The idea of including dance and movement in interventions for eating disorders may seem somewhat controversial; generally, exercise and physical activity are discouraged for individuals recovering from eating disorders. Including dance in therapeutic interventions might raise a few eyebrows given the links between appearance-oriented athletic endeavors such as ballet and gymnastics and the development of eating disorders.
However, some therapists and scholars interested in alternative therapies for eating disorders have suggested that certain forms of movement therapy may help individuals with eating disorders connect to their bodies in a different, more positive way.
In 2011, two such scholars from Portugal, Padrão & Coimbra, published a 6-month pilot intervention for individuals hospitalized for anorexia nervosa (AN) based around body movement.
Their aims were twofold:
- Find out more about the links between body movement and bodily experience in individuals with AN
- Observe the ways in which individuals with AN move and prefer to move.
Data consisted of observations of free movement and conversations that came up during and after the sessions. Their sample size consisted of only 7 young women hospitalized for anorexia.
I’ll admit that despite years of dance training and a keen interest in the potential of dance therapy in mental health treatment, I was skeptical of this study from the start. I thought a fair bit about the ethical implications of such a study: I’ve always been of the mindset that particularly for individuals whose disorders included a seriously disordered relationship with exercise, putting the brakes on all movement just seems intuitive.
The authors note that all patients involved in the study were medically cleared for light exercise and were monitored by doctors throughout the intervention. Sessions lasted for 75 minutes at a time, once per week.
Though it seems that the authors thought through the potential problems with engaging individuals hospitalized for AN in a movement-based intervention, I would have liked to see a deeper exploration of the potential psychological consequences of engaging in 75-minute-long movement sessions for those in early treatment/recovery. Still, the study presumably passed ethics, and so maybe there is more to the picture than is described in this particular article.
WHY DANCE?
The researchers’ curiosity was driven by prior research indicating that individuals with AN may be less aware of and less able to express their emotions (sometimes called alexithymia, see Sifneos, 1973). They also discuss the relationship between anorexia and the need for control (Bruch, 1962 (full paper), 1973) and how this may play into the ways in which individuals with AN experience their bodies.The linkages between anorexia and low sexual interest were also of interest to researchers (see, for example, Morgan et al., 1995).
Bringing the discussion to the level of dance therapy, the authors explain where dance therapy may be effective in healing the relationships AN patients have with their bodies: developing comfort with touch (of self and from others), trust, safety, empathy, and loss of control. For example, dance therapists would challenge patients to explore, through movement, what it feels like to lose control.
They use Laban’s (1971) system of movements (a common, well-established approach in dance and movement therapy) to guide interventions that are intended to bridge the gap between body image and body sensation, which they suggest might be inhibited in anorexia.
Despite my hesitations about the study design and potential pitfalls, I was curious to find out about the results.
SUMMARY OF MAIN FINDINGS
So what did they find?
At the beginning of the study, they noted the following characteristics in their sample’s movements:
- Feeling uncomfortable with being touched
- Rigidity and restricted movement
- “Obsession” with lightness and lacking sense of the force of the body’s weight
- Initiation of movement from the ends of limbs
- Distorted sense of time
- Use of different parts of the body in isolation, rather than as a unified whole
- Shallow breathing
- Alternating desire and avoidance of “sensual movements”
- Dislike of movement/music bringing participants close to the ground
In terms of the way that participants made links between experiences and movement, researchers found the following:
- Participants described sensual movements as “looking good” on others, but being not ready or willing to use these movements themselves
- Participants brought up themes of childhood happiness was brought up and associated these with loss/the inability to return to a happier time
- Participants often used words denoting lightness (ex. “float,” “fly”)
- Participants described themselves/their identities as tied to their eating disorders
As the intervention progressed, the researchers noted changes in the ways the participants moved, as well as the ways that they discussed their bodies in relation to their movements. The authors make the claim that these findings help to support theories that link AN to difficulties identifying and responding to bodily sensations, situating control at the center of the disorder. While this may be true, I had difficulty linking these conclusions to the observations they describe.
The claim they make about observations of bodily movement in individuals with AN seem more plausible; their findings relating to rigidity, isolated movement of body parts, monotonous movements, and shallow breathing seem to relate to several other studies of movement profiles in individuals with anorexia. There also seem to be echoes in their findings relating to earlier research on difficulties of sensuality in eating disorder patients.
While the findings relating to the ways in which individuals with anorexia move are certainly interesting, it seems premature to make a claim for the effectiveness of dance therapy for these patients. I’d like to see more studies with larger groups of patients, including those diagnosed with other eating disorders. Further, in order to draw conclusions about what these movements mean, I think that more attention needs to be paid to how patients describe their experiences with dance therapy.
Going back to my initial concerns, I’m also curious about whether using movement in therapy brought up any urges for exercise.
Still, this study raises the possibility of therapies that go beyond the traditional, which is encouraging for those interested in alternative therapies and those who feel that traditional forms of therapy have been unhelpful. I’d certainly be interested to learn more.
References
Padrão, M., & Coimbra, J. (2011). The Anorectic Dance: Towards a New Understanding of Inner-Experience Through Psychotherapeutic Movement American Journal of Dance Therapy, 33 (2), 131-147 DOI: 10.1007/s10465-011-9113-7
I have the same question as someone on the Science of Eating Disorders Facebook page:
“Why did they base this research on such ancient, unscientific publications (Sifneos, 1973; Bruch, 1962/1973; Laban, 1971; Morgan et al., 1995)?”
Also, did they track weight/BMI? Did they do any psychometrics or just asked the participants to describe how they feel?
My skepticism doesn’t come from the calories burned during exercise or whatever, but more with the utility of this in treatment. I mean, yeah, it can be a great adjunct for people who are already into dance and perhaps don’t have a history of being obsessive with it, but… meh. I don’t know. ‘Meh’ is my response, really.
Also, what were the BMIs of the patients and duration of illness at starting point, do they mention that?
I’ll post my comment here, too (from Facebook):
As far as Laban goes, I feel like that’s kind of the seminal “dance therapy” guiding text- however, I’m not a dance therapist so I could be wrong. Knowing relatively little about the authors, it is possible that they are not as familiar with more recent eating disorder literature. I would have preferred to see more recent literature as well- the majority of their citations are from the 80s and 90s, though they do cite some more recent (like 2006ish) literature on interoceptive awareness, which is not something I went into detail about in my post. The study did certainly leave something to be desired, and I really got the feeling that the authors might be more familiar with dance therapy in general than with AN in particular… Curiously, in my search for literature on this topic this was one of the only articles I came across, which is why I wrote about it… but yes, definitely cause for pause.
They mention BMI at the beginning of the article (under participant characteristics: range was 11-14.5, mean 12.9, SD 1.14), but they don’t follow up with that afterward. In terms of data collection, they collected “verbalizations” rather than responses to a set scale with valid psychometrics; they were going for a grounded theory approach (though to be honest it doesn’t seem all that rigorous).
I do hope my skepticism came through in the post; I was extremely intrigued by the study and really hoped that it would have valid, interesting results; however, it really left a lot to be desired. I think that alternative and creative therapies have wonderful potential, and I would love to see a more rigorous study done with this topic.
Your skepticism definitely came through.
Yeah, the BMI thing makes me raise my eyebrows. It does seem like a poorly done study, as you allude. How hard is it to follow-up on BMI?
It would be interesting to see larger follow-up studies but to be honest, I think money can be much better spent. But, I am not in charge of deciding which grants get funded.
My daughter used to love dancing prior and during the onset of AN. She’s not danced for years – I would also be interested to learn more about this therapy and see more study results. Are there any dance therapists in the UK? My daughter may benefit from it, although I worry that she over-exercises as it is…
Hi Jen,
I’m not sure, I imagine there are dance therapists in the UK; however, if you’re worried about the over-exercise element you’d definitely want to clear things with your daughter’s treatment team before trying it out (which I’m sure you know!) Anecdotally, I found dance helpful in later recovery but I don’t think it would have been as helpful for me earlier- but of course that’s just me! Thanks for your comment!
I’ve loved dancing all my life too, and I do feel movement can have a part in helping people with eating disorders to become more comfortable with their bodies – for me, I find that when I get past the anxiety and get to ballet lessons now, it always makes me feel a lot better about my body. I become more focussed on what it can DO and how it feels, than what it looks like. But that is just me.
I do hear your concerns about the place of exercise in treatment for patients who, to have been hospitalised, are very unwell and often have over-excericising tendancies – I’d have to hope that the movements encouraged in their therapy were not so much for exercise as moving – exploring space around their bodies, exploring how moving certain ways made them feel etc. Not so much dancing as moving. I do think that it can help when going through the refeeding process as our bodies feel SO uncomfortable and bloated. Maybe having this movement can help with accepting the ‘new’ body a bit faster, feeling a bit more comfortable with it and easing feelings of bloatedness. I think it could also model a more responsible amount of exercise.
In some of my earlier admissions there were Tai Chi classes every morning in the OT department, and at that stage all ED patients had to attend. Tai Chi is very non-impact, flowing movements… but we all HATED it. Even me. The reason for this was it was immediately after breakfast and we would be so full, and so self conscious. It was really hard and uncomfortable to do those movements feeling that way – maybe had we explored more of why we felt that way and how to become a bit more accepting of it, it might have helped? I don’t know.
Very interested in this, and hope to see more studies with a larger number of participants in the future. Thank you for sharing 🙂
Thanks for your comment, Fiona! I have actually found the same in terms of dance/movement helping me to feel better about my body; the focus becomes less about what I look like and more how I feel, and feeling strong. It’s interesting, because exercise was a huge part of my pathology, but in different forms. I have danced for most of my life, but when I was at my sickest my exercise was completely unrelated to dance! I’m conscious of the fact that some people might have the opposite experience, though- again, raises the individual differences in eating disorder experiences and recovery.
Interesting, too, about the Tai Chi classes that everyone hated- I think the timing would be incredibly important, because as you say, right after a meal there’s that awareness of one’s body in a different (uncomfortable/awkward) way. I think that doing more processing in conjunction with the movement is a key suggestion- without exploring the awkward feelings they stay just that.. awkward.
Anyway, thanks again for your comment!
“I become more focussed on what it can DO and how it feels, than what it looks like.”
Yes, definitely. Though for me, high-intensity cardio is what makes me feel great about what my body can do (and not in a gym, but always outside, enjoying the weather–whatever it is–connecting with nature, that kind of fluffy stuff. Not at the gym where I’m just looking at how many calories I’m burning). Dancing didn’t do that for me, though I like dancing. Of course high-intensity cardio is wholly inappropriate for patients at a BMI ~13.
Dance was my therapy… When I stopped because of college i began struggling with an ED, which has gone on nearly12 years now. In my personal experience I feel good when I dance. My body feels strong and its a great outlet for me. I can definitely see where there is a fine line and using dance/movement concurrently with other treatment can potentially be risky. For me, I think I would make a major difference, and for the better 🙂
Just need to find a studio for “retired” dancers! Thats for this post! It validated what I’ve always felt but was told by therapists it wouldn’t be a good idea..