Dance Movement Therapy: Kinesthetic Approach in Modern Medicine

It starts with the hand lift – the body moves with the melody while the mind thinks about a feeling that has yet to be worked and the lungs breathe as they travel through space. Calmness, happiness, release. Imagine doing this for just thirty minutes, once a week. This is the foundation of Dance Movement Therapy (DMT).

Standard Western practices gravitate towards traditional pharmaceutical pathways to alleviate symptoms of an illness. DMT intends to alleviate the same symptoms in a more natural non-invasive approach, offering a new option to combat disease progression when standard drugs have failed. This intervention focuses on the patient’s physical and emotional presence. Quantitative and qualitative analysis reveals that dancing has a major benefit on the patient’s well-being and quality of life.[1] This therapeutic approach has a strong connection with three main areas of neurological functioning.

First, DMT capitalizes on musical exercise in a regimen that smoothly blends music and exercise through modulating the arousal and rest system in the brain that maintains hormone level homeostasis. Combining both increases the levels of endorphins, serotonin, and dopamine – neurotransmitters commonly associated with positive emotions. The “runner’s high” that one gets after a run is a prime example of the positive emotional benefits of exercise.

Next, given that DMT is based on an art, this therapeutic intervention is rooted in a platform that encourages emotional regulation through movement exploration. DMT focuses on proprioception – body placement in space – which encourages internal awareness.[2] Such awareness comes from the subtle changes in posture, breathing patterns, and eye focus.[2] For example, slower and longer breaths may indicate that the dancer is in a calmer state, reflecting positively on the short-term effects of the intervention. This dance intervention provides space and challenges the patients to work through negative emotions such as guilt, shame, and rage.

Finally, DMT enhances the mirror neuron system during both the teaching and dancing parts of therapy sessions.[3] Initially discovered in monkeys, this neuronal system activates the same set of neurons when watching and performing the same movement. It is for this reason that the audience winces when a ballerina falls on stage - the audience sees themselves falling and feeling that pain. In addition, one’s capacity for empathy seems to be tightly linked to the mirror system, suggesting that if the mirror neuron system is activated, this may benefit the individual’s ability to empathize with others. Through mirror neuron activation, DMT may allow patients to develop more positive social interactions as their ability to understand another’s emotion increases over time.[3]

As an underappreciated practice with potential for growth, DMT is slowly establishing a footing in the medical field as a standard form of treatment. In recent years, DMT has been becoming a part of patients’ treatment regimens for a variety of illnesses: depression, autism, and Parkinson’s disease. This article discusses the positive effects of DMT intervention for the three aforementioned diseases, how its use could affect the patient’s neural system, and limitations of the field that could be preventing its widespread use as a regularly practiced therapeutic tactic.

Depression

Scientists show that various types of depression, such as postpartum depression, could be linked to lower levels of dopamine and serotonin.[4] Logically speaking, the relationship between these neurotransmitters and a person’s mood is easily explained by looking at the hormone’s function. Increased serotonin levels have been linked with happiness and increased dopamine levels to euphoria. If these are low, then a patient with depression will feel less pleasure and less happiness than a patient without depression.

Current treatment for clinical depression may use Selective Serotonin Reuptake Inhibitors (SSRIs), which is a common antidepressant that increases the activity of serotonin at synapses by blocking its reuptake. Other treatment options include Monoamine Oxidase Inhibitors and tricyclic antidepressants, both of which attempt to increase the serotonin levels at synapses. Unfortunately, unintended consequences to these pharmacotherapy treatments has been the side effects, such as nausea and fatigue, most of which decrease a person’s quality of life.[5] By focusing on a non-pharmaceutical approach like DMT, scientists hope to decrease the side effects that come with the standard psychotherapy and pharmacological interventions.[5] Hypothetically, if exercise and music--the two parts that make up dance—both increase levels of serotonin and dopamine, then this may be able to provide temporary relief with possible long-term benefits for patients diagnosed with depression.

That is exactly what Dr. Jeong found at the Wongkwang University in 2005. Dr. Jeong and his colleagues selected 40 middle school girls who qualified for the study after four weeks of testing to confirm a depression diagnosis in each individual. These individuals were randomly selected and assigned to a dance-movement group or a control group.[5] The dance movement group participated in three 45-minute sessions every week for twelve weeks with four major themes: awareness of the environment, symbolic quality of movement, imagery, and integration of feelings in the dance. Each theme included various subthemes, some highlights being inner vs. outward expression, quality of movement, and expression of feelings.

Compared to the control group, the dance movement group self-reported lower psychological distress post-treatment. DMT participants showed significant improvements in negative psychological symptoms like anxiety, hostility, and phobic anxiety. This is consistent with previous reports showing that DMT reduces emotional disturbance and improves self-esteem.[5] Of particular note, plasma levels of serotonin and dopamine in the dance group participants increased after 12 weeks of dance therapy. The increased levels of serotonin and dopamine plasma may be the mechanism responsible for the decrease in psychological distress and depression in the DMT group.[5] These data suggest that DMT may have a relaxation effect by stabilizing the sympathetic nervous system and may provide a new avenue to improve symptoms of mild depression.

Though this may initially seem like a temporary fix to a long-term illness, the research suggests that at a neurochemical level, the deficit in neurotransmitters linked to depression can be elevated with DMT. This provides a more natural solution to alleviating depression symptoms without ingesting artificial pharmaceuticals. DMT may be able to supplement treatments by being coupled with current regimens, such as taking SSRIs. Adding DMT for the patients will not only compound the effects of SSRI, as more serotonin will be released due to DMT, but also prevents unwanted reactions that could happen if two pharmaceuticals are taken at once.

Autism

Autism spectrum disorder (ASD) is a developmental condition that impairs a person’s ability to socially interact and communicate with others. Some common patterns in those on the autism spectrum are behavioral disturbances, short attention span, and poor eye contact. Scientists have reported a decrease in identified mirror neuron activity in the parietal lobe for ASD individuals, as well as no modulation in the left amygdala when imitating an action, suggesting a lack of emotional attachment - a trait seen in people with ASD.[6] Such results emphasize poor integration from other visual, motor, proprioceptive, and emotional functions, which is outwardly shown as the poor social skills and decreased attention span typically associated with an individual with ASD.

DMT intervention for ASD individuals targets on the patient’s weaker mirror neuron circuit. Dr. Deverearux from the Antoich University of New England interviewed thirteen educators working in special education classrooms where DMT was already included in the school structure. For the special education classes of five to seven students, weekly group DMT lessons lasted 30 minutes. After the interviews with the educators were recorded and analyzed, results suggest a perceived improvement in regulatory behaviors, such as problem-solving.[7] DMT was associated with increased focus and higher energy levels for students in this study. Of particular interest, many educators noted how DMT supported healthy social skills by unifying and joining the students with each other as they conducted the same dance movements. A possible explanation for this could be related to the increase in activation of the mirror neuron circuit. Because there is evidence that dance activates the mirror neuron system, long-term DMT for ASD individuals could potentially strengthen those weak connections that cause poor integration of perceptual and emotional functions.

In a more controlled experiment, Dr. Hartshorn at the University of Miami provided 38 ASD children DMT in small groups, ranging from three to eight. Dance classes were conducted as 30-minute biweekly sessions for two months. Each child in the small setting was randomly observed six times during the first 18 minutes of the first and last dance session. For all one-minute periods, behaviors were recorded in 10-second sample units. Those units were then converted to percent time different behaviors occurred – a few of them were wandering and making eye contact. Overall, DMT sessions led to an increase in attentive behaviors and decrease in behaviors indicating stress, such as looking at the instructor and looking around the room, respectively. Results showed that the DMT children spent less time wandering, more time showing on-task behavior, less time showing negative responses to being touched, and less time resisting the teacher.[8] Similar to the previous study mentioned, this may also suggest that DMT strengthened their mirror neuron systems through the dance imitation constantly practiced for two months. By strengthening the integration from other visual and emotional functions to the mirror neuron system, DMT was able to alleviate the negative symptom of a child with ASD.

Such improvements in ASD patients are large milestones for their families. Though DMT may not be able to replace standard therapy practices for ASD patients, it can be another supplement to improve current regimens. Dr. Deverearux also suggested that more drastic results may be seen if the studies were conducted for a longer period of time. Unlike hormone levels for depression, improvements in known ASD effects like making eye contact may not necessarily be detected over a two-week period of implementing DMT. Tests that measure eye contact in ASD individuals may take longer to show statistical significance because results may be more subjective than a hormone test. Regardless, short-term DMT intervention seems to have a positive effect on ASD individuals, with possible benefits rooted in the strengthening of the brain’s mirror neuron system.

Parkinson’s Disease

Parkinson’s Disease (PD) is a neurodegenerative disease that primarily results from death of dopaminergic neurons in the substantia nigra, which is located in the basal ganglia – an area of the brain typically associated with movement and learning.[9] The neurological differences potentially caused by some sort of cascade det off by the decrease in dopamine levels translate to many symptoms: tremor, poor balance, memory loss, and, interestingly enough, depression. This leads to a decreased quality of life as it becomes harder to complete simple day-to-day tasks, like picking up a fork or remembering loved ones. There are four stages of PD, with Stage I being the mildest and Stage IV being the most severe. Many current treatments focus on milder cases of PD because those are the patients who have a better prognosis. DMT hopes to provide relief for all stages of PD.

Similar to other pharmacological treatments, DMT provides an approach to alleviate symptoms. However, what sets it apart is that DMT for PD patients relies on a more natural intervention: social dancing. Dr. McKee at the Massachusetts General Hospital had 33 individuals with mild-to-moderate PD assigned to twenty 90-minute adapted tango lessons over 12 weeks.[10] The control group was assigned to twenty academic lectures. Over the time course of the experiment, participants underwent three evaluations: one the week before, one the week after, and one 10-12 weeks as a follow-up. Dr. McKee decided to have participants engage in tango lessons because this form of dance involves consistent attention to spatial orientation with respect to the partner, step patterns, and the path traveled in the room. Thus, tango became a perfect dance form to encourage the PD dancers to focus on spatial function – an aspect of orientation that they struggle with. Results show a statistically significant improvement in disease severity and spatial cognition compared to patients taking academic classes. Tango participants also improved in balance and executive function and the follow-up report that stated how such improvements were maintained 10-12 weeks post-intervention.[10] This is momentous because currently, there is no way to cure PD. However, DMT at the very least gives the patients a bit of their quality of life back as the disease continues to inevitably progress.

A couple years later, Dr. McRae at the University of Denver did a similar study to find how DMT affects self-efficacy in the long term. She surveyed 61 persons with PD in four well-established Dance for Parkinson’s Disease (DfPD) classes in New York City. The median length of DfPD class attendance was 12 months. Half of the surveyed participants attended class one a week or every two weeks.[11]  Possible differences in class attendance could be attributed to PD patients having different initial base-line energy levels. For someone with more energy, that individual may have the bodily resources to expend on biweekly classes. Self-efficacy was measured by an eight-item scale that related to patients’ beliefs about managing PD. DfPD participants felt more confident that they could develop a sense of community with others and have fun and make new friends, when compared to the average PD patient. When patients were asked how much they believe DfPD helps with physical and psychosocial functioning, they noticed an improvement in mood and an increased sense of wellbeing.[11] Despite using different dance forms, DMT intervention for depression and PD individuals seems to have been a buffer against depressive symptoms. This may suggest the wide variety of dance styles that could be executed to garner similar psychological effects on the patients. Though an unconventional means of studying the effects of DMT on a patient population, Dr. McRae’s results suggest that DMT effects impact daily functioning outside the studio space through increased self-efficacy, functional mobility, and quality of life.

Current treatment options for Parkinson’s are rather bleak. DMT may not be a cure for such an aggressive illness, but results show that there is hope for PD patients to live a more comfortable life as the disease progresses. Though dance therapy will not bring back memories, nor will it provide a way for neurogenesis to occur in the substantia nigra, it does increase quality of life by decreasing multiple symptoms typically felt by the PD patient population. Such an involved treatment adds a social component to the healing process and provides special attention to areas necessary to improve. In addition to standard treatment options, DMT could become another therapy for PD patients to implement that can build on short term accomplishments, like gait stability, and better long-term accomplishments, like feeling a part of a community or more grounded in their illness.

Caveats

Although treatment has been promising for depression, autism, and PD, there are many hurdles that DMT will need to overcome in order to be a well-established supplemental treatment option. To highlight, some research shows that this wide-scope treatment may have a narrow scope of illness candidates. Specifically, Dr. Endrizzi and her colleagues found that DMT in patients with fibromyalgia (chronic pain), did not have improving pain, stiffness, depression, or anxiety ratings with statistical significance.[12] Despite having some similar symptoms to Parkinson’s and depression, fibromyalgia patients did not experience the expected improvement post-intervention. Her study emphasizes how DMT may be tailored to a specific subset of patients with deficits that DMT is able to target, such as the mirror neuron system in ASD individuals. A possible explanation is that fibromyalgia patients do not seem to have any complications in their mirror neuron system or hormone levels. Another possible speculation could be that because the patients already feel pain while moving, having them dance and experience pain may counteract the projected positive effects of DMT.

Dance therapy may also need to rely on social interaction to get the enhanced effects of the intervention. Specifically, for ASD and PD patients, experiments tend to be done in group settings. Humans are social creatures. The kind of energy and presence that others bring to the dance studio space or classroom affects the other patients in the room. This was documented by Dr. Kunkel in PD patients. He found that PD patients’ experience with DMT is influenced by the relationship and compatibility with their dance partner. Those who danced with their spouse appeared to enjoy the dancing intervention the most.[13] This suggests that dance partnership will impact both dance enjoyment and continued participation in future dance classes, which is a big limitation for doctors who suggest DMT to PD patients. Having a variety of partner dynamics may decrease the statistical significance of how effective DMT may be, which harms the ability for DMT to be seen as a legitimate form of therapy. Patients who are open to learn and who are good partners will experience a completely different dance lesson compared to patients who are conservative in their body language and refuse to participate with intention.

Research suggests that not all dance styles have the same effect. Dr. McGill used motion sensors on the nineteen PD patients who participated in ballet intervention.[14] Her study found no statistically significant changes in gait coordination and trunk stability, which suggest that there is a need to find the optimal dance style and class frequency regimen to allow for potential improvements seen in other studies. This emphasizes the greatest limitation for DMT intervention: lack of a protocol. There needs to be more scientific rigor in documenting the effects of DMT, at the very least, in patients with the same illness.

Improvements for this field to consider are to standardize testing for DMT trials. The wide variety in testing and analysis makes it hard for the scientific community to effectively highlight the positive benefits that patients reap after DMT intervention. Having a standard therapy regimen would allow for a greater conformity throughout all different types of DMT. Another consideration would be to complete more preliminary studies that compare regimen types to find the most effective class timeline that still shows statistically significant improvements in symptoms, without overshadowing the patient’s entire care with DMT.

Though potentially unnecessary for some disorders, DMT may be a crucial component for increasing quality of life for individuals with long-term disorders, where pharmacological techniques are lacking. Recent studies have shown the potential effectiveness of DMT as an individual treatment for depressed individuals, ASD individuals, and PD individuals. If considered an addition to current treatment regimens, DMT may become the catalyst to making the symptoms more manageable for such individuals. By legitimizing DMT as a standard form of treatment, healthcare providers will have a new avenue to target symptoms of depression, ASD individuals, and PD through a natural and less invasive process.

Citations:

[1] Quiroga Murcia, C., Kreutz, G., Clift, S., & Bongard, S. (2010). Shall we dance? An exploration of the perceived benefits of dancing on well-being. Arts & Health, 2(2), 149-163. doi: 10.1080/17533010903488582

[2] Homann, K. B. (2010). Embodied concepts of neurobiology in dance/movement therapy practice. American Journal of Dance Therapy, 32(2), 80-99. doi: 10.1007/s10465-010-9099-6

[3] Winters, A.F. Emotion, Embodiment, and Mirror Neurons in Dance/Movement Therapy: A Connection Across Disciplines. Am J Dance Ther 30, 84 (2008). doi: 10.1007/s10465-008-9054-y

[4] Maurer-Spurej, E., Pittendreigh, C., & Misri, S. (2007). Platelet serotonin levels support depression scores for women with postpartum depression. Journal of Psychiatry and Neuroscience, 32(1), 23. PMCID: PMC1764545

[5] Jeong, Y. J., Hong, S. C., Lee, M. S., Park, M. C., Kim, Y. K., & Suh, C. M. (2005). Dance movement therapy improves emotional responses and modulates neurohormones in adolescents with mild depression. International journal of neuroscience, 115(12), 1711-1720. 10.1080/00207450590958574

[6] Williams, JHG., Waiter, GD., Gilchrist, A., Perrett, D. I., Murray, AD., & Whiten, A. (2006). Neural mechanisms of imitation and 'Mirror Neuron' functioning in autistic spectrum disorder. Neuropsychologia, 44(4), 610-621. doi: 10.1016/j.neuropsychologia.2005.06.010

[7] Devereaux, C. (2017). Educator perceptions of dance/movement therapy in the special education classroom. Body, Movement and Dance in Psychotherapy, 12(1), 50-65. doi: 10.1080/17432979.2016.1238011

[8] Hartshorn, K., Olds, L., Field, T., Delage, J., Cullen, C., & Escalona, A. (2001). Creative movement therapy benefits children with autism. Early Child Development and Care, 166(1), 1-5. doi: 10.1080/0300443011660101

[9] Dauer, W., & Przedborski, S. (2003). Parkinson's disease: mechanisms and models. Neuron, 39(6), 889-909. doi: 10.1016/S0896-6273(03)00568-3

[10] McKee, K. E., & Hackney, M. E. (2013). The effects of adapted tango on spatial cognition and disease severity in Parkinson's disease. Journal of motor behavior, 45(6), 519-529. doi: 10.1080/00222895.2013.834288

[11] McRae, C., Leventhal, D., Westheimer, O., Mastin, T., Utley, J., & Russell, D. (2018). Long-term effects of Dance for PD® on self-efficacy among persons with Parkinson’s disease. Arts & Health, 10(1), 85-96. doi: 10.1080/17533015.2017.1326390

[12] Endrizzi, C., Di Pietrantonj, C., D’Amico, G., Pasetti, M., Bartoletti, L., & Boccalon, R. (2017). Dance movement psychotherapy for patients with fibromyalgia syndrome. Body, Movement and Dance in Psychotherapy, 12(2), 111-127. doi: 10.1080/17432979.2017.1290685

[13] Kunkel, D., Robison, J., Fitton, C., Hulbert, S., Roberts, L., Wiles, R., ... & Ashburn, A. (2018). It takes two: the influence of dance partners on the perceived enjoyment and benefits during participation in partnered ballroom dance classes for people with Parkinson’s. Disability and rehabilitation, 40(16), 1933-1942. doi: 10.1080/09638288.2017.1323029

[14] McGill, A., Houston, S., & Lee, R. Y. (2019). Effects of a ballet-based dance intervention on gait variability and balance confidence of people with Parkinson’s. Arts & health, 11(2), 133-146. doi: 10.1080/17533015.2018.1443947