CLINICAL TRIAL

published: 12 August 2020

doi: 10.3389/fpsyg.2020.01687

The Effects of Dance Movement

Therapy in the Treatment of
Depression: A Multicenter,
Randomized Controlled Trial in
Finland
Katriina Hyvönen* , Päivi Pylvänäinen, Joona Muotka and Raimo Lappalainen
Department of Psychology, University of Jyväskylä, Jyväskylä, Finland

This multicenter research investigates the effects of dance movement therapy (DMT)
on participants diagnosed with depression. In total, 109 persons participated in the
study in various locations in Finland. The participants were 39 years old, on average
(range = 18–64 years), and most were female (96%). All participants received treatment
as usual (TAU). They were randomized into DMT + TAU (n = 52) or TAU only (n = 57).
Edited by: The participants in the DMT + TAU group were offered 20 DMT sessions twice a
Vicky (Vassiliki) Karkou,
Edge Hill University, United Kingdom
week for 10 weeks in addition to standard care. The measurement points included
Reviewed by:
pretreatment measurement at the baseline, posttreatment measurement at the end
Eleonora Volpato, of the intervention, and a follow-up measurement 3 months afterward. The observed
Fondazione Don Carlo Gnocchi Onlus
effects of the intervention among participants in the DMT+TAU group were a greater
(IRCCS), Italy
Indra Majore-Dusele, reduction in depression and in indicators of physical and psychological distress in
Riga Stradins̆ University, Latvia comparison to the participants who received TAU-only. At the 3-month follow-up, the
*Correspondence: corrected between-group effect sizes (ESs) were medium and in favor of the DMT + TAU
Katriina Hyvönen
katriina.i.hyvonen@jyu.fi
group (d = 0.60–0.72). These results are in line with the increasing number of research
studies showing the benefits of DMT intervention among participants with depression,
Specialty section: and these results indicate that DMT may improve the effectiveness of standard care.
This article was submitted to
Psychology for Clinical Settings, Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04421651.
a section of the journal
Frontiers in Psychology Keywords: dance movement therapy, randomized controlled trial, adults, depression, Beck Depression Inventory,
Clinical Outcomes in Routine Evaluation—Outcome Measure, The Symptoms Check List-90
Received: 04 December 2019
Accepted: 22 June 2020
Published: 12 August 2020
Citation:
INTRODUCTION
Hyvönen K, Pylvänäinen P,
Muotka J and Lappalainen R (2020) The debilitating condition of depression is the leading cause of ill health and disability in the adult
The Effects of Dance Movement population worldwide, and the prevalence of depression has increased between 2005 and 2015 by
Therapy in the Treatment over 18% (WHO, 20171 ). Depression is therefore a considerable burden to families and societies
of Depression: A Multicenter, across the world. The same trend can be seen in Finland, where mental health problems have
Randomized Controlled Trial
in Finland. Front. Psychol. 11:1687. 1
WHO, 2017: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=31927
doi: 10.3389/fpsyg.2020.01687 89A665A9D4F33D0EC6FCE80C9F8?sequence=1.

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Hyvönen et al. DMT in the Treatment of Depression

been the leading cause of work disability retirements since year have at least two of the first three symptoms and in total four or
2000, and among the mental health problems, depression has more of these symptoms. These symptoms need to be present
been the most prevalent (Findikaattori, 20192 ). over a 2-week period with the symptoms being considered
There is increasing evidence of the effectiveness of dance to cause clinically significant impairments in functioning. In
movement therapy (DMT) with a range of client groups and Finland, 6.5% of the population have depressive states during a
conditions (see reviews by Ritter and Low, 1996; Cruz and year (Pirkola et al., 2005).
Sabers, 1998; Koch et al., 2014, 2019), including the reduction The acute treatment of mild and moderate depression
in the symptoms of depression (Jeong et al., 2005; Koch involves antidepressants or psychotherapies, and their
et al., 2007; Röhricht et al., 2013; Punkanen et al., 2014; combination is recommended in the Finnish Current Care
Meekums et al., 2015; Pylvänäinen et al., 2015; Karkou et al., Guidelines4 . The treatment of mild and moderate depressive
2019). DMT is a form of creative arts therapy, which aims to states is focused on antidepressants or psychotherapy, and the
integrate physical, emotional, cognitive, and social aspects into combination of medication and psychotherapy has been shown
psychological treatment (Stanton-Jones, 1992; Meekums, 2002; to be most effective. In severe and psychotic depression, the
EADMT Ethical Code, 20103 ). DMT works in the sphere of combination of treatment modalities is emphasized. The aim of
embodiment and the integral relationship that the body has to psychotherapy is typically to promote recovery and functioning.
the functioning of the mind (Homann, 2017; Payne et al., 2019). Psychotherapies can include various evidence-based, short- or
The methods involve shifting attentional states and moving in long-term applications of cognitive, behavioral, psychodynamic,
deeper relationship to self and others, for example, by fostering interpersonal, acceptance and commitment, and resource- and
attuned interoceptive sensing, somatic awareness, and interactive solution-focused therapies. Some of the therapy approaches may
dance (Homann, 2017). In DMT, also labeled as dance movement include applications of methods from creative arts therapies.
psychotherapy, the two central constructs are the healing power Treatment programs in hospital units, day hospitals, and
of conscious movement and the embodied creative experience outpatient psychiatric clinics may provide some physical activity
(Payne, 1992; Caldwell, 2017). In the work during the therapy options and, sometimes, also creative arts therapies, such as art
session, the careful balancing of breathing, moving/expressing, therapy, music therapy, and DMT. Furthermore, DMT can be an
and feeling/sensing is essential (Caldwell, 2017). alternative for clients who want to process experiences through
Dance movement therapy engages the patients in physical and not only verbal articulation but also bodily experiences.
verbal exploration of their experiences generated in movement-
based interaction. In the DMT research, there have been Description of the Dance Movement
only three previous randomized controlled trials involving Therapy
participants with depression, and the number of participants in In this research, we refer to DMT, but DMT is also called
these studies has ranged from 31 (Röhricht et al., 2013) to 72 dance therapy, dance movement psychotherapy, movement
(Xiong et al., 2009) participants (for reviews, see Meekums et al., psychotherapy, dance/movement therapy, or dance-movement
2015; Karkou et al., 2019). In the present research, we aimed to therapy (Meekums et al., 2015). The European Association
respond to this research gap by including a larger number of Dance Movement Therapy5 has defined DMT as “the therapeutic
participants (N = 109) than had been done in previous studies use of movement to further the emotional, cognitive, physical,
utilizing randomized controlled trials in research designs. Our spiritual, and social integration of the individual.” Dancing is
study has generated further information about the effectiveness considered central to DMT and is seen as body movement,
of DMT groups in the rehabilitation of depression, as it was creative expression, and communication. A dance movement
conducted in five cities across Finland. This type of multicenter therapist analyzes body movement to assess clients and devise
research can provide a realistic picture of the typical practice of a movement interventions based on the basic premise of DMT: the
range of dance movement therapists working with participants in interrelations of the mind and body as well as emotional states
various geographic locations. and relationships.
Dance movement therapy can be practiced by individuals
Depression (one-to-one) or in groups with a range of client populations
Depression is a psychiatric syndrome that is described by 10 from children to the elderly. The aim of DMT practice is
symptoms: low mood, a loss of interest or pleasure, fatigue, to integrate physical, emotional, cognitive, and social aspects
decrease in self-confidence or feelings of worthlessness, excessive in the treatment (e.g., Stanton-Jones, 1992; Meekums, 2002).
feelings of guilt and self-blame, thoughts about suicide or self- DMT focuses on embodied experiences emerging through body
harm, self-harming behavior, decreased concentration, either movements, expressions, and interactions with the environment
slowed or agitated movement, sleep disturbances, and changes in (Koch and Fischman, 2011). In addition, participants can benefit
appetite or weight (International Classification of Diseases, 10th from the physical responses related to exercise (Meekums et al.,
Revision diagnostic system; Finnish Current Care Guidelines, 2015; Karkou et al., 2019). In DMT, the participants can tune
20164 ). To fulfill the criteria for the diagnosis, a person needs to their awareness to these embodied experiences of their own self
in a group therapy setting with others. This can support and
2
Findikaattori, 2019: https://findikaattori.fi/fi/76.
3
EADMT Ethical Code, 2010: http://www.eadmt.com/?action=articleandid=22. 5
The European Association Dance Movement Therapy, 2013: http://www.eadmt.
4
Finnish Current Care Guidelines, 2016: https://www.kaypahoito.fi/hoi50023. com/?action=articleandid=22.

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Hyvönen et al. DMT in the Treatment of Depression

strengthen therapeutic alliances, when experiences are reflected depression in two of the studies. However, due to the low
and communicated in words (Pylvänäinen, 2018). Zubala (2013) methodological quality of the studies and small sample size,
suggests that central to the treatment of depression in arts no firm conclusions regarding the effectiveness of DMT can
therapies is the cultivation of relatedness to oneself and to others. be drawn (Meekums et al., 2015). A recent meta-analysis of
Also, fostering attentiveness and connection to body sensations DMT found that studies with moderate to high methodological
develops one’s body image, self-relation, and action modulation. quality demonstrate strong support for the effectiveness of
This can result in an improved perception of one’s body DMT concerning depression (Karkou et al., 2019). This meta-
image, that is, increased awareness of the embodied phenomena, analysis took into account studies that had controlled designs
a more accepting and more neutrally descriptive relation to and involved pre- and posttreatment testing. The preliminary
one’s body, and improved tolerance of others (Pylvänäinen and results of the present study were included in that meta-
Lappalainen, 2018). Therapeutically, the creative change process analysis by Karkou et al. (2019). This research now presents the
is the core component of DMT, involving movement metaphors detailed findings that have been referred to in the published
that surface in clients’ postures or movement experiences (Ellis, meta-analysis. The research responds to the need for larger
2001; Meekums, 2002; Meekums et al., 2015; Karkou et al., 2019). randomized controlled trials regarding the effectiveness of
Metaphors can yield information about a client and shape new DMT in the treatment of depression that could provide more
perspectives, aiding in working through problematic experiences reliable information for use in developing the treatment and
(Ellis, 2001). rehabilitation of depression.
Meta-analyses have shown that DMT and the therapeutic use
of dance can be effective with a range of disorders, including
psychiatric symptoms, autism, eating disorders, and stress (Ritter Present Study
and Low, 1996; Cruz and Sabers, 1998; Koch et al., 2014, As depression has become a globally recognized problem in
2019). Furthermore, DMT has been shown to improve well- society, it is crucial to investigate alternative treatment methods
being, mood, affect, quality of life, body image, and interpersonal and choices available for clients to engage in as therapy. In this
competence, as well as reducing clinical symptoms, such as research, we utilized a multicenter study design to investigate
depression and anxiety (Koch et al., 2014). The research thus the effects of group DMT on depression symptoms among
far has systematically shown, albeit with smaller numbers of participants who have been diagnosed with clinical depression.
participants, that DMT can be an effective intervention in the In our research, we compare individuals who took part in a DMT
treatment and rehabilitation of depression (Jeong et al., 2005; intervention with those who received treatment as usual (TAU).
Koch et al., 2007; Röhricht et al., 2013; Punkanen et al., 2014; Participants in the DMT group also continued their TAU in their
Pylvänäinen et al., 2015; Karkou et al., 2019). In addition, in psychiatric outpatient clinic, occupational health service, or other
the Finnish context, previous studies (Punkanen et al., 2014; health service provider responsible for the standard care. Our
Pylvänäinen et al., 2015; Pylvänäinen and Lappalainen, 2018) research questions were as follows:
have shown that DMT is effective in alleviating depressive
symptoms and improving mood. Participants in DMT groups
1. Is there a change in depression symptoms [Beck Depression
have reported, for instance, an increase in their secure attachment
Inventory (BDI)] and other psychological and physical
style measured by the Relationship Questionnaire (Punkanen
symptoms [Clinical Outcomes in Routine Evaluation—
et al., 2014) and described that after DMT group therapy, they
Outcome Measure (CORE-OM) and The Symptoms
tolerated others better, were more active in social interaction, and
Check List-90 (SCL-90)] among participants in the DMT
felt less tense and more trusting of their own body (Pylvänäinen
treatment group at the three measurement points: before
and Lappalainen, 2018). Specifically, DMT groups can have
the intervention period (pretreatment measurement), after
positive influences on the body image of participants with
the intervention (posttreatment measurement), and after
depression (Pylvänäinen and Lappalainen, 2018). Participants’
the 3-month follow-up period (follow-up measurement)?
body image changed toward a more positive relatedness to
2. Is the change in symptoms different among participants
their own body. The positive change in body image from the
in the DMT treatment group with standard care
pre- to posttreatment measurements of the groups predicted a
(DMT + TAU) compared with those participants who
more significant reduction in depression and other symptoms
receive standard care only (i.e., the control group;
from the pretreatment measurement to the 3-month follow-up.
TAU only)?
Specifically, a more positive change in body image predicted
better mood.
A Cochrane review of the effects of DMT on depression Previous research has shown that DMT alleviates symptoms of
compared the effects of DMT with no treatment and with depression and other psychological and physical problems (e.g.,
standard care, psychological interventions, drug treatment, and Jeong et al., 2005; Koch et al., 2014, 2019; Punkanen et al., 2014;
other physical interventions (Meekums et al., 2015). Only Pylvänäinen et al., 2015; Karkou et al., 2019). Based on those
three studies met the Cochrane review inclusion criteria, findings, we expected that the reduction in depression and other
covering 147 participants in total. DMT was found to psychological and physical symptoms among participants in the
have reduced symptoms of depression at the follow-up DMT treatment group would be significantly greater than the
measure more so than standard care among adults with change in the control group.

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Hyvönen et al. DMT in the Treatment of Depression

FIGURE 1 | The progress of participants through the trials.

METHODS services, occupational health services, and psychiatrists in private

health clinics. The possibility to participate in the research and
Recruitment Procedure DMT groups was also advertised in local newspapers and through
The present research is part of a larger intervention study funded social media. Persons interested in taking part in the study
by the Finnish Social Insurance Institution on the effectiveness contacted the researchers by phone or email to book a time for a
of DMT in treating depression. The DMT group sessions took screening interview conducted over the phone during the spring
place in seven cities across Finland. This research focuses on and summer of 2017. The researchers interviewed altogether 235
the data collected from the randomized controlled trials that persons over the phone.
were performed in larger cities in the Greater Helsinki (three The aim of each screening interview was to check if the
groups), Tampere (one group), Jyväskylä (two groups), and inclusion criteria of the study were met by the participant. First,
Joensuu (two groups). In the smaller cities, the randomization the participant needed to have a diagnoses of depression by a
of the participants was not possible due to the small number psychiatrist or general practitioner (International Classification
of participants there; hence, those non-randomized participants of Diseases—diagnostic system). Second, the researchers checked
were excluded from this research. The participants in this that the participants were working age (18–65 years of age)
research were randomly allocated to parallel groups: either in and fulfilled the criteria for rehabilitative psychotherapy in
the treatment group (DMT + TAU) or the control group (TAU Finland (KELA, 20206 ): at least 3 months of relevant treatment
only). Participants in the treatment group participated in the since depression was diagnosed; the participants’ ability to work
DMT sessions in the autumn of 2017. In addition, the participants or study is impaired by depression; and a psychiatrist has
in the control group had the opportunity to attend DMT sessions determined that rehabilitative psychotherapy is necessary to
in the spring of 2018. Figure 1 shows the progress of participants improve or support the participant’s ability to work or study. The
through the trials. exclusion criteria were (1) active suicidal ideation, (2) psychotic
Participants were recruited through public and private mental
health services, which included outpatient clinics, student health 6
KELA, 2020: https://www.kela.fi/web/en/rehabilitative-psychotherapy.

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Hyvönen et al. DMT in the Treatment of Depression

symptoms, and (3) substance misuse that is on a critical level were analyzed with independent t-tests and chi-square tests.
(Audit questionnaire scores above 10). Also, interviewees who No differences were found between respondents and non-
had pain-related problems that restricted daily life or were respondents in relation to the age, use of antidepressant
pregnant were not admitted to the study. Study participants medication, previous depression episodes, or outcome measures.
were given an information leaflet regarding the participation in
the study and were asked to sign a consent form. The board
Dance Movement Therapy Treatment
of research ethics at the Central Finland Health Care District
The participants who were randomly assigned to the treatment
has affirmed the present research with a favorable statement
group received a DMT group intervention that took place twice
(Dnro 8U/2016). The research is registered and posted on the
a week for 10 weeks starting in September 2018. In total, the
ClinicalTrials.gov public website (identifier: NCT04421651).
intervention period included 20 sessions, which were 75 min
In total, 118 participants were randomized into the treatment
each. The duration and frequency of the treatment period was
and control groups. The coordinating researchers responsible of
similar to the one used in the study by Punkanen et al. (2014),
the data collection used the SPSS program to randomly select
but sessions were 15 min longer than in their study. The
59 participants in the treatment and 59 participants in the
number of participants in each group varied between 4 and
control groups. The contact details of the participants in the
8. There were altogether eight DMT groups in different cities
treatment group were forwarded to the therapists working in
across Finland, and these were facilitated by eight trained dance
different locations. The therapists facilitating the treatment were
movement therapists whose first degrees varied (e.g., health care
responsible in organizing suitable locations for their group. The
professionals and teaching degrees). In addition, all therapists
therapists were in contact with the participants to inform them
about the dates, times, and location of the DMT groups and
organize pretreatment interview.
The researchers contacted the participants in the control TABLE 1 | Demographic information on participants in the treatment and control
groups.
group to inform that they had been randomly selected to the
control group. Nine of these participants dropped out before Treatment Control Total
the pretreatment measurement of the research and start of group group
the DMT group sessions for reasons such as changes in life
circumstances since the screening interview (e.g., moved town) n = 52 n = 57 N = 109

or the times of the group sessions not having been suitable. Sex (%)
This study focuses on those participants (n = 109) who were Female/male 98.1/1.9 94.7/5.3 96.3/3.7
randomly allocated to either the treatment group (n = 52) Age in years
or control group (n = 57). At the pretreatment measurement, Average 41.8 36.5 39.03
before the DMT intervention commenced, all participants Min. 18 18 18
responded to an electronic survey regarding their psychological Max. 63 64 64
and physical symptoms related to depression. The posttreatment Education (%)
measurement was conducted immediately after the intervention Comprehensive school 7.7 5.3 6.4
and the response rate was 84% (92 participants), comprising Secondary education 30.8 36.8 33.9
81% of participants from the treatment group and 88% from Vocational school 11.5 10.5 11.0
the control group. The follow-up measurement was conducted Lower university degree 26.9 22.8 24.8
3 months after the intervention, and the response rate was 71% Higher university degree 21.2 17.5 19.3
(77 participants), consisting of 73% of participants from the Other (e.g., Ph.D.) 1.9 7.0 4.6
treatment group and 68% from the control group. All participants Employment situation (%)
continued their usual treatment during the research. The TAU Full-time employment 21.1 14.0 17.4
included antidepressant medication among 56% of participants. Part-time employment 17.3 5.3 11.0
Almost 68% of participant also had individual sessions with a Unemployed 5.8 14.0 10.1
health care professional once in 4 weeks or more frequently. Disability allowance 5.8 8.8 7.3
The demographical information of the participants and other Studying 19.2 29.8 24.8
treatment they received during the research are shown in Table 1. Other (e.g., sick leave, freelance, scholarship) 30.8 28.1 29.4
The nature of the missing information (i.e., non-responses) Antidepressant medication (%)
in the data was analyzed using Little’s missing completely Yes/no 65.4/34.6 47.4/52.6 56.0/44.0
at random test. The missing completely at random test was Other treatment (%)
valid and showed that information was missing at random: Individual sessions every 1–2 weeks 28.6 33.3 31.1
x2 (21) = 12.884, p = 0.913. More specifically, 69% (n = 75) Individual sessions every 3–4 weeks 34.3 38.5 36.5
of participants responded at three measurements, whereas 31% Individual sessions every 5 weeks or less frequently 22.9 15.4 18.9
(n = 34) responded at one or two measurements. Differences Weekly treatment group 2.9 12.8 8.1
between these groups in age, use of antidepressant medication, Self-initiated hobbies and leisure groups 25.7 35.9 31.1
and previous depression episodes as well as outcome measures Previous depression episodes (%)
(BDI, CORE-OM, and SCL-90) at pretreatment measurement Yes/no 73/27 70/30 71.6/28.4

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Hyvönen et al. DMT in the Treatment of Depression

attended the 12-day intervention training before the beginning from 0 to 40. The higher the score, the more severe symptoms the
of the group sessions and were provided supervision during respondent has. Between the general and clinical populations, the
the intervention period. The potential advantages, disadvantages, clinical cutoff point is 10 points (Connell et al., 2007). The CORE-
and unintended effects were outlined in the information leaflet OM all-items score has a correlation of 0.85 with the BDI-I and
given to the participants. The participants were informed that 0.88 with the SCL-90-revised version (Evans et al., 2002). The
it is possible that they do not benefit from the treatment. The Cronbach alphas for the CORE-OM were 0.77 for pretreatment,
participants were also told that the DMT practices are safe, 0.83 for posttreatment, and 0.79 for follow-up measurements.
participation does not require physically demanding exercises, The Symptoms Check List-90 (Holi, 2003) uses 90 items to
and the groups are facilitated by experienced DMT practitioners. measure nine primary symptomatic dimensions, including
The disadvantages of participation included for the participants somatization, obsessive–compulsiveness, interpersonal
the time required for responding to the surveys and that sensitivity, depression, anxiety, hostility, phobic anxiety,
they were attending the group on their own time. The paranoid ideation, and psychoticism. The level of distress is
unintended effects of participation could relate to the process scored on a scale from 0 to 4. An average score of the 90 items
of working through difficult feelings or experiences in therapy. is calculated, which represents the severity of the participant’s
The participants were encouraged to discuss with the therapist, symptoms, that is, the Global Severity Index (GSI). The
researchers, or their doctor regarding their experiences in the higher the GSI, the more symptoms the participant has. In the
group if they were uncertain about continuing in the group. community sample, the GSI mean was 0.60 and in the patient
The DMT treatment was based on an integrative perspective sample, 1.56 (Holi, 2003). The Cronbach alphas for the SCL-90
on the treatment of depression, and different theories and were 0.96 for pretreatment, 0.98 for posttreatment, and 0.98 for
concepts were applied from psychotherapy approaches: follow-up measurements.
psychodynamic, cognitive, solution-focused, trauma therapy, The following demographic characteristics were taken into
object relations, interpersonal theories, and relational–cultural consideration in the analyses: age in years (continuous), use
theories. This type of integrative approach is typical of DMT. of antidepressant medication (1 = no, 2 = yes), and previous
The DMT methods used included dance and movement depression episodes (1 = no, 2 = yes).
improvisations, mindfulness practices, use of props (e.g.,
fabrics and balls), and reflection through drawing, writing, and Statistical Analysis
discussion. The group meetings consisted of orientation within First, between-group differences in demographic data were
the group, thematic working, and closure. The themes that these analyzed with independent t-tests and chi-square tests. Second,
groups were built upon were based on previous DMT research the effects of the intervention were analyzed using hierarchical
regarding the treatment of depression: goals, movement options linear modeling (HLM) in Mplus (version 7) (Muthén and
and boundaries, body awareness and resources, symbols, safety, Muthén, 2012). By means of HLM with the full information
regulation, expressing emotions, body narrative, playfulness, maximum likelihood estimation method, we can use all of
needs, being and doing, agency, and processing the time span the available information and include all the participants who
of the group and one’s own life (for more details, see Punkanen started the study in our analyses. The missing data in the
et al., 2014; Pylvänäinen et al., 2015). HLM and full information maximum likelihood are assumed
to be missing at random. The between-group difference in the
Outcome Measures change of symptoms was analyzed with the Wald test. If the
Beck Depression Inventory I (Beck et al., 1961, 1988, 1996) interaction between group × time was statistically significant,
measures depressive symptoms with 21 items and is frequently the group differences were tested for the intervention period
used in clinical assessment. Each item is scored 0–3, and sum (pretreatment to posttreatment measurement) and follow-up
scores are calculated on the basis of participants’ responses. The period (posttreatment to follow-up measurement) separately.
total sum score can range from 0 to 63. A score from 0 to 9 The participants’ use of antidepressant medication was controlled
indicates no or very few depressive symptoms, from 10 to 18 for in the analyses. Also, the within-group differences in
indicates mild depression, from 19 to 29 moderate depression, symptoms were analyzed with the Wald test.
and from 30 to 63 severe depression. The Cronbach alphas for Third, the effect sizes (ESs) were calculated. The between-
the BDI-I were 0.86 for pretreatment, 0.91 for posttreatment, and group ES were calculated at the pretreatment, post-treatment,
0.91 for follow-up measurements. and follow-up measurement times by dividing the difference
Clinical Outcomes in Routine Evaluation—Outcome Measure between the treatment group mean and the control group
(Evans et al., 2002; Barkham et al., 2005; Connell et al., 2007) mean by the pooled standard deviation (SD) of the conditions.
measures participants’ mood and distress. The CORE-OM is Due to possible differences between groups at the pretreatment
sensitive to change in symptoms and can therefore be used to measurement point, between-group ES differences at the
assess the clinical effectiveness of therapy (Evans et al., 2002). posttreatment and follow-up measurements were corrected by
The CORE-OM comprises 43 items and four dimensions of well- taking into account their baseline differences. Thus, corrected
being, problems, life functioning, and risk for aggressive/suicidal between-group ES are reported here. The within-group ES was
behavior. Each item is scored from 0 to 4. CORE-OM items are calculated for both pre- and posttreatment measurements by
summed and then divided by the number of answered items, dividing the mean change from the pretreatment measurement
which is then multiplied by 10, that is, the total scores ranges by the combined (pooled) SD (Feske and Chambless, 1995;

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Hyvönen et al. DMT in the Treatment of Depression

Morris and DeShon, 2002). A between-group ES of 0.2 was to the outcome measures used. Of the demographic
considered small, 0.5 medium, and 0.8 large. And within-group characteristics considered, only the use of antidepressant
ES of 0.5 was considered small, 0.8 medium, and 1.1 large medication was related to lower scores on the BDI-I and
(Roth and Fonagy, 1996). CORE-OM measures and also to higher age. Therefore,
The effectiveness of the DMT intervention was also examined we chose to control for the use of medication in the
with the Reliable Change Index (RCI; Jacobson and Truax, 1991) subsequent analyses.
of the BDI-I scores. The RCI can help determine whether the
participants’ change is statistically reliable and not due to a
measurement error. The RCI indicates the clinical significance of Levels and Changes in Symptoms
the change in depression symptoms and whether the participants Across the Measurements
can be considered to have improved during the intervention. The means and SD of the outcome measures, as well as
The RCI classification accounts for whether a participant’s extent the corrected between-group ES and the results from the
of improvement has passed the weighted midpoint between the Wald tests, are shown in Table 3 for the three measurement
means of the general population and the clinically symptomatic points. First, it can be noted from Table 3 that, at the
one (Jacobson and Truax, 1991; Seggar et al., 2002); if so, the pretreatment measurement time, there were no statistically
participant would be classified as recovered. For the BDI-I, the significant differences between groups in the BDI-I, CORE-
weighted midpoints were 13.13 for the treatment group and OM, or SCL-90, indicated by the estimates of the Wald
13.89 for the control group. Participants whose BDI-I scores test. Furthermore, in line with our expectations, we observed
were above the weighted midpoint were included in the RCI significant differences between participants in the treatment
calculations. Participants whose BDI score was below the cutoff and control groups with respect to the outcome measures for
point at the pretreatment measurement time were excluded the period from the pretreatment to follow-up measurement.
from the classification. If a participant’s RCI is below –1.96 However, no differences in the change of outcome measures
and passes through the cutoff point, the participant is classified were observed for the posttreatment to follow-up measurement
as recovered. If the RCI is below –1.96 but does not pass the time span between the participants in the treatment and control
cutoff point, the participant is classified as improved. If the groups, that is, the levels of symptoms remained stable during the
participant’s RCI is between –1.96 and 1.96, the participant is follow-up period. Figures 2–4 show the means and error bars of
classified as unchanged. If the participant’s RCI is above 1.96, outcome measures for the treatment and control groups at the
the participant is classified as deteriorated. We examined, using three measurement points.
analysis of variance and chi-square tests, whether there were The measurement time had a main effect on the BDI,
differences in demographic characteristics and BDI-I scores at CORE-OM, and SCL-90, and the symptoms they measured
the pretreatment measurement time between participants with showed a significant decrease across the measurement times
different RCI classifications. -
among participants in the DMT group. Interaction effects were
We calculated post hoc power in BDI with the MPlus using observed between time and group, indicating that the symptoms
Monte Carlo Simulations in which the number of replications measured by the BDI, CORE-OM, and SCL-90 decreased more
was 10,000. The post hoc power of the Wald test (time × group) among the participants in the treatment group compared with
was 0.991. The power was 0.840 for the parameter, in which those in the control group, wherein no decrease in symptoms
the change between pre- and posttreatment measurements was was observed.
explained by the group. The power was 0.499 for the parameter, To assess the size of the intervention effects, the corrected ES
in which the change between posttreatment and follow-up were analyzed. At the follow-up measurement point, between-
measurements was explained by the group. group ES showed medium differences for all the measures
(d = 0.60–0.72). In the treatment group, the within-group
ES were small between the pretreatment and posttreatment
RESULTS measurements with respect to the BDI-I (d = 0.60) and close
to small for the CORE-OM (d = 0.44) and SCL-90 (d = 0.42).
Descriptive Results Between the pretreatment and follow-up measurements, the
The participants in the treatment and control groups were within ES were medium (d = 0.89) with respect to the BDI-I and
compared in terms of demographic characteristics to test whether small or close to small with respect to the CORE-OM (d = 0.53)
there were differences between groups at the pretreatment and SCL-90 (d = 0.45).
measurement point. The participants in the treatment group In the control group, the within-group ES were very small
were older (M = 41.8 years) than the participants in the (BDI-I, d = 0.17; CORE-OM, d = –0.01; SCL-90, d = –0.11)
control group (M = 36.5 years), t(107) = 2.25, p > 0.05. There between the pretreatment and posttreatment measurements.
were no differences between the groups in the representation The within-group ES were also small between the pretreatment
of sex, level of education, employment situation, use of and follow-up measurements (BDI, d = 0.21; CORE-OM,
antidepressant medication, other treatments, or previous d = 0.01; SCL-90, d = –0.05). Thus, in the treatment group, the
depressive episodes. within-group ES varied between the pretreatment and follow-
Table 2 shows the correlation of age, use of antidepressant up measurements from 0.45 to 0.89 compared with that in the
medication, and previous depression episodes in relation control group’s, -0.11 to 0.21.

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Hyvönen et al. DMT in the Treatment of Depression

TABLE 2 | Correlation coefficients for the demographic variables and the outcome variables at the pretreatment measurement and their change between the
pretreatment and follow-up measurements.

Variables 1 2 3 4 5 6 7 8 9

Depression (BDI-I)
1. Pre-treatment measurement –
2. Pre to Follow-up 0.158 –
Psychological distress (CORE-OM)
3. Pre-treatment measurement 0.809*** 0.083 –
4. Pre to Follow-up 0.078 0.790*** 0.209 –
Psychiatric symptoms (SCL-90)
5. Pre-treatment measurement 0.712*** 0.014 0.827*** 0.047 –
6. Pre to Follow-up − 0.028 0.729*** 0.016 0.774*** 0.102 –
Demographic characteristics
7. Age in years 0.046 0.206 − 0.007 0.089 − 0.032 0.06 –
8. Medication (1=no; 2=yes) − 0.273** 0.060 − 0.365*** − 0.156 − 0.188 0.119 0.189* –
9. Previous episodes (1=no; 2=yes) − 0.036 −0.140 − 0.042 − 0.204 0.072 −0.113 0.047 − 0.109 –

*p < 0.05; **p < 0.01; ***p < 0.001.

TABLE 3 | Means and standard deviations of outcome measures in treatment and control groups: results of the Wald tests, including estimates and corrected
between-group effect sizes.

Measurement Pretreatment Posttreatment Follow-up Wald test time Wald test time × group

BDI 11.69**
1. Treatment group 21.49 (8.86) 15.87 (9.71) 13.85 (8.33) 35.65***
2. Control group 22.40 (8.00) 20.55 (9.98) 20.84 (10.27) 5.26, ns
Estimates for group comparisons –0.12, ns –3.94*1 –2.162 , ns
Between-group ES 0.11 0.451 0.723
CORE-OM 9.87**
1. Treatment group 16.28 (5.75) 13.35 (7.26) 12.95 (6.77) 15.36***
2. Control group 16.94 (5.13) 16.98 (5.87) 16.89 (5.56) 0.01, ns
Estimates for group comparisons 0.06, ns –3.34**1 –0.522 , ns
Between-group ES 0.12 0.551 0.603
SCL-90 9.21*
1. Treatment group 1.31 (0.58) 1.04 (0.73) 1.03 (0.67) 18.55***
2. Control group 1.26 (0.46) 1.32 (0.61) 1.28 (0.55) 1.11, ns
Estimates for group comparisons 0.09, ns –0.36**1 0.0452 , ns
Between-group ES 0.10 0.641 0.603
1 Pre–Post; 2 Post–Follow-up; 3 Pre–Follow-up; *p < 0.05; **p < 0.01; ***p < 0.001.

The RCI classification was first analyzed for the participants In the control group (n = 35), five (14.3%) participants
in the DMT treatment group, whose BDI-I scores were above had either recovered (n = 2; 5.7%) or improved (n = 3;
the cutoff point at the pretreatment measurement time and who 8.6%). A large majority of the participants in the control group
had responded at the measurement points (n = 30). Of these remained unchanged (n = 29; 82.9%), and one participant
participants, 13 (43.3%) had either recovered (n = 9; 30%) or deteriorated (n = 1; 2.9%).
improved (n = 4; 13.3%). In addition, 17 (56.7%) participants
were classified as unchanged, and none had deteriorated. There
were no differences between the participants with different RCI DISCUSSION
classifications regarding age, use of antidepressant medication,
or previous depression episodes. However, the participants The main finding of this study shows that for participants with
who were classified as improved had reported significantly depression, attending a DMT group, in addition to TAU, can
higher levels of symptoms in the BDI-I measure at the study reduce their depression symptoms, as well as other psychological
baseline (M = 30.8) compared with the participants who and physical symptoms, more so than by receiving TAU only.
recovered (M = 22.56) or remained unchanged (M = 21.9), In other words, adding a DMT group intervention to the
F(2,27) = 3.587, p < 0.05. usual treatment of depression improved the effectiveness of

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Hyvönen et al. DMT in the Treatment of Depression

FIGURE 2 | Means and error bars BDI-I in the treatment and control groups between pre- and follow-up measurement.

FIGURE 3 | Means and error bars in CORE-OM in the treatment and control groups between pre- and follow-up measurements.

the depression treatment as observed across three measurement of different therapists that were facilitating groups in various
points that spanned from the beginning to the end of the locations across Finland.
DMT intervention plus a follow-up 3 months afterward. The
participants with depression who are motivated to address
personal experiences through movement and dance benefit Clinical Significance of the Changes in
from having the possibility to join DMT groups, and their the Levels of Depression
symptoms decrease more than if they were just receiving The clinical significance of these differences in the levels of
their usual psychological and medical treatment. These findings depression symptoms between the DMT + TAU and TAU-
are in line with previous research among smaller number only groups at the different measurement times was considered
of participants with depression in Finland (Punkanen et al., through ESs and reliable clinical index classifications. First, it
2014; Pylvänäinen et al., 2015) as well as in international was noted that the corrected between-group ESs between the
meta-analyses (Koch et al., 2007; Karkou et al., 2019). The DMT + TAU group and TAU-only group, the latter having
research gives support that DMT groups can be a beneficial received standard care only, were medium at the end of the three-
and cost-effective form of short-term group therapy. The month follow-up period (d = 0.72) in favor of the DMT group.
participants who committed to the group were also likely to The between-group ES of over 0.70 suggests that about 66% of the
complete the group process, which was seen across a number DMT participants benefitted from the DMT treatment compared

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Hyvönen et al. DMT in the Treatment of Depression

FIGURE 4 | Means and error bars in SCL-90 in the treatment and control groups between pre- and follow-up measurements.

to 50% of the non-participants (see Cohen, 1988; Norcross and variance. The difference in the ESs in our research compared
Lambert, 2010). The number needed to treat (NNT) indicates to those in the study by McDermut et al. (2006) may also
the number of participants who need to receive an intervention be explained by the different characteristics of the control
in order to achieve one success. An ES of 0.70 refers to an group, which in their case included untreated participants.
NNT of 3; that is, three participants needed to receive DMT to In our research, all of the participants in the control group
achieve one success compared to non-participants in a control received standard care during the research. The standard care
group. In addition, the within-group ESs were considerably larger that the participants in the treatment and control groups
among participants attending to the DMT group. These ESs are received included weekly or fortnightly individual sessions for
comparable to the ESs found in other studies on the effectiveness around a third of the participants, and slightly over half of the
of DMT in the treatment of depression in Finland that have participants attended individual sessions every 3 weeks or less
involved treatment and control groups (Pylvänäinen et al., 2015). frequently. In addition, 13% of the participants in the control
For instance, in the study by Pylvänäinen et al. (2015), among group reported attending other treatment groups, whereas only
participants in Finland with diagnosed depression, the between- 3% of the participants in the DMT group reported attending
group ESs ranged from medium to large. The decrease in the other treatment groups. However, it should be noted that this
mean level of symptoms examined with the BDI-I was similar difference in standard treatment between the two groups in
(7.64 points) to what has been observed in the study by Punkanen our study was not statistically significant. In the present study,
et al. (2014) using a comparable DMT group intervention with in both the DMT + TAU and TAU-only groups, participants
20 sessions. In their study, the reduction of the BDI-tested used antidepressants, and this can also play a role in the
symptoms from the baseline to the post-treatment measurement change patterns.
was 11.17 points. Also, a shorter DMT intervention in Finland Furthermore, among the participants in the DMT+TAU
(Pylvänäinen et al., 2015) including 12 sessions indicated a group, over 40% were classified as recovered or improved
favorable mean reduction in depression symptoms (measured on the basis of changes in the BDI-I scores calculated
with the BDI-II), that is, 10.11 points. The results of these three with the RCI classification. In comparison, only 14% of the
studies in Finland show that beneficial changes are seen in DMT participants in the TAU-only group recovered or improved.
interventions that are (1) 12 × 90 min sessions once a week Demographic characteristics did not seem to be related to the
(Pylvänäinen et al., 2015); (2) 20 × 60 min sessions twice a week extent to which participants benefitted from the DMT group
(Punkanen et al., 2014); and (3) 20 × 75 min sessions twice a treatment. Interestingly, the participants who were characterized
week in this research. When there are more group sessions and as improved had reported a higher level of depression symptoms
longer meeting time, the group may benefit from slowing down than other participants at the study baseline. These findings
and working through group experiences at an unhurried pace. suggest that participants who have a fairly severe level of
The ESs observed in a meta-analysis of group psychotherapies symptoms can also gain benefits from a DMT intervention.
showed larger ESs, averaging 1.03 at the post-treatment However, it should be noted that the number of participants
measurement time across studies (McDermut et al., 2006). classified as improved in the DMT group, four persons, was small.
Then, in a later meta-analysis (Cuijpers et al., 2010), group These findings for the ESs and RCI classifications suggest that
therapies were found to have an ES of 0.31. Clearly, there is the favorable changes observed in depression when the DMT was

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Hyvönen et al. DMT in the Treatment of Depression

added to the TAU have clinical significance. It is notable that investigating the effectiveness of DMT. In addition, less than
there are participants who are particularly motivated to work 4% of participants were male, and therefore, the role of gender
through difficult personal issues in therapy groups that include in benefiting the treatment could not be taken into account. It
the opportunity to engage in creative movement and reflection would be advisable to have more equally gender-balanced data
on embodied experiences. This can be useful especially in the in future research. On the other hand, the majority of patients
treatment of depression, which is a condition involving many with depression are female; thus, information specifically on the
body-related changes and difficulties (e.g., exhaustion, fatigue, female patients’ experience and recovery is relevant (Koponen
loss of pleasure). et al., 2018; WHO, 20207 ).
Although the participants were randomly divided into the
Changes in Other Psychological and DMT + TAU and TAU-only groups, the comparisons of these
groups showed that the participants in the DMT + TAU group
Physiological Symptoms were slightly older than those in the TAU-only group. We can
The reduction in depression symptoms among the DMT + TAU see from the percentages of participants’ current employment
group was in line with changes seen in other measures of status that, in the TAU-only group, there seemed to be more
symptoms. A significant improvement in the DMT + TAU students and fewer participants who were in either full- or part-
group over the TAU-only group was also observed in regard time employment; albeit, these differences were not statistically
to psychological distress measured with the CORE-OM and significant. Furthermore, there were no differences between the
psychiatric symptoms measured with the SCL-90. In fact, groups in their level of depression or other psychological or
in the SCL-90, about a third of the items on the scale psychiatric symptoms at the baseline of the study. Participants’
measure experiences that relate to somatization or arousal age also seemed unrelated to the level of symptoms at the baseline
of the autonomous nervous system. It is therefore notable and to the change in symptoms across the measurement times.
that a DMT intervention also relates to changes in the way A longer follow-up period in future research may be important
in which participants experience their bodily felt symptoms to gain further information about longer term effects of DMT. It
(Pylvänäinen et al., 2015). could be that some effects take longer to surface. On the other
Overall, the reduction in various symptoms is in line with hand, it is also possible that, for a number of participants, a
previous studies with a wide range of participants having 20-session group treatment is not sufficient to address the root
different disorders (e.g., Koch et al., 2014, 2019; Meekums causes and patterns of their depression and produce permanent
et al., 2015; Karkou et al., 2019). These previous reviews and improvements in their symptoms. For those reasons, on the basis
studies confirm the benefits of DMT in relation to psychiatric of our current findings, we cannot yet draw firm conclusions
symptoms as well as positive indicators of well-being, such as about the stability of the positive trend seen in the reduction of
quality of life (Bräuninger, 2012) and vitality (Koch et al., 2007). DMT participants’ symptoms. A further limitation is that 29%
A growing body of research suggests that DMT is an effective of the participants who initially participated in the survey did
treatment for participants with depression. The mechanisms of not respond at the 3-month follow-up measurement time. In the
change have been suggested to relate to participating in dance, statistical analyses, we were able to include all the participants
which can be an art form as well as exercise, emphasizing who took part in the research. We do not have information
one’s experience, sensation, presence, and expression through from all of the non-respondents about the reasons why they
movement (Pylvänäinen et al., 2015; Karkou et al., 2019). For had not responded or decided to drop out from the research.
instance, a Cochrane review concluded that exercise can be as Several participants withdrew from the study due to changes in
effective as antidepressants or psychological therapies in reducing their life circumstances, such as in their employment situation or
the symptoms of depression (Rimer et al., 2012). At the same having started psychotherapy rehabilitation. However, there were
time, DMT can provide a therapeutic alliance in which the also participants who did not inform us about their reasons for
embodied relationships, symbolic unconscious material, and withdrawing from the study. It is therefore possible that some
integration through reflection, movement, and creativity are non-respondents’ health may have deteriorated and they felt too
central and focused upon (Karkou et al., 2019). It is also vitally burdened to participate.
relevant that, in DMT, it is possible to create involvement through The strength of our multicenter research is that there were
moving in ways that are on the level of the participants’ physical more participants in this study than in previous randomized
capacity, current energy level, and motivation. controlled trials of DMT with participants diagnosed with
depression in various geographical locations. The groups
Study Limitations and Future Research were facilitated by eight different therapists, and the group
There are several study limitations, as well as strengths, that composition varied between 4 and 10 participants. Thus, there
should be taken into account when making inferences on the was likely to be similar heterogeneity in the skills and experience
bases of these findings. The main limitation of the study is same- of the therapists as well as in the motivation and the severity of
source bias, as only self-report measures were used. In future symptoms among the participants, as in real life therapy settings.
research, it may be useful to include also other physiologically The group processes could be different depending on the number
oriented or movement-based measurements. Clearly, there is
a physical component to DMT, so physiologically oriented 7
WHO, 2020. Gender and women’s mental health: https://www.who.int/mental_
or movement-based measurements would be relevant when health/prevention/genderwomen/en/.

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Hyvönen et al. DMT in the Treatment of Depression

and specific needs of the group members. The therapists adjusted treatments, such as DMT, with the prospect of enhancing and
the structured therapy process introduced in the training when thereby improving the effects of the depression treatment.
necessary to respond to the needs and processes of the groups.
In this type of multicenter research, we cannot conclude to what
extent the results reflect the structured group process and what DATA AVAILABILITY STATEMENT
changes can be attributed to the responsiveness of the therapists
running the group (see Stiles, 2013). The datasets generated for this study are available on request to
A higher number of participants would be needed to assess the the corresponding author.
differences between participants who either recover or improve
during the intervention and also among those whose symptoms
do not change. Out of 52 participants in the DMT group, only ETHICS STATEMENT
30 participants responded at each measurement point, and their
BDI-I scores were above the weighted cutoff points. In future The studies involving human participants were reviewed
research, it would be relevant to investigate, with a larger sample, and approved by the Board of Research Ethics at the
the type of profiles that can be identified among participants Central Finland Health Care District (Dnro 8U/2016). The
in the DMT group. With a person-oriented approach (e.g., patients/participants provided their written informed consent to
Wang et al., 2013; Bergman and Lundh, 2015), future research participate in this study.
should identify profiles of participants who are as homogenous
as possible within one profile as well as heterogenous between
profiles. This type of analysis would be able to address what AUTHOR CONTRIBUTIONS
demographic characteristics and intervention-related factors
predict benefitting from a DMT intervention. All authors have made substantial contributions to planning,
The main findings of our research show that individuals designing, collecting the data, analysis and interpretation of
participating in a DMT group treatment can benefit from this data, participated in drafting the manuscript and writing and
type of intervention in addition to their other treatment. In fact, commenting the content, and also approved the version to be
the participants who were in the TAU-only group experienced, submitted in the journal.
on average, no improvement in their symptoms. The DMT group
sessions in the different cities were facilitated by a number of
trained dance movement therapists, so these results are more FUNDING
likely to reflect DMT methods than the characteristics or skills
of a specific therapist (Karkou et al., 2019). Our research thus This article is based on a research project funded by the Social
encourages the application of creative and experiential group Insurance Institution of Finland.

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Frontiers in Psychology | www.frontiersin.org 13 August 2020 | Volume 11 | Article 1687