Savidaki et al. Journal of Eating Disorders (2020) 8:22 https://doi.org/10.1186/s40337-020-00296-2 RESEARCH ARTICLE Open Access Re-inhabiting one’s body: A pilot study on the effects of dance movement therapy on body image and alexithymia in eating disorders Maria Savidaki1† , Sezin Demirtoka1† and Rosa-María Rodríguez-Jiménez2* Abstract Background: Body image disturbance and alexithymia are two core aspects of Eating Disorders (EDs). However, standard treatments for EDs do not include specific techniques to approach these issues on a bodily level. This pilot study evaluated the effects of a Dance Movement Therapy (DMT) intervention on body image and alexithymia in patients with EDs, and also explored their experience of the therapeutic process. Method: 14 patients with EDs were recruited from a private clinic. Seven were assigned via quasi-randomization to the DMT group and the others (n = 5) continued their treatment as usual. The length of the intervention was 14 weeks. All participants completed the Multidimensional Body Self Relations Questionnaire (MBSRQ) and the Toronto Alexithymia Scale (TAS-20) at the beginning and at the end of the intervention. Additionally, the DMT group wrote reflective diaries about their experience at the end of each session, which were analyzed using qualitative methods. Results: Between the pre- and post-intervention, the participants of the DMT group significantly improved in Body Areas Satisfaction (effect size: 0.95) and Appearance Evaluation (effect size: 1.10), and they decreased significantly in Appearance Orientation (effect size: 1.30). A decrease in Overweight Preoccupation was observed (effect size: 0.75), however this was not statistically significant. The control group did not show significant changes in any of the MBSRQ subscales. Neither the DMT group nor the control group improved significantly in the alexithymia scores. The qualitative analysis revealed valuable insights into the participants’ processes throughout the sessions. In general, participants received the DMT intervention positively. They reported improvements in their mood states and an increase in their self-awareness. They also appreciated the relationship with the group and the therapist. Conclusion: These results indicate that DMT might be a complementary treatment option for EDs, as it may be able to address body image issues more effectively than verbal therapies. More studies with larger samples are needed to confirm these promising preliminary results. Keywords: Eating disorders, Dance movement therapy, Body image, Alexithymia, Emotions, Quantitative, Qualitative, Controlled trial *Correspondence: rosamaria.rodriguez@universidadeuropea.es † Maria Savidaki and Sezin Demirtoka contributed equally to this work. 2 Universidad Europea de Madrid, c/Tajo, s/n, 28670 Villaviciosa de Odón, Madrid, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 2 of 20 Plain english summary self-regulation [17]. As people with alexithymia face dif- The effects of a 14-week DMT intervention on body image ficulties in mentalizing the emotional state of others and and alexithymia were tested in 12 patients with EDs. The their own, they can be perceived as non-empathetic and DMT group (n=7) improved in various aspects of body experience difficulties in social relations [18]. Alexithymia image after the treatment, while no change occurred in the is also associated with poor creative capacity and a limited control group (n=5). Both groups continued to receive the ability of symbolization and play [19]. The absence of con- standard treatment offered by the Clinic. Neither of the sciousness of the internal experience and the difficulty of groups improved significantly in alexithymia scores. The trusting the perception of one’s emotions, sensations, and qualitative analysis revealed that participants were satis- reflections are related to the sense of poor self-efficacy fied with this intervention. According to this analysis, the that patients with EDs face, as a result of not being able to DMT sessions increased their self-awareness, improved resolve the conflict between the illusion of perfectionism, their mood states, and promoted the building of meaning- their actual potentials, and the expectations of others [20]. ful relationships. Taken together, the findings suggest that The development of body image and socioemotional DMT could contribute to the treatment of EDs on various functioning starts on a nonverbal level in infancy [21]. levels. The infant first experiences its body through the tactile experience provided by the caregiver [11]. The empathet- Background ically attuned interactions with the caregiver provide a The prevalence of Eating Disorders (EDs) is increasing secure holding which defines the infant’s inner state by worldwide [1]. Dropouts [2] from eating disorder therapy offering psychological and physical soothing, something and full relapses are common [3]. Comorbidity with other that is the critical basis for secure attachment [22]. The psychological disorders and health issues pose a challenge term of psychesoma as defined by Winnicott [23] has its for professionals and require multidisciplinary treatments origins in the holding phase. When the handling is good [4]. Widely used specialized treatments for EDs mostly enough the psyche can indwell in the body (soma) provid- focus on cognitive-behavioral aspects and weight restora- ing a sense of internal reality and structure of the self [23]. tion [5]. However, randomized controlled trials have gen- On the contrary, misattunement with the needs of the erated contradictory results regarding the effectiveness of infant can arouse an inner confusion and a detachment those treatments [6]. Furthermore, patients with EDs are between the subjective and physical elements of emotions, often not content with the treatment they receive accord- which is at the core of ED’s pathology [20]. The founda- ing to a review of qualitative research [7]. In light of these tion of emotion-regulation and self-regulation is based on findings, many authors have underlined the need for novel the secure attachment with the caregiver [24]. It is well approaches to treat EDs [8, 9]. established that attachment insecurity is an important risk One of the core characteristics and a risk factor of EDs is factor for the development of EDs and a predictor for body image disturbance, which has implications on cogni- poor outcomes [25]. One study has found that improve- tive, emotional and behavioral levels [10]. A person’s body ment in attachment insecurity led to a decrease in inter- image is formed since birth. The first experience of the self personal problems in patients with EDs [26]. Moreover, is through proprioception, i.e. sensations that arise from a review of three meta-analytic procedures found that within the body, which develops by a person’s percep- secure attachment style is a crucial predictor for beneficial tions while relating to others and influences the emotions, psychotherapeutic outcomes [27]. These findings indicate attitude, psychological functioning, and self-value [11]. that treatment models for EDs should address attach- Cash describes it as an “inner view” which refers to the ment related disorders. Considering that the development multidimensional embodied experience related mostly to of attachment is rooted in a pre-verbal phase, such a one’s physical appearance [12]. Patients with EDs, espe- treatment model can make use of a bodily, non-verbal cially those with anorexia nervosa, tend to focus on shape, component. weight, and food perhaps as a way of ignoring thoughts The importance of bodily experiences and body mem- and emotions that provoke anxiety [13]. Thus, they con- ory for the psychological functioning has been shown sider their bodies with disdain and often fail to recognize by cognitive neuroscience studies [28]. Recent research their bodily needs [14]. in interpersonal neurobiology considers the brain in Another personality construct that is common in indi- the whole nervous system, existing in the whole body viduals with EDs is alexithymia [15], which literally means [29]. These findings have encouraged psychotherapists to “no words for emotions”. Alexithymia is characterized investigate the role of the body in verbal psychothera- by an externally focused cognitive style and a difficulty pies [30]. One bodily based approach is Dance Movement in differentiating between feelings and bodily sensations Therapy (DMT), which explores and uses movement in a [16]. This personality construct is also related to poor therapeutic way with a focus on self-awareness, in order Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 3 of 20 to promote the psychophysical integration of the individ- the therapeutic process [35]. The bodily and sensorimo- ual [31]. This psycho-dynamic model, forms part of the tor components of empathy are indicated by studies in Creative Art Therapies, in which music, art, and drama neuroscience [47] so that, the psychotherapeutic use of therapy are also included [32]. Some of the core charac- body movement in DMT can enhance empathy among teristics among others for this group of therapies are the alexithymic individuals. In the same way, DMT can help possibility of active participation, the self-expression, the people who suffer from EDs to experience themselves in a emphasis in imagination, and the mind-body connections more complete and embodied way, since they are encour- [33]. In particular, DMT was formed by dancers and psy- aged to make connections between the cause factors of chotherapists in the 1940s, who realized the therapeutic EDs and the corporal manifestations of them [48], gaining impact of the artistic expression in mental health patients body awareness [34]. [33]. It is a form of psychotherapy based on embodiment Significant improvements have been associated with and enaction [34]. The core basis of DMT is the innate the use of DMT as an adjunct in the treatment of a connection between body and mind [34]. The uninten- wide variety of disorders, including anxiety, depression, tional expression through movement is fostered, which schizophrenia, dementia [49, 50]. Improvements included permits the enactment of unconscious ideas and emotions an increase in quality of life ratings, as well as inter- that often cannot be put into words [35]. This not only personal and cognitive skills [50]. Such outcomes were discharges psychological or corporal tensions but, simul- comparable to pharmacological interventions and verbal taneously, can help the individual become aware of his/her psychotherapies [49, 50]. Some studies have found DMT emotional resources and strengths [36]. This therapeu- interventions to improve the body image in patients with tic approach is both non-verbal and verbal [37, 38]. The obesity [51], cancer [52] and fibromyalgia [53]. Apart from non-verbal interactions can promote insights regarding those findings, a major amount of research regarding the participants’ behavior, beliefs, relationship patterns, DMT is focused on case studies and qualitative research and emotional apparatus [39]. The verbal communication which could be explained by the characteristics of DMT of thoughts and emotions has a fundamental role in the as the emphasis is put on the subjective experience, ther- therapeutic process, and gives meaning to the symbolic apeutic relationship, personal development and change aspects of the movement [33]. The therapist-patient rela- of the person as well as on the creative and aesthetic tionship is a central component in DMT approximation. part of the therapeutic process [54]. Considering the alex- The DMT therapist uses specific tools of movement anal- ithymic aspects and body image issues in EDs, treatment ysis in order to observe and interpret the participants’ should promote the physical and psychic integration of body language. Building upon these observations, tech- the individual, which is why DMT is a potentially adequate niques such as attunement and mirroring are applied, approach for patients with EDs. which provide a link between attachment and non-verbal The proposed therapeutic intervention was designed for behavior [40]. The creative play and the transitional object the needs of a group, which consisted of patients with EDs. concepts are also included in the therapeutic process [41]. As it was mentioned in previous studies, difficulties in Those means help the improvement of embodied rela- accessing self and body awareness as well as the resistance tionships and give meaning to the movement [42]. The towards movement exploration [55] and negative body emotional state of the patients, as well as their early experiences were identified [56]. The guided imagery by misattuned experiences with the caregiver, can be expe- Reddemann [57] was used as a mediator to facilitate the rienced, explored, felt and understood by the patient [34] connection of the participants with the body and the self through a deep attunement with the therapist on an emo- in movement and to enrich one’s movement vocabulary. tional and bodily level [43]. These moments of meeting The current research is a pilot study. It aims to explore serve as a healing emotional experience [44]. The union a DMT intervention that could complement the already between body and mind, as opposed to the mind-body existing ED treatment in an attempt to provide a more dualism, assumes the principle that “the body reflects holistic and effective approach. Due to the theoretical the mind and the mind reflects the body” [43]. Follow- considerations, research findings and the mixed nature ing up on this principle, our expectation is that changes of the sample, a transdiagnostic perspective was fol- in movement patterns can cause a modification in the lowed [58]. Firstly, changes in the body image and alex- internal comprehension of the individual and vice versa ithymic traits as a result of the proposed intervention were [45]. Other authors like Jung have mentioned the impor- explored. Secondly, as the DMT intervention on the ED tance of the symbolic part in the therapeutic process [46]. population is rarely investigated, a qualitative analysis was The symbolic part of movement and the communica- included in the research, to develop a better understand- tion via movement metaphors, which is a core feature of ing of the patients’ experience. To the authors’ opinion, DMT, can be helpful for alexithymic patients as it can pro- a mixed study that integrates quantitative and qualitative mote the exploration of one’s emotional state and facilitate analysis can provide a more holistic view. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 4 of 20 Method Therapy, which runs under the Department of Psychology Participants of the Autonomous University of Barcelona. The sessions The participants were 14 young women who attended a were facilitated by a dance movement therapist in train- private day clinic in Spain, specializing in the treatment of ing, who received clinical supervision from the University EDs. Participants’ ages ranged from 14 to 32 (M = 20.28, during the entire process. The research was supervised by SD = 5.91). BMI ranged from 14.03 to 24.69 (M = 18.94, a researcher from a different university, who specialized SD = 3.56). Criteria of inclusion were: receiving standard in DMT and EDs. Another dance movement therapist in treatment from the Clinic and having been diagnosed with training participated in the data analysis. an ED according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [59]. Exclu- Intervention sion criteria were: comorbidity with personality disorders The DMT sessions were based on Chace’s model [60], and and/or the administration of medications, as those could guided imagery according to Reddemann [57]. Each ses- modify the movement qualities of the participants. These sion was divided into 6 parts: check-in, warm-up, guided criteria were aiming at creating a more homogeneous imagery, exploration in movement, writing, check out. group in order for the obtained results to be as represen- During check-in, the participants were invited to share tative as possible for the ED population. One participant their current emotional state. Based on that, the thera- was excluded from the study as she did not complete the pist guided the warm-up in order to activate the body predetermined criteria. The final sample size was deter- and prepare the participants for the main part of the ses- mined by the number of the patients in the Clinic who fit sion. During the guided imagery part, the participants these criteria. were provided with self-regulatory techniques in order to remain in the “here and now” and to reduce stress- Setting and procedure ful thoughts. The aim was to experience feelings of safety The Clinic where the study was conducted offered mainly and comfort as well as to explore one’s own emotional a cognitive behavioral treatment approach. The weekly resources. During the exploration in movement, themes schedule consisted of three group therapies, six psychoed- that have emerged in the check-in, warm-up or guided ucational sessions, and one individual therapy session for imagery part could be accessed in depth. The creative pro- each patient. The number of sessions that each patient cess aimed to transform participants’ inner experiences received was adapted according to her needs. The Clinic into external realities. The objectives and dynamics pro- was informed of and approved the structure, content, and posed in the movement exploration part are shown in procedures related to the DMT intervention, as well as the Table 1. Afterwards, the participants had to write down possibility of publication of the obtained research data. their reflections upon the process. In addition, to the Written approval was provided to the authors by the ethi- investigation purposes, this part also aimed at reinte- cal committee of the Clinic. All participants signed a con- grating the lived experience. During the check-out, the sent form, agreeing to the anonymized use of self-report participants were given the opportunity to verbalize and questionnaires in the current study. The DMT group share their experiences. signed a second consent form regarding the anonymized The sessions lasted 90 minutes. For the check-in and use of reflective diaries that were used in this investi- check-out (oral verbalization) 10’ was given for each. The gation. As part of the consent forms, they were pro- warm-up took 10’. For the guided imagery part the partici- vided with detailed information about the framework of pants had 20’, followed by the movement exploration (30’). the investigation and the research questions. The groups Finally, the writing part (personal reflections) took 10’. The were quasi-randomized, as a professional from the Clinic time could be varied according to the general group status. assigned the participants to the DMT group or the control The intervention was divided into the following phases: group depending on their timetable. The DMT group was in the first four sessions (1-4), the focus was on creating semi-open; new participants could join the sessions once an atmosphere of safety and trust which played a cru- they entered the day clinic and they had to leave the group cial part throughout the whole therapeutic process. The when they were released from the Clinic. Twelve sessions connection of the participants with their own self was were conducted over a 14-week period. Participation was also promoted from the very first encounters. From the optional. Both, intervention and control group, continued 5th to the 10th session the focus was shifted to a facilita- their treatment in the Clinic as usual. Self-report ques- tion of the group cohesion. Participants were invited to tionnaires were first completed prior to the participants’ explore their movements in pairs which led to empathetic entry to the DMT sessions, and again within four weeks interactions among the group members. The main aim of from the last session. The control group followed the same this phase was to promote self- and body-awareness as procedure. The research, as well as the interventions, well as creating a safe atmosphere where the participants were part of the Master’s training in Dance Movement could share their experiences. During the last two sessions Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 5 of 20 Table 1 Dynamics of the DMT sessions Objective Intervention Examples Connection with one’s Breathing exercises –Participants observe the impact of deep breathing in their bodies. self – Breathing in circle: A touches her stomach and the back of B, B touches her stomach and the back of C, and so on. Use of light and sustained movements. – Participants observe their own breathing and the one of the other’s. Body awareness Exploration with –Participants move an object through different parts of the body objects and observe the impact of this contact and the difference between the parts of the body that have not been touched. Use of light, free, direct, and sustained movements. Interaction among the Movement in pairs – Participants work in pairs: participants – A touches B and B responds by accepting or rejecting the touch. –A touches B and B moves that part of the body. Light, indirect movements. – A touches B and B resists by putting force in that part of the body. Strong, direct movements. Exploration of limits Exploring the space – Participants use objects (e.g., wool, elastics, fabrics) to visualize their personal space. - Exploration with elastics: First each participant uses an elastic band to integrate her muscles in movement and explore her limits. As a next step, they continue this exploration in pairs, sharing one elastic band. Use of different movement qualities. Group cohesion Group games – First in a circle, participants pass each other the ball in a certain order, saying the name of the person that the ball is directed to. They continue in the same order without saying the names. Movement and music can be introduced and the pace can be varied. – Use of fabrics: After experimenting individually with a fabric, participants get together in small groups and create a group dance. Empathy Movement exploration -One participant chooses a place in the room and closes her eyes (optional). Other group members slowly approach her and offer the touch they think she needs (e.g., holding a hand, gently touching the head). This activity can be proposed once there is sufficient confidence in the group. Participants are advised to say no if they feel uncomfortable. Use of light, direct, and sustained movements. Reflection Group circle – After experimenting with different movement qualities (e.g. fluid, robotic) participants are invited to share their associations with these, and possibly relate them to their personal lives and ED symptoms. – Participants use different objects to transmit to the group what they felt during the session. Note: The references in movement qualities, derived from Laban movement analysis that is used in DMT. They are related to the indulgence or the resistance of the participant and may indicate the way of relating with the other. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 6 of 20 (11-12) the focus was shifted in preparing the participants [67]. The subscales Appearance Evaluation (satisfaction or for the upcoming closure of the DMT intervention. The dissatisfaction with one’s physical appearance), Appear- therapist brought the participants’ attention back to the ance Orientation (importance placed on one’s physical connection with their own self and with others, as a way appearance and effort put in maintaining one’s looks), to support their internal reorganization. Body Areas Satisfaction (satisfaction or dissatisfaction The sessions were conducted in a spacious room of with specific body areas e.g., stomach, legs, etc.) and Over- the Clinic, where participants could move freely. Objects weight Preoccupation (ideas regarding fat anxiety, weight played a significant part in the therapeutic process. They vigilance, etc.) were used in this pilot study. Cronbach’s were used in the majority of the sessions in order to α were calculated for the MBSRQ subscales used in the facilitate the contact of the individuals with their bodies, current study. All the subscales were found to have ade- as well as their interaction with the other participants. quate internal consistency (α=0.937, α=0.867, α=0.929, The objects used were: elastics, different forms of fabrics, α=0.900). small hard (tennis) balls and soft balls, balloons, ribbons, scarves, paper and crayons. Data analysis Following the confirmation of the parametric distribu- Qualitative measures tion of the quantitative variables, paired-samples t-tests Participants of the DMT group were invited to keep were conducted to compare differences pre- to post- reflective diaries in order to obtain a better understanding intervention in each group. Cohen’s d effect sizes were of their processes. Each participant was given a note- calculated. For not normally distributed data, Wilcoxon book and wrote in it freely at the end of each session. Signed Rank test was applied to compare pre- and post- Due to the exploratory nature of this study, no spe- intervention scores in each group and Rosenthal’s r effect cific instructions were given about the content of these sizes were calculated. Values of 0.2, 0.5, and 0.8 are inter- texts. The therapist told the participants to write about preted as small, medium, and large effect sizes respec- whatever they wanted, in order to minimize possible tively [68]. Given the small sample size, both statistically biases. Reflective diaries were transcripted, and codified. and clinically significant results were taken into account. Successive readings of the material were made looking for Statistical Package for the Social Sciences (SPSS), ver- themes. This process was repeated until saturation was sion 20.0 for Windows [69] was used for statistical reached, following a classical content analysis [61]. Inves- analysis. tigator triangulation was applied by including a second researcher who independently and blind to the interven- Results tion process, carried out the content analysis. The whole Demographic summary analysis was made once the therapeutic process was over. Of the 14 young women who were recruited for the study, Nvivo 12 software was chosen for the analysis [62]. The 7 were assigned to the DMT group and 7 to the control extracts from the reflective diaries presented in the cur- group. They were all high school or university students rent research were translated to English by one of the of Spanish nationality. The DMT group consisted of 4 authors. The trainee therapist’s observation diary was also EDNOS and 3 AN patients aged between 14 and 32 (M = included as another source of data collection. Informa- 20.1, SD = 5.9). The BMI of the DMT group ranged from tion from the therapist’s observation diary was used to 14.03 to 24.69 (M = 19.82, SD = 4.37). The length of time illustrate some specific moments during the sessions. since their admission to the Clinic at the beginning of the intervention ranged from 1 to 23 weeks (M = 13.43, SD Quantitative measures = 9.11). Two participants from the control group did not Two self-report questionnaires were used for the quanti- complete the follow-up questionnaires, so that they had tative part of this study. to be excluded from the sample. The final control group Toronto Alexithymia Scale (TAS-20) [63, 64]. The Span- (n = 5) consisted of 2 AN, 2 EDNOS and 1 BN patients ish version [65] of the TAS-20 was used to measure aged between 17 and 23 (M = 20.3, SD = 2.5). The BMI of alexithymia. Items are rated on a 5-point Likert scale. the control group ranged from 17.33 to 22.9 (M = 19.07, It consists of three subscales: Difficulty Identifying Feel- SD = 2.28). The length of time since their admission to the ings, Difficulty Describing Feelings to others, Externally Clinic at the time of the first data collection ranged from Oriented Thinking. The scales have adequate reliability 24 to 59 weeks (M = 42, SD = 15.7). T-tests showed that (α=.794, α=.732, α=.613 respectively) and adequate con- the two groups were homogeneous concerning their age vergent validity. (t=0.21; p=0.84) and BMI (t=0.19; p=0.83), however not Multidimensional Body-Self Relations Questionnaire regarding the length of time at the Clinic. The participants (MBSRQ) [66]. The 45-item Spanish adaptation of the of the control group had been in the Clinic for significantly MBSRQ questionnaire was used to measure body image longer period at the time of the first data collection, t=4.0, Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 7 of 20 p=0.02. The implications of this difference for the current α=0.04) and Appearance Orientation (F=5.54; ηp2 = 0.36; study are considered in Limitations. α=0.04). For Body Areas Satisfaction time effect was not The 7 participants in the intervention group completed significant (F=2.23; ηp2 = 0.18; α=0.17). Regarding the a minimum of 4 and a maximum of 11 sessions (M=7.71, interaction effect of time and group, significant changes SD=2.93). One participant completed 11, two completed appeared in Appearance Orientation (F=6.90; ηp2 = 0.41; 10, one completed 9, two completed 5 and one completed α=0.03) and Body Areas Satisfaction (F=6.32; ηp2 =0.39; 4 sessions. As a result, an average of 4 to 5 participants α=0.03). The interaction effect for Appearance Evalua- were involved in each DMT session. tion was not statistically significant (F=1.09; ηp2 = 0.09; α=0.32). Finally, for the Overweight Preoccupation the Quantitative outcomes ANOVA model was consistent with the previous analysis. The mean scores for the MBSRQ subscales are presented Neither time (F=1.55; ηp2 = 0.13; α=0.24) nor interaction in Table 2. Prior to intervention, for Appearance Evalu- effects (F=2.90; ηp2 = 0.23; α=0.12) were significant. ation participants in the DMT group were more than 1 Prior to the intervention, alexithymia scores ranged SD below the norm (M = 3.36, SD = 0.87). For Appear- between 47 and 71 in the DMT group and 27 to 60 ance Orientation they were within 1 SD from the norm in the control group. According to the cutoff scoring, (M = 3.91, SD = 0.60). For Body Areas Satisfaction they in the DMT group 4 participants did not display alex- were more than 1 SD below the norm (M = 3.23, SD = ithymia, 1 displayed possible alexithymia and 2 displayed 0.74). For Overweight Preoccupation they were more than alexithymia. In the control group, 4 people did not dis- 1 SD above the norm (M = 3.03, SD = 0.96) [66]. As all play alexithymia, and 1 displayed possible alexithymia. As the MBSRQ subscales were normally distributed in both the data was not normally distributed, Wilcoxon Signed groups, paired samples t-tests were conducted to com- Ranks tests were undertaken to compare pre- and post- pare the pre- and post-intervention scores in each group. intervention results of the DMT and control groups (see As can be seen in Table 2, the DMT group increased Table 3). There was a slight tendency of decrease in significantly in Appearance Evaluation and Body Areas the total score and the subscales of alexithymia in the Satisfaction, and decreased significantly in Appearance DMT group, which was not statistically significant. Small Orientation pre- to post-test. Large Cohen’s d effect sizes Rosenthal effect sizes were observed in Difficulty Iden- were observed for each of these variables. There was a tifying Feelings and in Difficulty Describing Feelings to tendency to decrease in Overweight Preoccupation which Others. On the contrary, the control group had a ten- was not statistically significant, however a medium to dency to increase in the total score and the subscales large effect size was observed. Post-test mean scores of the of alexithymia. This increase was not statistically signifi- DMT group for Appearance Evaluation, Body Areas Satis- cant, however moderate effect sizes were observed in the faction, and Overweight Preoccupation were within 1 SD Alexithymia total score, in Difficulty Identifying Feelings, from the norm. No significant differences were found in and in Difficulty Describing Feelings to other, and a small the control group between pre- and post-test in any of the effect size was observed in Externally oriented thinking. subscales. When a mixed-effects ANOVA model was applied, Qualitative outcomes results for time effect were consistent with previous There were five domains that emerged from the analy- results for Appearance Evaluation (F=5.93; ηp2 = 0.37; sis of the qualitative data. Within each domain, a number Table 2 Results of paired samples T-Test for pre- and post-intervention for MBSRQ subscales in DMT and Control groups Descriptive statistics T-test MBSRQ Group Pretest Posttest t (df) p Cohen’s d Subscales Mean (SD) Mean (SD) Appearance DMT 2.34 (1.09) 2.94 (0.81) -2.51 (6) .046 -.95 Evaluation Control 2.80 (0.97) 3.04 (0.89) -1.04 (4) .358 -.46 Appearance DMT 3.92 (0.79) 3.41 (0.73) 3.44 (6) .014 1.30 Orientation Control 3.43 (0.88) 3.46 (0.73) -.23 (4) .831 -1.02 Body Areas DMT 2.24 (0.80) 2.76 (0.71) -2.91 (6) .027 -1.10 Satisfaction Control 3.07 (1.27) 2.93 (1.12) .75 (4) .494 .34 Overweight DMT 4.29 (0.76) 3.64 (0.56) 2.00 (6) .093 .75 Preoccupation Control 2.70 (1.92) 2.80 (1.82) -.41 (4) .704 -.18 Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 8 of 20 Table 3 Results of paired samples T-Test for pre- and post-intervention for Alexithymia subscales in DMT and Control groups Descriptive statistics Wilcoxon signed rank test Group Pre Mdn Post Mdn z p Rosenthal’s r (IQR) (IQR) Alexithymia DMT 49 (48-70) 46 (42-61) -0.593 .553 -.16 Total Score Control 35 (30-52.5) 50 (40-53) -1.753 .080 -.55 Difficulty DMT 21 (17-26) 20 (12-26) -0.734 .463 -.20 Identifying Feelings Control 9 (9 - 21.5) 13 (10-23) -1.841 .066 -.58 Difficulty Describing DMT 14 (13-20) 11 (10-19) -1.156 .248 -.31 Feelings to Others Control 10 (6.5-13.5) 13 (11.5-14.5) -1.604 .109 -.51 Externally Oriented DMT 18 (15-23) 17 (15-21) -0.171 .865 -.05 Thinking Control 14 (11-22) 19 (12.5-24.5) -0.816 .414 -.26 Note: Cut-off scoring for Alexithymia total score goes as follows: <51 = non-alexithymia, 51-60 = possible alexithymia, >60 = alexithymia of themes are identified (see Table 4). Each theme is to describe a feeling is considered later, under the theme presented, followed by a selection of related extracts of metaphors). from the data. Due to space limitations only some of the evidences are presented to illustrate each category. Extracts 1 The code of each quote indicates the code given to “Today I was emotionally less calm and peaceful the participant and the number of the session when because of circumstances and decisions to take in the the text was written (e.g., P1S01 refers to Participant 1, near future.” - P1S04 Session 1). “Today I came in feeling indifferent and tired, I didn’t Domain 1: Emotion, mood, and alexithymia feel like doing anything after feeling not understood by Emotional and mood states my father yesterday.” - P5S08 All the participants made attempts to identify and describe how they felt at the beginning, during or at the These participants described their moods briefly, com- end of the session, related to both the present moment paring it to the previous days or weeks, or relating it and the larger context of their lives. The level of detail of to a situation that triggered these feelings. They mostly their descriptions varied, from “fine” to naming specific referred to anxiety vs. calmness, happiness vs. sadness and emotions to describe how they felt (the use of metaphors a lack of motivation. Table 4 Qualitative analysis. Domains, themes, and sub-themes Domain Theme Sub-theme 1. Emotion, mood, 1. Emotional states (7) 1.1.1. Patterns of mood changes and alexithymia during the sessions (6) 1.1.2. Getting in touch / dealing with strong feelings (3) 1.2. Alexithymia, connection, and disconnection (6) 2. Body and movement 2.1. Joys of movement (7) 2.2. Difficulties related to DMT activities (7) 2.3. A pattern of activating during the session (6) 3. Interpersonal aspects 3.1. Enjoyment of the interactions in the group (6) 3.2. Difficulties in relationships (5) 4. Metaphors 4.1. “Safe place” (6) 4.2. The use of metaphor to describe a feeling (2) 5. Reflections 5.1. Reflections on one’s process (3) 5.2. Looking back on the DMT sessions (4) Numbers in parentheses indicate how many participants shared this category Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 9 of 20 A pattern of mood shift during the session difficulties to stay with these feelings. P6 expresses how Most participants reported changes in their moods dur- P2’s process inspires her to work through difficult feelings ing the sessions. herself. Extracts 2 Alexithymia, connection, and disconnection In addition to the quality of a feeling, a theme of recogni- “Today I’ve felt very calm. I’ve been through a couple of tion and awareness of the feelings emerged. Participants days with a lot of anxiety and the session helped me to often included a dimension of being “connected” versus lower it.” -P7S12 “disconnected” when talking about their mood states, “I’m leaving the session more energetic and happy, which in clinical terms seem to describe their varying feeling better than I was before. Motivated to do many experiences of dissociation. The term dissociation is used things and endure whatever may come. Stronger.” -P5S10 loosely here in order to encompass the wide range of experiences of being more or less present in the body as “I am leaving the session a bit calmer and more relaxed described by the participants. (even though I don’t think it will last long, but I’m happy that even though for only a while I wasn’t stuck in my Extracts 4a negative thoughts.)” -P6S10 “I don’t know exactly how I felt.” - P2S05 In these instances, the participants considered that the DMT sessions helped them reduce their anxiety, “Initial feeling: I’ve been emotionally shattered the or offered a temporary relief from it. Moreover, they whole week, without knowing exactly how I feel. reported feeling more motivated after the sessions. Physically I feel well, but inside I’m nervous (because of the exams), tired of everything, sad. . . ” - P5S03 Getting in touch with strong feelings Some participants described getting in touch with strong These participants recognized their difficulties in identi- feelings that they probably were unaware of. fying feelings. P5 described an apathetic mood that had Extract 3a been going on for several days. “I was surprised that I cried so much, so deeply and so Extracts 4b intensely. I wasn’t aware that I was feeling all that so intensely.” - P6S07 “I felt very comfortable during the session. That’s for sure, but sometimes it was easy for me to disconnect P6 expresses her surprise as she becomes aware of the and think about other things.” - P3S03 strong feelings that were unknown to her before the session. “At the beginning of the session, I found it very difficult to connect with myself, to stop connecting with my Extracts 3b anxieties and unease, and to focus on the moment, on living in the moment.” - P5S11 “When A.1 encouraged me to work through my anger, I started feeling it very strongly (even crying), first I “Today I feel absent, my head is somewhere else. I thought it was anger towards myself, and then I realized realize that everything is heavy. My body, my head, my it was anger towards the disease.” P2S08 soul, everything. . . ” - P6S08 “I felt moved by P2’s thing. Oddly enough my head was These extracts show the variety of meanings that connec- very lucid there, I was left with the urge to deal with my tion and disconnection have for the participants. Both P3 own anger because I feel that I have a lot and I quite and P5 mention having difficulties to live in the present identify the images, where they come from. But again, if moment and an urge to think of other things. For P3, this I don’t have a clear secure place to turn to, perhaps it’s seems to enable her to escape from current stimuli “it not a good idea to go to this anger because I might get was easy for me to disconnect”, while for P5 getting into stuck there [. . . ] I feel confused, my head is going to contact with the present is overwhelming. In general, explode.” P6S08 these extracts present a tendency of these individuals to live more in their minds rather than in their bodies. In the These extracts illustrate the attempts of these participants last quote, as P6 acknowledges her feelings of absence, to accept and work through their anger, as well as their her level of self-awareness increases paradoxically as she 1 A. pseudo-initial for the therapist. directs her attention to the other aspects of her being. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 10 of 20 Extract 4c body. Immediately light, indirect and free movements emerged while the participants were experimenting “After the breathing exercises, I felt very RELAXED. I with the quality of time. When I proposed them to do was so focused on the breathing and on A.’s voice in my exactly the opposite, resist to the movement, something head that I even forgot about the existence of my body completely different happened. They had to put force and it wasn’t until when A. told us to delicately start and use the weight of their body as well as they had to moving it [our bodies] that I remembered it again and I find a minimum grounding. P5 seemed very started feeling it and connecting with it again. It was a comfortable and she was enjoying challenging P4. She strange feeling but very pleasant and I felt an absolute surprised everyone with what her body was able to do.” physical and mental relaxation.” - P6S12 “As I was using the rope, at first the space was smaller P6 describes a subjective disconnection from the body and more closed, even though with a slit so someone during relaxation that she experiences as pleasant. Her could come near. I liked interacting with the balls, I felt narrative suggests a powerful experience “forgot about the comfortable, integrated and at the same time with the existence of my body” that is positive to her, probably space for myself. I also liked observing how others because she takes a break from the negative thoughts that interacted with each other.” - P2S04 were mentioned in the previous section. A vignette of S04 from the therapist’s diary is presented: Domain 2: Body and movement “ Each participant created her own personal space This domain includes participants’ responses to DMT using a woollen thread. They started exploring that activities that involve the body and its movement. These space having in general a low tone. I observed light, activities can vary from breathing techniques, becoming sustained, indirect and bound movements, while there aware of the body and exploring different movements was no interaction among the participants. In an with it, individually, in pairs or as a group, with or without attempt to facilitate the group coherence I added some materials. (Interpersonal aspects of these activities will be balls in the available materials and put some upbeat discussed in Domain 3). music. The participants started to interact with each other. At first everyone was lying down and was The joys of movement Participants enjoyed different throwing the balls without using any force. I was aspects of the movements in the session. mirroring their movements making them progressively Extracts 5 bigger and bigger. Suddenly, the participants started to put force in their movements and they were throwing “[...]with the ball, I was able to identify which parts of the balls far away, something that made them change my body were more receptive.” - P6S05 from the low to the medium-high level. Their A vignette of S05 from the therapist’s diary is presented: movements were strong, sudden, free and direct. Their “ They had their eyes closed and seemed very bodies seemed bigger, more open and they transmitted a concentrated on themselves. Their movements were free, sense of grounding2 .” direct, sustained and light. I was observing them while In the first quote, P6 describes how her sense of body they were passing the ball across their body. There was awareness increased by getting in physical contact with no expression in their faces and I was trying to an object. P5 describes how she connects with her “play- understand what they were experiencing, what the ful” side, perhaps a side that she has not been in touch contact with the object made them feel. I noticed that with much since she developed the ED, or even before. they would only take care of, touch with the ball, the P2’s comments experience is an example of how the use front part of their body, while ignoring the rear part.” of different objects (e.g. ropes, balls) can facilitate the “Later when we had to walk, my fun and “playful” side interaction between the participants and also give them got out with the ball and the big red cloth (like power).” - a chance to symbolically explore their personal space and P5S10 limits. A vignette of S10 from the therapist’s diary is presented: Difficulties Several difficulties were mentioned by the “ They were all trying the movement proposals. I was participants with regard to the DMT activities. very surprised that everyone not only permitted the contact with the other group members but also seemed to enjoy it, laughing and searching different body parts 2 The references in movement qualities, from the therapist’s diary, derived from Laban movement analysis that is used in DMT. They are related to the to propose. Seeing that this was well accepted I proposed indulgence or the resistance of the participant and may indicate the way of them to follow the touch of their partners with all of their relating with the other. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 11 of 20 Extracts 6 make the movements and the only way for me to be comfortable was on the floor with my face covered. On “Sometimes I felt that my body couldn’t move as much the other hand, when we started passing the ball I as I wanted, that the movements were smaller than I cheered up much more and I even enjoyed it at some wished.” - P2S05 point. I think the music cheered me up a lot and helped “The part with pushing and using strength, me.” - P3S04 UNCOMFORTABLE. I felt awkward. I couldn’t simply “I couldn’t find a safe place and the blanket that was enjoy [the activity] because I didn’t fully let myself go. covering me (imaginary) was bothering me. As I opened The cloth was great but since we were holding it my eyes, the feeling diminished. Then we made an between us all, I didn’t feel completely free, to move as I activity of using strength, which soothed me very much. actually needed, to flow.” - P6S06 I felt liberated, feeling less burdened. The movement “Today we started with breathing. There I felt nervous.” made me feel lighter. The tiredness of this week has left - P7S10 me, I feel more active. Now I feel content and motivated to talk and move.” - P7S10 “At the beginning of the session I didn’t feel like doing movements because I felt embarrassed, but as time Analyzing these extracts, it is observed that often the passed, I started feeling more and more comfortable. participants who were burdened with negative feelings at Today I listened more to my body and less to my fears.” - the beginning of the session (as presented in theme 1.1.) P4S06 and without any motivation or energy to move, struggled during the initial self-awareness exercises that required “Later they (my companions) touched me where they them to be alone with themselves. The key moments that believed I needed it, and I touched them. It was very shifted the energy level were identified to happen in pair difficult for me to think “where they need it” or “what or group interactions. Moreover, the use of objects like they need”. And when they touched me, I felt that they cloths and balls, and of music further facilitated such didn’t touch me where I needed it, even though I liked it, playful interaction. P7 self-regulates her feelings of anxi- actually I didn’t know what I needed either.” - P7S12 ety by opening her eyes, and later she finds the activity that requires the use of strength soothing, even though “I missed some music in the movement part. It would such activities were received more skeptically by some of have made it easier for me.” -P3S03 the participants. A variety of difficulties are mentioned in these extracts. P2 recognizes her difficulty using her body fully when Domain 3: Interpersonal aspects moving. In the same line, P4 expresses an initial resistance Interpersonal aspects were identified as a domain by to moving due to feelings of embarrassment that she itself, due to the abundant evidence that the participants eventually, at least partially, overcomes. Certain activities presented around this theme. and movement qualities tended to be more challenging than others and triggered ambiguous responses, espe- Enjoyment of the interactions in the group cially the use of strength and breathing exercises. P7 The interactions in the group were identified as an impor- acknowledged her difficulty in recognizing her bodily tant resource for the participants, in order to raise their needs as well as guessing others’. The lack of music was a energy level. Here they are considered in more detail. challenging factor for P3. Extracts 8 A pattern of activating during the session Some of the difficulties mentioned above were overcome during the course of the session as their energy level “I liked having P7 as my partner. I was surprised increased. These extracts were examined in order to positively and it has been a new and different way to get identify the helpful elements in the session that triggered to know her and get a little closer to her.” - P6S10 a change in the participants’ attitude. “Later, as P6 was touching me and I had to move, I felt Extracts 7 very comfortable and as time passed, we were finding each other more. Finally, we were moving freely but “I had two opposite feelings during the session. On the looking at each other, something that made me nervous one hand, in the beginning, I was angry and anxious at first, but in the end, I felt very comfortable and and didn’t want to do anything. It was very difficult to confident.” P5S05 Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 12 of 20 “I really liked the next exercise as well. Someone Extracts 9b touching my chin, holding it from below. It made me feel especially good, it was like never doubt or never forget to “I didn’t have the strength or energy to look for contact hold your head up high.” - P6S12 but when it came to me (when the others came near to interact) it made me feel good, even though also a little In addition to the increase in the energy level that sad at the same time for not being able to do the same, was mentioned in the previous section, these extracts for having so little energy. - P6S09 show the impact of the non-verbal interactions on the participants. P5 describes an intimate moment she found “[. . . ] I only wanted to feel human contact (...) She [the with another participant, as they encountered each other therapist] told us to get in pairs and it was the last thing through their movements. P6 describes her enjoyment as I wanted to do, and when I could, I started playing with she gets in physical contact with the other participants in the balloon alone. I connected with the feeling of an exercise focused on giving and receiving care from one loneliness that I have been carrying for a while, usually, another. For her, this encounter has a symbolic meaning it comes up with losses. The best of the session: When P4 of being supported by her companions. came to give me a hug.” - P5S11 While the participants were eager to give care and Difficulties in interpersonal relationships and interac- received it thankfully, it was difficult for them to ask for it. tion When P6 receives the contact that she needed, she is not Several challenges and difficulties were mentioned with able to enjoy it purely as she is concerned that she cannot respect to interactions and relationships, within the offer the same to the others. P5 recognizes her need for group and outside. These issues can be summarized as contact but she is ambivalent about it and tries to avoid fear of intimacy, difficulty expressing one’s needs, and others by playing alone. It is noteworthy that even though preoccupations about what others might think of oneself. these participants did not express their needs openly, in some cases the group sensed them and responded to Extracts 9a them. “The thing with eye contact was very intense for me. It is Extracts 9c like letting someone in. It wasn’t exactly uncomfortable, but maybe strange, a little violent perhaps.” - P6S05 “Today I found it harder to connect than usual, I don’t think I could really connect, because I was thinking “I also liked interacting with the other person, especially about what others would think of me (that’s why I don’t when I was the one being touched, feeling the movement think the movement part helps me much since I hold of the other person conveyed more uncertainty because myself back.” - P4S03 you don’t know where she will take you. I felt more uncomfortable having to move while looking at the “I felt very comfortable with her, even though I was other, the movements were less fluent as if they were worried that she didn’t feel the same way” (referring to conditioned.” - P2S05 an exercise in pairs) - P5S10 “I didn’t want to let people enter my life just to leave “I am sad, sad because I don’t have P. now [she is later. I went back to dancing on the terrain, finding my referring to her long-distance relationship] and I look companions without any kind of tie that would bind me for any tiny detail to support my distortion that he to someone. I felt free, liberated.” - P7S09 doesn’t like me and he will end up getting tired of me (. . . ). I feel sorry that today was the last session and I’ve Touching another group member was mostly received been so distant [...].” - P5S12 positively, yet maintaining eye contact with a partner, especially while moving, was challenging for many partic- The first two quotes express the participants’ worries ipants. P6 expresses her discomfort and her words suggest about what others might think about them, whether they that it is linked to a fear of intimacy “like letting someone will be liked or accepted. This seems to impair their capac- in”. P2 also describes the uncertainty she felt concerning ity to get the most out of the movement experience. In “where [the other person] will take [her]”. Similarly, P7, the last quote, P5 expresses a deep fear of not being loved who was new in the group at this point, expresses her by her significant other, and while rationally she regards distrust of others and reluctance in building meaningful this as her “distortion”, emotionally she seems to be heav- relationships with people “just to leave later”, suggesting ily burdened to the point that she is not able to be present an underlying fear of abandonment. in the session. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 13 of 20 Domain 4: Metaphors silent and he hugged me while we were watching the According to Lakoff and Johnson [70], metaphor is village. I felt calm, safe and loved.” - P5S07 understood widely as a general function of the mind where a concept is described by its similarity to another, “Today we returned to the safe place but I hate that the and it includes not only linguistic representations but also village is not my safe place if P. isn’t there, so I imagined dreams, memories, and feelings. another moment, when I was with T. but without focusing on her company.” - P5S08 The inner safe place “My safe place turns out to be a person, I realized this Imaginative techniques were applied frequently in the today, since the last time we did this exercise, this sessions. In one of the imaginative techniques borrowed person was present in my mind again so that I came to from psychodynamic imaginative trauma therapy called realize that it’s not about the place, it’s about the the “inner safe place” [57], the participants were guided to person. E. is my safe place. This scares me and frightens think of a place, which could be a real place or a fantasy me. Each time we finished and A. told us to slowly say place that conveyed them a sense of safety and security. goodbye and that we could always return to it, I felt a Most participants wrote about their inner safe place in tremendous pain because I don’t have this certainty. So their journals, often including vivid and detailed descrip- my safe place scares me, mostly because I’m afraid to tions, and they also mentioned the process of looking for lose it and since I feel that it is so safe and comfortable, their inner safe places and their relationship to it. that would be very painful.” - P6S07 Extracts 10a In these extracts, the focus of the inner safe place is shifted to another person. P5 enjoys the feeling of being “This time my safe place was the beach but without loved by this person, and it seems that she finds it difficult many people and even though it was hot, it wasn’t to feel safe when this person is absent. She copes with this overwhelming (. . . ). It’s warm and I only feel cold as I’m by imagining the company of a friend, and thus shifting leaving because the sun has set, but I am happy, feeling her focus. Similarly, P6 has difficulties with the exercise the touch of that warmth on my skin.” - P2S07 of the safe place, when she comes to realize that she is “My place of protection is my room, but with some projecting her sense of security onto a person, and she changes. The window opened to a terrace with a grass faces her fear of losing this person. In these cases, the safe floor (it’s night and you can hear the noise of the leaves place technique provided a source of self-knowledge for moved by the wind). Terrace, bed, table, window, grass, these participants. night, wind, leaves.(. . . ) Music is heard in the room (. . . ) Extracts 10c and cats accompany me. They don’t make a mess and they don’t kill each other.” -P4S08 “What I did realize is that as we were given the instructions, I was trying to change or question “my safe “I can’t see the ocean but it’s inside me. Confusion. A place”, like it was difficult to rationally trust my coffeehouse in Paris, empty, and made from dark wood. decision” - P1S08 There are many tables with many white cups, and emptiness in all of them. Paris looks nice. . . The Eiffel “Today I felt confused, impotent and frustrated. My Tower, trees, bicycles, what a cliche. . . But it is in the head was running a thousand per hour and I found it exterior. I can observe the landscape through the big hard to focus on my safe place.” - P6S08 windows of the cafe. Calmness.” -P4S09 “In today’s session, I imagined the safe place again. [. . . ] While these two participants have different styles describ- I didn’t feel so safe. This made me nervous. So, dancing ing their safe place, some common elements can be lightly, I imagined myself dancing on the terrain, detected in their writings: natural elements (sea, ocean, making it mine. I felt relieved because it became [safe] wind, etc.), emptiness, people or the absence of them. again.” - P7S09 Both descriptions are rich in sensory elements, making the reader imagine these places vividly. These participants refer to the process of finding their safe place which was not always easy. P1 finds it difficult Extracts 10b to maintain her focus on one safe place. P6’s inability to focus her wandering mind gets in the way of accessing her “We imagined a safe place. It wasn’t difficult for me to safe place. When P7 does not feel safe, she uses symbolic imagine it at all: the village. It was summer and we movements and dance to regain her feeling of safety and were in the village seated on a boat at sunset. It was all she achieves it. Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 14 of 20 Metaphorical expressions In these extracts, P5 changes attitude towards the Some participants described their experience via treatment. The movement activity in an earlier session metaphorical expressions. confronts her with her low body weight and makes her think of the “long path” in front of her. It is unclear Extracts 12 whether this is a source of despair or motivation. Later, she reveals her skepticism about the treatment at first, “(. . . ) I remained like the flower in the middle, I haven’t both the Clinic in general and the DMT sessions, and that taken everything out, I haven’t completely opened she has changed her mind. In the last quote, she expresses myself. I feel somewhat relieved but not liberated.” - her frustration in the Clinic as she believes that her life is P6S06 back on track and coming to the Clinic is what holds her “What is this mental capsule that I am in? It is so back. She uses an observational and cognitively focused strong, no one can break it. It has a little window at eye style in these extracts. level through which I can see. I am protected but it seems like a bad place, unhealthy, an exaggerated cover, Extracts 13b or protection.” - P4S11 “Fear, fear, fear. I want to do things and there it is. The present fucked me up. It is okay, maybe fucked up is too In these extracts, the participants do not name the rele- much because there is a way out and it is in me.” - P4S10 vant emotions in order to describe their feelings, instead they use metaphors that help the reader get closer to that “(. . . ) I don’t feel invisible as I am writing these lines, I particular experience. With “the flower in the middle”, P6 don’t feel like I’m hiding, but rather, I’m taking some is referring to a drawing that she made during this session, time for myself, that I am connected with myself and at where she drew three flowers in the process of opening: the same time I am seen, and this causes me some kind the first one being closed, the second one half-opened, of insecurity.” - P4S11 and the third one being completely opened. The inside vs. outside theme from the safe place can be recognized “Loneliness. I think that’s what it’s mostly about, next to in P4’s writing again. The strong capsule functions as a other things. In the end, the core of all my worries is fear defense mechanism, and she recognizes its dysfunction- and the base of it loneliness, not feeling cared for, loved, ality (unhealthy, bad, exaggerated cover) as well as being as if I am not worthy of it or don’t deserve it.” P4S12 protected by it. These extracts show P4’s process throughout the last sessions as she gets in touch with difficult feelings such as Domain 5: Reflections fear and loneliness, and expresses them in her writings. Reflections on one’s personal process An evolution Her expression suggests awareness and authenticity. In in the reflections of the participants was visible when the last session, she develops an insight as she links her they attended the sessions for the whole period. Below, a problems to feelings of worthlessness. collection of extracts from the writings of two patients is presented. On the DMT sessions As the therapeutic process was coming to an end, some Extracts 13a participants included an overall view of the therapy in their reflective diaries, offering a qualitative evaluation of “We started by becoming aware of our bodies through a it, and revealing what it meant for them. ball. It made me realize the long path that I have in front of me to recover my weight.” - P5S05 Extracts 14 “I am more open-minded now because I’ve learned that: “(. . . ) these sessions have been very special for me. I was If I don’t want to do something (in this case [coming in] able to connect with myself more and see things or neither the clinic nor the sessions), before I wouldn’t do discover thoughts or internal worries that were it, but having continued, it’s been good for me to change unknown to me. I had the opportunity to feel closer to my mind.” - P5S07 my companions and create a new type of connection where words haven’t been necessary. That’s why I’m very “As I am so well outside the center, at home and with P., thankful to have had the opportunity to do dance . . . I feel that my life starts to flow again. Coming to the therapy with A. - P6S12 clinic makes me feel as if I’m wasting time, since life is passing and I’m still shut-in, without being able to “Even though I wish we had more sessions, this is the move.” - P5S11 reality and I decide to stay with what I’ve learned, the Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 15 of 20 skills, the moments and emotions. Thank you for Areas Satisfaction. With the necessary caution because of accompanying me during such a hard time.” - P4S12 the small sample size, these results suggest that it might be beneficial to include a treatment component to work “At first I thought this therapy wouldn’t help me, that it with individuals on a bodily level in order to address was nonsense. It showed me much more than that. It body image issues. Considering that body image is an helped me connect with myself, to get to know myself important maintenance and prognosis factor in EDs [71], better, where are my limits, how to calm myself down helping individuals construct a healthy body image is a when there are strong feelings. I am very thankful to you crucial element that needs to be covered in any treatment A. for all that you’ve achieved in me.” - P5S12 modality. “These sessions helped me a lot even though I did it for There is a growing body of evidence suggesting that little time. When I entered demotivated, I left feeling DMT has positive effects on body image in various pop- very content and active. When I entered with a lot of ulations [49, 50]. Regarding the field of EDs, one study anxiety, it helped me decrease it.” - P7S12 has found DMT to improve body image and self-esteem, and decrease psychological distress, in obese women with Most participants expressed their thankfulness to the emotional eating [51]. However, despite the existence of therapist. They reported that the DMT sessions promoted rich theoretical contributions that dance movement ther- self-awareness, helping them connect with themselves, apists made to the field of EDs [72] and several DMT identify their feelings, and recognize their limits. P4 feels case studies [73–75], to the authors’ knowledge, no empir- sorry that the therapy did not last longer. Also partici- ical studies evaluated the effects of a DMT intervention pants perceived that the sessions reduced their levels of in individuals with AN, BN, and EDNOS. Therefore, the anxiety and gave them energy and motivation. It is note- present pilot study has been an initial attempt to fill in worthy that P5 attributes the source of change entirely an important research gap, especially bearing in mind to the therapist: “all that you’ve achieved in me”. Finally, the central role that body image plays in EDs. Hopefully, the exploration of non-verbal interactions with the peers, these promising preliminary results will encourage other the creation of new bonds and the accompaniment of the researchers to conduct similar studies with larger samples. therapist were appreciated. The alexithymia scores of the DMT group tended to reduce or remain stable, while there was a tendency Discussion to increase in the control group, however these changes The primary aim of this pilot study was to analyze the were not significant for either group. The stability in impact of a DMT intervention on body image and alex- alexithymia in the DMT group is not surprising, concern- ithymia in individuals with EDs. Secondly, a qualitative ing that the paucity of studies testing effects of diverse study arm was integrated in order to gain a deeper under- psychological treatments on alexithymia in patients with standing of the therapeutic process. The following dis- EDs raised diverging results [15, 76]. Even in studies that cussion of the quantitative outcomes should be regarded achieved to reduce alexithymia scores through treatment, cautiously, as the small sample size does not allow making the alexithymia levels often remained elevated, so that the any generalisations of the obtained results. Instead, they clinical significance of these results is unclear [76]. As should be taken as a departure point for future studies. alexithymia seems to be a trait that is resistant to change, The participants who took part in the DMT group longer treatment periods might be necessary to achieve improved on the Appearance Evaluation and Body Areas significant results. On the other hand, the tendency to Satisfaction scales, meaning that they felt more posi- increase in alexithymia that was observed in the control tively about their bodies after the DMT intervention. They group was unexpected. While this result should be inter- scored lower on the Appearance Orientation scale after preted with caution due to the small sample size ( n = 5 for the therapy, which suggests that they were less preoccu- the control group), it can be an interesting research ques- pied with their looks. These changes were both statisti- tion whether cognitive behavioral techniques, when these cally and clinically significant. The decrease in the Over- do not specifically target alexithymia, increase alexithymia weight Preoccupation scale was not statistically significant levels in patients with EDs, as it encourages the patients to but a medium to large effect size was observed, suggesting take a distant stance from their personal experiences [77]. that there have been clinically significant improvements The TAS-20 was used to measure alexithymia in the which were not statistically significant due to the small present study. While the TAS-20 is a widely used and sample size. The control group that continued the treat- accepted instrument, one study criticized its use with ment as usual did not change significantly in any of the patients with EDs, as they found that patients with EDs body image aspects measured by the MBSRQ. A mixed- with high alexithymia levels according to TAS-20 per- effects ANOVA model showed significant results in the formed equally well as the control group on tasks of interaction effect for Appearance Orientation and Body emotion identifying and reporting. They also found that Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 16 of 20 depression and anxiety states can alter alexithymia scores dopamine and serotonin levels as well as a decrease in psy- [78]. While there is no way of knowing if such an effect chological distress after a 12-week DMT intervention in occurred in the current study, the qualitative analysis has middle school students [81]. shed more light on alexithymia and related issues in the However, it is important to note that such effects can participants of the DMT group. only partially be explained by the benefits of physical The results of the qualitative analysis demonstrated activity, as one study comparing a single circle dance inter- difficulties in identifying feelings and a difficulty to be vention to exercise on a home trainer bike found that present in the moment. Some participants reacted defen- depression levels decreased in the dance condition and sively when they encountered strong feelings during the not in the exercise condition [82]. Dancing in a group sessions. However, in some instances, they were able to seems to have more components that promote mental face and accept these strong feelings. The DMT sessions health than physical exercise only, like the physical and seem to have provided a secure base for the participants affective interaction between group members. What is to explore such feelings. In their overall evaluations of more, physical exercise is a complicated issue in the treat- the intervention, participants reported that the sessions ment of EDs [83] as patients often use excessive exercise helped them be more present in the moment, identify for complex psychological reasons [84]. DMT could pro- their feelings, and get to know themselves better. Even vide an alternative to traditional physical exercise, since though no significant results were obtained in the TAS- it seems to have the potential to promote body aware- 20 scores, these patient accounts suggest that the DMT ness, as well as benefit the body and mental health on a sessions had an impact on some aspects of alexithymia. neurohormonal level. This would be valuable for ED treat- Specific attention was given to the use of metaphors as ment, as patients often suffer from comorbidities with patients’ with EDs impaired symbolic thinking and their depression and anxiety [85]. Larger scale studies including tendency to somatize their emotional experience have biomarkers are needed in order to test these assumptions been identified as a challenge to traditional psychother- for patients with EDs. apy [79]. The use of rich metaphors by some patients Some interpersonal difficulties that are associated with and their vivid descriptions of their “safe place” contradict EDs according to a recent systematic review [86], have with the impoverished inner fantasy life that is associated emerged in the participants’ reflective diaries, such as with alexithymia [19]. The work with active imagination interpersonal distrust, fear of intimacy, and difficulty in movement is a core aspect of DMT. This process allows expressing one’s needs. At the same time, the empathetic the patient to work with metaphors and symbolism, thus interactions in the group, both with each other and with may help the patient access contents that were previ- the therapist, were valued by the group members, similar ously not conscious. These results suggest that the use to findings in a cognitive behavioral therapy group [87]. A of imagery techniques and creative movement in DMT, novelty in this study is the focus on the nonverbal aspect while putting an emphasis on body awareness, can help of these interactions. The reflective diaries showed clearly combat these limitations. that the participants enjoyed getting to know one another The participants reported that the intervention had a on verbal and nonverbal levels. At the same time, some of positive effect on their mood, helping them feel more the DMT techniques prompted them to reflect on their cheerful or motivated, and less anxious, confused or real-life relationships. Bearing in mind the importance of angry. These qualitative results are in line with a previ- positive social relationships in the recovery of EDs [71], ous study using self-report questionnaires that revealed an and the various interpersonal problems that they often increase in energy and decrease in anger and confusion in suffer from [86], attending the interpersonal aspects has a adolescents in a day hospital after the DMT sessions [80]. crucial role in ED treatment. DMT can be an innovative In the present study, the extracts from the patients’ diaries way to address these issues, as it combines implicit and also shed light on how the DMT sessions facilitated such explicit learning, verbal and nonverbal interaction. change in mood. Most participants described a similar While the group format seems to have helped the par- pattern of entering in the session in a depressed or anxious ticipants enhance in relationship dimensions, it should mood and initially had difficulties engaging in the activ- be noted that individual DMT sessions would have its ities. The therapist accepted and attuned to their initial own advantages, such as the patients having more space mood while gently encouraging them to explore different to explore their movements freely. The privacy and con- movements. Furthermore, the use of music and materi- fidentiality that individual therapy offers could allow als such as balls and cloths facilitated playful interaction patients to feel more secure and talk about personal issues between the group members and raised their energy level. in depth. These effects can be related to neurohormonal effects Interestingly, the participants made few references to of movement, as a previous study observed changes in body image issues in their reflective diaries. This might be Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 17 of 20 because they were more focused on their lived bodies dur- received. The sessions were conducted by a DMT trainee, ing the DMT sessions, and not so much on their appear- who was doing her clinical internship in the Clinic. She ances. It also suggests that the improvements in body was at the moment in the beginning of her learning pro- image found in the MBSRQ scores happened through cess and had no previous experience with this population. implicit ways. For instance, the writings indicate a pure A therapist with more experience might have worked enjoyment of the playful social interactions that the par- more efficiently and adapt better to the particularities of ticipants experienced in the sessions. Considering that each participant or the ones of the group. patients with EDs tend to experience their bodies through Another shortcoming was that the DMT group was a external means such as weighing scales, mirrors, etc. semi-open group. For the therapeutic process this implies [79], the enjoyment through the lived body that DMT working with individuals who can be in different moments offers can be very valuable and this might be account- of their personal process, which might present an addi- able for the improvement in body image found by the tional challenge to the group therapist. A closed group MBSRQ. This implicit aspect marks a significant differ- would be beneficial for the patients in terms of devel- ence between DMT and approaches that put an explicit oping trust in the group and getting used to working focus on body image issues, such as cognitive-behavioral with their bodies. In terms of methodological rigor the techniques. Lastly, most participants expressed their grat- variation in the number of sessions that each participant itude to the therapist in their reflective diaries. Overall, attended to, poses another variable that can not be con- they were satisfied with the intervention proposed. There trolled. The setting of the DMT group was adjusted to the were no dropouts in the DMT group and the no-show needs of the private clinic where the study was conducted. rates were low, suggesting that the patients were commit- In line with the Clinic’s policies, two interns attended as ted to the therapy. This seems important considering the observers the majority of the sessions, which presented a high dropout rates in EDs [88]. confounding variable that might have affected the results. Finally, this was an all-Spanish sample, and some inter- Limitations ventions might not work in the same way with patients The findings of this pilot study have to be considered in from other cultures, e.g. interventions that include touch light of some important limitations. As authors such as and eye contact, as these aspects of nonverbal commu- Schweizer and Furley emphasize, prior to any research the nication vary significantly across cultures. Practitioners appropriate sample size should be calculated in order to should take the cultural context into account. obtain more accurate, reliable and reproducible results. To the best of the authors’ knowledge, there are no However, these authors also recognize that in certain cir- quantitative studies evaluating the impact of DMT inter- cumstances this could make research difficult in certain ventions on the body image and alexithymia rates of areas of knowledge in which access to a sufficiently large patients with EDs. The authors had no reference point sample is limited by numerous factors [89]. when designing this pilot study. The findings are promis- The authors of the present study are extremely cau- ing despite the mentioned limitations, as significant tious about the quantitative results obtained, as Button et improvements were observed in body image, and a slight al. suggest. They consider the choice of a methodological tendency for improvement in alexithymia, compared to design such as the mixed one to be an ethical procedure. the control group. It would be interesting to be able to Given the difficulty of having a sufficiently large sample, follow this line of research with larger samples which this makes it possible to incorporate other data collec- would minimise statistical analysis limitations. Last but tion and analysis tools that offer information of interest in not least, it should be taken into account that in bodywork relation to the subject matter being dealt with [90]. approaches like DMT, a large sample does not make it Another issue that compromises the reliability of the possible to do in-depth work. In any case, mixed method- quantitative results is the heterogeneity between the ological research design is crucial, since the qualitative groups. The intervention and the control groups were information collected from the patients themselves offers homogeneous concerning their age and BMI, however the a better understanding of the process by giving space to control group had been in the Clinic for a considerably each of their individual experiences. The integration of longer period than the DMT group. A larger sample would both approaches, quantitative and qualitative, should be, be necessary to determine the influence that the time in the authors’ opinion, the optimal way to proceed in this spent in the Clinic had on the results. Furthermore, the field. sample was heterogeneous concerning the ED subtype, with the majority in both conditions being EDNOS or Conclusions AN, and only one BN patient in the control group. There- To the authors’ knowledge, the present pilot study is the fore, it remains unknown if the diagnosis of a particular first controlled trial to evaluate the impact of a DMT inter- ED subtype had an effect on how the DMT sessions were vention on body image and alexithymia in a mixed group Savidaki et al. Journal of Eating Disorders (2020) 8:22 Page 18 of 20 of patients with EDs, i.e., AN and EDNOS. Furthermore, Consent for publication the study has provided valuable insights into the expe- The intervention group signed a consent form agreeing to the anonymized publication of extracts from the reflective diaries that were used in this study. rience of patients with EDs, using qualitative analysis of the reflective diaries written by the participants at the Competing interests end of each session. The DMT group showed significant The authors declare that they have no competing interests. improvement in various body image scales, while there Author details were no significant changes in the alexithymia scores. 1 Psychology Department, Autonomus University of Barcelona, Plaça Cívica, Moreover, the qualitative analysis revealed other factors 08193 Barcelona, Spain. 2 Universidad Europea de Madrid, c/Tajo, s/n, 28670 Villaviciosa de Odón, Madrid, Spain. of the DMT sessions that were appreciated by the par- ticipants, as they reported an increase in self-awareness, Received: 5 November 2019 Accepted: 17 April 2020 improvement in emotional states, as well as they valued verbal and non-verbal interaction with the group mem- References bers and with the therapist. More research is necessary 1. Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of to confirm these promising findings. 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