest and reverence to the body, it may eventually bring supportive and
emancipating experiences. This change of perspective can be translated as im-
proved internal attunement. Siegel (2007) perceives mindfulness as a form of
internal attunement: in mindfulness one searches for a way to be aware and
awake to what is happening as it is happening. Siegel analyses mindfulness as
consisting of three streams of awareness:

(1) direct sensory experience – i.e. raw sensation of one’s body &
perceptions
(2) the conceptual stream – thoughts, words
(3) observer - the inner witness

In DMT the patient is working with these three streams of awareness: s/he
practices to develop a more conscious skill to be attentive to these. In order to
do so, s/he needs to move the body, to experience the moments of moving. The
body movement and embodied experience create the ground and the concrete-
ness with which to interact. Siegel (2007) proposes that mindfulness may in-
volve more than sensing; it may also essentially involve observing the experi-
ence. This internal ‘being-with-the Self’ through the function of inner witness
can have similar beneficial effects on the person as we know the attuned inter-
action has. When in DMT intrapersonal and interpersonal attunement happen
simultaneously, it can be an experience that elicits change and transformation.

The connections between interpersonal neurobiology and DMT

Interpersonal and affective research orientations in neurobiology offer very in-

spiring and relevant information for understanding, what happens in the brain
and the body in moments of interaction. I am specifically referring to Schore (as
presented in his lecture in Helsinki, 2007), Siegel (1999, 2007) and Cozolino
(2002). From the DMT perspective, what is essential in this information is that
the right hemisphere of the brain is dominant in processing the information re-
lating to the corporeal self. The right hemisphere dominates in non-verbal, kin-
esthetic communication and stores the repertoire for nonverbal affective signals,
which are facial expressions, prosody and gestures. In the brain, the most direct
and integrated map of the state of the body is generated in the right hemi-
sphere. The sense of the subjective self is the right hemispheric emotional, im-
plicit self. It is called implicit because we are limited in our conscious attentive-
ness to this information processing. This implicit emotional self is centrally in-
volved in emotional processes, nonverbal communication, attachment, subjec-
tivity and intersubjectivity, in empathy, in the processing of unconscious self
images, threat detection, bodily-based stress regulation and survival.

The right hemisphere is in close interaction with the limbic system. The limbic
system rapidly processes information, in particular the sensory information that
enters the brain, and makes evaluations whether the information signifies
pleasantness or unpleasantness, threat or safety. Cozolino (2002, p. 71) describes
the limbic system ‘as an intersection of the internal and external worlds where
the primitive needs of the organism negotiate with the requirements of the
world’. The integration of the information processing in the right hemisphere
and in its networking to the left hemisphere shape the intersubjective relation-
ships the individual creates. The quality of interpersonal interactions and rela-
tionships is influenced by nonverbal, kinesthetic behaviour and the sensitivity
to it.

This information presented by Schore, Siegel and Cozolino (they build their
work on the research by other scientists and specialists in the field of interper-
sonal neurobiology) offers a solid rationale for the core fundamental of DMT,
which is the use of movement and bodily experiences as the ground for the
therapeutic work. In DMT we work bottom-up: we create the interaction on the
body-centred level and emphasise movement communication and exploration.
This experience of interaction can be rewarding because there is a space for
right brain to right brain communication. Right brain to right brain connected-
ness, or connectedness through movement and body sensitivity, is essential in
creating an intersubjective attachment bond. Schore (2007) considers this level
of bodily-based affective and often implicit communication to be the core of
change mechanism at unconscious level in the therapeutic alliance. Change ul-
timately requires connection to bodily experience that the individual has been
disconnected from.

For the use of DMT, I have earlier (Pylvänäinen, 2003, 2008) proposed a tri-
partite model of body image, consisting of the body-self, image properties and
body memory (see Table 1 presenting this model.) Body image as a concept is
utilised to convey the psychological and experiential (phenomenological) signif-
icance of the body. Gallagher (2005) argues for the distinction between body
image and body schema on the level of concept construction. Knowing that my
model does not make that distinction, I would still like to bring it into this dis-
cussion because I find it meaningful when approaching the contents of the lived
body and the experiences of embodiment.
Of the elements of the tri-partite model of body image, the body-self refers to
the experiencing and interacting core self. It is the same as what is referred to as
an implicit self by Schore. Body-self relates to environment in the present mo-
ment, responds affectively in interaction and essentially creates the sense of self.

Body memory is the container of past experiences and it functions as a reference

for evaluating the current sensations. Schore (2007) refers to Shuren and Graf-
man (2002) saying that the right hemisphere holds representations of the emo-
tional states associated with events experienced by the individual. When the
individual encounters a familiar scenario, representations of past emotional ex-
periences are retrieved by the right hemisphere. On the phenomenological lev-
el, the body memories are wordless and independent of the conscious will (Ca-
sey, 1987); it is the way body remembers in sensations, movement and emotion.
Body memory influences the responses we create through the body-self in the
present moment.

The third element of body image is image properties, which consists of the cul-
turally shaped attitudes, opinions, preferences and judgements relating to body,
body appearance and style. The image-properties conceive the body as some-
thing that is owned by the person, the body being malleable and under an out-
side gaze. This approach to body dominates in our culture, in media and in the
word centred communication, because image-properties can quite easily be ar-
ticulated and visually expressed. Even though the image-properties relate to the
external and visual qualities of the body appearance, the associated emotional
attitude and self-image shape the movement responses of the body-self.

Schore (2007) suggests the corporeal self is equal to the Winnicottian term‘true
self’, and I want to suggest that the body-self is equal to the concept of corpore-
al self. These concepts explore the same terrain, an interactive body and the
shaping of the self in that process, but with slightly different ways of shaping
the information. Schore elucidates the preciousness of non-verbal, kinesthetic
communication in interaction and offers information about how these events
evolve at the level of neurology. The body-self brings into focus the relevance of
the body, its sensitivity and responsiveness, and the fact that all our actions,
whether doing or being, are carried out through the body. Returning to Win-
nicott’s writing about true self, which he uses to describe the feeling of being
real, whole and spontaneous (St Clair, 1996), reveals that the essential nature of
body in interaction and in the sense of self has been noted decades ago, but it
has not been verbalised and understood in a clear and plain way. Winnicott
(1971, p. 80) states that ‘no sense of self emerges except on the basis of (this) re-
lating in the sense of being. The sense of being is something that antedates the
idea of being-at-one-with, because there has not yet been anything else except
identity’. The identity that we have from the very start is the body, and we need
to sense the being-in-the-body. This sensing is the function of the body-self. We
need to perceive the actions and sensations of the body and also our becoming
conscious about them to some extent. Interestingly, Winnicott also says it is on-
ly in being creative that the individual discovers the self. He suggests that in
this context, creativity is a feature of life and total living. I see this kind of crea-
tivity appearing in the spontaneous creation of responses and connections as
we interact with the environment. Again, it is the body that does these. Win-
nicott describes what kind of setting is most supportive for this kind of creative
exploration: one needs to enter a nonpurposive state (allow a visit to formless-
ness) in an atmosphere of trust and relaxation (Winnicott, 1971, pp. 54–55).
From a state of resting in the body-self and in a relationship, a creative reach-
ing-out can emerge.

The DMT group processes

In the DMT process, the elements of the body image are encountered and the
body-self has a chance to be carefully attended to. At the psychiatric clinic I
have written session notes of the DMT sessions, and these notes document the
process each of the five groups moved through over the treatment period. The
processes of the groups demonstrate issues that the adult patients with depres-
sion, anxiety and chronic pain discover and work on. The creative nature of
DMT has allowed the group members to unfold these themes through move-
ment explorations and body-oriented awareness and mindfulness. When a
mindful approach is applied on movement experiences, the therapist models
astance characterised by curiosity, openness, affection and loving kindness.
Then, for the observation of the movement experience, the attention is opened
towards being aware of sensations, images, feelings and thoughts. Essential in
this working atmosphere are confidentiality, respect, compassion (especially
being non-judgmental) and non-violence.

The patients joined the DMT group after an initial interview. The basis for en-
tering the group was the patient’s own willingness and motivation to enter
DMT and the suitability of this treatment form in his/her situation. For the
suitability, the essential factors are that the patient can tolerate being in a group
and moving, and also find some cognitive rationale for joining this kind of ac-
tivity. The groups were closed (no new members during the treatment period)
and had 5–11 participants, who gathered weekly for a 90-minute session. The
sessions were offered in a spacious gymnastics room which was located at a
public sports facility. This arrangement allowed a clear space for moving, which
was not available in the office rooms at the site of the clinic.

The group processes can be seen as a triad of beginning, middle process and
end (Schmais, 1985). Another way to describe these phases, and to acknowledge
their overlapping nature, is to call the three phases of the processes as positive
expectations/experiences, the shadow and the resolution. The positive expecta-
tions and hopes the groups worded at the beginning of the process were: a wish
to experience safety and a belonging into the group, sharing movement and
thoughts, playfulness, to integrate mood and body, to observe one’s body, to
learn to relax while others are around, to cope with pain, to have some relief to
anxiety and tension, to find a calm mind, joy of dance and a discharge of emo-
tions, to be able to go beyond one’s anxiety causing limitations, and to discover
one’s femininity in a positive way. Various movement qualities and orientations
were welcomed: to move with quick tempo and slow tempo, to move aggres-
sively, to move gently, to move rhythmically, to move with imagery, to move
with music, and to move emotionally.

In the DMT session we moved to warm-up the body and to make movement
explorations. In the warm-up, the focus was to enhance the personal body
boundaries, the sense of groundedness, the various options for the use of space
and movement qualities, and very gently bring the attentiveness to breathing.
In the DMT work the group members could experience release of tension, re-
laxation, joy and the pleasure of movement, and even playfulness. In addition
to these positive experiences within the individual, the aim in the warm-ups
was to build safety in the body, in the interaction, and in the shared space. It is
good to remember Schore’s (2007) notion that the safe holding environment in
the therapeutic relationship is created through the nonverbal activity and pre-
verbal communications.

However, the shadow often and sometimes very quickly appeared in experi-
ences. This could be observed in single sessions as well as in the path ofthe
group process. I use the word ‘shadow’ to refer to the uncomfortable, unpleas-
ant sensations, discomfort and anguish that relate to movement experiences.
These kinesthetic sensations may relate to the unconscious and rejected con-
tents in the Self, but in the immediate experience in the DMT session they arise
from what is happening in the moment and in movement interaction. To go to
specifics, these themes included feelings of tiredness and lack of energy, anxie-
ty, emotional and physical pain, difficulty in being in the group and interacting
with others, aggression, demands and feelings of guilt, memories of the past
interactions and relationships, and negative and critical image of oneself. The
groups gradually worked their way through these themes in movement and
words, and created some kind of resolutions with them.

The DMT group aims to use the constructive elements of movement to support
the patient while s/he is going through the process of encountering the strug-
gles with the discomfort and anguish discovered in the body. It was common in
the group process that initially the suffering was expressed in words describing
tiredness, anxiety, difficulty to function, etc. The general atmosphere in the
group was frequently depressed in this phase. Patients might sit quite immo-
bile, in closed and sunken postures. There was lack of spontaneity in interac-
tion. Sometimes someone shared a particularly anxiety evoking narrative, about
a dream or some event or incident in life. In DMT we have the option of direct-
ing the group activity at this point to the body level, and we can choose wheth-
er we use the movement to search for a more neutral and safer experience, or
move to express and explore the suffering. I often chose the first option of using
emotionally neutral movement which focuses on the body basics of grounding,
body boundaries, personal space and tension releasing movement in vertical
posture. The improved sense of the body image, safer grounding in the body-
self, increased awareness of the body sensations and experience of movement
abilities and movement options offered the patient a stronger sense of the body-
self. This contributed to the sense of trust, safety and mastery in oneself. Also,
when the body was activated into movement, the state in the body and in the
brain changed, which could change the experienced mood. As a modelling of
emotion regulation, my choice of neutral movement offered the patient the op-
tion of not freezing into immobility with anxiety, but to safely move in spite of
it and with it.

When we explore through movement, it is important to remember the potential

of different movement qualities and the different ways we can use space in
movement. The change of tempo (Time-effort), the change of strength in
movement (Weight-effort), the change in the orientation to space (Space effort)
and the change in the freedom or boundness of the movement flow (Flow-
effort) can significantly transform the experience the movement brings to a per-
son. The options of qualitative changes in movement also open the options of
gentle and natural changes. While movement is the language of emotion, inter-
action and the right brain hemisphere, the possibility for different qualities in
movement is the venue to search for transformation via this movement lan-
guage. It is paradoxically concrete and abstract at the same time. Also, move-
ment qualities create the space for creative and symbolic expression. For exam-
ple, in the group an improvised movement exploration can start with a bound
and stiff movement quality, which can express in movement the experience of
anxiety. When we add an active use of time-quality for example through
rhythmic shaking of hands or stepping of the feet, we can alter the boundness
and allow a safe expression of restlessness. Then we can change the quality of
strength into stronger and express assertion or aggression and, as the stamina
naturally decreases, we can explore lighter weight, which can express delicacy
or ease. This was an example of an actual movement improvisation one group
once created at the end of a session, which had been filled with anxiety and
hopelessness.

Sometimes it is imagery that guides the movement changes. For example, once
a group was improvising movement with an octopus-shaped, colourful, lycra-
cloth. I asked the group members what they want to do with the cloth, and they
begun to comment on how it looks like to them. The cloth seemed scary like a
spider; it was a soft jellyfish, it was like mucus. To others the cloth was like a
sun, it was welcoming in a pleasant way. We begun to explore these images in
movement, and the activity turned very lively. The group discovered move-
ments expressing disgust, aggression, and dropping away, letting go of long
held tensions in the body. During the activity someone commented that the
cloth looks like a neuron. As the intensity of the active movement gradually and
naturally eased, I offered the idea of exploring what the cloth gives tooneself;
the cloth invites into movement, its extensions can give something to oneself. I
suggested the group members play and explore in movement with the idea that
the body can receive. At the end then, the body could find a suitable way of
separating from the contact to the cloth. Here the imagery allowed a safe space
to express some personal issues symbolically and through movement. Imagery
allowed play and creative expressions. We used words but did not have to ana-
lyze why we used the words we used. Sometimes this can be a way of emotion-
al expression the person can consciously accept and tolerate, and at the same
time the body-self, the emotional core-self is actively engaged in the expressive
process.

Acknowledgement and sharing of these contents of movement explorations is

an important part of the work. When we are involved with movement in DMT,
the attitude towards it is mindful. At its core, mindful awareness is acceptance:
there is an intention to be open to perceive without judgment whatever arises in
the experience and awareness. There is no active attempt to achieve an outcome
or change, we simply explore, and this actually is one pathway to release us
from suffering. In a DMT session, we always return to reflect on the movement
experiences. Sometimes we can reflect on the experience through movement by
creating movement that expresses what was essential in the previous move-
ment experience. Or we can draw a picture of what was essential in the experi-
ence. However, because in adult interaction verbal expression plays a signifi-
cant role, we frequently search for a verbal reflection of the movement experi-
ences. The method to get a hold on the movement experience in words is to de-
scribe what movements one did, what body sensations one had, what emotions
arose, and what imagery or associations were evoked during the movement
experience. Again, the attitude is mindful; we aim to observe and to
acknowledge. This allows the group members to practice a more body-oriented
way of self-observation, a more concrete and embodied way of using words
and an orientation to the present moment. The observation and body-based
grounded description of what happened helps in recognising response patterns.
When this practice is done repeatedly, it allows a possibility to ‘decouple au-
tomacity’ in responses (Siegel, 2007); the person becomes aware of her typical
embodied responses in some situations, and this gives her an option to alter her
responses by deliberately choosing to change some quality in her body shape or
movement qualities. Here I want to refer to Siegel’s (2007) proposal that in clin-
ical work with suffering there may be a need to amplify the observer capacity to
‘decouple automacity’ to begin the process of balancing. Also, the act of verbal-
ly describing movement based experiences activates integrative connections in
the brain.
 Central themes in the processes: sensitivity and threat vs. safety

The engagement in movement activity with an attitude of observation brings us

to the theme of sensitivity. When we are willing to be open to experiences and
perceive something, we are choosing to keep our senses open and we are in-
tending to be able to sense. Sensing and sensitivity is a very fundamental and
multilayered theme. One aspect of sensing is how one senses one’s own move-
ment. In one session a group member told us that she had just moved in a way
which did not quite feel like her own, except for when she was stretching her
back. This very observation of the difference ‘when the movement feels like my
own – when it does not feel like my own’ is essential in consciously connecting
with one’s own activity and in one’s body-self.

Another group in its seventh session encountered the theme of sensitivity when
the movement suggestion was to create movement about a word that describes
oneself. The words that the group members chose for themselves were
dull/tired, sensitive and timid/timorous. The task took the group to a low en-
ergy and stuck movement. When we discussed this experience, the group
members spoke about feelings of unease and discomfort, annoyance and disin-
terest, and dullness. So the invitation to move about oneself took the group
members to an uncomfortable and anxiety invoking place, which led to the
shadow and suffering coming right up. It was interesting that the words
thegroup members had chosen had all something to do with sensitivity: dulled
sensitivity, fearful sensitivity, too much sensitivity. The shared challenge of the
group members was this difficulty with sensitivity. This opens up a broader
array of questions: what is one’s personal attitude towards sensitivity, has one
ever learned ways to live with the sensitivity the body holds, what is the atti-
tude the surrounding culture seems to hold towards sensitivity and the sensi-
tive, sensing body-self. In this particular session, one group member eventually
commented that she feels like she is too sensitive to this world. And she is not
alone with this theme; in DMT it has appeared several times that sensitivity, a
natural quality of the body, is often causing difficulty to the group members.
The difficulty seems to be two-fold: how one is willing to encounter one’s sensi-
tivity and what one’s sensitivity brings up.

Also, the theme of threat vs. safety in the being-in-the body has appeared in the
groups as a very essential theme. This, of course, relates to the theme of sensi-
tivity as well. Threat vs. safety is a quality in the experiential world of the body
image, particularly in the experiencing body-self (see also Fosha, 2003). Some-
times a threat is perceived in the environment outside of the body, sometimes it
is a more internal experience. The groups spontaneously brought the theme of
threat up; my task seemed to be to introduce the option of safety. What brings
safety, what movements can a group member experience as safe to herself, what
qualities of space create safety, what distance feels safe, and what sounds feel
safe? It is important to work to create the possibilities for the safety to develop.
When there is the polarity of safety, we can tolerate to observe also the sensa-
tions, emotions or imagery that we perceive as suggesting threat.

There were challenges and shadows on the way, but gradually the groups
worked towards some resolutions. The contents of the resolutions included ex-
periences of connectedness and sharing in the group, some taming of anxiety
and finding tolerable ways to be with it, and finding interest and a caring atti-
tude towards one’s body. After the DMT group process the members were
grasping the body-oriented attitude and had improved their connectedness to
their body-self. They were more grounded in their body, which enabled them to
function in a more grounded, aware and resourceful way. This was a basis they
could then continue to flow with.

Integrating conclusions

The following list summarises what DMT explorations in movement and inter-
action may bring:

- release, relaxation which relates to the calming of the state of the auton-
omous nervous system
- images, memories, associations
- symbolic expressions of the self
- varying ways of experiencing and encountering the world
- new ways of being and acting in interaction
- activated relationship to oneself: what one discovers in oneself, move-
ment expressions of this, connectedness to the body-self/core-self
- reflections in words of these experiences
- being in the body in the present

The embodied and reflective engagement in these explorations can change the
state of the patient in the present. They can give her new experiential infor-
mation about how she can be in her body, what she can do with her body, and
how she wants to and can reach out for others in these moments. Body, move-
ment and interaction are the ground and the space, mindfulness is the way to
observe the phenomena, and all this is reflected in the present activity of the
brain. Some of the experiences become stored in the brain, thus becoming a part
of the patterns in our behaviour. DMT supports creating integrated patterns on
the neurological level, which naturally supports more integrated behaviour and
a more integrated experience of self. Experiences in DMT bring us to the sphere
of being in the body, developing a more conscious settling into our embodied
nature, which fosters vitality for our reaching-out.
 Notes on contributors

Päivi Pylvänäinen, MSc in Psychology, MA in Creative Arts in Therapy, is a licensed

psychologist and a dance therapist. She completed her DMT degree at MCP Hahne-
mann University (Drexel), Philadelphia, as a Fulbright scholar. She has experience of
expatriate life. She has been involved with contemporary dance over 20 years and
while living in Tokyo she studied Butoh-dance, integrating that with the DMT practice.
In Finland she has worked in vocational rehabilitation and in adult outpatient psychia-
try. Currently she works as a clinical psychologist applying DMT in a psychiatric out-
patient clinic and in her private practice. Previously she has published articles on body
image and DMT applications with adult populations.

References

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Gallagher, S. (2005). How the body shapes the mind. Oxford: Oxford University Press.
Meekums, B. (2002). Dance/movement therapy. A creative psychotherapeutic
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Pylvänäinen, P. (2003). Body image: A tripartite model for use in dance/movement
therapy. American Journal of Dance Therapy, 25, 39–56.
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 II

BODY MEMORY AS A PART OF THE BODY IMAGE

by

Päivi Pylvänäinen 2012

In Body, metaphor and movement. Advances in Consciousness Research 84 (pp. 289–

306).

Reproduced with kind permission by John Benjamins Publishing Company,

Amsterdam.
Running Head: BODY MEMORY AS A PART OF THE BODY IMAGE

Body Memory as a Part of the Body Image

Päivi Pylvänäinen1
1
Clinical Outpatient Program, Tampere, Finland

.
 Abstract

First outlining body memory from a phenomenological perspective, this chapter then

relates that view with the information offered by neurosciences, especially with the

work of Kandel (2007), and makes efforts to understand, what is the nature of

connections between body memory and the body-self; is something one just

experienced part of body memory immediately after the lived moment; and how body

memory influences the responses and actions the body-self expresses. Through

vignettes from a clinical dance/movement therapy (DMT) group, it is explored how

patients encounter body memory related issues in DMT.

Keywords: body image, body memory, neuroscience, dance/movement therapy,

psychiatric outpatients
This chapter explores body memory in relation to the tri-partite model of body image

(Pylvänäinen, 2003, 2006, 2008). The tri-partite model of body image differentiates the

body image into the elements of body-self, body memory and image properties. The

body-self is an active, responsive element in the body image, the body's quality of being

present and in interaction with the environment. The body-self is actualized in the

present through connectedness with the sensory, kinesthetic and perceptual information

in the body. The image-properties are perceptions, thoughts, judgments, and values

related to the physical appearances of the body. The image-properties evoke emotional

responses in the person and these are experienced through the body-self. Body memory

is the name for the embodied information storage function of the body.

A Phenomenological View on Body Memory

Body memory on a phenomenological level has three spheres: habitual, traumatic and

erotic body memory (Casey, 1987). Habitual body memory is defined as the active

presence of the individual's past in the body. Habitual body memory contains the

embodied experiences of everyday routine activities and movement repertoire. This

essentially builds the sense of coherence, continuity and familiarity. It supports

orientation in the present situation. The habitual body memory, as it carries our

movement repertoire and embodied ways of coping, can foster a sense of safety,

mastery, and agency (Pylvänäinen, 2003). Traumatic body memory, according to Casey,

holds sensations and kinesthetic responses from moments of trauma and pain, whether

emotional or physical. These moments may have been personally lived, or observed in

others. In traumatic body memories the integration of the body is violated and the

experience of embodiment becomes fragmented. The third sphere of body memory,

erotic body memory, is the storage of embodied experiences of pleasure. Casey suggests

that erotic body memories are essentially interpersonal. As secure and attuned

interactions are nurturing and empowering to us, they also bring pleasure which is

experienced in the body and is then stored there. This has a positive impact on the

general state of the body-self.

In an interdisciplinary exchange on the concept of body memory (Pylvänäinen,

2010), the shared consensus was that body memory is a bodily resonance in relation to

some lived experience. However, as the nervous system and the brain integrate

information, body memories may become associated with olfactory information, visual

imagery, sounds and/or words that are related to the situation. Body memory is a hybrid

of time, space and kinesthesia. It has potential to make the past present through

embodied reminiscence, and yet it also may enable the person to recognize that the

present moment is distanced from the past. Body memory influences the state of the

body as it has an impact on how the present moment is experienced. Importantly, body

memory shapes the person's perception of his/her window of tolerance; what s/he feels

s/he can hold in his/her body and not to break. The contents of body memory arise from

how we are in relation with the other – how the body-self interacts with the other and

what kind of imprint that leaves into the body. Not only is body memory shaped by the

interactions with the other and our experiences of ourselves, it is also shaped by our

interactions with nature and environment. The patterns that the body repeats in the

tension cycles and body-attitudes in its relation to space and environment are contents

of body memory (Shahar-Levy, 2009, p. 275). Body memory stores our experiences;

what we have learnt through our experiences on the embodied level. The contents of

body memory are created through the interactive body-self.

 Body Memory Perceived through the Neurosciences

Kandel, a Nobel Prize winning neuroscientist, whose molecular biological approach has

revolutionized human understanding of how information received by our senses

becomes hard-wired, is an inspiring source of knowledge also when deepening the

understanding of body memory. In the year 2000 Kandel received the Nobel Prize in

Physiology and Medicine for his contributions to the study of memory storage in the

brain. Kandel differentiates two kinds of memory: implicit and explicit memory, both of

which can function in either short-term or long-term storage of information. He defines

conscious memory as explicit or declarative memory: conscious recall of people, places,

objects, facts, and events. Unconscious memory refers to implicit or procedural

memory: habituation, sensitization, classical conditioning, perceptual and motor skills

(Kandel, 2007, p. 132). Implicit memory guides us through well-established routines

that are not consciously controlled (ibid., p. 279). This unconscious, implicit memory

seems to equal with the content that has been related to body memory. Kandel notes,

“that constant repetition can transform explicit memory into implicit memory. Implicit

memory often has an automatic quality. It is recalled directly through performance,

without any conscious effort or even awareness that we are drawing on memory” (ibid.

p. 132). This is particularly true for habitual body memory, but also for traumatic and

erotic body memory. Implicit memories of skills, habits, and conditioning are stored in

the cerebellum, striatum, and amygdala (ibid. p. 130).

Body memory on a cellular level is manifest in how the neural pathways are

shaped to store information relating to sensations and kinesthetic responses in the body.

Information processing patterns and response patterns on the neural level are shaped by
experience. In his scientific work, Kandel's particular interest has been around what

actually goes on at the level of the synapse when behavior is modified by learning and

how different forms of learning and memory relate to each other on the cellular level.

He studied these phenomena on the cellular level in a fairly simple snail-like animal,

Aplysia, and was able to show what changes happen in neurons, when the animal learns

through habituation, sensitization, and conditioning. He also studied how this learning

becomes stored in implicit memory. Even though we like to think that humans are

different from snails, a biological fact is that different organisms – and different types of

cells - are made from the same material. Half of the genes expressed in the human

genome are present in much simpler invertebrate animals, such as the snail Aplysia

(Kandel 2007, p. 245). Thus the neural phenomena Aplysia demonstrates also

essentially apply to humans.

At the core of the lessons from Aplysia is the unfolding of the fact, that the living

body and its nervous system learn from the sensations received from the environment.

There are many kinds of learning, and one kind of learning – and eventually memory –

is mediated by sensory neurons, interneurons, and motor neurons. Kandel (2007, pp. 66-

67) sums Cajal's early findings on the nervous system:

Sensory neurons, which are located in the skin and in various sense organs,

respond to specific type of stimulus from the outside world - mechanical pressure

(touch), light (vision), sound waves (hearing), or specific chemicals (smell and

taste) - and send this information to the brain. Motor neurons send their axons out

of the brain stem and spinal cord to effector cells, such as muscle and gland cells,
 and control the activity of those cells. Interneurons, the most numerous class of

neurons in the brain, serve as relays between sensory and motor neurons.

By increasing the amount of glutamate a sensory cell sends to a motor cell,

sensitization strengthens the synaptic potential elicited in the motor neuron, thus making

it easier for that neuron to fire an action potential and cause the response pattern (ibid. p.

222). Thus there is a response pattern that is created by the living body and its nervous

system: initiated by sensory information received by the sensory neurons, and executed

by the motor, kinesthetic activity. The motor, kinesthetic action is related to a sensory

perception, and the information from the sensory perception is transmitted by the

intermediary neurons. The serotonin-releasing interneurons are called modulatory

interneurons because they do not mediate behavior directly; rather, they modify the

strength of response (the gill-withdrawal reflex in Aplysia) by enhancing the strength of

the connections between sensory and motor neurons (ibid. p. 223). The organism has,

and indeed needs, an integration of sensory, tactile, proprioceptive, and motor efferent

information; it is the essence of its ability for intelligent action, which can be shaped by

information from the environment and the organism's own state. Going to synaptic

level, Kandel and his colleagues found that in implicit memory

… the same synaptic connections between sensory and motor neurons that are

altered in short-term habituation and sensitization are also altered in long-term

habituation and sensitization. Specifically, in long-term habituation the number of

presynaptic connections among sensory neurons and motor neurons decreases,

where as in long-term sensitization sensory neurons grow new connections that

 persist as long as the memory is retained. There is in each case a parallel set of

changes in the motor cell. (ibid. p. 213)

The learning and its storage in memory thus shape the nervous system. In relation

to body memory, some fascinating and also baffling questions arise: Is something I just

experienced part of my body memory immediately after the lived moment? What is the

nature of connections between body memory and the body-self? How dominant is the

role of body memory in the choice of responses and actions the body-self expresses?

Pondering on these questions can organize the understanding of body image and body

memory. In Kandel's work, some perspectives on these questions may be found. He

discovered a clear pattern in the changes that take place in a single sensory and motor

cell for short- and long-term memory. A modulatory interneuron is activated by a

sensory cell, which receives information from a body part. The way of signaling the

modulatory neuron uses is the transmission of serotonin to the sensory neuron that is

directly connected to a motor neuron (Kandel, 2007, p. 224). Kandel discovered in his

experiments that one brief pulse of serotonin strengthened the synaptic connection

between the sensory and motor neuron for a few minutes by enhancing the release of

glutamate from the sensory cell. Glutamate is a major excitatory neurotransmitter. A

functional change happens as the synapse is strengthened via this enhanced release of

glutamate. At this stage, the nucleus of the cell is not involved. According to Kandel,

this is the phenomenon under short-term memory. Anatomical change happens after

several (5) pulses of serotonin: the synthesis of proteins in the nucleus is activated and

new synaptic connections grow, as well as the release of glutamate is enhanced (ibid.,

pp. 255-256). If we boldly try to apply this information on the level of body memory,
we would have to ask, how strong is the impact of an experience – is it just ”one pulse

of serotonin” or ”several pulses of serotonin”, which would make the nucleus of the

neuron change, and thus lead to a long-term storage of the information? This is quite an

abstract and technical question, but it does guide us toward acknowledging, that

experiences are sensed in varying intensity by our sensory system. The stronger or more

repetitive the stimulus, the stronger the signaling and the more happens in the neurons,

which increases the possibility that the neurons may become transformed by the

signaling for a shorter or even longer period of time.

Could we assume then, that the body-self, i.e. our sensory and motor systems, act

and respond, and when some more permanent transformation happens in the

configuration of the connections between the neurons in these systems, then a new

body-memory trace has settled into the system? It may be very relevant to recognize

that the nervous system is in a state of constant change in its almost infinite

connections. The human brain contains about 100 billion neurons (Kandel 2007, p.

443), and some of them function as sensory neurons. The amount of connections

between the nerve cells is huge: Kandel shares Bailey's and Chen's finding that a single

sensory neuron has approximately 1300 presynaptic terminals with which it contacts

about 25 different target cells - motor neurons, excitatory interneurons, and inhibitory

interneurons (ibid. p. 214). So a change in one connection is a very minor change in this

network of connections, and yet it has some impact on the way the nervous system and

the brain process information. Kandel states: "The cellular mechanisms of learning and

memory reside not in the special properties of the neuron itself, but in the connections it

receives and makes with other cells in the neuronal circuit to which it belongs (ibid. p.

142)". In the constant processes of experiencing and acting, the neurons make
connections, indeed struggle to make connections with each other. The connectedness

defines the survival and development of a neuron (Cozolino, 2002); the integration of

the nervous system defines the survival and development of an organism; and this

pattern is repeated in the significance of connectedness and interaction between

individuals. There must be some stability in the connections to enable and organize the

functioning, and there must be some changes in the connections as live processes take

place.

In a lived experience, it is clear that the body-self and body memory are closely

connected. The body-self responds and acts in the here and now, and in its responses it

is informed by information stored the body memory: the habits, the learnt thresholds

and response patterns. But, in our actions, do we only repeat what we have already

learnt? If we place the functions of sensitivity, kinesthesia and attention to the body-

self, there opens up an option for choice and the creation of new activity. I propose that

the body-self creatively shapes the response from the information body-memory offers

and on the basis of the present sensations and information from the environment. It

becomes essential, what is the focus of attention, and how much consciousness plays in.

Kandel (2007, p. 302) quotes Mountcastle:

...sensory nerve fibers, (are) our only information channels, our lifelines to reality.

They provide also what is essential for life itself; an afferent excitation that

maintains the conscious state, the awareness of self. Sensations are set by the

encoding functions of sensory nerve endings, and by the integrating neural

mechanics of the central nervous system.

 Kandel (2007, p. 313) reminds us, that in the field of psychology already one of

the original thinkers, William James pointed out that there is more than one form of

attention. Involuntary attention is supported by automatic neural processes and it is

particularly evident in implicit memory. Involuntary attention is activated by a property

of the external world. Voluntary attention is a specific feature of explicit memory and

arises from the internal need to process stimuli that are not automatically salient. I

propose the body-self holds both involuntary and voluntary attention. The coupling of

consciousness with attention defines whether the attention is involuntary or voluntary.

According to Kandel (2007, p. 374), "consciousness is a state of perceptual

awareness, or selective attention writ large. At its core, consciousness in people, is an

awareness of self, an awareness of being aware, ability to experience and attend to and

reflect upon those experiences." The ability for attention and consciousness that the

body-self holds enables the channelling of some of the contents of body memory into

our conscious processing. I propose the body-self holds the ability for consciousness

and attention because we need to be attentive to and conscious about something:

initially that something would be our sensory perceptions which can be perceived only

through the body. Kandel (ibid., p. 383) makes an interesting reference to the work of

Crick and Koch, who proposed that in the brain, claustrum may be a population of nerve

cells that mediates the unity of consciousness. Claustrum is a sheet of brain tissue that is

located below the cerebral cortex. Claustrum connects to and exchanges information

with almost all of the sensory and motor regions of the cortex as well as the amygdala,

which plays an important role in emotion. It is significant, that all of the neural

networks relating also to implicit learning and memory – sensory and motor networks

and amygdala – are areas that the claustrum is connected to as it makes consciousness
emerge. This, I propose, indicates that the body-self is involved with the creation and

maintenance of consciousness and attention. And yet, in the present moment, for these

functions, the body-self needs the connections to body memory.

Fascinating in this regard is the finding, which Kandel brings up from studies by

Kornhuber and Libert (Kandel, 2007, pp. 389-390). Kornhuber found in his experiment,

that invariably, each movement of the right index finger his study subjects executed was

preceded by a little blip in the electrical record of the activity in the brain. He called this

potential in the brain the "readiness potential" and found, that it occurred one second

before the voluntary movement. Later Libert found that the readiness potential appeared

200 milliseconds before a person consciously felt an urge to move his/her finger. Libert

proposes that the process of initiating a voluntary action occurs in an unconscious part

of the brain, but that just before the action is initiated, consciousness is recruited to

approve or veto the action. The body-self may start some activity unconsciously, and at

some point of the process, the activity may become conscious.

The body-self is active and responding in the present. The brain actually has a

more limited capacity for processing sensory information than what is the capacity for

measuring environment in the body and receptors (Kandel, 2007, p. 311). Attention acts

as a filter, selecting some objects for further processing, and yet, attention does not

necessarily imply consciousness. For example, studies have shown, that the neural

system stores both unconscious, emotionally charged memories and conscious, explicit

memories of feelings. They are stored because unconsciously or consciously, attention

was paid to the stimuli that evoked the emotions and feelings. In the neurological

research of emotion processing in humans, the unconscious recall of emotional memory

has been shown to involve implicit memory storage, whereas conscious remembrance
of the feeling state has been shown to involve explicit memory storage and therefore to

require the hippocampus (ibid., p. 342). Using the perception of fearful faces as the

setting in which to study the unconscious and conscious perception of emotional

information, Kandel and his colleagues (ibid. p. 387) found out, that in the unconscious

perception of fearful faces neural activation takes place in the basolateral nucleus of

amygdala, which receives the most of incoming sensory information and is the primary

means by which amygdala communicates with the cortex. In the conscious perception

of fearful faces the neural activation is located in the dorsal region of amygdala, which

contains the central nucleus, sending information to the regions of the brain that are part

of the autonomic nervous system - concerned with arousal and defensive responses. In

both instances, body-self mediated information is needed and processed. This again

gives ground to the understanding, that body-self can be functioning both consciously

and unconsciously.

The connections and exchange between the body-self and body memory are

fundamental; they enable each other and function in an orchestrated way. In the study

about the perception of fearful faces (Kandel, 2007, p. 387), it was also discovered, that

the higher the person's background anxiety, the greater the person's response. People

with low background anxiety had no response at all in the case of unconscious

perception of fearful faces. Unconsciously perceived threats disproportionally affected

people with high background anxiety, where as consciously perceived threats activated

fight-or-flight response in all volunteers in Kandel's and colleagues' study. Background

anxiety is presumably developed in connection with earlier experiences, and that

information is stored in body memory. Another interesting view to the

interconnectedness of the body-self and body memory appears in the neural

phenomenon that in the unconscious perception of an emotional signal, the signal goes

to those parts of the amygdala which communicate with the cortex, whereas in the

conscious perception the signal is sent onwards to the autonomic nervous system, which

shapes the state of arousal and defensive responses (ibid., p. 387). What happens then,

when the state of arousal changes and some defensive responses are activated?

Defensive responses may be perceived as information stored in body memory,

particularly in habitual and traumatic body memory. Through these changes in the

responsive body-self, the person has more embodied information and more time and

chances to attend to it. In doing this the body-self is actively involved, again combining

the information from body memory and from the present situation.

If the understanding is, that body memory influences the state of the body-self in

the present moment, how does it do it? The tension patterns, for example the

background anxiety, are one channel for body-memory to shape the state and responses

of the body-self. Koch (2007) reports some interesting results from experiments on how

movement in the present moment influences person's affect or cognitive evaluations.

She had participants move the arms in either fighting or indulgent movement qualities.

The results showed that when movement had a quality of fighting rhythms, it caused

higher negative affect (tense, aggressive, nervous, etc.). The quality of indulgent

rhythms caused higher positive affect (relaxed, joyful, playful, etc.). In two other

experiments she studied the influence of movement rhythms (indulgent versus fighting

movement qualities) and movement shape (approach versus avoidance arm movement)

on attitudes toward initially valence free Chinese ideographs (cf. Cacioppo, Priester, &

Berntson, 1993). These studies indicated that when movement was indulgent in rhythm

and approaching in shape it evoked the most positive attitudes toward the initially
valence-free Chinese ideographs. The quality combination of indulgent rhythm and

avoidance shape produced the least positive attitudes. The combination of fighting

rhythm with either approaching or avoidance shape caused fairly similar impact on

attitudes, and in both instances the attitudes were significantly less positive than in the

condition of indulgent rhythm and approaching shape. However, when the combination

was congruent, i.e. fighting rhythm was combined with avoidance shape, the attitudes

where more positive than when the combination was clashing, i.e. the indulgent rhythm

was combined with avoidance shape. I find it very interesting to consider these results

in relation to body memory: what kind of experiences and learning have previously

related to these rhythm and shape combinations? It seems, that the activation of positive

body memories – indulgence signaling safety and approaching signaling connection and

gratifying encounter – has the most positive impact on the present state of the body-self

and the experienced affect and attitudes. The fighting quality combined with either

approaching or avoidance shape produces somewhat positive attitudes. This could echo

the experiences of successful use of own strength, which may activate a sense of agency

and sense of control. The least positive impact on attitudes arises from the clashing

combination of indulging rhythm and avoidance shape, which in combination may

relate to experiences of displeasure, the loss of volition and sense of agency. In these

ways, the qualities of our interactions, which become stored in the body memory, return

to influence the responses the body-self creates in the present moment.

Encountering the Body Memory in a Dance/Movement Therapy Group

In my work as a psychologist in a psychiatric outpatient clinic, facilitating a

dance/movement therapy (DMT) group, it is fascinating to explore how the concept of

body image is reflected in the experiences the patients have in a DMT process. The

source of the vignettes presented in the following is a 15-session DMT group for eight

women, aged 21-59 years. The group members have signed a consent form allowing the

sharing of the material from the group in this text in a manner that protects each

individual's privacy. The information about the group is stored in written process notes

that I kept in order to support the containment and understanding of the process. There

is no video material about the sessions. Consequently, all the information about the

embodied, sensory experiences that evolved in the sessions has had to be transformed

into words for the purpose of communicating about them in this text.

The patients in the group had various diagnoses: depression (moderate or severe),

bi-polar disorder (depressive phase), ADD, eating disorder and social anxiety disorder.

Several of the patients had a challenging life situation, e.g. a chronically demanding

family situation, burn-out from work, significant changes in relationships or personal

roles. Many of the patients had traumatic experiences in their life-history. Two of the

patients had gone through an individual psychotherapy (2.5 and 3 yrs), one had received

individual psychophysical physiotherapy for a year, one had participated in a group for

patients with eating disorders and one had studied expressive therapy. All of the patients

had received individual counseling or supportive therapy at the clinic prior to this

group. Thus, all of the patients had some experience and skills in reflecting on their

experiences. Most of them used medication to support their recovery.

The patients were chosen for participation in this group on the basis of their own

interest in doing movement based work and their willingness to participate in a group.

In an initial interview the patient's situation was discussed. Mostly the focus was in the

present, screening also the patient's experience and thoughts about her body: how she
has moved recently, what preferences she has in movement, what her opinions or

concerns in relation to her body were. Often the narrative about one's body connected

with the mood, the level of the sense of agency and with self-appraisal, i.e. how content

or discontent the patient was with herself.

One of the goals of the initial interview was to discuss the personal themes and/or

goals for the patient's participation in the group. The patients (with their avatar names)

are here in the order of age, the eldest first:

Amalia: To continue the exploration of embodiment and the development of

regulation skills for the state of tension one holds in the body.

Birgitta: Exploring the tensions one carries in one-self. Patient also noticed she

needs to develop her skill to recognize and describe and differentiate what is one's

bodily experience and what is the feeling.

Carla: Exploring the fact that one is middle-aged and lives in a certain way. As

her life situation was challenging, the patient expected the DMT group to function as a

refueling place. At the start of the group she also thought that the verbal sharing about

one's experiences in the group could be a positive and supportive element of the work.

Dora: To explore embodiment, to improve body awareness and the ability to be

attentive to the body in everyday life, to deepen one's understanding about the

connections between body and mood. Patient was also interested in exploring

gentleness and interaction through movement.

Eva: To continue to reflect on one's bodily responses; this patient had already

made significant notions about her response patterns which were built on her

experiences in earlier interactions in her life. She wanted to maintain the possibility to

be engaged with moving and physical activity. Participating in a group therapy was new
for her, and she was curious about it. One theme in the process was coming to terms

with one's expectations and with what one does in reality. The patient had experienced

several disappointments of placing hard expectations on herself and then finding the

situation impeding.

Fanni: To strengthen one's sense of self, to develop stress management skills and

the ability to relax. The patient was interested in developing her own way of doing, her

own space, and her own tempo in her sense of agency. This related to her work and also

to her way of participating in social interaction. Since the patient was pregnant at the

start of the group, the DMT group would also allow her to encounter her changing body

and her path into motherhood in movement interactions.

Gail: The patient had noticed her body image as unstable; sometimes she would

be content, sometimes discontent with it. She would like to develop a skill to orient

towards her body and movement from an internal rather than external perspective. She

also would like to develop her body image towards being able to tolerate the changes

that in her future may come along with pregnancy and motherhood.

Hanna: As the patient had recognized her body image was distorted, she wanted to

explore it. She had undergone a psychotherapy and wanted to embody the learning she

had achieved there: to talk about herself, to be gentle and merciful towards one-self. She

found relaxing difficult and was interested in developing the ability to relax. For her, the

weekly routine and structure provided by the group was also welcome. She wished the

DMT group to be a place to listen to one-self.

The body image related themes came up in various ways in the patients' individual

themes. Most of them related to the body-self: developing skills to recognize and

regulate the state of the body-self, the sensations and tensions in the body-self, bringing
the body-self into interaction, differentiating between sensations and emotions. The

exchange between body-memory and the body-self become apparent when a patient

acknowledged the impact of her past life events on her typical ways of reacting and

responding with her body-self. No-one in the group placed her themes or expectations

directly in the image-properties, but rather, the image-properties topics were filtered

through the body-self, e.g. in Gail's theme of learning to relate to her body through

internal experience instead of the perspective of an external gaze.

When the group worked together for the first time in the first session, the goals the

group as a unit held were explored. The group members chose a postcard with an image

which had something that interested them. Later, after a movement warm-up, we

returned to these cards with a question “what do these images contain that expresses

something one wants to bring into the group as a quality in interaction or as a theme to

work on?”. This was first expressed verbally, and we then improvised movement

holding in consciousness the themes that emerged in the verbal sharing. In this indirect

and creative way the patients shaped some goals for the group:

secure space

physicality

trust, safety – feeling - happiness, joyfulness - calming down

caring - there is support - helping each other - sharing joys and sorrows together

being different, going into the same direction - there is space for each person

it does not matter even if one's wing was hurt - freeing one-self from old

dependencies

adventure - something forms, ripens - nourishment for the soul

 Grouped in this way, the goals actually unfold a theme of a developmental

process: sense of safety, physicality, emotion, gratifying interaction, tolerance of

difference, acceptance and change, and adventuring into something unknown, which

can be nourishing. Even though the group did not present its goals in this grouping

order, it molded its essential nature through this list of words. All these words relate to

secure and attuned interaction which enables the individual to explore and integrate the

experiences. In particular, these words describe a physical, emotional, and social

environment which allows the body-self to be fully engaged. The patients described it

spontaneously, initially orienting with their sense of interest.

In the therapy process that unfolded over the 15 sessions approximately half of the

time was spent in movement and half in discussing the experiences. Central themes

were group formation, exploring moving in the group and exploring one's own

kinesthesia. At some points, an educational approach was utilized and the patients

received information about body image, body memory, embodiment, the significance of

the non-verbal in interaction and about mindfulness. This information supported the

patients in getting a cognitive perspective on and understanding of the movement work,

and also in developing an accepting and non-judgmental attitude towards one's

embodied experiences. The group was committed to this work. As the trust in the group

developed, also the troubles and difficulties in relation to one's body and in interaction

started to emerge in the sharing. In its interactions, the group created support to the

members. Through the creative process of moving and verbalizing, the group members

had several meaningful insights into their situation, which helped them to understand

themselves and their ways of coping in their everyday lives. In this process, the body
image changed: there was more respect, consciousness, and compassion in relation to

one's body image.

The process brought up body memory related issues with varying nuances.

Sometimes a movement pattern activated body memory. For example Carla, in the

middle of a confusing and rushed life situation, in session three, found a rolling

movement on the floor, which gave her an embodied experience of being carried by the

floor, relaxation and trust. The movement also reminded her of her childhood plays,

where rolling was a sort of releasing and letting go. This made her note that now in

adulthood one can also let go, ease, and enjoy it; that it is important to acknowledge

both the strong, fighting side and the indulging side in oneself.

Sometimes it was a movement quality that activated a body memory. In one

interaction situation, Carla and Amalia felt that the interaction was uncomfortable,

unsatisfying. When talking about this experience and reminiscing on what was the

trouble, a mismatch in their tempos was discovered. Carla had felt the tempo of the

shared movement was rushed, too quick. Her immediate response was unwillingness to

join this, a desire to take her own space and tempo. Simultaneously, she was reminded

that in her professional and family life she had for years been going along the tempos

and needs the others brought in. She remembered the repeated situations with her

mother who was always rushing her when it was time to get going, controlling her in

this way. Carla observed that these childhood and work-life memories of forced tempos

activated in her stomach a tight, pressing, squeezing sensation, which was radiating into

the back.

Sometimes the elicited patterns of body memory were acknowledged specifically

as a coping mechanism. For Amalia, in the above mentioned interaction with Carla, the
mismatch of connection and tempos brought a notion about her way of coping over the

years: when in an uncomfortable and non-motivating situation, she has tried to use

quickness as a way to get through the moment. This had also meant shutting off the

sensing, just performing. This interaction made her notice and pay attention to this often

used coping pattern. In the discussion, the option of a more sustained tempo was

connected with the possibility of sensing more, when it is safe to sense. In this way, the

old, body memory based coping pattern received some new input for the future.

Like in the previous example of Carla's and Amalia's experience, it quite often

was the social, interactional situation, which was the key to activate the surfacing of the

body memory. In some moments the history of interactions was alluded to through self-

reflections. For example, Birgitta commented in one session, that it is very difficult to

find one's own movement when for the whole life-time one had to always do what

others told to. In an other session Birgitta experienced again something which was

deeply connected with her body memories. The theme was to move with a cotton cloth.

These cotton cloths were differently patterned. Birgitta had quickly picked up the cloth

with a pattern she desired, and someone remarked, she would also have wanted that

cloth. This had made Birgitta to feel guilty, and she shrinkingly curled under the cloth,

becoming invisible, in a small shape and feeling she no longer exists. She noticed, that

the old traumas of moments when feeling “I am not existing” joined into the present

experience. Quietly she pulled and pressed the cloth into her fist and then threw it away,

with a genuine feeling of disgust and rejection. After a little while she stood up, walked

after the cloth, picked it up and folded it into her hands, squeezed it with full strength,

and felt hatred towards the cloth. At the same time she collected herself into an upright,

handsome stance, and then felt clearly she was existing. It was also fascinating, that in
the cloth Birgitta chose for herself, the pattern was small dots, which Birgitta described

as a representation of her feelings of smallness (inferiority). She thought a large pattern

might have been attractive to her as well, but she would have been unable to take it. At

the end of her movement, her own body shape was a large pattern.

Quite frequently, body memory emerged in a subtle way, intertwined with the

body-self in the present, reflecting life history and the way of being in one's body, that

has been shaped by the past experiences. In these moments, there was not necessarily a

sense of dealing with a memory nor of dealing with the past. The body memory entered

the present moment through habitual patterns of sensing, moods, and bodily states. At

the first glance one might have thought the patient's response is solely arising from the

present situation, but as similar patterns kept returning in slightly different situations, it

gradually became possible to perceive the impact of body memory in the responses. For

example Eva, in a long phase of depression, at the start of the therapy process said that

she felt, metaphorically speaking, a difficulty in going through her own birth, she felt a

need of nurturance and a sense of not being alone. In the second session, in her

movement she discovered that she is able to do movement by receiving good support

from the ground. In the fifth session, through a theme of moving a picture drawn to

represent one's mood, Eva discovered a squatting position, where she begun to feel

sleepy. She surrendered into her bodily desire to rest, lay on her back on the floor, and

in so doing, realized this was possible: she continued to exist even though she felt tired

or even fell asleep. The curiosity about movement did not escape from her even if she

allowed herself to sense her tiredness. In the middle of the therapy process, she

frequently sensed her bodily heaviness, agitation, tightness in the muscles and

breathing, and tiredness. Occasionally her sensory perceptions about her body brought
to her attention that she was feeling comfortable as she engaged with movement: it was

easier to breathe when standing than when sitting, self-touch clarified the body

boundaries and a smile eased her state in another session. One day she noticed moving

felt easy and free-flowing. In session ten she noted, that even though her situation in her

everyday life was much improved now, her body could not let go of the sense of a

struggle, which stayed inside her, while on the outside she seemed calm. The

discomfort, that “was” her in the middle phase of the therapy, now started to emerge as

something she could consciously and deliberately observe and reflect on. The old

patterns of being in the body, shaped by her body memory, had been repeatedly

encountered in the activity of the body-self in the present, and the reflection on these

sensations gradually allowed a more conscious relationship to them. In a later session,

Eva's discomfort and restlessness in the moment significantly eased as she played with

dropping down and picking up a cotton cloth. In this movement, she said she was

exploring the idea that she could release her own controlling and let things settle on

their own. At the end of this movement exploration, she sat down and loosely entwined

the cloth around her own ankles. She thought the entwining contained her restlessness,

but she wondered how it could do so, as the binding was not tight at all. I suggested,

perhaps the contact, just the resting in contact with something, was helpful. As a

movement metaphor, this action in an implicit way echoed the patient's need to

experience nurturance and to not be alone. The next session she did not feel restless.

The Lived Experience in the Body Is the Base

In the group process, it was central to take time for the development of the sense of the

group, familiarizing with moving in a group, and with the motility and sensory
information in one's own body. The participants were exploring and encountering their

own body image in the process through movement and reflection. At the start of the

process, the participants spontaneously brought up themes that shaped safety and a

sense of connectedness in the group. This is the base, a setting for the body-self to be

encountered. The more we moved and observed ourselves in movement, the more

information we had, which also opened the path for facing the contents of body

memory. This process elicited different kinds of responses, emotions, and thoughts. The

written feedback from the group members at the end of the group process demonstrated

this as follows:

Amalia: DMT brought to her an experience that her body is releasing tensions

and burdens. She frequently felt good and relaxed after the sessions. She felt a relief in

her body every time she noticed emotional tensions were released. Often after the

sessions Amalia felt energetic and wanted to talk (often about past events), to pour out

her thoughts also verbally. She found her physical and mental well-being had improved.

Birgitta: She found DMT to be fun. She discovered new sides of herself and her

body. She did not like to take a leadership role in Chacian circles (an improvisational

movement method of DMT). Her experience was that she gained more self-confidence

and acceptance towards her body in the group. After the process, she also felt proud of

herself since she always made herself come to the sessions.

Carla: Moving in the group made Carla to learn about her body and its rhythms.

She also found different personal meanings to small and large movements. For her,

moving was refreshing and it gave her strength. In the group setting, she learnt to focus

on herself even though there were others around. She came to appreciate her body as her

most precious and unique possession.

 Dora: The experience of the DMT process allowed Dora to connect with her

embodied sensations and feelings that might have otherwise been hidden or differently

understood on the verbal level. She was several times surprised by what she found her

body telling in movement and dance. She was able to live emotional states as she

focused on movement. Moving helped to release tensions that easily accumulate in the

body. For her, the process was an expedition into the body. She found the body to hold

wisdom and truthfulness. She developed the skill of perceiving the messages of the

body in herself. “Reading” the other's body was a challenge, and she noticed one often

makes conclusions based on what one perceives in one's own body. She felt the group

became familiar during the process, it was easy to be in it and sharing felt good, it was

possible to be what one is. Hearing the experiences of others gave help and brought new

ideas. In group, she also noticed which feelings were easy to share and which she

tended to hide from others, for example tears.

Eva: In DMT group, Eva noticed she longs for moving since moving brings her

pleasure and allows her to connect with her sensations in her body. She noticed she

tends to pay a lot of attention to strains and other unpleasant sensations in the body. For

her, the movement tasks first felt complicated or difficult to enter, but in most

occasions, she found into the movement and it did reflect her state in the moment. She

had found reinforcement to what kind of movements and being were typical of her, and

also insights to why this was so. Eva discovered her body as being curious also about

new kinds of movement – and whether she experienced them difficult or positive,

depended on her mental condition.

Fanni: Participating in the group helped Fanni to alleviate social anxiety. She

discovered it felt good to concentrate and listen to others – opening up to the shared
communication instead of withdrawing into an internal dialogue. The alternation of

conversation and moving felt good to her. Through movement and touch it was easy, or

easier, to work with themes that were difficult for her. She made a notion that facing

and accepting one's self-centeredness was hard.

Gail: In the beginning it was difficult for her to move when others were present

and could see her, but gradually her trust strengthened, timidity eased, and moving

became less of an act of performing. Through the DMT process she found a new way of

relating to the unpleasant sensations in her body: she could take a more observing and

reflective stance toward them which made her less anxious about her embodied

sensations. She felt her relationship to her own body became slightly more friendly and

accepting.

Hanna: DMT was often a puzzling experience: while moving, she felt she did not

get enough out of it, but after a few days or weeks, she noticed that something from the

movement exercise and experience had stayed in her mind and adhered in to her daily

life. After the DMT process she listened more to her body, wondering what her

sensations might mean. She felt able to describe her physical experiences in words and

to connect them with what was going on in her mind. One of the most significant

experiences in the DMT group for Hanna was the concretization of her body image. She

had hoped to learn to perceive her real physical boundaries, and after the DMT process

she perceived and felt them more clearly than before. She found a new kind of

appreciation toward embodiment.

How was body memory involved in what the group members consciously

recognized of their DMT experience? Generally, the release of tension relates to body

memory, as the body often is a container of tension. Amalia's experience of feeling an

urge to also verbally release her stories after having had an experience of a body-based

release of tensions, seems to indicate, that there are connections between body memory

and explicit, narrative memory. Body memory appears in some patients' feedback in the

context of old, social behavioral patterns, such as in Birgitta's comment about the

difficulty to take a leadership role. In her life experience she had learnt an opposite role,

and in her body memory the response patterns of trying to be invisible and compliant

were dominating. Her efforts of trying out new roles and new ways of responding could

be understood as her body-self creating new alternatives in the present moment,

negotiating between the old patterns drawn from the body memory and the present

potentials. Also, the patterns of social withdrawal vs. engagement, which appeared in

Fanni's experience, are rooted in body memory. Dora's comment about the differences

in how she expressed socially different emotions also relates to learnt interaction

patterns, which have much to do with body memory. Trust, an aspect that Gail's text

referred to, is to a large extent shaped by very early body memory. Carla's experience of

learning about the rhythms in her body and the meanings associated with small and

large movements was clearly connected with body memory, as in the DMT process she

recollected her life-history relating to these qualities. Here the connecting with the

contents of body memory supported her body-self to create new patterns and ways of

relating to the environment.

The DMT process clearly elicited new discoveries and learning in the group

members. It added new contents to their body memory, new response patterns for

interaction situations. One essential aspect seemed to be the change in thresholds; Gail

phrased it clearly when she described she could take a more observing and reflecting

stance at the sensations she perceived in her body, which made her less anxious. A
sensation from then on was not so much of an alarm for her but something that could be

neutrally observed. This kind of change helps the body-self to maintain more tolerable

levels of tension or vigilance, which echoes in the state of the whole nervous system.

In their own words, patients do not talk about body memory. They talk about their

lived experience. The lived experience in the body is the base. This experience could be

examined on a microscopic level, which would reveal the constant work of the neurons.

In the human experience the firing of nerve cells truly remains on an implicit level, and

we can only connect to what the firing activates: sensation, movement, emotion,

imagery, words. Yet it is valuable to acknowledge the neurological level, as it has

scientifically demonstrated the fantastic nature of a living organism, the miracle that a

material, living body is sensitive, responsive, creative, learning, and remembering. This

exploration indicates the relevance of paying attention to the information in the body.

Summary

First outlining the body memory from a phenomenological perspective, this chapter

then related that view with the information offered by the neurosciences, equaling body

memory with implicit memory. Referring to research by Kandel, it was suggested that

the living body and its nervous system learn from the sensations received from the

environment and from the body itself. The organism needs to integrate the sensory,

tactile, proprioceptive and motor efferent information as it is the basis of its ability for

intelligent action, which can be shaped by information about the environment and the

organism's own state. The ability for attention and consciousness that the body-self

maintains, enables the channeling of some of the contents of body memory into our
conscious processing. The tension patterns are one channel for body-memory to shape

the state and responses of the body-self.

In a clinical dance/movement therapy (DMT) group, facilitated at a psychiatric

outpatient clinic, it was possible to observe how patients encounter body memory

related issues in DMT. Most of the personal goals the patients had for the DMT group

were related to the body-self: developing skills to recognize and regulate the state of the

body-self, bringing the body-self into interaction, differentiating between sensations and

emotions. In the DMT process, body memory related issues were activated by

movement patterns or qualities, or by the social situation. Body memory also appeared

in the process through coping patterns and in the ways the patient related to her

sensations. The experience of the DMT group process produced new contents to

patients' body memory, new response patterns for interaction situations, and more

observing and neutral ways of relating to the sensations in the body.

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York: Routledge.
 III

A DANCE MOVEMENT THERAPY GROUP FOR DEPRESSED

ADULT PATIENTS IN A PSYCHIATRIC OUTPATIENT CLINIC:
EFFECTS OF THE TREATMENT

by

Päivi Pylvänäinen, Joona Muotka, and Raimo Lappalainen, 2015

Frontiers in Psychology, 6:980.
doi: 10.3389/fpsyg.2015.00980

Reproduced with kind permission by Frontiers (open access paper).

 ORIGINAL RESEARCH
published: 10 July 2015
doi: 10.3389/fpsyg.2015.00980

A dance movement therapy group for

depressed adult patients in a
psychiatric outpatient clinic: effects
of the treatment
Päivi M. Pylvänäinen 1, 2*, Joona S. Muotka 2 and Raimo Lappalainen 2
1
Tampere Psychiatric Unit, Tampere City Mental Health Services, Tampere, Finland, 2 Department of Psychology, University
of Jyväskylä, Jyväskylä, Finland

We were interested in investigating the effects of dance movement therapy (DMT) in

a psychiatric outpatient clinic with patients diagnosed with depression. DMT aims to
engage the patients in physical and verbal exploration of their experiences generated
in movement based interaction. The assumption was that DMT, which includes both
physical engagement as well as emotional and social exploration, would alleviate the
Edited by:
Wolfgang Tschacher, mood and psychiatric symptoms. All adult patients (n = 33) included in the study
University of Bern, Switzerland received treatment as usual (TAU). Twenty-one patients participated in a 12-session DMT
Reviewed by: group intervention, and the remaining 12 patients chose to take TAU only. The majority
Naomi Lyons,
SRH Hochschule Heidelberg,
of the patients suffered from moderate or severe depression, recurrent and/or chronic
Germany type. The effects of the interventions were investigated after the intervention, and at
Marianne Gertrude Eberhard-Kaechele,
3-month follow-up. Compared to the TAU, adding DMT seemed to improve the effect
German Sport University Cologne,
Germany of the treatment. The effect of the DMT was observable whether the patient was taking
*Correspondence: antidepressant medication or not. At follow-up, between group effect sizes (ES) were
Päivi M. Pylvänäinen, medium in favor for the DMT group (d = 0.60–0.79). In the DMT group, the within ES
Tampere Psychiatric Unit, Tampere
City Mental Health Services,
at the 3 months follow-up varied from 0.62 to 0.82 as compared to TAU 0.15–0.37. The
Hallituskatu 8 B, PO Box 35, results indicated that DMT is beneficial in the treatment of depressed patients.
33200 Tampere, Finland
paivi.pylvanainen@tanssiterapia.fi Keywords: dance movement therapy, depression, antidepressants, treatment outcome, group therapy, psychiatric
outpatient clinic
Specialty section:
This article was submitted to
Psychology for Clinical Settings, Introduction
a section of the journal
Frontiers in Psychology The global burden of disease studies show unipolar depression as the leading cause of years lived
Received: 17 April 2015 with disability (YLD) in adult population throughout the world (WHO, 20131 ). In Finland in 2013,
Accepted: 29 June 2015 mental health problems were the reason for 40% of work disability retirement, and in this group,
Published: 10 July 2015 depression was the most common problem. Further, mental health problems have been the main
Citation: reason for the early retirement since the year 20002 .
Pylvänäinen PM, Muotka JS and In Finland, the Current Care Guidelines3 base the treatment of depression on comprehensive
Lappalainen R (2015) A dance diagnostic, clinical, and psychosocial evaluation. The treatment consists of medication and
movement therapy group for
depressed adult patients in a 1 http://www.who.int/healthinfo/statistics/GlobalDALYmethods.pdf
psychiatric outpatient clinic: effects of 2 http://www.findikaattori.fi/fi/76
the treatment. Front. Psychol. 6:980. 3 Käypähoitosuositus, http://www.kaypahoito.fi/web/english/guidelineabstracts/guideline?id=ccs00062&suositusid=
doi: 10.3389/fpsyg.2015.00980 hoi50023

Frontiers in Psychology | www.frontiersin.org 1 July 2015 | Volume 6 | Article 980

Pylvänäinen et al. DMT treatment effects

psychotherapy (see Kupfer et al., 2012; Holma, 2013). The and from people with severe psychiatric problems to high-
recommended brief psychotherapy forms are cognitive, functioning people, who may be interested in strengthening their
interpersonal, psychodynamic, and problem-solving focused resources and self-development.
psychotherapy. In practice, medication is often the main One focus in DMT is engaging with movement: becoming
intervention to treat depression. It is acknowledged that physical concretely involved in movement activity in the here and
exercise can be beneficial in the treatment of depression, but it now. The other locus of activity is to be attentive to the
cannot replace medication and therapy. Treatment programs in movement experiences and to develop the skills to be conscious
hospital units, day hospitals and outpatient psychiatric clinics and reflective of them and to communicate about them in
may provide some physical activity, and sometimes also dance words. The relevant interactional elements in DMT are the
movement therapy (DMT) is used. engagement of moving body, the development of body awareness
The positive effects of physical activity in the prevention of and mindfulness, and the verbal reflection of the movement
depression (Brown et al., 2005; Teychenne et al., 2010; Luoto experiences, which focuses on the qualities of the experience
et al., 2013) and in coping with depression (Harris et al., 2005; (Meekums, 2002; Capello, 2009; Koch and Fischman, 2011;
Rimer et al., 2012) are frequently noted. The Cochrane review on Nolan, 2014). It is assumed, that this enables the patient to
the impact of exercise as a treatment of depression by Rimer et al. connect with the emotional core of his/her experience.
(2012) included 39 studies, totaling 2326 subjects. The review The early meta-analysis of the effects of DMT by Ritter and
indicated that exercise was equally effective as antidepressants or Low (1996) included five studies on people with depression.
psychological therapies in reducing the symptoms of depression. Two of these studies included psychiatric patients. Revisiting
Health care providers and sports researchers provide this meta-analysis, Koch et al. (2007) summarize DMT outcome
information on amounts of physical exercise that would be research on depression in a conclusion that the effect sizes
the minimum needed to gain the health effects for preventing in the treatment of depression have ranged from moderate to
illnesses, to support the level of functioning in the old age and to strong. A Cochrane review of the effects of DMT on depression
foster good mood and happiness4 . However, a physically active by Meekums et al. (2015) examined the effects of DMT for
lifestyle is challenged, because the way of living, the methods of depression compared to no treatment or to standard care, to
transportation and many occupational and leisurely activities psychological interventions, drug treatment, or other physical
are becoming increasingly sedentary. In Finland, collectively, the interventions. Only three studies met the Cochrane review
population is getting less physical activity (Husu et al., 2011) and inclusion criteria, totaling 99 adult subjects and 40 teenage
thus the connectedness to one’s embodiment is weakening. Lack subjects. When the authors compared group DMT to standard
of movement and physicality is not only a problem of physical treatment in adults with depression, DMT reduced symptoms
fitness, but also seems to have repercussions on the experiential of depression at follow-up measure, as indicated by clinical
level, i.e., on the level of body image (Pylvänäinen, 2003, 2012; observation using the HAM-D. Due to the poor methodological
Koch et al., 2013), which affects social interaction, self-awareness, quality of the studies and small sample size, the findings of
cognition, and coping. Interestingly, while physical activity in the effectiveness of DMT could not be considered conclusive.
the population has decreased, there are statistical records from A recent meta-analysis of the effects of DMT and dance on
the years 1990–2010 documenting a steady increase in the health-related psychological outcomes included the evidence
consumption of antidepressants in the Finnish population of 23 primary studies (Koch et al., 2014). The meta-analysis
(Finnish Medicines Agency and Social Insurance Institution, showed moderate effects for quality of life and for depression and
2012). Patients with depression often suffer from ailments, anxiety.
pain-problems, fatigue, and dissatisfaction with one’s own body. In the treatment of psychiatric patients the impact of DMT has
When depressed, it is a challenge to overcome the experiential been positive on body image, the perception of the body and self,
and emotional barriers and reach the benefits of physical exercise affect, motility and well-being, perception of relationships, and
and activity. A treatment intervention such as DMT, which biography (Koch et al., 2007, 2014). Goodill’s (2005) review of the
includes both physical engagement as well as emotional and DMT outcome research in clinical populations concludes that the
social exploration, starting on the level where the patient is, treatment brings favorable changes in the following dependent
would be feasible to increase self-awareness and emotional and variables: vitality, mood, anxiety, mastery, coping-skills, and
social flexibility among depressed patients (Kiepe et al., 2012; body image.
Kolter et al., 2012). Punkanen et al. (2014) conducted a pilot study where DMT
DMT is a form of therapy, which integrates the physical, group was used in the treatment of depressed patients. Twenty-
emotional, cognitive, and social aspects into treatment (Stanton- one depressed adult participants were recruited to participate
Jones, 1992; Meekums, 2002; Bloom, 2006; Payne, 2006a; in 20 sessions of group DMT, twice weekly. The psychometric
Chaiklin and Wengrower, 2009). DMT aims to engage the questionnaires were taken before and after the intervention. The
patients in physical and verbal exploration of their experiences mean score of the primary outcome measure, the BDI, decreased
generated in movement based interaction. DMT can be carried significantly from the pre- (M = 21.67, SD = 5.26) to post-
out as individual treatment or in groups. It can be applied measurement (M = 10.50, SD = 5.50), showing that the short-
to various populations ranging from children to the elderly, term, group DMT intervention had a positive effect on patients
with depression.
4 e.g., http://www.ukkinstituutti.fi/filebank/64-physical_activity_pie.pdf; As depression is so widespread in the population, it is
http://www.health.gov/paguidelines/guidelines/default.aspx#toc important to develop its treatment, and if possible, to augment

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Pylvänäinen et al. DMT treatment effects

the choices of effective treatments. Research on a current period, after 3 months (12 weeks) and after 6 months since the
clinical practice in a natural setting is relevant for improving first measurement point. The replies could be sent in stamped,
the treatment of depression. Thus, for the development of addressed envelope.
outpatient psychiatric care, we were interested in investigating Patients interested in joining the DMT group came to a
the effect of DMT in an outpatient psychiatric clinic. This study recruitment interview according to the normal practice. At the
plans to add to the knowledge of the effects of DMT in the end of the interview the patient could decide whether to agree
treatment of psychiatric outpatients diagnosed with depression. to participate in the research and sign the consent form. After
The main research question concerned, whether DMT-group the interview, the set of self-evaluation measures was sent to
intervention produces alleviation in the symptoms of depression. the patient via mail and s/he mailed them back in a stamped
We compared DMT + treatment as usual (TAU) with TAU. addressed envelope. This procedure aimed at distancing the
Thus, we were interested in whether adding DMT to TAU has research aspect of the group and the therapy process. Similarly
benefits as compared with TAU alone. This information may to the TAU group, the measurements were completed at the start
provide legitimation for the choices made on the use of DMT in of the intervention period (pre), after the 3-months (12-weeks)
psychiatric outpatient care. DMT intervention (post) and after 3 months (follow-up).
During the data collection period, a total of 25 patients were
Methods recruited for the DMT groups. Sequentially, they formed four
groups. The therapist/researcher worked with one group at a
Recruitment Procedure time. Four patients were excluded from the sample on the basis
The research plan was approved by the City of Tampere Research of the inclusion criteria. Thus, 21 patients could be included in
Board, which also is a regional board for ethical research the study, and 19 completed all measures. Two patients did not
practices. All participants in the study were recruited from respond to the self-evaluation measures after the treatment or
a psychiatric outpatient clinic, which is a part of specialized at the follow-up measurement, but they were included in the
public health care. The patients enter the clinic on a referral statistical analysis. In the DMT group, 84% of the participants
from a physician. The patients’ treatment is carried out by stayed in the study and in analyses.
a multi-professional team, which includes a psychiatrist, a The TAU groups were collected at the same time as the
psychiatric nurse, a psychologist, and a social worker. The clinic DMT groups. A total of 18 patients joined and provided written
offers pharmacological treatment, individual counseling, and consent. Twelve patients answered the pre-measurement self-
a selection of group interventions. There are various psycho- evaluations and were included in the study. However, only eight
educational groups focusing on coping with psychiatric disorder patients completed the self-evaluations at all three measurement
and its symptoms. The DMT group (8–12 sessions) has been one points. In the TAU group, 67% of the initial participants who
option in the available treatment since 2007. The clinic does not completed the first evaluation stayed in the study. Supplementary
provide physical exercise groups as a treatment option. Figure A summarizes flow of the data collection.
Announcements of the study were posted in the lobbies of Selecting the sample and assigning the groups this way
the clinic. The staff received e-mails about the study, inviting creates a quasi-experimental research design, as there is no
them to tell to patients with depression about the opportunity to randomization. This limits the validity of the results, but this
participate. The patient information described the study aiming design was chosen in order to remain close to the everyday
at exploring the treatment of depression and its outcome by practices of the clinic. Also, it was assumed that self-selection to
comparing TAU and the DMT group intervention. the groups would minimize the drop-out rate in the DMT group.
The inclusion criteria were: depression diagnosis and
depression as primary symptom. The exclusion criteria were Participants
psychosis, suicide attempts or clear suicide plans, diagnosis The background information presented on the participants is
of severe personality disorder, diagnosis of current alcohol or based on the patient records (see Table 1). About 60% (57.5%)
substance abuse problem, or debilitating somatic symptoms. of the participants had two or more psychiatric diagnoses. On
Patients entered the study voluntarily and could choose between the basis of the patient records, in the TAU group the most
participating in the DMT group or in the TAU group, where common diagnoses were F32.1—moderate depressive episode
they received the other treatment options the clinic provides. At (42%) and F32.2—depression severe/major without psychotic
the clinic, the common practice is that the patient can choose, symptoms (25%). In the DMT group the most common diagnosis
which of the recommended groups to join. Group participation is was F32—major depressive disorder, single episode (29%) and the
never imposed on the patient. Patients participating in the study total percentage of patients with F32-range diagnoses was 43%. In
received information about it, their contribution and freedom the DMT group, 19% of the participants had an F33 diagnosis—
to withdraw from the study at any time without consequences recurrent depressive episode. During the treatment period at
for their access to treatment. All the participants in the study the clinic, the medical examination indicated the severity of
were recruited between August 2011 and September 2012 and depression to be moderate or severe in the majority of patients
provided written consent to participate in the study. in both groups.
Patients joining the TAU group signed the consent, which was In the whole group, there were five patients, whose primary
then sent to the researcher. The TAU group participants were diagnosis was of anxiety or eating disorder or in the personality
mailed the set of assessment measures at the start of the research disorder range. This reflects the common clinical situation in

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Pylvänäinen et al. DMT treatment effects

TABLE 1 | Participant data at the pre-measurement—depression TABLE 2 | Participant data at the pre-measurement—treatment
characteristics. features.

Descriptives of subjects DMT TAU Total Descriptives of DMT TAU Total

at pre-measurement group group participants at baseline group group

N 21 12 33 N 21 12 33

Gender Male 5(23.8%) 4(33.3%) 9(27.7%) Duration of the current >6 months 10(47.7%) 5(41.7%) 15(45.5%)
Female 16(76.2%) 8(66.7%) 24(72.7%) treatment period 7–12 months 6(28.5%) 4(33.3%) 10(30.3%)
13–35 months 3(14.4%) 1(8.3%) 4(12.0%)
Age M (SD) 42(12.7) 38(10.4) 41(11.9) 36–96 months 2(9.5%) 2(16.6%) 4(12.0%)
Min 20 Min 22 Min 20 M = 21.1 M = 15.8 M = 14.24
Max 59 Max 55 Max 59
Antidepressant Yes 12(57.1%) 12(100%) 24(72.7%)
Number of diagnosis 1 7(33.3%) 7(58.3%) 14(42.4%) medication No 9(42.9%) 0(0%) 9(27.3%)
2 10(47.6%) 4(33.3%) 14(42.4%)
Other psychotropic Yes 8(38.1%) 5(41.7%) 13(39.4%)
3< 4(19.1%) 1(8.3%) 5(15.1%)
medication No 13(61.9%) 7(58.3%) 20(60.6%)
Severity of depression Mild 5(23.8%) 1(8.3%) 6(18.2%)
(psychiatrist’s recorded Frequency of individual 1x/week 1(4.8%) 0(0.0%) 1(3.0%)
Moderate 9(42.9%) 7(58.3%) 16(48.5%)
assessment) counseling/therapy at every other week 3(14.3%) 3(25.0%) 6(18.2%)
Severe 5(23.8%) 4(33.3%) 9(27.3%) pre-measurement every 3–4 weeks 7(33.3%) 5(41.7%) 12(36.4%)
Not assessed 2(9.5%) 0(0.0%) 2(6.1%)
5 or more weeks 9(42.9%) 4(33.3%) 13(39.4%)
interval
Years since first 1 1(4.8%) 4(33.3%) 5(15.2%)
episode of depression 2–3 4(19.1%) 1(8.3%) 5(15.2%) none 1(4.8%) 0(0.0%) 1(3.0%)

4–8 11(52.4%) 3(25.0%) 14(42.5%)

Psychoeducational Yes 4(19.0%) 11(91.7%) 15(45.5%)
9–25 5(23.8%) 4(33.3%) 9(27.1%) group experience No 17(81.0%) 1(8.3%) 18(54.5%)
M = 7.9 M = 6.4 M = 7.4
years years years
Psychotherapy Yes 12(57.1%) 3(25.0%) 15(45.5%)
experience No 9(42.9%) 9(75.0%) 18(54.5%)
Significant relational Yes 20(95.2%) 12(100%) 32(97.0%)
stress in history or No 1(4.8%) 0(0%) 1(3.0%)
currently

In the DMT group, 57% of the patients had experience

of psychotherapy and in the TAU group 25%. At the pre
specialized psychiatric care, that patients’ depression is rarely just measurement, in the TAU group 92% of patients had experience
plain depression. This is also reflected a in the second diagnoses of psychoeducational groups and in the DMT group 19%. The
the patients had. Of the whole group 58% had a second diagnosis. difference was statistically significant (x2 = 16.24, df = 1,
Twenty-four percent of these second diagnoses related to soma: p < 0.01), and was due to the fact that seven patients (64%) in
pain, heart, lungs, diabetes, hyperkinesis. Fifteen percent of the the TAU group were participating in a psychoeducational group
second diagnoses related to anxiety. In the whole group, 18% of for depressed patients during the evaluation of the intervention.
the patients reported a history of alcohol abuse.
The mean duration of time since the first episode of depression Intervention Procedure
was 6.4 years in the TAU group and 7.9 years in the DMT Both the DMT and the TAU group received individual counseling
group. The mean length of the current treatment period was during the study. In the TAU group 33% of the patients had
16 months in the TAU group and 21 months in the DMT an individual counseling appointment every 5 weeks or less
group. At the pre-measurement, for the majority of the patients, frequently, and 25% had counseling every 1–2 weeks. In the DMT
the length of the current treatment period was less than group 67% of the patients had counseling every 5 weeks or less
12 months. frequently, and 20% every 1–2 weeks.
In the TAU group, all the patients were taking antidepressant The DMT intervention was delivered by a psychologist and
medication (Table 2). In the DMT group, 57% of the participants dance movement therapist trained in the DMT methods of
were taking antidepressant medication, 43% (nine patients) were Marian Chase and in authentic movement. The essence of the
not. The difference in the use of medication between the DMT Chacian approach is engaging in improvised, shared movement,
and TAU groups was statistically significant (x2 = 7.07, df = 1, and creating an interactional space through movement (Levy,
p < 0.01). One reason for the referral to the psychiatric unit was a 1992; Fischman, 2009). The Chacian method is primarily a
medication resistant depression, where the patient did not benefit DMT form of group therapy. Authentic movement, initially
from antidepressants. In the DMT group, 38% of the patients developed by Mary Whitehouse and Janet Adler, can be applied
were taking some other medication for psychiatric reasons, and as a method in individual or group therapy (Payne, 2006b).
in the control group 42%. The application of authentic movement based practices in DMT

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Pylvänäinen et al. DMT treatment effects

in psychiatric outpatient care means emphasizing the non- et al., 1961, 1996; Dozois et al., 1998) measures depressive
judgmental empathetic witnessing of movement expression as symptoms. The score range is 0–63. Higher points indicate more
it appears, the cultivation of conscious awareness of movement, severe depression (0–13 indicates no or very few depressive
and the allowing of the person to be visible and seen in his/her symptoms, 14–19 indicates mild depression, 20–28 moderate
movement (Adler, 1999; Penfield, 2006). Both the Chacian depression and 29–63 severe depression). HADS screens for
method and authentic movement promote the integration of depression and anxiety symptoms (Norton et al., 2013).
intra-actional (within the individual) and interactional (relating HADS is indicating symptoms, when the score is above 8 in
with the environment) systems (Capello, 2009). anxiety (HADS-A) and depression scales (HADS-D), respectively
The DMT group intervention consisted of 12 (Bjelland et al., 2002), or when the total score is ≥9 (Kjærgaard
dance/movement therapy sessions (one session a week for et al., 2014). Both BDI-II and HADS are frequently used in
12 weeks). Each session was 90 min long and included discussion clinical assessment of depression.
(20–40 min), movement warm-up and process (30–40 min) and The SCL-90 (Symptoms Check List- 90) is a psychiatric
a verbal reflection and closure of the movement experience (15– self-report inventory consisting of 90 questions. The questions
30 min) facilitated by a dance/movement therapist-psychologist. assess a wide range psychiatric symptoms, including depression,
The therapy groups were small with 4–7 participants. The anxiety, and somatization (Holi, 2003). Many of the symptoms
guiding principles for the group facilitation were: reflect bodily states and autonomous nervous system arousal. A
single number representing the severity of the patient’s condition
• supporting the safety in the body by paying attention to
is GSI (global severity index), which is the average score of the 90
grounding in the movement, body boundaries, respect for
questions of the inventory.
personal space, and the mover’s position as a modulator of
CORE-OM (Clinical Outcomes in Routine Evaluation—
his/her own movement
Outcome Measure) shows the patient’s experience of his/her
• supporting the sense of agency by emphasizing the choice
mood and interactions with others and environment. It addresses
making in movement, paying attention to the ways one uses
the patient’s global distress and portrays the dimensions of well-
one’s body in movement and interaction, recognizing the
being, problems, life functioning, and risk for aggressive/suicidal
resources the body offers
behavior. Between the general and clinical populations, the
• supporting mindfulness skills by paying attention to the
clinical cut-off point is 10 points (Connell et al., 2007) or as a total
experience of the body sensations, movements, and states,
mean score for women 1.29 and for men 1.19 (Evans et al., 2002).
fostering the ability to verbalize these as well as the emotions
CORE-OM is sensitive to change in condition. The CORE-OM
and imagery relating to the body sensations
all-items score has a correlation of 0.81 with BDI-II and 0.88 with
• being attentive to interaction by paying attention to body
SCL-90-revised version. CORE-OM is applicable to a wide range
responses in the group interaction situations, acknowledging
of populations. It can be used for assessing clinical effectiveness
the impact of expectations, and anticipation in the body
of various models of therapy (Evans et al., 2002).
responses
The self-evaluation measurements were presented to the
• fostering the interaction by being present and attentive to
participants at the start (pre-assessment), after 3 months (post
the patients, conveying seeing and hearing them as they are,
assessment), and 3 months after the end of the intervention
respecting the body experience, and encountering via shared
(follow-up assessment).
movement qualities
As DMT is based on interaction, the group facilitation in practice Statistical Analysis
was an integration of these principles, pre-planned structures and Baseline between-group differences in demographic data and
themes, and responses to the needs and themes of the group pre-treatment measures were analyzed with independent t-tests
in the moment. The same therapist working with each group and chi-square tests, or using Mplus statistics (see below). The
was the constant factor. All sessions included a discussion at the effects of interventions were analyzed using hierarchical linear
start and after the movement explorations. The discussions were modeling (HLM) in Mplus (version 7) (Muthén and Muthén,
oriented toward expressing embodied experiences and reflecting 2012). The most important advantage in using HLM with full
on them. Discussions also echoed the process and needs of the information maximum likelihood (FIML) estimation method
group. Table 3 presents a model of the 12-sessions group process. instead using repeated measures ANOVA/MANOVA is that it
uses all the available information. Thus all participants who
Outcome Measures started the study (DMT, n = 21, TAU, n = 12) were included
The background information assessment included the patient’s in the analyses. The missing data in HLM&FIML is supposed
gender, date of birth, diagnosis, duration of illness, severity of to be Missing At Random (MAR). ANOVA/MANOVA approach
depression, use of medication, and the treatment received by uses listwise deletion requiring that the missing data have to be
the time of answering the inquiry. The researcher/therapist had Missing Completely At Random (MCAR). This listwise deletion
also had access to the research subjects’ patient records. The self- has a greater effect on statistical power than the HLM/FIML
evaluation measures used in the study and reported in this paper method. The HLM uses a full information approach, with
were: BDI-II, HADS, SCL-90, and CORE-OM. standard errors that are robust in the case of a non-normal
BDI-II (Beck Depression Inventory) and HADS (Hospital distribution (MLR estimator in Mplus). The analyses were as
Anxiety and Depression Scale) measure mood. BDI-II (Beck follows. First, the group x time interaction was tested with Wald

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Pylvänäinen et al. DMT treatment effects

TABLE 3 | A group model based on the integration of the four different DMT group processes.

Theme Process exercises

1 Introduction, start Circular motion in joints.

Improvisation with name gestures.
With picture cards, expressing one’s expectations of the DMT group.

2 Familiarizing with the space, moving, and collaboration Exploring the space/room by moving in it in various ways and acknowledging the others.
In a dyad, reflecting each other’s movement.

3 Safety and agency, playfulness Recognizing how one directs attention: outwards, inwards.
Sensing body boundaries.
Moving eyes open or closed.
Exploring the spatial options in movement.

4 Playfulness, agency, finding different options Exploring spine motility.

Imagery and improvisation: If you were an animal, how would the animal move?
In a circle, moving by holding hands.

5 Intuition, sensitivity Activation of the body, starting from the feet.

Playing with different movement qualities.
Mindfulness skills and breathing: sensing one’s walking.

6 Relieving achievement pressure Sensing hands through different movements.

Breathing exercises.
Bartenieff Fundamentals* basic exercises.
Mindfulness skills: breathing and seeing the other.
Polarity: familiar and unfamiliar in movement.

7 Boundaries, distances, directions Activating hands and breathing, sensing body boundaries, sensing center/core also with
strength.
Movement improvisation with a focus on near space, middle space, far space.
Walking in a dyad and sensing the connection.
Drawing a picture of one’s experience.

8 Space for motion, boundaries, surfaces—balancing being, and action Self-nurturing movement and moving on the floor level.
Bartenief Fundamentals* basic exercises.
Getting into vertical slowly and through different postures.

9 Emotion—acceptance and agency in one’s life and in relation with Movement improvisation from the words selected to express one’s present state.
environment/others Exploring earth, water, air, and fire through movement improvisation—expressing and
describing associated feelings.

10 What do I need—attention and focusing in action In a dyad, hand massage.

On a tape line, improvising movement in relation to the line; working with a partner who
accompanies the movement in the way one asks for.

11 Accepting needs—nurturing, simplicity, freedom Moving with breath, gradually engaging the whole body.
Simple qigong exercise (breath, clear movement pattern, a sense of opening/stretching,
focusing).
Requesting from a pair something one needs in movement and/or presence.
Homework: to write a poem of one’s experiences in this group.

12 Closure—what have I learnt? Activating the body, grounding, being aware of the body.
Simple qigong exercise (same as in the session 11)
Poems: sharing them, improvising movement on them.
Feedback of the process.

* See Bartenieff and Lewis, 1980.

test. Secondly, if the interaction was statistically significant the and the TAU group mean by the pooled standard deviation
group differences were tested for the intervention period (pre to of the two conditions. The within-group ES was calculated for
post), and follow-up period (post to follow-up) separately. both the post- and follow-up measurements by dividing the
Effect sizes (ES) were calculated as follows. The between- mean change from pre-measurement by the combined (pooled)
groups ES was calculated after the treatment and at follow- standard deviation (SD) (Feske and Chambless, 1995; Morris and
up by dividing the difference between the DMT group mean DeShon, 2002). Due to possible differences between groups at

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Pylvänäinen et al. DMT treatment effects

pre-measurement, between-group ES differences at post- and at TABLE 4 | Mean scores and standard deviation for depression (BDI-II),
follow-up measurements were corrected by the pre-measurement anxiety and depression (HADS), physical and psychological symptoms
(SCL-90), and global distress (CORE) at pre, post, and 3-month follow-up.
difference. Thus, corrected between-group ES were reported.
A between-group effect size of 0.2 was considered small, 0.5 Out- Pre M Post M Fup 3-mo Wald test P-value
was medium, and 0.8 was large. A within-group ES of 0.5 was come (SD) (SD) M (SD) df = 2
considered small, 0.8 was medium, and 1.1 was large (Roth and
Fonagy, 1996; Öst, 2006). BDI-II 2.93 0.231
DMT 25.00(11.70) 14.89(13.60) 16.24(13.62)
Results TAU 32.50(7.60) 28.97(8.65) 29.66(9.85)
d −0.67 −0.60
Symptom Measurements HADS 5.39 0.068
At the pre-measurement, the groups were statistically DMT 20.81(7.99) 13.43(10.24) 14.22(9.85)
significantly different in their BDI-II -scores (DMT group TAU 24.58(4.65) 23.54(6.47) 23.15(7.75)
m = 25.00, sd = 11.70; TAU group m = 32.50, sd = 7.60; d −0.97 −0.79
Estimate = −7.50, p = 0.026) and CORE-scores (DMT group SCL-90 8.23 0.013
m = 17.00, sd = 6.61; TAU group m = 20.65, sd = 3.55; DMT 1.39(0.76) 0.95(0.74) 0.91(0.67)
Estimate = −3.66, p = 0.036). BDI and CORE described TAU 1.59(0.41) 1.58(0.37) 1.53(0.55)
the depression symptoms and psychiatric condition to be d −0.70 −0.67
more severe in the TAU group than in the DMT group at the CORE 4.14 0.126
pre-measurement. Based on the HADS and SCL-90 scores, DMT 17.00(6.61) 11.95(7.96) 12.31(7.02)
the groups were not statistically significantly different at the TAU 20.65(3.55) 20.05(4.55) 19.78(6.04)
pre-measurement. d −0.85 −0.73
Symptoms (SCL-90) decreased more in the DMT group than
in the TAU group during the study period. When the intervention Between-group effect-sizes (d) are also presented (corrected with pre-measurement
difference).
and follow-up periods were analyzed separately it was observed
that SCL-90 scores changed statistically significantly differently
in the DMT and TAU groups during the intervention (Estimate Differences between the Groups on the Basis of
= −0.425, p = 0.011) but not during the follow-up (Estimate the Use of Antidepressants
= 0.031, p = 0.086). In the HADS scores, there was a trend for When analyzing the data on the subjects’ use of medications,
a significantly different change over the three measures. During it was revealed that all the patients in the TAU group
the intervention the scores changed statistically significantly (n = 12) were on antidepressive medication, but in the
differently between the DMT and TAU groups (Estimate = DMT group there were nine patients, who were not taking
−6.295, p = 0.024), but not during the follow-up (Estimate = antidepressants, leaving 12 with antidepressants. Table 5 presents
0.741, p = 0.714). In the BDI-II- and CORE-scores there was the differences that can be observed when the subjects are
a greater reduction in the DMT group than in the TAU group, grouped on the basis of the DMT intervention and the use of
but over time, the groups did not change statistically significantly medication.
differently (Table 4). The duration of the participants’ illness, the length of the
To assess the size of the treatment effects, effect sizes were current treatment period, and the measurements score level
analyzed (see Supplementary Table 1). Between groups ES showed differed according to the use of antidepressant medication.
large differences (d ≥ 0.80) at post measurement in HADS and Compared to no-antidepressants patients, patients taking
CORE, and medium size (d ≥ 0.50) in BDI-II and SCL-90. At antidepressive medications had suffered longer from their
follow-up between groups ES were medium in favor of the DMT illness and had more severe psychiatric symptoms at the
group (d = 0.60–0.79). The difference in HADS at 3-month pre-measurement point. The TAU group participants on
follow-up was close to large (d = 0.79). In the DMT group, antidepressive medication had the most severe psychiatric
the with-in group ESs were medium or close to medium size at symptoms in this material. However, the mean duration of their
post measurement BDI-II (d = 0.87), HADS (d = 0.92), and illness and the length of the current treatment period were
CORE (d = 0.76), and small in SCL-90 (d = 0.57). In the shorter than in the subgroup of DMT antidepressant users. Since
follow-up the within ES were medium for HADS (d = 0.83) medication could have affected the results we decided to conduct
and close to medium in BDI-II (d = 0.75). ESs were small for additional analyses. We were especially interested to ascertain, if
CORE (d = 0.71) and SCL-90 (d = 0.62). In the TAU group the DMT group on medication showed a different change pattern
the within ESs were small (BDI-II, d = 0.47) or very small from that in the TAU group (on medication). Further, we were
(HADS, d = 0.23; SCL-90, d = 0.02; CORE, d = 0.18) at post also interested in comparing the members of the DMT group
measurement. The within ESs were also small in the follow-up with medication and without medication.
(BDI, d = 0.37; HADS, d = 0.31; SCL-90, d = 0.15; CORE, Wald test showed that the DMT group with medication
d = 0.26). Thus, in the DMT group the within ESs at the 3- changed differently from the TAU group (on medication) during
month follow-up varied from 0.62 to 0.82 as compared to TAU the intervention regarding the scores on SCL-90, Wald test =
0.15–0.37. 13.46, df = 2, p = 0.001. In this comparison, the change was

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Pylvänäinen et al. DMT treatment effects

TABLE 5 | Differences between outcomes in the DMT and TAU groups when the subgroup distribution is based on DMT intervention and taking
antidepressants.

Variable DMT group, pts taking DMT group, no TAU group, pts taking
antidepressants n = 12 antidepressants n = 9 antidepressants n = 12

Mean duration of the treatment period 17 months 10 months 15 months

Years since first episode of depression (mean) 10 years 5 years 6 years

INVENTORY M SD M SD M SD

BDI-II Pre 25.58 10.43 24.22 13.16 32.50 7.60

Post 18.02 13.76 11.55 11.92 28.97 8.65
Follow-up 19.59 11.88 13.36 14.77 29.66 9.85

HADS Pre 20.67 7.00 21.00 9.13 24.58 4.65

Post 15.67 10.57 11.00 9.06 23.54 6.47
Follow-up 16.96 10.01 11.22 8.57 23.15 7.75

SCL-90 Pre 1.45 0.67 1.30 0.86 1.59 0.41

Post 1.06 0.80 0.81 0.63 1.58 0.37
Follow-up 1.03 0.75 0.77 0.54 1.53 0.55

CORE Pre 17.54 5.53 16.13 7.95 20.65 3.35

Post 13.44 7.79 10.21 7.70 20.05 4.55
Follow-up 13.36 7.07 10.77 6.50 19.78 6.04

statistically significantly different during the intervention period in this group the ESs were small. In the TAU group, where all the
(Estimate = −0.378, p = 0.008), but not during the follow-up patients were on antidepressant medication, the changes in the
period. scores during the data collection time were minor. The range of
The HADS scores showed a tendency for a statistically within-group effect sizes (d) was 0.02–0.47.
significantly different change pattern when comparing the DMT
with no medication and the TAU group (Wald test = 5.472, Discussion
df = 2, p = 0.06). In this comparison, the change was
statistically significantly different during the intervention period This study investigated the effect of adding dance/movement
(the Estimate = −8.936, p = 0.026). During the follow-up period group therapy (DMT) to the treatment of psychiatric outpatients
there was no statistically significant change. with a diagnosis of depression. Compared to the TAU, adding
In all other comparisons Wald test did not reveal any DMT seemed to improve the effect of the treatment. There was a
statistically significant difference. As there were no statistically tendency for the effect of DMT to be slightly better with patients
significant differences between the score changes of the DMT who were not taking antidepressive medication.
group with no medication and DMT with medication subgroups, Between-group effect sizes between the DMT + TAU and TAU
DMT appears to be effective whether the patient is taking indicated medium or large differences (d = 0.60–0.85) in the
antidepressive medication or not. four measures used in this study in favor of the DMT + TAU. In
At the post-measurement, assessing the clinical significance addition, the within-group effect sizes were considerably larger
of the changes after the intervention period, the greatest among patients attending to the DMT group. This suggests, that
improvements in the condition appeared in the group of DMT the favorable changes observed when the DMT was added to the
participants who were not on antidepressant medication (see TAU may have clinical significance. However, more studies are
Supplementary Table 2). In this group, the within-group pre to needed to confirm the clinical effects of DMT.
post effect sizes ranged from d = 0.56 to d = 1.07, i.e., from small The indication of a statistically significantly greater
to medium. The effect sizes in the pre- follow–up measurements improvement between the DMT + TAU and TAU groups
comparison ranged from small to large, d = 0.62–1.10. The appeared in the SCL-90 measuring psychiatric symptoms and
DMT participants on antidepressants had also clearly improved, HADS measuring depression and anxiety symptoms. In these
but the within-ES changes were slightly smaller than for the self-evaluation assessments, the verbal content of the statements
DMT participants not on antidepressants. In the DMT group is geared toward bodily felt sensations, symptoms, and emotions.
on antidepressants the range of effect sizes (d) was 0.59–0.76 at In the SCL-90 one third of the questions refer to somatization
the pre-post measurements comparison, and at the pre-follow- or phenomena that relate to autonomous nervous system
up comparison the range was from d = 0.53 to d = 0.71; thus arousal. This may be one reason why the change was expressed

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Pylvänäinen et al. DMT treatment effects

more clearly through these measurements. In addition to these of particular interest that at the pre-measurement point in the
changes, the DMT group showed favorable changes, although DMT group, the patients on antidepressive medication and those
not statistically significant, in symptoms of depression (BDI-II) without antidepressive medication had a fairly similar level of
and global distress (CORE-OM). These observations are in symptoms, but the score differences between these two subgroups
line with the study by Punkanen et al. (2014) using a similar had clearly increased at the post-measurement, in favor of no
DMT group intervention. In their study the mean decrease on antidepressants sub-group. The question arises as to whether the
the BDI from baseline to post-measurement was 11.17 points DMT participants on antidepressants had a more difficult type of
compared to 10.11 points in the present study. Both these depression and the medication had alleviated their symptoms so
studies produced a similar favorable outcome in the treatment that their symptom scores were on the level of a less complicated
of depression. Punkanen et al. (2014) used a 20-session group depression at the pre-measurement point. If this was the case,
intervention provided twice a week while the present study it could be assumed that the smaller score changes after the
applied a 12-session intervention. This suggests that favorable intervention could have been due to the more difficult type of
changes could also be achieved using a shorter DMT group depression.
intervention. This study has limitations to be born in mind when drawing
The observations made in this study are also in accordance conclusions from the results. One concern is the use of self-
with the previous reviews by Meekums et al. (2015), Koch et al. evaluation measures only, and the lack of movement based
(2014), and Papadopoulos and Röhricht (2014). These suggested assessment of the effects of the intervention. Videotaping the
positive effects of DMT on quality of life and on depression and sessions was not part of the usual clinical practice at this
anxiety. One focus in DMT is engaging with movement activity clinic, and the goal was to study the natural clinical practice.
in the here and now. Further, the aim of activity is to be attentive Without video recordings it is difficult to produce any reliable
to the movement experiences and to develop the skills to be movement assessment of the four groups. Even with video
aware of experiences, and to communicate about them in words recordings, movement observation of group activity would have
(Meekums, 2002; Koch and Fischman, 2011; Nolan, 2014). Thus been challenging to carry out reliably.
DMT involves experiential exercises including mindfulness skills The participants joined the research groups on the basis
and attention training. There are several other studies suggesting of self-selection. They were not randomly divided among the
that this type of training, which includes experiential exercises, groups. Thus, we cannot ignore the possibility that the selection
could be beneficial to the patients (Hayes et al., 2011; Michalak bias has affected the results. In fact, at the pre-measurement
et al., 2012; Horst et al., 2013; Payne, 2015). It could also be point the TAU group reported significantly higher value for
speculated that DMT increases psychological flexibility, which depression symptoms and global distress compared to the DMT
has been shown to be associated with wellbeing and quality of life + TAU. On the other hand, the DMT group had a slightly
(Hayes et al., 2011; Keng et al., 2011), as the skills for observation, longer history of illness, more frequently two diagnoses and
reflection and body state modulation improve. Thus, given that more frequently an experience of psychotherapy than the TAU
DMT is a useful intervention method for patients with depression group patients. Also, as more patients in the DMT group had
symptoms, more studies are needed to examine the possible experience of psychotherapy, it is possible that DMT attracts
mechanism of change. patients who are positively disposed to therapeutic work, willing
A tendency was observed for the greatest improvement the and able to use self-reflection and interaction as means for
be achieved when the patient participated in the DMT group their recovery. Both the DMT and the TAU group participants
and was not on antidepressive medication. However, it should may have had expectations about the treatment they received.
be noted that the patients in the DMT group without or with As we did not systematically assess their expectations, we can
antidepressant medication benefited from the intervention, and draw no conclusions of the impact of expectations on the
no statistically significant differences were observed between results.
the groups. Thus, more studies are needed to investigate the Further, the follow-up time was relatively short (3 months),
impact of DMT interventions with or without medication. thus in light of the current data it is difficult to draw firm
The importance of observing medication in the treatment is conclusions about the long-term effects of DMT. Another
emphasized by the fact that the more difficult symptomology limitation is the small number of participants included in the
appears to go along with more complex diagnosis set, longer study. In the TAU group there was a fairly high drop-out
treatment period, and taking of medication. We observed that rate. However, we applied hierarchical linear modeling in data
those patients not taking medication had typically had current analyses, since it included all the patients who started the
treatment periods under 6 months (67% of the patients) and only treatment. According to the patient records, all the patients who
one diagnosis (44% of the patients). Those patients, who used left the research did continue their treatment at the psychiatric
medication at the pre-measurement, had typically two or more clinic over the study period. No data were collected about their
diagnosis (63% of the patients) and had more than 6 months of reasons for leaving the study.
treatment (63% of patients). The TAU patients were not interested in joining the DMT
When comparing DMT + TAU to TAU among patients on group, but this study offers no information about their reasons
antidepressant medication, it was observed that all the four for this. Compared to the TAU group, a higher percentage of
outcome measures tended to improve more in the DMT group, the DMT group patients continued in the study. This prompts
with especially SCL-90 showing significantly larger change. It is a question, whether the participation in the DMT group,

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Pylvänäinen et al. DMT treatment effects

personal commitment and joining the interaction supported the and experiential therapy interventions in the treatment of
motivation for treatment and also the alleviation of depression. depression.
If this was the case, DMT seems to offer a suitable social context
to be utilized in health care to offer new interactional experiences Acknowledgments
and learning through them.
The TAU did not significantly improve the patients’ wellbeing. PP wants to acknowledge her gratitude to the City of Tampere
This study suggests that experiential treatment methods such as Psychiatric Clinic for providing a base for this research. This
DMT could improve the effects of treatment. However, not all paper forms a part of her doctoral studies in psychology at the
clients want to join a DMT group as was observed in this study. University of Jyväskylä.
In the future, more attention could be devoted for increasing
patients’ motivation for experiential and action based treatment Supplementary Material
methods.
The results indicated that adding DMT to TAU is beneficial The Supplementary Material for this article can be found
in the treatment of patients with depression. These results online at: http://journal.frontiersin.org/article/10.3389/fpsyg.
encourage the use of creative, interactive, psycho-physical, 2015.00980

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Frontiers in Psychology | www.frontiersin.org 11 July 2015 | Volume 6 | Article 980

 IV

CHANGE IN BODY IMAGE AMONG DEPRESSED ADULT

OUTPATIENTS AFTER A DANCE MOVEMENT THERAPY
GROUP TREATMENT

by

Päivi Pylvänäinen and Raimo Lappalainen, 2018

The Arts in Psychotherapy, 59, 34–45.

Reproduced with kind permission by Elsevier.

 The Arts in Psychotherapy 59 (2018) 34–45 ! ! ! ! ! !


    
 

 


The Arts in Psychotherapy ! ! !

 

 




 
 

Research Article !

Change in body image among depressed adult outpatients after a ! ! ! ! ! ! ! ! !

dance movement therapy group treatment ! ! ! !

Päivi Pylvänäinen a,b,∗ , Raimo Lappalainen b ! ! !

a
Tampere Psychiatric Unit, Tampere City Mental Health Services, Tampere, Finland ! ! ! ! ! ! ! ! !

b
University of Jyväskylä, Department of Psychology, P.O. Box 35, 40014 JYVÄSKYLÄN YLIOPISTO, Jyväskylä, Finland! ! ! ! ! ! ! ! ! ! ! ! !

a r t i c l e
! ! ! ! ! ! ! i n f o ! ! ! a b s t r a c t ! ! ! ! ! ! !

Article history: !

This study reports on the body image of depressed psychiatric outpatients, and the impact thereon of
! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Received 3 August 2016 ! ! !

a dance movement therapy (DMT) group. Body image is perceived as a tri-partite construct consisting
! ! ! ! ! ! ! ! ! ! ! ! ! !

Received in revised form 8 June 2017 ! ! ! ! ! !

of image-properties, body-self, and body memory. Depressed patients in an outpatient mental health
! ! ! ! ! ! ! ! ! ! ! !

Accepted 7 October 2017

service participated in a DMT group treatment consisting of twelve 90-min long sessions in groups of
! ! !

Available online 16 October 2017

! ! ! ! ! ! ! ! ! ! ! ! ! ! !

4–7 patients. Patients (N = 18) responded to a structured Body Image Assessment (BIA) before and after
! ! ! !

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

the treatment. !

Keywords:
Initially, the depressed patients’ body image was characterized by fragmentation, distortions, and
Dance movement therapy
! ! ! ! ! ! ! ! ! ! !

shallowness of body awareness. The DMT group treatment aimed to offer the patients a safe space for
! !

Group therapy !
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Depression exploring their embodied experiences in a validating social setting. This produced positive changes in ! ! ! ! ! ! ! ! ! ! ! ! !

Body image !
the body image: finding a better sensation of one’s body, tolerating the sensations, settling in the body,
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Attachment finding pleasure and meaningfulness in the experiences. BIA scores indicated large effect sizes in the ! ! ! ! ! ! ! ! ! ! ! ! ! !

Mindfulness change between pre- and post-treatment assessments. Change for more positive body image during the ! ! ! ! ! ! ! ! ! ! ! ! !

treatment predicted fewer depressive symptoms at the follow-up measurement. ! ! ! ! ! ! ! !

© 2017 Elsevier Ltd. All rights reserved. ! ! ! ! ! !

Introduction maintain high stress-levels increase the risk of depression and its ! ! ! ! ! ! ! ! !

long duration. !

It is first relevant to review information on depression, body

! ! ! ! ! ! ! ! !
Reciprocal interaction (Fosha et al., 2009; Porges, 2009) with ! ! ! ! ! ! ! !

image and dance movement therapy (DMT). The selected refer-

! ! ! ! ! ! ! !
others shapes and is built on biological response patterns and ! ! ! ! ! ! ! ! !

ences present 1) an embodied and interaction oriented view on

! ! ! ! ! ! ! ! !
attachment patterns, i.e. the learned ways in which an individual ! ! ! ! ! ! ! ! !

depression, 2) a view on body image applicable in DMT and in ! ! ! ! ! ! ! ! ! ! !

relates to others. Reciprocity in interaction refers to the shaping ! ! ! ! ! ! ! ! !

the treatment of depression, and 3) DMT research that focuses on

! ! ! ! ! ! ! ! ! !
of the movements, level of arousal, attention, and verbal expres-
! ! ! ! ! ! ! ! !

depression. sions in response to what is perceived from the other’s expressions.

! ! ! ! ! ! ! ! ! !

Attachment may be secure or insecure. Attachment patterns are ! ! ! ! ! ! ! !

shaped in early childhood, and they continue to affect an indi-

Depression
! ! ! ! ! ! ! ! ! !

vidual’s behavior and emotional responses. Attachment style is ! ! ! ! ! ! !

stored to a large extent into implicit memory; attachment style is

Depression involves an experience of a loss of agency and
! ! ! ! ! ! ! ! ! !

embodied (Schachner, Shaver, & Mikulincer, 2005; Bentzen, 2015).

! ! ! ! ! ! ! ! !

reduced energy level (Fuchs & Schlimme, 2009). Difficulties in

! ! ! ! ! ! !

In interaction, attachment can be reshaped throughout the course

! ! ! ! ! ! ! !

interaction are a prominent aspect of depression (McCullough,

! ! ! ! ! ! ! !

of life (Levy, Ellison, Scott, & Bernecker, 2011), but through the
! ! ! ! ! ! !

2000; Riso & Klein, 2004; Pettit & Joiner, 2006). Patients suffering
! ! ! ! ! ! ! ! ! !

interactional expectations and learned response patterns that con-

! ! ! ! ! ! ! ! ! !

from depression perceive themselves, the world, and others neg-

! ! ! ! ! ! !

stitute the attachment style, individual spontaneously tends to

! ! ! ! ! ! ! !

atively and find it hard to recognize a gratifying impact on their

! ! ! ! ! ! !

maintain what he/she has already acquired (see an example in

! ! ! ! ! ! ! ! ! ! !

relationships and living environment. Interactional patterns creat-

! ! ! ! ! ! ! ! !

Soth, 2006, p.120-123). Research has shown that insecure, i.e.

! ! ! ! ! !

ing vulnerability to disappointments, conflicts, and behaviors that

! ! ! ! ! ! ! !

avoidant or anxious-ambivalent attachment style is characteris-

! ! ! ! ! ! !

! ! ! ! ! !

tic of patients with depression. Insecurity in the attachment style

! ! ! ! ! ! ! ! !

produces difficulties in behavioral self-regulation and also in inter- ! ! ! ! ! ! ! !

∗ Corresponding author at: Tampere Psychiatric Unit, Tampere City Mental Health ! ! ! ! ! ! ! ! !

personal regulation (Mikulincer & Shaver, 2007). Roberts et al. ! ! ! ! ! ! ! !

Services, Hatanpäänkatu 3 B (2nd floor), 33900 Tampere, Finland. ! ! ! ! ! ! ! !

(1996) propose that dysfunctional attitudes towards self and low ! ! ! ! ! ! ! !

E-mail addresses: paivi.pylvanainen@tanssiterapia.fi (P. Pylvänäinen),

self-esteem, which are caused by insecurity in attachment rela-
! ! ! !

raimo.i.lappalainen@jyu.fi (R. Lappalainen). ! !

! ! ! ! ! ! ! !

https://doi.org/10.1016/j.aip.2017.10.006
0197-4556/© 2017 Elsevier Ltd. All rights reserved. ! ! ! ! ! !
 P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! ! ! 35

tionships, produce vulnerability to depression. The evolutionary ! ! ! ! ! !

aspects of body memory that hold information about the surround- ! ! ! ! ! ! ! ! !

theories of depression interpret sadness and low mood as social ! ! ! ! ! ! ! ! !

ing environments and incorporate social habits and embodied
! ! ! ! ! ! !

pain, and consider social exclusion to be the trigger for this social
! ! ! ! ! ! ! ! ! ! !
patterns. Body memory can be equated with implicit memory. ! ! ! ! ! ! ! !

pain (Eisenberger, 2012; MacDonald & Leary, 2005; Rosenström

! ! ! ! ! ! !
Relating that view to the information afforded by the neuro- ! ! ! ! ! ! ! ! !

et al., 2013).
! !
sciences, particularly referring to research by Kandel (2006), it has ! ! ! ! ! ! ! ! !

The concept of affordances (Gibson, 1966) is based on an ! ! ! ! ! ! ! ! !

been suggested that the living body and its nervous system learn ! ! ! ! ! ! ! ! ! !

interactionist view of perception and action: people perceive the ! ! ! ! ! ! ! !

from the sensations received from the environment and from the ! ! ! ! ! ! ! ! !

environment in terms of their ability to act in it. Factors that affect ! ! ! ! ! ! ! ! ! ! ! !

body itself (Pylvänäinen, 2012). The integration of sensory, tactile, ! ! ! ! ! ! ! !

physical ability and thus influence perception include body size, ! ! ! ! ! ! ! !

and proprioceptive information and motor efferent information is
! ! ! ! ! ! !

body control and coordination, energetic potential and the chal- ! ! ! ! ! ! ! !

the essence of the organism’s ability for intelligent action. Body
! ! ! ! ! ! ! ! !

lenges of the task (Witt, 2011). This physicality also creates a basis ! ! ! ! ! ! ! ! ! ! !
memory stores the integration, the capacities, and dispositions ! ! ! ! ! ! !

for cognitive and social interactional abilities. Triberti & Riva (2016)
! ! ! ! ! ! ! ! !
(Koch et al., 2012, 2013) that are shaped in the body and nervous ! ! ! ! ! ! ! ! ! ! ! !

perceive presence as the relevant link between intentions and affor- ! ! ! ! ! ! ! ! ! system through life experiences. The ability for attention, percep- ! ! ! ! ! ! ! !

dances. Rietveld (2008) has defined affordances “as an organism’s ! ! ! ! ! ! ! !

tion, and responsiveness that the body-self maintains, enable the
! ! ! ! ! ! ! !

possibilities for action in some situation (p. 978)”. According to ! ! ! ! ! ! ! ! !

channeling of some of the contents of body memory into our con- ! ! ! ! ! ! ! ! ! ! !

Rietveld, affordances are experienced as potentiating and have an ! ! ! ! ! ! ! ! scious processing. !

affective allure. In depression the person has troubled presence ! ! ! ! ! ! ! !

The tension patterns in the body are one channel for the ! ! ! ! ! ! ! ! ! !

and perceives fewer or meager affordances, thus finding the situa-

! ! ! ! ! ! ! ! !
body memory to shape the state and responses of the body-self. ! ! ! ! ! ! ! ! ! !

tion even more stressful, because coping and completing actions in

! ! ! ! ! ! ! ! !
Depressed individuals characteristically show muscular tension, ! ! ! ! !

the situation becomes jeopardized. Consequently, a self-enhancing

! ! ! ! ! !
shallow breathing, lack of energy, a predisposition to exhaustion ! ! ! ! ! ! ! !

negative spiral develops. ! !

and loss of sensory awareness (Stötter et al., 2013). When early
! ! ! ! ! ! ! ! ! !

Attachment and affordances are embodied and learned predis- ! ! ! ! ! ! !

childhood attachment experiences have been marked by insecurity, ! ! ! ! ! ! !

positions to responding. The symptoms of depression − low energy, ! ! ! ! ! ! ! ! !

and the individual suffers from depression, it has been observed
! ! ! ! ! ! ! ! !

anhedonia, pains, sleeping problems, anxiety, and in severe depres- ! ! ! ! ! ! ! !

that these individuals are typically lacking in mindful body aware-
! ! ! ! ! ! ! ! !

sion suicidality − can be seen as features and outcomes, which are

! ! ! ! ! ! ! ! ! ! !
ness (Segal, Williams, & Teasdale, 2002). This means that they may
! ! ! ! ! ! ! ! ! !

shaped by attachment styles that are dominated by insecurity, and ! ! ! ! ! ! ! ! !

not be aware of the sensations in the body nor have a habit of nam-
! ! ! ! ! ! ! ! ! ! ! ! ! !

by affordances that are not perceived as enabling. These result in

! ! ! ! ! ! ! ! ! !
ing the sensations with an accepting, non-judgemental attitude.
! ! ! ! ! ! !

increased stress-levels in the individual. ! ! ! !

The research on how depressed patients experience their body ! ! ! ! ! ! ! !

As depression has such a strong impact on the sense of agency ! ! ! ! ! ! ! ! ! ! !

image is very scant. A study by Noles et al. (1985) presented their ! ! ! ! ! ! ! ! ! ! ! !

and interrelatedness, and as it often includes somatic symptoms −

! ! ! ! ! ! ! ! !
findings in a student population, and built around the question ! ! ! ! ! ! ! ! !

fatigue, pain, somatic illnesses, loss of energy, and weight prob- ! ! ! ! ! ! ! ! !

whether the depressed people feel more dissatisfaction with their ! ! ! ! ! ! ! !

lems − it is relevant to explore how a creative and interactive,

! ! ! ! ! ! ! ! ! ! ! body image. This is a narrow perspective on the body image, but ! ! ! ! ! ! ! ! ! ! !

body focused form of psychotherapy functions in the treatment of ! ! ! ! ! ! ! ! !

Noles et al. did discover that depressed students reported more ! ! ! ! ! ! ! ! !

depression. The view on depression taken in this study perceives ! ! ! ! ! ! ! ! !

body image dissatisfaction than did non-depressed students. ! ! ! ! ! !

that the body-mind condition, the embodied response patterns and

! ! ! ! ! ! ! ! Rosenström et al. (2013) found a link between chronically ! ! ! ! ! ! ! !

the implicit, procedural information individuals use in their behav-

! ! ! ! ! ! ! !
elevated dysphoria and body image dissatisfaction. Their study ! ! ! ! ! ! !

ior, attachment and affordances, are relevant in the treatment of

! ! ! ! ! ! ! ! !
sample of 156–192 subjects (varying between follow-up years) was ! ! ! ! ! ! ! !

depression. derived from a population-based “Young Finn” −study (n = 1 050), ! ! ! ! ! ! ! ! ! !

and the subjects were examined four times over a 16-year period.
! ! ! ! ! ! ! ! ! !

Body image !
In this study, high body-image dissatisfaction was associated with
! ! ! ! ! ! ! !

chronic dysphoric status, indicated by high depression scores in ! ! ! ! ! ! ! !

Grogan (2008, p. 3) defines body image as “a person’s percep- ! ! ! ! ! ! ! ! ! !

adapted BDI. In this study, women had slightly higher body image ! ! ! ! ! ! ! ! ! !

tions, thoughts, and feelings about his or her body”. Body image ! ! ! ! ! ! ! ! ! ! dissatisfaction than men. Although the average body image dissat- ! ! ! ! ! ! ! !

refers to the lived experience contained in the body and the psy- ! ! ! ! ! ! ! ! ! ! !
isfaction in the population declined between the ages 15 and 30, ! ! ! ! ! ! ! ! ! !

chological significance of the body. Typically the research on body ! ! ! ! ! ! ! ! !

the between-subject differences in body image dissatisfaction were
! ! ! ! ! ! !

image has focused on body image dissatisfaction and body image ! ! ! ! ! ! ! ! !

more temporally stable than any of the other symptoms. ! ! ! ! ! ! ! !

distortions in eating and somatoform disorders (Cash & Smolak, ! ! ! ! ! ! ! !

The study by Papadopoulos and Röhricht (2014) describes 31 ! ! ! ! ! ! ! !

2011). In dance movement therapy (DMT) the perspective on the ! ! ! ! ! ! ! ! !

depressed patients who initially showed a poor body satisfaction ! ! ! ! ! ! ! !

body image is phenomenological and experiential. For the pur- ! ! ! ! ! ! ! !

and feelings of being detached and distant from their own body.
! ! ! ! ! ! ! ! ! !

poses of DMT, the body image is perceived to consist of three ! ! ! ! ! ! ! ! ! ! !

Patients found it difficult to be grounded, i.e., were cut-off from ! ! ! ! ! ! ! ! ! !

aspects: the image-properties, the body-self and the body mem- ! ! ! ! ! ! ! !

sensing a contact to the ground and from sensations in their bod- ! ! ! ! ! ! ! ! ! ! !

ory (Pylvänäinen, 2003). The body-self is the body’s active quality

! ! ! ! ! ! ! ! !
ies. They also experienced their body boundaries as weak and easily
! ! ! ! ! ! ! ! ! !

of being present, sensing and in interaction with the environment

! ! ! ! ! ! ! ! !
penetrated. Regarding the tension patterns in their bodies, their ! ! ! ! ! ! ! !

now. The body-self is actualized in the present through connect- ! ! ! ! ! ! ! ! !

body posture typically included a sunken chest, hunched shoulders, ! ! ! ! ! ! ! !

edness with the sensory, kinesthetic, and perceptual information ! ! ! ! ! ! !

narrow body stance, and downcast eye line gaze with an inter- ! ! ! ! ! ! ! ! ! !

in the body. This information relates to the external surroundings

! ! ! ! ! ! ! ! ! nal and withdrawn focus. Their breathing was typically shallow
! ! ! ! ! ! ! !

and to the state prevailing within the individual.

! ! ! ! ! ! !
and mainly involved the upper chest region. The core characteris-
! ! ! ! ! ! ! ! !

Image-properties are perceptions, thoughts, judgments, and ! ! ! ! !

tic in their movement and bodily presence was bound flow. They
! ! ! ! ! ! ! ! ! !

socio-cultural values related to the physical appearances of the ! ! ! ! ! ! ! !

felt fatigue and pains in the body. The essential outcome from the
! ! ! ! ! ! ! ! ! ! !

body. The image-properties evoke emotional responses in the per- ! ! ! ! ! ! ! !

20 bi-weekly sessions of body psychotherapy group, facilitated by
! ! ! ! ! ! ! !

son and these are experienced through the body-self.

! ! ! ! ! ! !
an experienced dance movement therapist, was that the patients
! ! ! ! ! ! ! !

Body memory refers to the embodied information storage func- ! ! ! ! ! ! ! !

became more aware of their embodiment, their bodily sensations ! ! ! ! ! ! ! !

tion of the body. Body memory, outlined from a phenomenological

! ! ! ! ! ! ! ! !
and movement patterns, and were able to see how these related to
! ! ! ! ! ! ! ! ! ! !

perspective, has three spheres: habitual, traumatic, and erotic ! ! ! ! ! ! !

their depression. !

(pleasurable) body memory (Casey, 1987). Koch et al. (2012, 2013) ! ! ! ! ! ! ! ! ! Bunce et al. (2014) and Grogan et al. (2014) report a pilot study ! ! ! ! ! ! ! ! ! ! ! !

propose a more detailed categorical differentiation, which specifies ! ! ! ! ! ! !

in an educational setting with 17-year old, normal young adults,
! ! ! ! ! ! ! ! !
36 ! P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! !

who participated in one DMT session. The session aimed to enable

! ! ! ! ! ! ! ! ! !

self-awareness can increase adaptive empathy and communicative ! ! ! ! ! !

a focus on body function and body appreciation, to explore how the

! ! ! ! ! ! ! ! ! ! !
capacity (Smears, 2009), as the person is using his or her sensory ! ! ! ! ! ! ! ! ! ! !

body responds to feeling, and how this produces a body sensation,! ! ! ! ! ! ! ! ! !

information, especially kinesthetic and tactile, in a richer and more ! ! ! ! ! ! ! ! !

which intra-subjectively increases awareness of the body. These ! ! ! ! ! ! !

refined way. This is beneficial to the ability to maintain awareness ! ! ! ! ! ! ! ! ! !

young adults felt a sense of freedom in the way they could express ! ! ! ! ! ! ! ! ! ! ! !
of both the internal experiences and the interactional perceptions
! ! ! ! ! ! ! !

themselves in the session. The participants in this pilot felt they ! ! ! ! ! ! ! ! ! !

of the surroundings and others.
! ! ! !

had better connection to the body or body parts after the session
! ! ! ! ! ! ! ! ! ! !

There are a few studies on the use of DMT in the treatment ! ! ! ! ! ! ! ! ! ! ! !

and more understanding of the body. This created more acceptance

! ! ! ! ! ! ! ! !
of depression. A Cochrane review has been published (Meekums,
! ! ! ! ! ! ! !

and awareness of one’s body, which was perceived as a more posi-

! ! ! ! ! ! ! ! ! ! !
Karkou, & Nelson, 2015) with the focus on examining the effects ! ! ! ! ! ! ! ! ! !

tive body image. The participants had a more connected sensation

! ! ! ! ! ! ! ! !
of DMT on depression with or without standard care, compared
! ! ! ! ! ! ! ! !

between the body and the mind. ! ! ! ! !

to no treatment or standard care alone, psychological therapies,
! ! ! ! ! ! ! !

drug treatment, or other physical interventions. The low-quality ! ! ! ! ! ! !

Dance movement therapy ! ! evidence from three small RCT’s (total N = 147) did not allow any ! ! ! ! ! ! ! ! ! ! ! !

firm conclusions to be drawn regarding the effectiveness of DMT ! ! ! ! ! ! ! ! !

Dance movement therapy (DMT) is a form of therapy, which ! ! ! ! ! ! ! ! !

for depression. The authors suggested larger trials of high method-
! ! ! ! ! ! ! ! !

integrates the physical, emotional, cognitive, and social aspects ! ! ! ! ! ! ! ological quality for assessing the use of DMT in the treatment of ! ! ! ! ! ! ! ! ! ! !

in treatment (Chaiklin and Wengrower, 2009; Goodill, 2005;

! ! ! ! ! ! !
depression.
Meekums, 2002; Payne, 2006; Stanton-Jones, 1992). DMT is defined ! ! ! ! ! ! ! !
An earlier review article (Mala et al., 2012) identified two stud- ! ! ! ! ! ! ! ! ! !

by the European Association Dance Movement Therapy (EADMT)

! ! ! ! ! ! !
ies, which presented findings from a randomized controlled trial
! ! ! ! ! ! ! !

as “the therapeutic use of movement to further the emotional, cog-

! ! ! ! ! ! ! ! ! !
design and used a clear DMT intervention (Jeong et al., 2005; ! ! ! ! ! ! ! ! ! !

nitive, physical, spiritual, and social integration of the individual. ! ! ! ! ! ! ! !

Stewart et al., 1994). The results in these studies showed a posi- ! ! ! ! ! ! ! ! ! ! !

Dance as body movement, creative expression and communication, ! ! ! ! ! ! !

tive outcome for the treatment of depression. Röhricht et al. (2013)

! ! ! ! ! ! ! ! ! !

is the core component of DMT. Based on the fact that the mind,
! ! ! ! ! ! ! ! ! ! ! ! report of a manualized body psychotherapy treatment (20 sessions, ! ! ! ! ! ! ! !

the body, the emotional state and relationships are interrelated,

! ! ! ! ! ! ! !
bi-weekly n = 21, control group n = 10). Punkanen et al. (2014) did a ! ! ! ! ! ! ! ! ! ! ! ! ! !

body movement simultaneously provides the means of assess- ! ! ! ! ! ! !

pilot study on the use of DMT group in the treatment of depression ! ! ! ! ! ! ! ! ! ! ! !

ment and the mode of intervention for DMT.” (EADMT Ethical Code ! ! ! ! ! ! ! ! ! !
(20 sessions, bi-weekly, N = 21). Pylvänäinen et al. (2015) present
! ! ! ! ! ! ! ! ! !

2010, http://www.eadmt.com/?action=article&id=22, retrieved on ! ! !

results from a quasi-experiemental, clinical practice-based study, ! ! ! ! ! !

March 21, 2017). ! !

where participants underwent 12-session DMT-group processes ! ! ! ! !

DMT offers an approach to the self, relating, and interaction. ! ! ! ! ! ! ! ! !

(n = 21, control group n = 12 receiving treatment as usual). These
! ! ! ! ! ! ! ! ! ! ! !

One focus in DMT is engaging with movement, becoming concretely

! ! ! ! ! ! ! ! !
three European studies report positive outcomes from the use of ! ! ! ! ! ! ! ! !

involved in movement activity in the here and now. The other locus ! ! ! ! ! ! ! ! ! ! !
group form DMT in the treatment of depression. ! ! ! ! ! ! !

of action is to be attentive to the movement experiences and to

! ! ! ! ! ! ! ! ! ! ! The findings of Pylvänäinen et al. (2015) are particularly rel- ! ! ! ! ! ! ! ! !

develop the skills to be conscious and reflective of them − i.e., to ! ! ! ! ! ! ! ! ! ! ! !

evant here, because the research subjects (n = 21) are the same ! ! ! ! ! ! ! ! ! ! !

develop mindfulness − and to narrate the movement experiences ! ! ! ! ! ! ! !

individuals, whose experiences of body image and the DMT group ! ! ! ! ! ! ! ! !

in words. Considering the above, DMT practice naturally addresses

! ! ! ! ! ! ! !
process are presented in this paper. We have previously reported ! ! ! ! ! ! ! ! !

body image. !
that among these depressed patients, when compared to the treat- ! ! ! ! ! ! ! ! !

The relevant effective elements in DMT are the engagement ! ! ! ! ! ! ! !

ment as usual (TAU), adding DMT seemed to improve the effect of ! ! ! ! ! ! ! ! ! ! !

of the moving body, creativity − spontaneity, playfulness, move-

! ! ! ! ! ! ! !
the treatment in a psychiatric outpatient clinic. In the DMT group
! ! ! ! ! ! ! ! ! !

ment exploration/improvisation, and the use of metaphors − the ! ! ! ! ! ! ! !

we observed medium or close to large within-group effect sizes at
! ! ! ! ! ! ! ! ! !

development of body awareness and mindfulness, and the verbal ! ! ! ! ! ! ! !

post measurement for depression (BDI-II, d = 0.87; pre M = 25.00, ! ! ! ! ! ! ! ! ! ! !

reflection of the movement experiences, focusing on the qualities ! ! ! ! ! ! ! !

SD = 11.70, post M = 14.89, SD = 13.60), for depression and anxiety
! ! ! ! ! ! ! ! ! ! ! ! !

of the experience (Bräuninger, 2014; Papadopoulos and Röhricht,

! ! ! ! ! ! !
symptoms (HADS, d = 0.92; pre M = 20.81, SD = 7.99, post M = 13.43, ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

2014; Payne, 2006). In the dialogue the experiences unfold with a ! ! ! ! ! ! ! ! ! ! SD = 10.24), and for patient’s experience of his/her mood and
! ! ! ! ! ! ! ! ! !

focus on kinesthetic, sensorial, and emotional qualities and embod- ! ! ! ! ! ! ! !

interaction with others and environment (CORE-OM, d = 0.76; pre ! ! ! ! ! ! ! ! !

ied perceptions. This may be concrete and situation specific. This

! ! ! ! ! ! ! ! !
M = 17.00, SD = 6.61, post M = 11.95, SD = 7.96). A relatively small
! ! ! ! ! ! ! ! ! ! ! ! ! ! !

enables the patient to connect with the emotional core of his/her ! ! ! ! ! ! ! ! ! !

effect size was found for psychiatric symptoms (SCL-90/GSI gen- ! ! ! ! ! ! ! !

experience. Moving and verbalizing about the movement experi- ! ! ! ! ! ! !

eral severity index), d = 0.57; pre M = 1.39, SD = 0.76, post M = 0.95,
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

ence are neurologically integrative activities. When done in a safe

! ! ! ! ! ! ! ! !
SD = 0.74). ! !

environment they naturally promote activation and integration of ! ! ! ! ! ! !

various neural networks. Functional integration of the neural net- ! ! ! ! ! ! ! !

works promotes well-being (Siegel, 2007). ! ! ! !

Aims
The safety of the DMT setting relates essentially to the pos- ! ! ! ! ! ! ! ! ! !

sibility of fostering interoseption and self-aware consciousness. ! ! ! ! ! !

The present study focuses on the body image contents and ! ! ! ! ! ! ! ! !

Orientation to the sensations and movements in the body provides ! ! ! ! ! ! ! ! !

change therein through a DMT treatment in adult psychiatric out- ! ! ! ! ! ! ! ! !

the basis for self-aware consciousness (Cloninger, 2004) and body-

! ! ! ! ! ! ! !
patients with depression. We had already studied the same sample ! ! ! ! ! ! ! ! !

awareness (Fogel, 2013). When the situation is safe, the interaction ! ! ! ! ! ! ! ! !

by using self-evaluation measurement tools (BDI-II, HADS, CORE-
! ! ! ! ! ! !

can include the orientation to one’s own bodily sensations and

! ! ! ! ! ! ! ! !
OM and SCL-90) and had found that the DMT treatment had ! ! ! ! ! ! ! ! ! !

experiences. When communicating a non-judgemental interest ! ! ! ! !

significant impact on depressive symptoms (Pylvänäinen, Muotka, ! ! ! ! ! !

during this process, body-awareness and self-aware consciousness ! ! ! ! ! !

& Lappalainen, 2015; see also above). In the present study, by uti-
! ! ! ! ! ! ! ! ! ! !

in the present can develop. This is also the core of mindfulness.

! ! ! ! ! ! ! ! ! ! !
lizing the tri-partite model of body image, we are interested in 1) ! ! ! ! ! ! ! ! ! ! !

Mindfulness is an attentional skill that supports connectedness ! ! ! ! ! ! !

investigating the body image of patients with diagnoses of depres- ! ! ! ! ! ! ! ! !

to body image. Mindfulness promotes being present, aware, and

! ! ! ! ! ! ! !
sion, 2) whether the DMT treatment produces changes in body ! ! ! ! ! ! ! ! !

open to an experience in a non-judgemental way. It is based on ! ! ! ! ! ! ! ! ! ! !

image and 3) how the patients experience the DMT group interven- ! ! ! ! ! ! ! ! ! !

the awareness of one’s body, and breath in particular (Leigh &

! ! ! ! ! ! ! ! ! !
tion; i.e., what features in the DMT interaction are relevant to them. ! ! ! ! ! ! ! ! ! ! !

Bailey, 2013; Michalak, Burg, & Heidenreich, 2012). Body awareness ! ! ! ! ! ! ! !

This aims to present a new way of approaching and understanding ! ! ! ! ! ! ! ! ! !

can also be seen as connectedness to the body image. Embodied

! ! ! ! ! ! ! ! ! !
depression by investigating the role of body image. ! ! ! ! ! ! !
 P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! ! ! 37

Methods DMT group, none of the participants had previously received DMT
! ! ! ! ! ! ! ! !

treatment.
Recruitment procedure !

In the DMT group, 57% of the participants were taking antide- ! ! ! ! ! ! ! ! ! !

pressants and 43% were not. In the DMT group 38% of the patients ! ! ! ! ! ! ! ! ! ! ! !

This is a practice-based clinical study. All participants in the ! ! ! ! ! ! ! ! !

were taking some other medication for psychiatric reasons. ! ! ! ! ! ! !

study were recruited from an outpatient mental health service, ! ! ! ! ! ! ! !

which is part of specialized public health care. The clinic offers phar- ! ! ! ! ! ! ! ! ! ! !

Treatment procedure !

macological treatment, individual counseling and a variety of group ! ! ! ! ! ! ! !

interventions. Since 2007, DMT group (8–12 sessions duration) has ! ! ! ! ! ! ! !

The DMT group treatment consisted of 12 DMT sessions. Each ! ! ! ! ! ! ! ! !

been one treatment option. ! ! !

session was 90 min long and was always structured in orien- ! ! ! ! ! ! ! ! ! !

The research plan was accepted by the City of Tampere Research ! ! ! ! ! ! ! ! ! !

tation/discussion, movement warm-up, movement process, and ! ! ! ! !

Board. The patient information described the research as a study on ! ! ! ! ! ! ! ! ! !

a verbal round-up of the movement experience facilitated by a

! ! ! ! ! ! ! ! !

the treatment of depression and its outcome by comparing treat-

! ! ! ! ! ! ! ! !

dance/movement therapist-psychologist. At the start of the pro- ! ! ! ! ! ! !

ment as usual and a DMT group treatment. The inclusion criteria ! ! ! ! ! ! ! ! ! !

cess, the same ground rules were presented to the group members:
! ! ! ! ! ! ! ! ! !

for the study were diagnosis of depression and depression as the

! ! ! ! ! ! ! ! ! !

confidentiality, respect for the body and experience, and no harm- ! ! ! ! ! ! ! ! !

patient’s primary symptom. The exclusion criteria were psychosis, ! ! ! ! ! ! !

ing of one-self or others. The basic principles of the DMT group

! ! ! ! ! ! ! ! ! ! !

recent suicide attempts or clear suicide plans, severe personal- ! ! ! ! ! ! ! !

facilitation were: !

ity disorder and significant alcohol abuse problem. The patients

! ! ! ! ! ! ! !

entered the study voluntarily. Patients participating in the study ! ! ! ! ! ! ! !

• supporting the safety in the body by paying attention to grounding ! ! ! ! ! ! ! ! ! !

received information about the study, their contribution and their ! ! ! ! ! ! ! !

in the movement, body boundaries (personal space and contact

! ! ! ! ! ! ! !

freedom to withdraw from the study at any time without conse- ! ! ! ! ! ! ! ! ! !

of the body with the environment via its surface), the respect for
! ! ! ! ! ! ! ! ! ! !

quences to their access to treatment. After the intake interview, ! ! ! ! ! ! ! ! !

personal space, and the mover’s position as a modulator of his/her ! ! ! ! ! ! ! ! ! !

participants provided written consent to participate in the study. ! ! ! ! ! ! ! !

own movement !

The participants in the study were recruited over a period of 13

! ! ! ! ! ! ! ! ! ! !

• supporting the sense of agency by emphasizing the choices made ! ! ! ! ! ! ! ! !

months. The therapist-researcher had an access to the participants’ ! ! ! ! ! ! ! !

in movement, paying attention to the ways one uses one’s body

! ! ! ! ! ! ! ! ! !

medical records. !

in movement and interaction, recognizing the resources the body

! ! ! ! ! ! ! !

offers
Participants • supporting mindfulness skills by paying attention to the experience ! ! ! ! ! ! ! !

of the body sensations, movements, and states, fostering the abil-

! ! ! ! ! ! ! ! !

The data was collected from four consecutive DMT groups. Dur- ! ! ! ! ! ! ! ! !

ity to verbalize these as well as the emotions and imagery relating

! ! ! ! ! ! ! ! ! ! !

ing the data collection period, a total of 25 patients were recruited

! ! ! ! ! ! ! ! ! ! !

to the body sensations ! ! !

for the DMT groups. Four patients were excluded from the sam-
! ! ! ! ! ! ! ! ! !

• being attentive to interaction by paying attention to body ! ! ! ! ! ! ! !

ple on the basis of the inclusion criteria. Thus, 21 patients could be

! ! ! ! ! ! ! ! ! ! ! !

responses in the group interaction situations, acknowledging the ! ! ! ! ! ! !

included in the study. Sequentially, they formed four groups. The ! ! ! ! ! ! ! ! !

impact of expectations and anticipation on the body responses ! ! ! ! ! ! ! !

therapist/researcher worked with one group at a time. ! ! ! ! ! ! !

• fostering the interaction by being present and attentive to oth- ! ! ! ! ! ! ! ! !

A background information questionnaire was used to collect

! ! ! ! ! ! !

ers, seeing and hearing them as they are, respecting the body ! ! ! ! ! ! ! ! ! !

information on patients’ gender, date of birth, diagnoses, duration ! ! ! ! ! ! ! !

experience, and encountering via shared movement qualities ! ! ! ! ! !

of illness, severity of depression, use of medication, and the treat-

! ! ! ! ! ! ! ! ! !

ment received up to the time of responding to the questionnaire.

As to the interaction that actually emerged in the group pro-
! ! ! ! ! ! ! ! ! !

The researcher/therapist had an access to the subjects’ patient

! ! ! ! ! ! ! ! ! !

cesses, an integrative model of the themes and movement practices

! ! ! ! ! ! ! !

records.
! ! ! ! ! ! ! ! !

which were flexibly used in the process of each group is presented

Of the 21 DMT group participants, five (23.8%) were male. The
! ! ! ! ! ! ! ! ! ! !

in Appendix A.
! ! ! ! ! ! ! ! ! !

mean age of the participants was 42 years (sd = 12.7). One third of
! !

! ! ! ! ! ! ! ! ! ! ! ! !

the patients had one psychiatric diagnosis and 48% had two. The
! ! ! ! ! ! ! ! ! !

most common diagnosis was F32 −depressive episode (29%) and ! ! ! ! ! ! ! !

Data collection tools ! !

the total percentage of patients with F32-range diagnosis was 43%.

! ! ! ! ! ! ! ! !

F33 −recurrent depressive episode diagnosis was also common

! ! ! ! ! ! !
To assess the body image and the patient’s experience of the ! ! ! ! ! ! ! ! ! !

(19%). In the majority of the patients (67%) according to the doctor’s ! ! ! ! ! ! ! ! ! ! !

DMT treatment, the primary data collection tool was the Body
! ! ! ! ! ! ! ! !

assessment, depression was moderate or severe. There were four ! ! ! ! ! ! ! !

Image Assessment (BIA). The BIA was done before and after the ! ! ! ! ! ! ! ! ! !

patients, whose primary diagnosis was of anxiety or personality ! ! ! ! ! ! ! !

DMT treatment. Before the treatment, the assessments were com-
! ! ! ! ! ! ! !

disorder range. !
pleted with the researcher/therapist in a clinical interview that ! ! ! ! ! ! ! !

Of the DMT group participants 67% had a second diagnosis ! ! ! ! ! ! ! ! !

lasted 50–60 min. As the interview was part of the regular clini- ! ! ! ! ! ! ! ! ! ! !

related to somatic illness in heart or lungs, diabetes, hyperkine- ! ! ! ! ! ! ! ! !

cal practice for entering the DMT groups, these interviews were
! ! ! ! ! ! ! ! !

sis, or pain, or a second diagnosis related to depression, anxiety

! ! ! ! ! ! ! ! ! !
not recorded. The researcher/therapist took detailed notes of the
! ! ! ! ! ! ! !

and personality disorders. History of alcohol abuse was reported patient’s responses, writing the expressions the patient used. After ! ! ! ! ! ! ! !

the DMT treatment, the BIA −questions were presented to the par-
! ! ! ! ! ! ! !

for 14% of the patients. In the medical records, for 20 out of 21 of

! ! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! !

the DMT group participants, there was a note of relational stress

! ! ! ! ! ! ! ! ! !
ticipants using a questionnaire. ! ! !

in the person’s history or current life situation. Relational stress

! ! ! ! ! ! ! ! !
BIA is based on the tri-partite model of body image (Pylvänäinen, ! ! ! ! ! ! ! ! ! !

refers to childhood abusive or insecure family situation, loss of par- ! ! ! ! ! ! ! ! ! !

2003) and on the clinical practice of discussing embodied experi- ! ! ! ! ! ! ! ! !

ent(s) in childhood, being bullied at school, problems or divorce in ! ! ! ! ! ! ! ! ! !

ences with the patients. The questions in the assessment are (in ! ! ! ! ! ! ! ! ! !

marital/intimate relationships and/or lack of intimate relationship. ! ! ! ! ! !

parentheses a classification based on the tri-partite model of body ! ! ! ! ! ! ! ! !

The mean time elapsing since the first episode of depression ! ! ! ! ! ! ! ! !

image, Pylvänäinen 2003): ! !

was 7.9 years. At the time of pre-assessment, for the majority of the
! ! ! ! ! ! ! ! ! ! ! !

patients (76%) the length of current treatment period was less than ! ! ! ! ! ! ! ! ! !
A How do you perceive your body and its appearances? (image-
! ! ! ! ! ! ! ! ! !

12 months. At pre-measurement the patient’s current treatment

! ! ! ! ! ! !
properties)
period had most commonly lasted less than six months. Before ! ! ! ! ! ! ! ! !
B What is it like for you to take physical action? (body-self)
! ! ! ! ! ! ! ! ! ! !
38 ! P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! !

C In your body, how do you typically sense or feel your everyday

! ! ! ! ! ! ! ! ! ! ! !

as “tired”, “clumsy”, “it is through faults one experiences one’s

! ! ! ! ! ! ! ! !

interactions with others? (body-self) ! ! !

body”. 2) Neutral or “pros & cons” −response was scored one (1) ! ! ! ! ! ! ! ! ! ! !

D What is the basic mood like in your body when you are by your-
! ! ! ! ! ! ! ! ! ! ! ! ! !
point, e.g. “my body is stiffened, but it cheered me up to lose some ! ! ! ! ! ! ! ! ! ! ! ! !

self? (body-self) !
weight”, “I like my body moving, but I get overstrained easily or ! ! ! ! ! ! ! ! ! ! !

E Do you have bodily memories of moments, when you have suf-

! ! ! ! ! ! ! ! ! ! !
at least more easily than before”. 3) Positive or favorable response
! ! ! ! ! ! ! ! ! !

fered or felt ill at ease? Please give an example of such a memory. ! ! ! ! ! ! ! ! ! ! ! ! !

was scored two (2) points, e.g. “I am very content with my body, I
! ! ! ! ! ! ! ! ! ! ! ! !

(body memory) !

accept myself more and more, I feel strong”, “I can be relaxed among ! ! ! ! ! ! ! ! ! ! ! !

F Do you have bodily memories of moments when you have felt

! ! ! ! ! ! ! ! ! ! !
strange people”. Questions regarding body memory were omitted ! ! ! ! ! ! !

good and enjoyed? Please give an example of such a memory. ! ! ! ! ! ! ! ! ! !

from the quantitative analysis, as the question behind the scoring
! ! ! ! ! ! ! ! !

(body memory) !
was the negativity-positivity of the body image content. The data
! ! ! ! ! ! ! ! !

G What is important for you in your body? (integrative personal

! ! ! ! ! ! ! ! ! !
collection time was 3–4 months, and naturally body memory con- ! ! ! ! ! ! ! ! !

evaluation; relationship to the body image) ! ! ! ! !

tents tend to take longer time to accumulate change in their general ! ! ! ! ! ! ! ! ! ! !

positivity.
Secondly, to give a voice to the participants’ experience of the ! ! ! ! ! ! ! ! ! ! The participants’ BIA responses were scored by the thera- ! ! ! ! ! ! ! !

treatment, an invitation to write a poem about one’s experiences ! ! ! ! ! ! ! ! !

pist/researcher and additionally, by a group of 70 Finnish dance ! ! ! ! ! ! ! ! !

in the DMT group was offered at the end of the 11th session.
! ! ! ! ! ! ! ! ! ! ! ! movement therapists. The therapists were introduced to the scor- ! ! ! ! ! ! ! !

Poem writing was done as a home assignment. The invitation to ! ! ! ! ! ! ! ! ! !

ing criteria, and then, in teams of 3–4 therapists, each team scored
! ! ! ! ! ! ! ! ! ! !

write a poem was intended as an activity for integrating the group

! ! ! ! ! ! ! ! ! ! !
a participant’s pre- and post-treatment responses to the BIA. The
! ! ! ! ! ! ! ! !

experience verbally and to promote embodiment by a reflective ! ! ! ! ! ! ! !

participant’s identifying information was undisclosed. This out- ! ! ! ! ! !

movement improvisation of one’s poem. The poems were shared ! ! ! ! ! ! ! !

side evaluation was done in order to check the reliability of the
! ! ! ! ! ! ! ! ! ! !

in the last session.

! ! !
researcher’s assessment of the responses. ! ! ! !

Thirdly, after the DMT group treatment, in the last therapy ses- ! ! ! ! ! ! ! ! ! !

The means of the scores were calculated for the pre- and ! ! ! ! ! ! ! ! ! !

sion, feedback was inquired from the participants by the following

! ! ! ! ! ! ! ! !
post-interviews for the questions A-D, and the statistical signifi- ! ! ! ! ! ! ! !

questions, to which participants responded in writing: ! ! ! ! ! !

cance of the differences was assessed by paired t-test using SPSS ! ! ! ! ! ! ! ! ! !

(Brace, Kemp, & Snelgar, 2012). Within- group effect sizes (d) were ! ! ! ! ! ! ! ! ! !

1. What were your main expectations of the DMT group?

! ! ! ! ! ! ! ! !
computed by calculating the difference between the mean values ! ! ! ! ! ! ! !

2. Did the DMT group meet your expectations?

! ! ! ! ! ! !
divided by the pooled standard deviation. These calculations were ! ! ! ! ! ! ! !

3. During the process, did something change in your experiences,

! ! ! ! ! ! ! ! !
done separately with the researcher’s scores and with the outside ! ! ! ! ! ! ! ! !

your condition or in your relation to the group? ! ! ! ! ! ! ! !

evaluation scores. !

4. What was important and wise in the group?

! ! ! ! ! ! ! !
Correlations between the BIA scores (sum of questions ABCD, ! ! ! ! ! ! ! !

5. What was difficult?

! ! !
researcher’s scoring) and self-evaluation measurements scores ! ! ! ! !

6. What felt irrelevant?

! ! ! (symptom measures, see Pylvänäinen et al., 2015) were ana- ! ! ! ! ! ! ! !

7. What was given too little space or attention in the group?

! ! ! ! ! ! ! ! ! ! !
lyzed using Pearson’s correlations coefficients. Correlating patients’ ! ! ! ! ! !

8. Any other comments?

! ! !
symptoms evaluation scores with the body image assessment sheds ! ! ! ! ! ! ! !

light on the co-changes of depressive symptoms and the quality of

! ! ! ! ! ! ! ! ! !

In addition to these data collection tools, the participants

! ! ! ! ! ! ! !
body image. Linear regression analyses by SPSS were performed to ! ! ! ! ! ! ! ! !

responded to the self-evaluation measurements (BDI-II, HADS, ! ! ! ! ! !

investigate whether the changes in BIA scores (sumABCD) after the ! ! ! ! ! ! ! ! !

CORE-OM and SCL-90) before the treatment period, immediately ! ! ! ! ! ! !

12-week treatment (pre-post change) predicted changes in symp- ! ! ! ! ! ! !

after it and after a 3-month follow-up period. BDI-II (Beck Depres-

! ! ! ! ! ! ! ! ! !
toms from pre-assessment to three-month follow-up. ! ! ! ! !

sion Inventory) and HADS (Hospital Anxiety and Depression Scale)

! ! ! ! ! ! ! !
To make a synthesis of the 18 poems the patients wrote, the ! ! ! ! ! ! ! ! ! ! !

measure mood (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; ! ! ! ! ! ! ! !

words and expressions used in them were reflected using the ! ! ! ! ! ! ! ! !

Beck, Steer, Ball, & Ranieri, 1996; Dozois et al., 1998; Norton, Cosco,
! ! ! ! ! ! ! ! ! ! !
Laban Movement Analysis (LMA) Effort −system. LMA is a method ! ! ! ! ! ! ! ! !

Doyle, Done, & Sacker, 2013). The SCL-90 (Symptoms Check List- 90) ! ! ! ! ! ! ! ! ! ! for systematically analyzing movement, its qualities, shapes, and
! ! ! ! ! ! !

assess a wide range psychiatric symptoms, including depression, ! ! ! ! ! ! !

unfolding (Bartenieff & Lewis, 1980; Hackney, 2002). LMA provides ! ! ! ! ! ! ! !

anxiety, and somatization (Holi, 2003). CORE-OM (Clinical Out- ! ! ! ! ! ! !

a vocabulary for identifying and naming movement qualities. The
! ! ! ! ! ! ! !

comes in Routine Evaluation— Outcome Measure) addresses the ! ! ! ! ! ! !

quality aspect of motion is called Effort, and its elements are Flow, ! ! ! ! ! ! ! ! ! ! !

patient’s global distress and portrays the dimensions of well-being, ! ! ! ! ! ! ! !

Space, Time, and Weight. These qualities can be observed as differ- ! ! ! ! ! ! ! ! ! !

problems, life functioning, and risk of aggressive/suicidal behav- ! ! ! ! ! ! !

ent combinations in movement. The Effort elements also relate to
! ! ! ! ! ! ! ! !

ior (Evans et al., 2002). The analysis methods and results of these
! ! ! ! ! ! ! ! ! ! !

specific questions and functions. Flow relates to the question what, ! ! ! ! ! ! ! ! !

measurements have been published in detail in Pylvänäinen et al. ! ! ! ! ! ! ! ! !

and its function is feeling. Space relates to the question where and
! ! ! ! ! ! ! ! ! ! !

(2015). its functions are awareness, orientation, and thinking. Time is a

! ! ! ! ! ! ! ! !

response to the question when, and relates to timing and decision- ! ! ! ! ! ! ! ! ! !

Analysis methods !
making. Weight relates to the question how, and its functions are ! ! ! ! ! ! ! ! ! !

presence and action. The words in the poems were associated with ! ! ! ! ! ! ! ! ! !

In the qualitative analysis, the material from the BIA responses

! ! ! ! ! ! ! ! !
these Effort element themes, and this enabled a movement-rooted ! ! ! ! ! ! ! !

was organized according to the main themes that emerged from

! ! ! ! ! ! ! ! ! reflection of the content of the poems, allowing an indirect reflec- ! ! ! ! ! ! ! ! ! !

the responses. A quantitative analysis of the responses was uti-

! ! ! ! ! ! ! ! !
tion of the therapy process and the participants’ experiences of it.
! ! ! ! ! ! ! ! ! !

lized to compare the differences between the responses before

! ! ! ! ! ! ! !
This affords an understanding of what kinds of experiences pro-
! ! ! ! ! ! ! ! !

and after the DMT treatment. To create a quantifiable measure of

! ! ! ! ! ! ! ! ! !

moted the changes in the body image. ! ! ! ! ! !

the responses to the BIA, the questions regarding body-self and

! ! ! ! ! ! ! ! !
The feedback questionnaire was analyzed thematically question ! ! ! ! ! !

image-properties (questions A-D, see “Data collection tools”) were ! ! ! ! ! ! !

by question. The key was to seek information about participants’
! ! ! ! ! ! ! ! !

classified into three categories: 1) No or a negative response was ! ! ! ! ! ! ! ! ! !

experiences in the treatment group and of the outcome of the treat- ! ! ! ! ! ! ! ! ! ! !

scored zero (0) point, i.e., negative attitude/experience/affect such ! ! ! ! ! ! !

ment.
 P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! ! ! 39

Results and its appearance (question A), their experience of physical activ-
! ! ! ! ! ! ! ! !

ity (question B), and in the change of the sum ABCD score. The effect
! ! ! ! ! ! ! ! ! ! ! ! !

The portrayal of the body image in depression before DMT

! ! ! ! ! ! ! ! !
sizes ranged between 0.85 and 0.96 in the therapist’s assessment ! ! ! ! ! ! ! ! !

treatment and between 0.70 and 1.09 in the outside evaluation. The consensus
! ! ! ! ! ! ! ! ! !

on the evaluations of questions A and B was 75% in pre-scores and

! ! ! ! ! ! ! ! ! ! ! !

Table 1 summarizes the patients’ verbal expressions of their ! ! ! ! ! ! ! !

78% in post-scores. Questions about of the impact of social interac-
! ! ! ! ! ! ! ! ! !

body image during the pre-treatment Body Image Assessment ! ! ! ! ! ! !

tion on one’s body (question C) and the quality one’s embodied state
! ! ! ! ! ! ! ! ! ! !

(BIA) interview, and the body image aspects of the themes related ! ! ! ! ! ! ! ! ! !
when alone (question D) yielded a 64% consensus in pre-scores ! ! ! ! ! ! ! ! !

to them. Patients experienced listlessness, feeling tired and lack-

! ! ! ! ! ! ! !
and 83% in post-scores. This was due to the therapist-researcher’s
! ! ! ! ! ! ! ! !

ing direction in their actions and in life in general. Patients

! ! ! ! ! ! ! ! ! !
tendency to evaluate the responses more negatively in the pre- ! ! ! ! ! ! ! ! !

reported social situations as demanding and difficult, e.g. feel- ! ! ! ! ! ! ! !

treatment and in the post-treatment assessment compared to the ! ! ! ! ! ! ! !

ing not accepted and being an outsider, feeling that coping with
! ! ! ! ! ! ! ! ! !
outside evaluators. Specifically, she considered responses indicat- ! ! ! ! ! !

the social and occupational world requires immense effort. Sev-

! ! ! ! ! ! ! ! ing non-attention to the body as negative (0 points) whereas the
! ! ! ! ! ! ! ! ! !

eral utterances were observed reflecting difficulties in accepting

! ! ! ! ! ! !
outside evaluators often scored non-attention as neutral (1 point). ! ! ! ! ! ! ! !

one’s body image, e.g. feeling that one’s body is “not good”, feel- ! ! ! ! ! ! ! ! ! ! !
Comparing BIA score (sum ABCD) at post-intervention with the pre- ! ! ! ! ! ! ! ! !

ing clumsy, finding it difficult to be with one’s body. Difficulties

! ! ! ! ! ! ! ! ! ! intervention score, the therapist’s scoring produced a higher score ! ! ! ! ! ! ! !

in accepting one’s body image seemed to be related to responses

! ! ! ! ! ! ! ! ! !
at the end for 14 patients (78%) and for 9 (43%) patients according
! ! ! ! ! ! ! ! ! ! ! !

indicating avoidance behaviors associated with body image, e.g. ! ! ! ! ! ! !

to the outside evaluation.
! ! !

actively trying not to think of one’s bodily appearance and using ! ! ! ! ! ! ! ! ! !

How the BIA responses related to the self-evaluation mea- ! ! ! ! ! ! ! !

activity to avoid sensing one’s body and self. Difficulties with ! ! ! ! ! ! ! ! !

surements (Pylvänäinen et al., 2015), which reflected the level of ! ! ! ! ! ! ! ! !

awareness of one’s body were reflected in statements such as not ! ! ! ! ! ! ! ! ! !

depressive symptoms, was studied by correlating these measure- ! ! ! ! ! ! !

being able to verbalize experiences, and finding some questions in ! ! ! ! ! ! ! ! !

ments with each other. At the pre-treatment measurement point ! ! ! ! ! ! ! !

the interview strange and unusual. In addition, patients reported

! ! ! ! ! ! ! !
there were relatively high correlations (r = 0.44–0.62) between the ! ! ! ! ! ! ! ! !

difficulties in relaxing and resting, worries concerning body weight ! ! ! ! ! ! ! !

symptoms scores and BIA scores (Table 3). This suggested that ! ! ! ! ! ! ! ! !

(e.g. the experience of being fat), experiences of having pain, and

! ! ! ! ! ! ! ! ! !
when depression symptoms are more severe, the BIA scores are ! ! ! ! ! ! ! ! !

memories of traumatic or difficult events that were associated with ! ! ! ! ! ! ! ! !

lower, meaning that the body image is more negative. Except for ! ! ! ! ! ! ! ! ! !

their body image (e.g. physical abuse by parents). See Table 1 for ! ! ! ! ! ! ! ! ! ! !
SCL-90 (General Severity Index was used in the calculations), all ! ! ! ! ! ! ! ! !

more detailed examples. ! !

correlations were statistically significant. At post measurement the ! ! ! ! ! ! !

correlations between the BIA scores and symptoms measures were ! ! ! ! ! ! ! !

Effects of the DMT treatment on the body image − the comparison ! ! ! ! ! ! ! ! ! ! !

even higher (r = 0.65–0.78). Also, changes in all symptom measures
! ! ! ! ! ! ! ! ! !

of the pre- and post-treatment BIA responses

! ! ! ! ! !
from pre-measurement to three-month follow-up correlated sig- ! ! ! ! ! !

nificantly with changes in BIA scores during the DMT treatment ! ! ! ! ! ! ! ! !

The patients responded to the Body Image Assessment (BIA) ! ! ! ! ! ! ! !

(pre-post). A pattern emerged: the higher the BIA scores at the ! ! ! ! ! ! ! ! ! !

questions before and after the DMT treatment. The post-treatment ! ! ! ! ! ! ! !

post-intervention, the lower the symptoms scores at the follow-up ! ! ! ! ! ! ! !

responses were completed by 18 of the 21 patients who partic- ! ! ! ! ! ! ! ! ! !

measurement.
ipated in the DMT treatment (86%). The responses portray the ! ! ! ! ! ! ! ! !
We also analyzed, how body image change during the interven- ! ! ! ! ! ! ! ! !

patient’s personal way of addressing the embodied experience of ! ! ! ! ! ! ! !

tion (pre-post) predicted symptom change (pre-follow-up). Table 4
! ! ! ! ! ! !

her body in relation to self and environment. The written responses

! ! ! ! ! ! ! ! ! ! presents the results of the linear regression analysis. Even though it ! ! ! ! ! ! ! ! ! !

were more concise than the pre-treatment responses, which were ! ! ! ! ! ! ! !

is impossible to identify a single cause of change for a patient partic-
! ! ! ! ! ! ! ! ! ! ! !

communicated in an interview dialogue. ! ! ! !

ipating in a treatment intervention, the positive body image change ! ! ! ! ! ! ! ! !

In the post-treatment BIA, the body and its appearance (question ! ! ! ! ! ! ! ! !

seemed to predict a statistically significant reduction in symptom ! ! ! ! ! ! ! !

A) were frequently described as overweight, heavy, and tense. The

! ! ! ! ! ! ! ! !
scores. Positive change in body image from pre- to post-treatment ! ! ! ! ! ! ! ! !

positive experiences related to feeling comfortable with the motil- ! ! ! ! ! ! ! ! measurement seemed to predict a more significant reduction in ! ! ! ! ! ! ! !

ity of the body, its strength, sensing one’s body as balanced and
! ! ! ! ! ! ! ! ! ! !
symptom scores from pre-measurement to three-month follow- ! ! ! ! ! !

healthy. Physical activity (question B) was perceived as a strain ! ! ! ! ! ! ! ! !

up, i.e., greater alleviation of depression. Body image change after
! ! ! ! ! ! ! ! !

because of problems with stamina and initiative. When physical ! ! ! ! ! ! ! !

the 12-week treatment explained 44% of the change on the CORE-
! ! ! ! ! ! ! ! ! !

activity was felt to be positive, it was described as the pleasure ! ! ! ! ! ! ! ! ! ! !

OM scores, 37% on the SCL-90 (GSI), 29% on the BDI-II, and 23% on
! ! ! ! ! ! ! ! ! ! ! ! !

of moving, ease, enjoying physical work and getting easily excited,

! ! ! ! ! ! ! ! !
the HADS from pre-assessment to follow-up.
! ! ! ! !

finding vitality in physical activity. The perceptions of the responses ! ! ! ! ! ! ! ! !

to social interaction in one’s body (question C) varied on a contin-

! ! ! ! ! ! ! ! ! ! !
Participants’ experiences of the DMT treatment ! ! ! ! !

uum from tension to non-recognition to comfort and relaxedness. ! ! ! ! ! ! ! !

The difference between being with strangers and with familiar peo-
! ! ! ! ! ! ! ! !
Participants’ voices: poems reflecting the relationship to the body ! ! ! ! ! ! ! !

ple was mentioned frequently, and the tension arising from being
! ! ! ! ! ! ! ! !
image and to interaction ! ! !

with strangers was specifically recognized. The perceptions of one’s ! ! ! ! ! ! ! !

The participants wrote all together 18 poems that were shared ! ! ! ! ! ! ! ! !

embodied state when alone (question D) ranged from fearful, ner- ! ! ! ! ! ! ! ! !

in the last DMT session (two examples are provided in Table 5).
! ! ! ! ! ! ! ! ! ! !

vous, and restless to pleasant, free, relaxed, and happy. In several ! ! ! ! ! ! ! ! ! ! Each poem was unique. At the data analysis phase, Laban Move-
! ! ! ! ! ! ! ! ! !

responses the fluctuating quality of one’s basic, embodied mood ! ! ! ! ! ! ! !

ment Analysis (LMA) Efforts were used to qualitatively analyze the ! ! ! ! ! ! ! ! !

was noted. The question “what is important to you in your body”

! ! ! ! ! ! ! ! ! ! !
content of the poems. In the following, examples and quotes from ! ! ! ! ! ! ! ! ! !

opened a selection of characteristic topics: health, harmony and a ! ! ! ! ! ! ! ! !

the patients’ poems are presented in order to describe patients’

! ! ! ! ! ! ! ! !

kind and interested attitude towards one’s body. ! ! ! ! ! !

experiences of the DMT group process. ! ! ! ! !

To compare the pre- and post-treatment responses, the patients’ ! ! ! ! ! ! ! !

Words reflecting the Flow Effort were used in the poems to ! ! ! ! ! ! ! ! ! !

responses to the four BIA questions assessing the present features ! ! ! ! ! ! ! ! !

describe awareness of the boundness or freedom of Flow in the ! ! ! ! ! ! ! ! ! !

of body image were evaluated on a three point scale: negative (=0),

! ! ! ! ! ! ! ! ! ! !
body and in breathing. The body was described being limp (actually ! ! ! ! ! ! ! ! ! !

neutral (=1) and positive (=2) (Table 2, see also Analysis meth- ! ! ! ! ! ! ! ! ! !
lacking Flow −element) or depressed; or bound, i.e., “tense”, “anx- ! ! ! ! ! ! ! ! !

ods). Statistically significant changes from pre- to post-treatment ! ! ! ! ! ! !

ious” or “like a stone”, “like a knot” (a knot was related to shame ! ! ! ! ! ! ! ! ! ! ! ! !

assessment were observed in how patients perceived their body ! ! ! ! ! ! ! !

in the writer’s experience). The transformation through the DMT
! ! ! ! ! ! ! !
40! P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! !

Table 1 !

Classification of main themes expressed regarding body image in the pre-treatment Body Image Assessment (BIA). ! ! ! ! ! ! ! ! ! ! ! ! ! !

Patients’ verbal expressions of the problem in body image ! ! ! ! ! ! ! ! ! Classification based on the tri-partite model of body
! ! ! ! ! ! !

image: image-properties/body-self/body memory

! !

lack of energy, tiredness ! ! !

– my body feels tired and listless

!

! ! ! ! !
body-self
– the listlessness in the body leads to lack of initiative in
! ! ! ! ! ! ! ! ! ! !
– the relationship to the environment via action and
! ! ! ! ! ! ! !

action experiencing
– I feel tired and sad
! ! ! ! !

lack of direction in action ! ! ! !

– feeling that I am driven by the wind (not by my own

! ! ! ! ! !

! ! ! ! ! !
body-self
ideas/will) – the relationship to the environment via action and
! ! ! ! ! ! ! !

– no planning, no desire for my actions, I just do

! ! ! ! ! ! ! ! ! !
experiencing
– it is not clear where I am heading to, I am doubting the
! ! ! ! ! ! ! ! ! ! ! ! !

sufficiency of my resources ! ! !

lacking a sense of agency − social situations appear demanding and difficult ! ! ! ! ! ! ! ! ! ! !

– I feel that I am not accepted as I am

! ! ! ! ! ! ! ! ! ! body-self
– it is difficult to join the community, feeling like outsider
! ! ! ! ! ! ! ! ! !
– the relationship to the environment via action and
! ! ! ! ! ! ! !

– I have my antenna hyper sensitive when I am with

! ! ! ! ! ! ! ! ! !
experiencing
people and this consumes a lot of my resources ! ! ! ! ! ! ! !

– I have feared social situations so much I have trembled

! ! ! ! ! ! ! ! ! !

and left the situation ! ! !

– I have shrunk and withdrawn in order to not to be seen

! ! ! ! ! ! ! ! ! ! ! !

– illness and death of a close relative

! ! ! ! ! ! !

– facing violence
! !

– experiences of work overload impacting health

! ! ! ! ! !

distortions/fragmentation in the body image ! ! ! !

– compared to the head, the rest of my body feels

! ! ! ! ! ! ! ! ! !
body-self
withered – the experience of one-self
! ! ! !

– my body moves in ways that feel unfamiliar to me

! ! ! ! ! ! ! ! ! !
the image-properties
!

– I feel blocked and tense

! ! ! ! !

– I feel clumsy
! ! !

– I feel my body is not good

! ! ! ! ! ! !

– I feel my body is contradictory

! ! ! ! ! !

– It is difficult to be with my body

! ! ! ! ! ! ! !

– I feel my body is not what I would want it to be

! ! ! ! ! ! ! ! ! ! ! ! !

– I am discontented with my looks

! ! ! ! ! !

a shallow consciousness of one’s body – avoidance of attending consciously to body-image

! ! ! ! ! ! ! ! ! ! ! !

– I only pay attention to my body when it aches and I

! !
body-self ! ! ! ! ! ! ! ! ! !

recognize I cannot function – the experience of one-self ! ! ! ! ! ! !

– I do not think of my bodily appearance because it easily

! ! ! ! ! ! ! ! ! ! !

provokes self-loathing !

– I do something all the time so I do not have to be with

! ! ! ! ! ! ! ! ! ! ! ! ! !

myself
– I have not quite learned to verbalize my experiences
! ! ! ! ! ! ! ! !

– I have had my attention too much in my head and a

! ! ! ! ! ! ! ! ! ! ! !

feeling that I lose touch with my physicality ! ! ! ! ! ! !

difficulty to relax and have a rest ! ! ! ! ! !

– I have not been able to rest

! ! ! ! ! ! !
body-self
– I cannot relax
! ! !
– the relationship to the environment via action and
! ! ! ! ! ! ! !

– I do not like to stop and calm down

! ! ! ! ! ! ! ! !
experiencing; the experience of one-self ! ! ! !

– when I try to settle down, it is difficult

! ! ! ! ! ! ! ! !

worry about weight ! !

– for health reasons and my looks, I would like to lose

! ! ! ! ! ! ! ! ! ! ! image-properties
weight
– I feel my body is overweight, I am fat (even if objectively
! ! ! ! ! ! ! ! ! ! ! !

of normal weight) ! !

pain
– I have a basic pain in my body
! ! ! ! ! ! ! ! body-self
– I have pain in different body parts
! ! ! ! ! ! ! – the relationship to the environment via action and
! ! ! ! ! ! ! !

– pain reduces my capacity to function

! ! ! ! ! !
experiencing body memory ! !

– emotional state causes me pain

! ! ! ! !

memories of traumatic events and/or circumstances in childhood ! ! ! ! ! ! !

– I was hardly ever hugged in my family

! ! ! ! ! ! ! !
body memory !

– with my parents, I could not express certain emotions

! ! ! ! ! ! ! ! !
– traumatic body memory and habitual body memory
! ! ! ! ! ! !

– severe parental illness or substance abuse

! ! ! ! ! !

– physical abuse by parents

! ! ! !

– I was bullied at school

! ! ! ! !
 P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! ! ! 41

Table 2 !

Body image assessment: a comparison between scores at pre- and post-assessment. Mean values (standard deviations), paired t-test, and effect sizes (d-values) are presented.
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Scoring by the researcher (R) and outside evaluation (OE). ! ! ! ! ! ! ! !

N = 18 ! ! R Pre M (SD) ! ! ! ! R Post M (SD)

! ! ! ! R t (df) ! ! ! Rp ! ! Rd ! ! OE Pre M (SD) ! ! ! ! OE Post M (SD) ! ! ! ! OE t (df) ! ! ! OE p ! ! OE d !

A: experience of appearance ! ! ! ! 0.28 (0.58) ! ! 0.94 (0.87) ! ! 3.69 (17) ! ! .002* 0.96 ! 0.39 (0.70) ! ! 1.11 (0.90) ! ! 4.08 (17) ! ! .001* 1.09
B: experience of physical activity ! ! ! ! ! 0.33 (0.59) ! ! 1.06 (0.94) ! ! 3.71 (17) ! ! .003* 0.85 ! 0.72 (0.58) ! ! 1.22 (0.81) ! ! 2.47 (17) ! ! .024* 0.70
C: sensations in interaction ! ! ! ! 0.61 (0.85) ! ! 0.94 (0.87) ! ! 1.57 (17) ! ! 0.083 ! 0.62 ! 0.89 (0.90) ! ! 1.00 (0.87) ! ! 0.62 (17) ! ! 0.54 ! 0.43
D: sensations when alone ! ! ! ! 0.44 (0.71) ! ! 1.28 (0.75) ! ! 2.92 (17) ! ! .002* 0.86 ! 0.83 (0.71) ! ! 1.11 (0.75) ! ! 1.32 (17) ! ! 0.21 ! 0.41
sum ABCD (possible range 0–8) ! ! ! ! ! 1.67 (2.22) ! ! 4.22 (2.80) ! ! 3.60 (17) ! ! .<0005* 0.91 ! 2.83 (2.09) ! ! 4.50 (2.81) ! ! 3.30 (17) ! ! 0.004* 0.73

A: How do you perceive your body and its appearances?

! ! ! ! ! ! ! ! !

B: What is it like for you to take physical action?

! ! ! ! ! ! ! ! ! !

C: In your body, how do you typically sense or feel your everyday interactions with others?
! ! ! ! ! ! ! ! ! ! ! ! ! ! !

D: What is the basic mood like in your body when you are by yourself?
! ! ! ! ! ! ! ! ! ! ! ! ! !

d = (x1 -x2 )/mean SD. In questions A-D, score range could be 0–2. Higher score indicates more positive content.
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

*
p < 0.05, statistically significant. ! ! ! !

Table 3 !

Correlations (N = 18) between Body Image Assessment (BIA sum ABCD) scores and symptom self-evaluation scores at pre- and post-assessment. ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

N = 18 ! ! Pre BIA ! p-value ! Post BIA ! ! p-value ! pre-fup change correlation with ! ! !

BIA-change (pre-post) p-value ! !

BDI-II ! −0.62 ! 0.007 ! −0.78 ! <0.001 ! −0.53 ! 0.022

SCL-90 ! −0.44 ! 0.068 (ns) ! ! −0.65 ! 0.003 ! −0.64 ! 0.005
HADS ! −0.60 ! 0.008 ! −0.78 ! <0.001 ! −0.48 ! 0.047
CORE-OM ! −0.57 ! 0.013 ! −0.72 ! 0.001 ! −0.66 ! 0.003

Table 4 !

Linear regression analyses. Body image (BIA −scores) change during the DMT treatment (pre-post) predicts symptom change (pre-fup) (N = 18).
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Change Pre-Fup ! ! R2 ␤ stand ! ! t ! p

BDI-II ! 0.285 ! −0.534 ! −2.53 ! 0.022

SCL-90 ! 0.368 ! −0.636 ! −3.30 ! 0.005
HADS ! 0.225 ! −0.475 ! −2.16 ! 0.047
CORE-OM ! 0.438 ! −0.662 ! −3.53 ! 0.003

Table 5 !

were many words that related to strengthening attention, think- ! ! ! ! ! ! ! !

Two examples of poems (translation from Finnish by the researcher/therapist).

! ! ! ! ! ! ! ! !

ing and insight: “I noticed, I realized, self-knowing, reason, insight,

! ! ! ! ! ! ! ! !

I was separate from myself

! ! ! ! ! Weakness. Sluggishness. Emptiness. ! !

understanding, interest”. The Space element was also presented in ! ! ! ! ! ! ! !

outside of myself Until a revelation about something else.

words that relate to spatially or directionally oriented movement:
! ! ! ! ! ! ! !

I noticed that through myself I can sense better

! ! ! ! ! ! ! ! ! Rising. Growing, !
! ! ! ! ! ! ! !

express more freely ! ! ! insight. rising, growing (in a direction in space), approaching (each other), ! ! ! ! ! ! ! ! !

exist in multiple dimensions in my being Mind and surrounding it,

following (one’s heart, dreams), listening (as in focusing attention
! ! ! ! ! ! ! ! ! !

Now I try to find a new perspective to myself, the frame of the body came
! ! ! ! ! ! ! !

! ! ! ! ! ! ! ! ! ! ! ! ! ! !

through my body. ! ! ! back. And maybe, more complete ! ! ! !

to listen to one’s heart). The body and movement defined and cre-
! ! ! ! ! ! ! ! ! ! !

than one would have assumed. ! ! ! !

ated Space. This occurred in expressions such as: “I found in the

! ! ! ! ! ! ! ! ! ! !

An opportunity arrived.
body/through the body, I found toes, hands, head (i.e., the body pro-
! !

! ! ! ! ! ! ! ! ! ! !

vided a location), I try to find a new perspective on myself through ! ! ! ! ! ! ! ! ! ! ! !

process resulted in “finding breathing” (a primary expression of ! ! ! ! ! ! ! !

my body”. The affective quality of Space changed in the poems:
! ! ! ! ! ! ! ! ! !

Flow), finding a Flow experience of being “capable and succeeding ! ! ! ! ! ! ! ! !

the initial emptiness and confusion transformed into expressions
! ! ! ! ! ! !

in one’s action”. Feelings of “liking the body”, “sensing one-self bet-

! ! ! ! ! ! ! ! ! !
of a space that was welcoming and inclusive: “to be accepted, to be
! ! ! ! ! ! ! ! ! ! ! !

ter”, “feeling freer”, and “feeling happy” emerged. Participants felt ! ! ! ! ! ! ! !

heard without having to be ashamed of one-self; we came to each ! ! ! ! ! ! ! ! ! ! !

they could “share feelings and emotions”. ! ! ! ! !

other, we were not alone anymore.” ! ! ! ! !

Flow and Weight Effort linked words together, and singular ! ! ! ! ! ! ! !

The Time Effort related words were used in the chronological ! ! ! ! ! ! ! ! !

Weight Effort linked words could be identified in many of the ! ! ! ! ! ! ! ! ! !

description of the unfolding of the experience, e.g. “yesterday I was ! ! ! ! ! ! ! ! ! !

expressions describing movement experiences in the DMT activ- ! ! ! ! ! ! !

a knot”; “the time to decide came”, “session one”, “until the change
! ! ! ! ! ! ! ! ! ! !

ities. The starting point was often the lack of Flow or Weight as ! ! ! ! ! ! ! ! ! ! ! !
happened”, “today I found”, “tomorrow I will try again”. Time was ! ! ! ! ! ! ! ! ! !

in “limpness” and “listlessness”. The increase in the energy was

! ! ! ! ! ! ! ! !
a quality in action: “I was in a hurry to get to experience, ‘hurried-
! ! ! ! ! ! ! ! ! ! ! ! !

expressed in words “rising, growing, experiencing, receiving, and ! ! ! ! ! ! !

ness and impatience lost their sharpness’, “I am waiting without ! ! ! ! ! ! ! ! !

giving”. “We sat, laughed, danced, talked and shared; I found myself ! ! ! ! ! ! ! ! ! !
expectations”. Time was opening to the future: “I am waiting for the ! ! ! ! ! ! ! ! ! ! !

moving” were expressions of experiencing and finding movement ! ! ! ! ! ! !

morning”. The experience of “waiting and being in a process”, “in ! ! ! ! ! ! ! ! ! !

and reflecting on it. There was an air of exploration and playfulness.

! ! ! ! ! ! ! ! ! ! !
the middle of a journey”, was expressed in several poems. There is
! ! ! ! ! ! ! ! ! ! !

Movement enabled connection: “touch, sharing, a story is told and ! ! ! ! ! ! ! ! !

a settling into time, not forcing time but instead going with its flow,
! ! ! ! ! ! ! ! ! ! ! !

I join it, it gives me”; “there is a lot of strength/power in our group”.

! ! ! ! ! ! ! ! ! ! ! ! ! !
being grounded in one’s body and finding support for grounding in ! ! ! ! ! ! ! ! ! !

The Space Effort related words were presented in many contexts ! ! ! ! ! ! ! ! !

the environment. !

in the poems. The Space element in the body was initially described
! ! ! ! ! ! ! ! ! ! !

as “emptiness”, “separateness”, “being outside of one-self”, “lacking

! ! ! ! ! ! !

Participants’ feedback of the DMT process outcomes ! ! ! ! ! !

interest” and “not knowing how to get a hold on to the tiredness, ! ! ! ! ! ! ! ! ! ! ! !

In their feedback, the patients reported they had expected that ! ! ! ! ! ! ! ! !

anxiety, and depression”. The “confusion in direction” and “disorga- ! ! ! ! ! ! ! !

the treatment would alleviate their depressive symptoms (42.1%
! ! ! ! ! ! !

nization”, and “being broken” were expressed. In the poems there ! ! ! ! ! ! ! ! !

out of 19 participants, who articulated expectations). Also, the
! ! ! ! ! ! ! !
42 ! P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! !

patients had wanted to learn something new (four responses, ! ! ! ! ! ! ! !

This study has limitations that need to be kept in mind when ! ! ! ! ! ! ! ! ! ! !

21.1%), and had expected to receive peer support (three responses, ! ! ! ! ! ! ! ! !

considering the results and conclusions. The participant group of ! ! ! ! ! ! ! !

15.8%). All reported after the treatment that the DMT group had ! ! ! ! ! ! ! ! ! !
this study was small. There was no systematic background data on
! ! ! ! ! ! ! ! ! !

given them more than they had anticipated. ! ! ! ! ! !

how healthy individuals would respond to the Body Image Assess- ! ! ! ! ! ! ! ! !

Four patients considered that he changes during the treatment ! ! ! ! ! ! ! !

ment (BIA). BIA was not presented to those patients who were ! ! ! ! ! ! ! ! ! !

were not relevant for them. Three patients described partly posi-
! ! ! ! ! ! ! ! !
receiving treatment as usual at the clinic, thus comparing how ! ! ! ! ! ! ! ! !

tive changes, although they did not perceive a change in their mood.
! ! ! ! ! ! ! ! ! ! !

TAU impacts body image was not possible. There was no follow-up
! ! ! ! ! ! ! ! ! !

The majority of the patients, 12 (63%), reported that they had expe-
! ! ! ! ! ! ! ! ! ! !
BIA, so the present study cannot directly describe how the patients
! ! ! ! ! ! ! ! ! !

rienced positive changes during the DMT treatment. The changes ! ! ! ! ! ! ! !

maintained the changes in their body image or how the change con- ! ! ! ! ! ! ! ! ! ! !

after the DMT treatment were for example: ! ! ! ! ! !

tinued to proceed. In the future more descriptions of body image ! ! ! ! ! ! ! ! ! !

contents and body image changes are needed to better understand ! ! ! ! ! ! ! ! !

• Improvement in well-being: fewer sleeping problems, more pos- ! ! ! ! ! ! !

in a sense of a complex dynamic system, how depression affects
! ! ! ! ! ! ! ! ! !

itive perception of one’s body, decrease or cessation of anxiety, ! ! ! ! ! ! ! ! !

the individual, and what supports the recovery.
! ! ! ! ! !

improved activity level ! !

In the pre-treatment BIA interview the body image was charac- ! ! ! ! ! ! ! ! !

• Reduction of tension ! !
terized by listlessness and the depressed patients seemed to have ! ! ! ! ! ! ! ! !

• Strengthening of feeling secure ! ! !

difficulties accepting their body image and appearance. In their ! ! ! ! ! ! ! !

• Increased awareness of self: attending to self, recognition of phys- ! ! ! ! ! ! ! ! !

embodied experience, they perceived their environment as difficult ! ! ! ! ! ! !

ical experience and its influence, strengthened trust in one’s body, ! ! ! ! ! ! ! ! !

and found it difficult to take a rest. Traumatic and stressful events
! ! ! ! ! ! ! ! ! ! !

adjustment of actions on the basis of observations of the body ! ! ! ! ! ! ! ! ! !

were frequently mentioned in the depressed patients’ narratives ! ! ! ! ! ! !

• Improved social interaction: better tolerance of other people, ! ! ! ! ! ! !

about their body memories. Depressed patients expressed shallow ! ! ! ! ! ! !

courage to approach others and to be more active in social sit- ! ! ! ! ! ! ! ! ! ! !

consciousness of the body, distortions, and/or actual fragmenta- ! ! ! ! ! ! !

uations, positive experience of peer support ! ! ! ! !

tion of the body image. Initially the body image qualities of the
! ! ! ! ! ! ! ! ! ! !

subjects were similar to what has been reported in earlier studies ! ! ! ! ! ! ! ! ! !

(Papadopoulos and Röhricht, 2014; Segal et al., 2002; Stötter et al.,

In the DMT group participants appreciated peer support, an
! ! ! ! ! ! ! ! ! !

2013): there was a lack of mindful body awareness, feelings of being

! ! ! ! ! ! ! !

opportunity to challenge themselves, the non-judgmental attitude

! ! ! ! ! ! ! ! ! ! !

detached and distant from one’s own body, difficulties in finding

! ! ! ! ! !

during the meetings, the opportunity to share and discuss experi-

! ! ! ! ! ! ! ! !

grounding, experiences of fatigue and pains. Essentially, most of

! ! ! ! ! ! ! ! !

ences with others, and the opportunity to acquire skills to observe

! ! ! ! ! ! ! !

the body image problems were problems of presence. There was a

! ! ! ! ! ! ! ! ! !

one’s body. Furthermore, the patients valued clarity in the group

! ! ! ! ! ! ! ! ! !

statistically significant correlation between a patient’s body image

! ! ! ! ! ! ! ! !

structure and in action during the meetings, and focusing on what

! ! ! ! ! ! !

and reports of psychological symptoms. These findings suggest that

! ! ! ! ! ! ! ! ! !

was happening in the present moment in the group and the therapy
! ! ! ! ! ! ! !

it is useful to pay attention to body image among patients with

! ! ! ! ! ! ! ! ! ! !

room.
! ! ! ! ! ! ! ! ! ! !

depression, as body image reveals characteristics of the patient’s

In the feedback, the participants did not report adverse effects
! ! ! ! ! ! ! !

depression and treatment addressing body image seems to alleviate

! ! ! ! ! ! ! ! !

of DMT, but they did report that the DMT group had also pre-
! ! ! ! ! ! ! !

the depressive symptoms.

! ! ! ! ! ! ! ! ! ! ! !

sented challenges to them. At times, they had found it difficult

! !

After the DMT treatment patients with diagnoses of depression

! ! ! ! ! ! ! ! ! !

to be attentive to other group members or to themselves dur-

! ! ! ! ! ! ! !

reported changes in their body image. This is encouraging since

! ! ! ! ! ! ! ! ! !

ing the interaction. Pair work, sharing experiences verbally, and

! ! ! ! ! ! ! ! !

for example Rosenström et al. (2013) report, that the body dis-
! ! ! ! ! ! ! !

telling about one-self in the context of the present experiences was

! ! ! ! ! ! ! ! ! !

satisfaction is a stable characteristic in chronic dysphoria. In the

! ! ! ! ! ! ! ! ! !

difficult especially at the beginning of the DMT process. It was par-

! ! ! ! ! ! ! ! !

present study the change observed could be due to social desir-

! ! ! ! ! ! ! ! ! ! !

ticularly burdensome to speak about what one perceived in the

! ! ! ! ! ! ! ! ! !

ability bias, but this concern is diminished by the finding, that the
! ! ! ! ! ! ! ! !

body and how one felt in the body. Finding and creating one’s own
! ! ! ! ! ! ! ! ! ! !

positive changes were communicated consistently through several

! ! ! ! ! ! ! ! ! ! ! !

movement were felt at times to be difficult.

! ! ! ! ! !

data collection tools. In the present study, as seen especially in the

! ! ! ! ! ! !

Almost all the participants (14/74%) expressed a wish for more

! ! ! ! ! ! ! ! ! ! !

poems and the feedback on the therapy process, the changes in the
! ! ! ! ! ! ! ! !

time for dancing, movement, and discussion during the DMT ses-
! ! ! ! ! ! ! ! ! ! !

body image were reflected in a willingness to be aware of the body

! ! ! ! ! ! ! ! !

sions. More sessions or a longer (two-hour) session time were

! ! ! ! ! ! ! ! ! ! ! !

image: being able to sense one’s body, to tolerate the sensations,

! ! ! ! ! ! ! ! !

suggested in the feedback. The group atmosphere had been per-

! ! ! ! ! ! ! ! ! !

to settle in the body and find some pleasure and meaningfulness in

! ! ! ! ! ! ! ! !

ceived as encouraging. One could be in the group as one is, in the

! ! ! ! ! ! ! ! ! ! !

the sensations and experiences. In DMT these processes are referred

! ! ! ! ! ! ! ! ! ! ! ! !

here and now. The therapist received thanks for sensitive and warm
! ! ! ! ! ! ! ! !

to as grounding (de Tord & Bräuninger, 2015), which means safe,

! ! ! ! ! ! ! ! ! !

facilitation. Some participants were concerned about feeling left on

! ! ! ! ! ! ! ! ! !

embodied connectedness to the body and the body’s connected-

! ! ! ! ! ! ! !

their own at the end of the DMT treatment. These participants won-
! ! ! ! ! ! ! !

ness with the environment. In the DMT group, the non-judgmental

! ! ! ! ! ! ! ! ! ! !

dered where to continue a similar practice and activity, and how to

! ! ! ! ! ! ! ! !

approach and the interest in the embodied experiences validated

! ! ! ! ! ! ! ! ! ! !

find a suitable movement group outside the mental health services,

! ! ! ! ! ! ! !

the patients’ experience of their own bodies. The validation of body-

! ! ! ! ! ! ! ! !

in the community.
! ! ! ! ! ! ! ! ! !

self constructs the base for trusting one’s body, perceptions, and
! !

! ! ! ! ! ! ! ! !

own assessment. It can develop awareness of one’s way of perceiv- ! ! ! ! ! ! ! ! ! !

Discussion ing the internal and external environment and relating to it. These
! ! ! ! ! ! ! ! ! !

changes can promote a sense of safety and a sense of agency. ! ! ! ! ! ! ! ! ! ! !

We have already shown (Pylvänäinen et al., 2015) that the DMT ! ! ! ! ! ! ! ! ! !

In their feedback of the DMT group, 63% of the patients reported ! ! ! ! ! ! ! ! ! ! !

intervention alleviated depressive symptoms as measured by self- ! ! ! ! ! ! !

they had noticed alleviation of their symptoms of depression after ! ! ! ! ! ! ! ! !

evaluation scores (BDI-II, HADS, CORE-OM and SCL-90). That part ! ! ! ! ! ! ! !

the intervention. The reports of a change for the better in depressive

! ! ! ! ! ! ! ! ! ! !

of the study was quasi-experimental and we found that the DMT-

! ! ! ! ! ! ! ! ! !
symptoms and also the improved BIA scores (sum ABCD) appear to ! ! ! ! ! ! ! ! ! !

participants improved more than the patients receiving treatment ! ! ! ! ! ! !

run parallel in this study sample. The symptoms scores correlated
! ! ! ! ! ! ! ! !

as usual. To study the DMT-participants further, the aim of this

! ! ! ! ! ! ! ! ! !
negatively with the BIA scores, i.e., when the quality of body image ! ! ! ! ! ! ! ! ! ! !

present study was to report on the body image of patients with ! ! ! ! ! ! ! ! ! ! !

improved, the psychiatric symptoms tended to abate. In addition, ! ! ! ! ! ! ! !

diagnoses of depression, the impact of the DMT treatment on body ! ! ! ! ! ! ! ! ! !

positive change in body image at the post-treatment assessment ! ! ! ! ! ! ! !

image, and to describe the patients’ experiences of the DMT group ! ! ! ! ! ! ! ! ! !

predicted a reduction in symptom scores from pre-measurement to ! ! ! ! ! ! ! !

treatment. three-month follow-up. Thus, this study suggests that more atten- ! ! ! ! ! ! ! !
 P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! ! ! 43

tion should be paid to investigating the role of body image in the

! ! ! ! ! ! ! ! ! ! ! ! image, which is shaped in our interactions, and which shapes how ! ! ! ! ! ! ! ! ! !

treatment of depression. ! !
we interact. It would be interesting to study, in light of interper-
! ! ! ! ! ! ! ! ! ! !

There is a need for more studies investigating essential pro- ! ! ! ! ! ! ! ! !

sonal neurobiology and neuroimaging techniques, whether these ! ! ! ! ! !

cesses in DMT that are responsible for changes in mood or ! ! ! ! ! ! ! ! ! !

patterns could be documented as different activation patterns in ! ! ! ! ! ! ! !

psychological wellbeing. For example, it is known that avoidant ! ! ! ! ! ! ! !

the brain. !

behavioral and attachment patterns are typical for patients ! ! ! ! ! ! !

In the future, with a larger study sample, it would be interesting ! ! ! ! ! ! ! ! ! ! !

with depression. In interactional situations, reciprocal movement

! ! ! ! ! !

to study individual differences between depressed patients par-

! ! ! ! ! ! !

behavior creates an experience of communication, which can ! ! ! ! ! ! !

ticipating in DMT groups. The severity of symptoms, the level of ! ! ! ! ! ! ! ! ! !

enhance the sense of connectedness and agency (Trevarthen & ! ! ! ! ! ! ! !

cognitive biases in information processing typical to depression, ! ! ! ! ! ! !

Fresquez, 2015). This reciprocal movement is frequently present ! ! ! ! ! ! !

the attachment style, and the quality of body image may be fac-
! ! ! ! ! ! ! ! ! ! !

in secure attachment interactions. DMT group aims to promote

! ! ! ! ! ! ! !
tors that characterize patient types who benefit differently from a ! ! ! ! ! ! ! ! !

the characteristics of secure attachment: presence, attunement,

! ! ! ! ! !
brief DMT group treatment. These factors would make it possible ! ! ! ! ! ! ! ! !

responsiveness, modulation of emotions, communication, and ! ! ! ! ! to monitor, as the time passes on, how the participants continue to
! ! ! ! ! ! ! ! ! ! !

reflection (Siegel 1999, 2007). Corroborating this, in the present ! ! ! ! ! ! ! !

maintain and further develop their learning, alternative response ! ! ! ! ! ! !

study the feedback and poems produced by the patients indicated

! ! ! ! ! ! ! ! !
patterns, and awareness gained in the DMT group. ! ! ! ! ! ! !

that the DMT group intervention made the participants’ presence

! ! ! ! ! ! ! ! In the treatment of depression, DMT offers methods and a ! ! ! ! ! ! ! ! !

more active, flexible, and open to new experiences.

! ! ! ! ! ! !
socially appropriate structure for exploring the contents of the body ! ! ! ! ! ! ! ! !

Nearly all the participants in this study (20 out of 21) had in their ! ! ! ! ! ! ! ! ! ! ! ! !
image and gaining new embodied experiences relating to self, oth- ! ! ! ! ! ! ! ! !

medical records a description of challenging and stressful experi- ! ! ! ! ! ! ! !

ers, and the environment. In the future, more research on this is
! ! ! ! ! ! ! ! ! ! !

ences in their relationships, either in their earlier lives or currently.

! ! ! ! ! ! ! ! ! !
needed, with larger samples and in an RCT (randomized controlled ! ! ! ! ! ! ! ! !

At the beginning of the DMT treatment, patients’ BIA responses

! ! ! ! ! ! ! ! !
trial, including a comparison group) research design. The present ! ! ! ! ! ! ! !

revealed they had a poor connectedness to the body sensations and ! ! ! ! ! ! ! ! ! !

study suggests that DMT group treatment enables positive changes ! ! ! ! ! ! ! !

a tendency to avoid bodily information, there was a lack of kind-

! ! ! ! ! ! ! ! ! ! !
in body image: improved recognition of the body, more kindness
! ! ! ! ! ! ! ! !

ness towards the body and self, a lack of liking the body, there was
!

! ! ! ! ! ! ! ! ! ! ! !
in relating to one’s body and bodily experiences, and a clearer val-
! ! ! ! ! ! ! ! ! ! !

a lack of will in patients’ actions, and a sense of difficulty in con-

! ! ! ! ! ! ! ! ! ! ! ! !
idation of one’s body sensations, expressed in verbalizing about ! ! ! ! ! ! ! !

necting with the environment/others. These features seem to echo ! ! ! ! ! ! ! !

the sensations, and improved access to body memories. As these
! ! ! ! ! ! ! ! !

the characteristics of an insecure, avoidant relationship style, and

! ! ! ! ! ! ! !
changes took place, patients also experienced alleviation of their ! ! ! ! ! ! ! !

also the avoidant behavioral patterns characteristic of depression.

! ! ! ! ! ! !
depression.
These attachment and behavioral styles not only apply to external
! ! ! ! ! ! ! ! !

relationships, it seems they also apply to the ways in which the ! ! ! ! ! ! ! ! ! ! !

Funding
individual relates to his/her body. It is possible that DMT affects ! ! ! ! ! ! ! ! ! !

these processes among depressed patients. The impression is, that

! ! ! ! ! ! ! !

This research did not receive any specific grant from funding ! ! ! ! ! ! ! ! !

the style of relating to the external and internal world may enhance
! ! ! ! ! ! ! ! ! ! !

agencies in the public, commercial, or not-for-profit sectors. ! ! ! ! ! ! !

each other, which may exacerbate the strains caused by an insecure

! ! ! ! ! ! ! ! ! !

attachment style and depression. ! ! !

Acknowledgements
Punkanen et al. (2014), studying the outcome of a DMT inter- ! ! ! ! ! ! ! ! ! !

vention in the treatment of depression, used in their study a brief ! ! ! ! ! ! ! ! ! ! !

With thoughtful gratitude and thanks to dance movement ther- ! ! ! ! ! ! ! !

relationship questionnaire (RQ), assessing the attachment style of ! ! ! ! ! ! !

apists Dr. Sabine Koch and Dr. Vicky Karkou for their collaboration ! ! ! ! ! ! ! ! ! !

the participants. In their study, the RQ scores indicated a change

! ! ! ! ! ! ! ! ! !

on this research project. ! ! !

towards a more secure attachment style after the intervention. ! ! ! ! ! ! ! !

Dance movement therapist Marcia Plevin, my longtime teacher ! ! ! ! ! ! !

However, body image was not assessed in their study. In future ! ! ! ! ! ! ! ! ! !

in authentic movement, gave helpful comments on the English

! ! ! ! ! ! ! !

research it would be particularly interesting to focus on the con- ! ! ! ! ! ! ! ! ! !

writing style of this paper − thank you. ! ! ! ! ! ! !

nections between attachment styles, self-compassion, and body ! ! ! ! ! !

image. This can enhance the understanding of the impact of DMT ! ! ! ! ! ! ! ! ! !

Appendix A. A group model based on the integration of the ! ! ! ! ! ! ! ! ! !

interventions. It would also enhance our understanding of body ! ! ! ! ! ! ! !

four different DMT group processes. (Pylvänäinen et al., ! ! ! ! ! ! !

2015).

Theme ! Process movement practices

! !

1 ! Introduction, start ! ! Circular motion in joints. ! ! !

Improvisation with name gestures. ! ! !

With picture cards, expressing one’s expectations of the DMT group.

! ! ! ! ! ! ! ! !

2 ! Familiarizing with the space, moving, ! ! ! !

Exploring the space/room by moving in it in various ways and acknowledging the
! ! ! ! ! ! ! ! ! ! ! !

and collaboration !
others.
In a dyad, mirroring on each other’s movement.
! ! ! ! ! ! !

3 ! Safety and agency, playfulness ! ! ! ! Recognizing how one directs attention: outwards, inwards. ! ! ! ! ! !

Sensing body boundaries. ! !

Moving with eyes open or closed.

! ! ! ! !

Exploring the spatial options in movement. ! ! ! ! !

4 ! Playfulness, agency, finding different ! ! ! Exploring spine motility. ! !

options
Imagery & improvisation: If you were an animal, how would the animal move?
! ! ! ! ! ! ! ! ! ! ! !

In a circle, moving by holding hands.

! ! ! ! ! !

5 ! Grounding, intuition, sensitivity ! ! Activation of the body, starting from the feet. ! ! ! ! ! ! !

Playing with different movement qualities.

! ! ! !

Mindfulness skills and breathing: sensing one’s walking. ! ! ! ! ! !

44! P. Pylvänäinen, R. Lappalainen / The Arts in Psychotherapy 59 (2018) 34–45
! ! ! ! ! ! ! ! ! ! !

Theme ! Process movement practices ! !

6 ! Relieving achievement pressure ! ! ! Sensing hands through different movements. ! ! ! !

Breathing exercises. !

Basic movement exercises allowing grounding and sensing the kinesthetic

! ! ! ! ! ! ! !

connections in the body structure. Mindfulness skills: breathing and seeing the other. ! ! ! ! ! ! ! ! ! ! !

Polarity: familiar and unfamiliar in movement. ! ! ! ! !

7 ! Boundaries, distances, directions ! ! Activating hands and breathing, sensing body boundaries, sensing center/core also ! ! ! ! ! ! ! ! !

with strength. !

Movement improvisation with a focus on near space, middle space, far space. ! ! ! ! ! ! ! ! ! ! !

Walking in a dyad and sensing the connection. ! ! ! ! ! ! !

Drawing a picture of one’s experience. ! ! ! ! !

8 ! Space for motion, boundaries, surfaces ! ! ! !

Self-nurturing movement and moving on the floor level. ! ! ! ! ! ! !

− balancing being and action ! ! ! !

Basic movement exercises allowing grounding and sensing the kinesthetic connections
! ! ! ! ! ! ! ! !

in the body structure. Getting into vertical slowly and through different postures.
! ! ! ! ! ! ! ! ! ! !

9 ! Emotion − acceptance and agency in ! ! ! ! !

Movement improvisation from the words selected to express one’s present state. ! ! ! ! ! ! ! ! ! !

one’s life and in relation with ! ! ! ! !

environment/others
Exploring earth, water, air and fire through movement improvisation − expressing and ! ! ! ! ! ! ! ! ! ! !

describing associated feelings. ! !

10 ! What do I need − attention and ! ! ! ! ! !

In a dyad, hand massage.
! ! ! !

focusing in action ! !

On a tape line, improvising movement in relation to the line; working with a partner
! ! ! ! ! ! ! ! ! ! ! ! ! !

who accompanies the movement in the way one asks for.

! ! ! ! ! ! ! ! !

11 ! Accepting needs − nurturing, ! ! !

Moving with breath, gradually engaging the whole body. ! ! ! ! ! ! !

simplicity, freedom !

Simple movement exercise (breath, clear movement pattern, a sense of

! ! ! ! ! ! ! ! !

opening/stretching, focusing). !

Requesting from a pair something one needs in movement and/or presence. ! ! ! ! ! ! ! ! ! !

Homework: to write a poem of one’s experiences in this group. ! ! ! ! ! ! ! ! ! !

12 ! Closure − what have I learnt? ! ! ! ! ! ! Activating the body, grounding, being aware of the body. ! ! ! ! ! ! ! !

Simple movement exercise (same as in the session 11)

! ! ! ! ! ! ! !

Poems: sharing them, improvising movement on them.

! ! ! ! ! !

Feedback of the process. ! ! !

Fosha, D., Siegel, D. J., & Solomon, M. F. (Eds.). (2009). The healing power of emotion:
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