Body, Movement and Dance in Psychotherapy: An

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Dance movement therapy with the elderly: An international Internet-based survey undertaken with practitioners Iris Bräuninger

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Department of Research and Development, University Hospital of Psychiatry Zürich, Lenggstrasse 31, Zurich 8032, Switzerland Published online: 21 May 2014.

To cite this article: Iris Bräuninger (2014) Dance movement therapy with the elderly: An international Internet-based survey undertaken with practitioners, Body, Movement and Dance in Psychotherapy: An International Journal for Theory, Research and Practice, 9:3, 138-153, DOI: 10.1080/17432979.2014.914977 To link to this article: http://dx.doi.org/10.1080/17432979.2014.914977

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Body, Movement and Dance in Psychotherapy, 2014 Vol. 9, No. 3, 138–153, http://dx.doi.org/10.1080/17432979.2014.914977

Dance movement therapy with the elderly: An international Internet-based survey undertaken with practitioners Iris Braüninger* Department of Research and Development, University Hospital of Psychiatry Zu¨rich, Lenggstrasse 31, Zurich 8032, Switzerland (Received 28 January 2014; accepted 9 April 2014) The over 65 age group is constantly increasing in size. Resource-oriented treatment approaches such as dance movement therapy (DMT) are becoming more important as they preserve the dignity of the elderly, respect their individual needs and improve social participation. An international internetbased survey was sent to 683 DMT colleagues, of which 113 practitioners from Austria, Germany and Switzerland responded to the following questions: To what extent can older people benefit through DMT? What themes emerge in the sessions? Which therapeutic interventions are applied? What are the recommendations with regard to working conditions and the strengths and coping strategies of therapists? The qualitative data analysis reveals that practitioners agree that DMT improves the quality of life of elderly people, fosters maintenance of their relationships and expands their resources and participation in activities. The results assist us in formulating specific intervention recommendations. Keywords: dance movement therapy; the elderly; practitioners’ opinion; internet-based survey; practice-based evidence

Introduction In the coming decades, it is anticipated that in German speaking countries the 65 þ age group will increase in size by more than 25% and those aged 80 þ by more than 50% (Bundesamt fu¨r Statistik, 2010; Bundesministerium des Inneren, 2012; Statistik Austria, 2012). Thus, a much larger number of elderly people is expected to enter dance movement therapy (DMT) treatment. This article gives an overview of a survey on DMT with the elderly and presents results of an international internet-based survey undertaken with practitioners from a range of countries on themes, interventions and recommendations. Case vignettes offer insight into the practice of DMT with the elderly. Limitations and perspectives for future research projects are discussed. Research on DMT with the elderly Depression (Boerner, 2004) and anxiety disorders (Kinzl, 2013) in the elderly are frequent. The effect of DMT and dance in depression has been well documented

*Email: [email protected] q 2014 Taylor & Francis


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(Cross, Flores, Butterfield, Blackman, & Lee, 2012; Heimbeck & Ho¨lter, 2011; Jeon et al., 2005). Results from randomised controlled trials show that the depression scores reduce only in the treatment groups of university students (Akandere & Demir, 2011), of outpatient undiagnosed adults (Braüninger, 2012a) and of psychiatric patients (Koch, Morlinghaus, & Fuchs, 2007) but not in the control groups. A randomised control study reveals DMT’s efficacy in women affected by breast cancer (n ¼ 49, mean age 65.6 years) by reducing anxiety about recurrence, improving quality of life (QOL) and increasing mindfulness (Crane-Okada et al., 2012). Two meta-analyses (Cruz & Sabers, 1998; Koch, Kunz, Lykou, & Cruz, 2013; Ritter & Low, 1996) support the findings that DMT is effective in reducing depression and anxiety. ‘Dementia is one of the major causes of disability and dependency among older people worldwide’ (WHO, 2012). In the 65 þ age group, 5% suffer from dementia, with 20% suffering in the 80 þ age group (WHO Regional Office for Europe, 2014). Therefore, ‘the search for effective interventions that claim to address the person as a whole is becoming particularly urgent’ (Karkou & Meekums, 2014, p. 4). The development of self-awareness is associated with the awareness of others (Fogel, 2013). This seems crucial for elderly who often participate less in social life (von Steinbu¨chel, Lischetze, Gurny, & Winkler, 2005; Winkler, Matschinger, & Angermeyer, 2006). Dancing shows a preventive effect against dementia (Verghese et al., 2003), a salutary effect in improving cognitive functioning (Hokkanen et al., 2008; Van de Winckel, Fey, De Weerdt, & Dom, 2004) and of reducing aphasia and agnosia (Dayanim, 2009). Body psychotherapy has been found to improve general well-being, mood, concentration and communication in dementia patients (Hamill, Smith, & Ro¨hricht, 2012). Thus, it is possible that DMT may help to increase the QOL and to maintain the capacities and performances of daily activities of the elderly (Strassel, Cherkin, Steuten, Sherman, & Vrijhoef, 2011). Study aims The first aim of this study is to present major themes that arise in DMT sessions with the elderly and to report on successful DMT interventions, second to identify how practitioners evaluate the benefits of DMT, third to identify the coping strategies employed by therapists, fourth to suggest optimal working conditions and finally to set out the basis of the theory and practice of DMT with the elderly. Method Participants and data collection This study is conducted in three German-speaking countries. The author contacted the Swiss and Austrian DMT Associations’ presidents, and they emailed the invitation to their members. The author sent the invitation to the email list of the German Association, to 13 colleagues of a major Swiss psychiatric hospital and to 10 dance movement therapists (see flow chart). Data was collected using a secure web-based link (a SurveyMonkeyw Application).


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Internet-based survey of DMT with the elderly The questionnaire has been developed by the author to document therapists’ expertise with the elderly. Grounded theory (Charmaz, 2006), resilience (Schumacher, Leppert, Gunzelmann, Strauß, & Bra¨hler, 2005) and QOL research in old age (von Steinbu¨chel et al., 2005; Winkler et al., 2006) form the conceptual basis for the data analysis. Data is collected about demographics (gender, age, education), the country of employment, membership of associations, years of work experience, characteristics of work and therapy settings and diseases of the clientele. Questions were presented in a closed, semi-open and open format. Participants were able to stop the questionnaire any time; questions could be skipped and multiple answers were possible. One question records whether elderly people profit from participating in DMT (Question 13 with 11 items): ‘Should DMT be offered on an outpatient basis (item 1)?’ ‘Does it improve QOL: General Health (item 2)/Physical Health (items 4, 5, 8)/ Psychological Health (items 7, 11), and Social Life (items 3, 6)?’ another item asked ‘Does it improve Resilience (items 9, 10)?’ All answers are given on a 5-point intensity scale (with values of 5 for I agree to 1 for I disagree). Personal experiences and practical examples were collected in six qualitative questions: Questions 10 and 11 asked which themes emerge, also about suicidality, sadness, and physical impairment and which DMT interventions therapists apply. Therapists are asked to name three ways in which they believe that the elderly benefit from DMT (Q12), what working conditions are advisable (Q14), what therapeutic qualities a therapist needs (Q15) and which coping strategies assist them (Q16). Procedure The questionnaire underwent two revisions by practitioners. It can therefore be assumed that the final version shows face validity. An email invitation was sent to therapists (N ¼ 683). The response rate of 16.7% (N ¼ 113 responses, 93.5% women) was below the 20% of online surveys (Dillman, Reips, & Matzat, 2010). However, as it can be assumed that not all of the therapists have worked with the elderly, the return rate thus could be estimated as higher. To ensure confidentiality the electronic tracking information has been deleted before the execution of the statistical analysis. Data analysis The data about the client group is descriptively analysed. Quantitative evaluation (Question 13) The alpha values of internal consistency have been calculated with good results regarding the Resilience scale (a ¼ .85, n ¼ 58, M ¼ 4.7, SD ¼ .52), acceptable results regarding the QOL subscale Social Life (a ¼ .73, n ¼ 59, M ¼ 4.9, SD ¼ .3), and moderate results regarding QOL subscale Physical Health (a ¼ .65, n ¼ 59, M ¼ 4.9, SD ¼ .25).1



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Qualitative questions The coding system of SurveyMonkeyw is used for the text analysis of the six qualitative questions. After a first look at the raw data, it seemed reasonable to assign the themes of the sessions asked for in questions 10 and 11 to specific categories of QOL and Resilience and to non-specific categories. The detected themes are categorised according to QOL categories Psychological Health, Physical Health, Social Relationships (Angermeyer, Kilian, & Matschinger, 2000), Autonomy, Participation and Death and Dying (von Steinbu¨chel et al., 2005; Winkler et al., 2006). Personal Competence and Acceptance of Self and Life (Schumacher et al., 2005) were used as Resilience categories. All DMT themes and interventions were presented by frequency and content analysis (Mayring, 2010), including the results related to Questions 12 – 16. Results Therapists are on average 49.5 years old (SD ¼ 8.9), 46.4% work in Switzerland, 43.3% in Germany and 10.3% in Austria; 30% hold a university degree and 25% graduated in tertiary education. More than half work in statutory settings, nearly one-third in private practice, a quarter in facilities for the elderly or care facilities; four-fifths treat people with depression and mood disorders and two-thirds treat people with anxiety disorders, respectively dementia, Alzheimer’s or other organic disorders. Every second therapist works with somatoform, respectively acute stress disorder and trauma. Nine-tenths offer group therapy and nearly two-thirds, individual therapy. Practitioners have on average 10 years of experience working with the elderly. DMT themes and interventions with the elderly The most frequently themes relate to QOL (154 £ ). Other categories are Lifeweariness and Suicidality, Cognition and Dementia and Security. Topics associated with Resilience are Acceptance of Self and Life and Personal Competence. The most frequently employed DMT interventions were guided movements (specific exercises, moving various body parts), games, improvisation and dancing in pairs or in a circle. Psychological health (QOL) (54 £ ) Anxiety and Depression were most frequently treated with open interventions (improvisation, everyday movements), guided exercises (grounding/breathing exercises), Chace Circle and Circle Dances. The most useful interventions for increasing Impulse Control were seen as working with the group and with the Effort Weight. Lack of Energy can be treated by gaining awareness and by focusing on a movement’s quality rather than its quantity. Awareness exercises may furthermore lead to inner calmness thereby increasing energy levels. Interaction and expressive arts processes seem to have been perceived by the respondents as particularly successful in treating Addictive Disorder and activating autonomy and personal resources. Utilising performance and expression allows the client to emotionally

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distance himself and to control overwhelming feelings. This is especially important when working with Trauma. It can be concluded from the respondents comments that DMT allows the client to externalise internal feelings/thoughts/experiences, to build up a structure and to foster psychological stabilisation. (Braüninger, submitted) Physical health and sensory functions (QOL) Physical limitations (23 £ ) like reduced physical skills and the ageing body were strongly present as themes. Movement disorders, unsteady gait and insecurities, blockages to movement and risk of falls are major limitations. The treatment goal was thought to provide positive experiences and awareness of remaining physical resources: . . . . .

Guided movement exercises foster physical stabilisation Free movements strengthen resources Freedom of choice to take part or not promotes participation and autonomy Passive/active exercises, lying down/sitting regulate the tonus of the body To take a bath in sensory material stimulates the senses and the differentiation of perception. (Therapist 28)

Balance problems (10 £ ) negatively impact stance and mobility. Directive movement exercises counteract this: . Working on the floor with an unstable ground and utilising simple gymnastic exercises increase balance . Grounding exercises provide security . Visualisation encourages self-perception . Creative dance and improvisation expand personal skills . Linking dysfunctional body parts to the rest of the body creates a sense of wholeness It can be summarised that the therapists reported that DMT interventions aim to reduce physical limitations. Focussing on the whole body helps to update self image (Therapist 28) and strengthens personal boundaries. Somatisation (7 £ ). Participants talk about pain and dizziness. . . . .

Limiting the range of movements and making them smaller supports stability Working in a sitting position enhances mobility and promotes expression Slowing down and working with a movement focus reduces dizziness Not to work with the pain but to work where it does not hurt; to focus on experiencing oneself and not reduce oneself to the pain. (Therapist 8)

DMT, according to these therapists, appears to stimulate movement-based psycho-education, focuses on positive experiences, enhances personal skills and expands coping strategies. Sensory function (5 £ ). DMT deals with the decline of sensory functions: . Sensory stimulation builds confidence and a sense of security . Experiencing moving in space supports structure . Grounding exercises centre


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. Self-contact stimulates sensory perception . Experiencing rhythm builds up orientation in the here and now


Therefore, DMT was thought to increase coping strategies when dealing with sensory loss. Life-weariness and suicidality Practitioners recommend two steps when dealing with Life-weariness (36 £ ) thoughts: First their presence is accepted: To relax on the floor, to experience being held and carried, to indulge and to give in to the feeling of fatigue. (Therapist 14) To accept the downcast feeling, to make and to hold contact, to offer tension regulation exercises (with/without medium) and to provide a space for whining. (Therapist 7)

Second, body awareness is promoted and the focus is shifted onto the positive aspects of one’s existence: To discover resources by means of intermodal work, to find a connection to personal experiences, music, movement, walking, writing. (Therapist 11) Perceiving consciously one’s own body lets the spirits awaken. (Therapist 1) Directing one’s attention to the moment and to the current experience (music, movement, fellow patients). (Therapist 7)

Thus, it could be said that the awareness shifts to the present, which creates freedom and calmness. Biographical work was thought to allow personal resources and painful emotional memories to be discovered: Dancing pleasant memories (here couple dance with the therapist), which reminded him of dancing with his wife. In doing so, he came in a joyous mood and planned to go to tea dance on a regular base after his discharge. (Therapist 4)

In conclusion, it appears that the therapists believe that they help clients to discover possibilities for activities and validates their feelings and perceptions of reality. This has a revitalising effect. Suicidality (26 £ ). The state of life-weariness is intensified in suicidality and may lead to actual life-threatening actions. The situation and the client’s feeling of deep despair are always taken seriously. Acute suicidality may require hospitalisation, direct accompaniment and/or referral to the treating physician or the emergency psychiatrist. Several practitioners point to the importance of a reliable trusting relationship between client and therapist and of the highly personal and concrete support in critical phases. The therapy setting depends on the client’s situation, needs, preferences and on the treatment context. . . . . .

Tension flow exercises help to focus on the here and now Body work, touching one’s body, grasping objects, anchor in the present Strength as energy transformed into shapes provides positive self-experiences Walking together in the room/in nature helps the client to calm down and rest Feeling physical resistance (the wall/floor/material) allows the client to feel safe . Working with the feet provides a secure stance and Being here. (Therapist 35)

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From the respondents’ comments it appears that the therapist adjusts to the client’s world, supports his expressiveness and promotes social contact. Situations of overstimulation and stress are controlled by low-threshold interactions. Spontaneity and usually moments of joy emerge as well as moments of mutual esteem (Therapist 4) by meeting other participants. Therapists appear to perceive that providing a safe space allows the client to relax and to express feelings. A change of focus to what was and what is worthwhile in life stimulates new perspectives and hope. Social relationships (QOL) (21 £ ) The loss of loved ones can lead to loneliness and social withdrawal. . . . .

Moving together in pairs or in the group enables contact Circle and couple dance offers positive community experiences Movement games promote interaction Partner massage creates bonding

In summary, it was thought that experiencing DMT may provide comfort over the loss of relationships and offers interaction: Mark the centre of the room – the group walks an eight with different walking speed/ rhythms. Encounters automatically occur at the intersection of the eight (the marked centre of the room). Try different ways to meet: Saluting/dodging/granting the passage with gestures. (Therapist 54)

In summary, it can be proposed that DMT provides positive experiences in the community, strengthens social empowerment and helps to find ways out of loneliness and to regain courage for networking. The therapist supports social networking and offers a point of contact. Death and dying (QOL) (13 £ ) The death of loved ones and personal limitations confront the elderly with new situations. . Dance rituals and spiritual dance enable farewell rituals . Mindfulness offers a space for mourning . Music activates positive experiences and reminiscence and regulates stressful emotions and thoughts In DMT, as can be shown from the above respondents’ comments, participants are supported to experience a sense of wholeness and belonging: Strengthening their own resources, finding meaning in life and joy in movement, finding access to other levels of consciousness (spirituality). (Therapist 55) Providing group experiences – for example working with touch – offering simple dances in a circle. (Therapist 39)

In palliation, the client is accompanied in a respectful way. The therapist is fully present, with and without words, and intervenes with gentle touch, sensitive attention and breathing: Breathing, the theme of letting go and dedication, and trust are fundamental. (Therapist 1) The fear of illness and death is often seen as a taboo and therefore not spoken about in everyday life. Movement work including media and symbols –the mindfulness dealing


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with oneself through dance experiences – removal of taboos and reality testing. (Therapist 47)


Grief can be present for various reasons: the loss of a partner, of work, of physical and sensory functions and of participation. DMT provides a container for these feelings: . . . .

Centring and awareness exercises provide support and structure Expressing grief can positively strengthening the self Combining movement and art work enables access to feelings Positively reinforcing and transforming movements is a successful affectregulation strategy

Death, dying and bereavement are central themes in ageing. DMT, according to the analysis, can be an emotional support for hopelessness and despair, as well as comfort and joy through dance rituals and group dances. Autonomy (QOL) (12 £ ) Questions on autonomy, safety and independence are addressed: . Mirroring movements in the interaction makes competencies visible . Performing and labelling small movements promote safety and validates existing resources . Deepening movement impulses strengthens autonomy . Improvisation supports independence . Working with resistance and leading in a pleasurable way to power and aggression (Therapist 32) promote self-efficacy Autonomy is closely linked to independent living and to decision making. Meeting them with respect (for autonomy-needs), mirroring their skills and their will in the interaction, letting them decide. (Therapist 28)

Sometimes a client decides to not actively participate in a session. Strengthening the client’s will also means accepting his expression of independence and autonomy and understanding his desire for freedom. Participation (QOL) (9 £ ) Elderly people suffer from the feeling of being a burden to and depending on others, not feeling needed, not participating any more in others’ lives and doubting the meaning of life. DMT’s goal is to awaken a sense of belonging: . Choreographing a group dance builds up community . Learning simple steps and movement sequences in a circle or folk dance offers successful experiences . The Chace-circle and movement games (with props) create a sense of belonging . Exercises of leading-and-following illustrate in a pleasurable way the connection between independence and dependence . Improvisation provides a satisfying feeling about one’s own activity In summary, DMT may promote participation of the elderly in the group and in the community.


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Dementia and cognition Different themes related to Dementia come up in sessions. Dementia (10 £ ). The term dementia describes a variety of diseases including Alzheimer’s. People with dementia gradually lose the knowledge about themselves. Their communication changes, sometimes interaction worsens. Verbal expression may reduce and physical restlessness, states of agitation or depressive symptoms may increase. DMT emphasises interventions on a body level and with regard to interaction: . Movement games and dancing (alone, in pairs/group/circle/sitting) vitalise, raise joy and validate personal skills . Well-known dances and music support reminiscence . Theme-directed dances promote a sense of community . Rhythmical work (clapping, stamping) develops structure and orientation . The body remembers without the mind. (Therapist 52) Confusion, disorientation, cognitive impairment (5 £ each) and forgetfulness (4 £ ). Elderly people often feel confused, lose orientation with regard to time and space and show reduced memory performance. . Awareness exercises (sensing the surface of floor, standing/walking/laying/ relaxing/dancing on it) provide grounding experiences . Mirroring each other’s movements in couples strengthens spatial orientation, reality testing, physical stability and memory . Learning simple functional movements strengthens competences Stimulating the senses enables new experiences and evokes memories. DMT fosters the connection to one’s personal history, simultaneously supporting orientation in the present. By incorporating the latest findings of memory research it can be shown that DMT reactivates forgotten movement experiences and knowledge and supports finding ways of dealing with cognitive limitations. Security (8 £ ) In unsettling times, DMT offers continuity and security: . Providing choices (What movements do I like? Where do I feel comfortable?) promotes self-awareness . Focusing on movement resources decreases feelings of insufficiency . Walking in various manners provides security . Sensory stimulation of the feet promotes stability . Light or strong movements and light music vitalise . Moving means to collect joy. (Therapist 45)

Resilience The acceptance of self and life (8 £ ) deals with changing processes. Personal competence (4 £ ) addresses the question of how challenges can be confronted with courage and resilience: . Expressive work supports coping mechanisms


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. Self-massage promotes self-acceptance . Gradual movement flow invites relaxation


DMT works in a concrete and playful way with physical strength and resistance, positively stimulating resilience. DMT with the elderly: the benefits About 90% of the practitioners fully agree that DMT should be offered on an outpatient basis. They are convinced of improvements in QOL, mobility, psychological health, social contacts and in the reduction of isolation. Two-thirds of the practitioners are fully convinced that DMT reduces suicidal thoughts or risk of falls. They trust that positive physical experiences improve mobility, the connection to the body and oneself and have a vitalising effect. Practitioners stress that mood improves, cognitive limitations reduce and resources are activated. The group experience and interaction improve social life and participation, which prevents isolation and social withdrawal. Therapeutic characteristics The practitioners mention the following therapeutic characteristics as the most important: . . . . . . .

Ability to listen Confrontation with one’s own ageing (Therapist 62) Empathy Giving time and space Knowledge about brain-physiology and psychology of ageing Patience Understanding the conditions and the changes related to ageing

Second they identify: . . . . .

Adaptability to the elderly Authenticity Humour Love and appreciation for this clientele Respect and curiosity for individuals’ life stories

Third: . . . .

Clarity and precision Modesty and humility Own joy for life Serenity

While these therapeutic characteristics are generally important, they suggested that in this work, the therapist and clients take different roles: The therapist, often the younger in the relationship, works with clients who are in a parental role with a longer life experience. By incorporating this knowledge, the therapeutic qualities become a resource for recovery.


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Personal coping strategies Practitioners validated their own personal attitudes as the most important coping strategy. Moreover, recreational activities, supervision and intervision are important too. Personal attitudes towards ageing help the therapist to accept human life as limited and to perceive death as part of life (Therapist 61), thus enabling the therapist to meet others with tolerance, empathy, humour, honesty and sincerity. In order to sustain the joy of life and work, it seems helpful to be centred on and mindful of one’s own body signals. Living the moment consciously and incorporating phases of relaxation foster self-regulation mechanisms. Leisure activities such as dancing, meditating, exercising and being in nature can strengthen the work. Having worked through relationships of one’s family of origin (Therapist 109), poetry and a peaceful heart (Therapist 92) and yoga and reflection (Therapist 85) increase the therapist’s awareness of her personal role. Supervision, intervision and case discussions serve many therapists as a source of inspiration, refuelling and support, enabling them to distance themselves from work. Setting for therapy sessions Co-leadership The majority of practitioners think that a co-leader is crucial when working with elderly people. The co-leader can be an auxiliary worker (student, intern, nurse). Group Some therapists suggested offering mixed groups with respect to diagnoses and gender. One therapist however recommended forming a homogeneous group of similar socio-cultural status. The number of participants should not exceed six participants if the group consists of a high proportion of demented people. The group may however consist of 10– 12 people, if a co-leader is always present. Therapy space and props When working with the elderly, therapists gave the following recommendations: The room should be easily accessible with bright, not dazzling light and good acoustics. The contrast between floor colour, furnishings, and props needs to be strong. Sufficient space for parking wheelchairs and access etc. should be available. A closed room will allow work in a concentrated way without external distraction. However, work in open space provides weaker patients with the possibility of being an onlooker who can enter cautiously from a certain distance. (Therapist 106) The floor will need to be firm but not too hard without carpet, non-slippery and well insulated (for floor exercises). Chairs should be light enough to be moved aside or piled, with a backrest/a few with armrest. Stools need to be stable and seats disinfected. Material should be washable, balls have good flight characteristics (not too light/heavy, easy to grasp). Music and songs may be from earlier times. A great variety of sensory material of different size/quality, special cushions/rolls for neck and knees, sticks (not too long) and wide floor mats need to be available.


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To ensure security, handles for holding, and walking and supporting aids should be in place when working in standing position. Secure footwear for the participants (no open slippers) etc., anti -slip socks OK) – . risk of falling; any objects (handbags, walking sticks, etc.) should not be on the ground – . danger of stumbling! Make sure that no dangerous furniture restricts the movement or could hurt. Non-slippery floor! Chairs with backrest but without armrests are good (because of the movements of the arms – . injury while sitting with armrests!). (Therapist 57)

Additional conditions Some practitioners emphasised the importance of creating a comfortable, cosy atmosphere and expanding the boundaries to a ‘milieu therapeutic’ setting in order to foster therapy goals: Combining therapeutic and atmospheric work, i.e. by having tea together after a session. (Therapist 101) The involvement of the therapist in daily life aims to build up a relationship and a motivation with the demented client. (Therapist 13)

The provision of drinks before, during and after the sessions and offering small snacks like fruit will help to satisfy basic needs. A chair-circle at the beginning supports stability and grounding experiences. Sitting safely opens up new possibilities for mobility and interaction. Chairs should be placed in such a way that participants can hold hands. Regarding the setting, a high frequency of group therapy is recommended (3–5 £ per week) to promote emotional reliability, orientation and stability in participants. Some therapists integrate family members once a week into sessions or offer mixed groups of children and the elderly. Informing other disciplines about the process and progress in DMT helps clients to improve their QOL. Interdisciplinary teamwork, regular contact and exchange with and feedback to other professionals are crucial as well as communication to the referring physician and/or the institution. Discussion The first aim of this study was to detect which themes emerged and to identify which interventions were used. The second aim was to examine how participants benefitted from DMT from the perspective of the survey respondents. The analysis of 113 questionnaires offers intervention guidelines and examples for different contexts. All therapists agreed that DMT would improve elderly people’s QOL. Their opinions are supported by QOL research, especially with reference to the improvement of physical health (Braüninger, 2012b; Jeon et al., 2005) and psychological health (Braüninger, 2012a, 2012b; Crane-Okada et al., 2012; Cross et al., 2012; Cruz & Sabers, 1998; Hamill et al., 2012; Heimbeck & Ho¨lter 2011; Hokkanen et al., 2008; Koch et al., 2013, Ritter & Low, 1996). Furthermore, practitioner-respondents agreed that DMT can stimulate participation and reduce isolation for the elderly. Research on the improvement of social relationships (Braüninger, 2012b; Koch et al., 2013) and the theory that the development of selfawareness is linked to the awareness of others (Fogel, 2013) supports this insight.


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Practitioners reported that DMT and dance group interventions show stabilising effects, which is confirmed by studies on cognitive abilities (Hokkanen et al., 2008; Van de Winckel et al., 2004), memory recall (Dayanim, 2009) and the delayed onset of dementia (Verghese et al., 2003). These findings are significant for health care providers’ economic viewpoint because group DMT is cost-effective (Pinniger, Brown, Thorsteinsson, & McKinley, 2012) and moreover seems to reduce medical costs (Jeon et al., 2005). The third aim identifies the therapists’ personal attitude as the most important coping strategy. Working with the elderly requires a special dedication and enthusiasm and the therapist should feel comfortable, be authentic and have love and respect for the elderly. The fourth aim of the study was to identify positive working conditions. The main result stresses the indispensability of a co-leader, in sharing the responsibility and attending to the different needs of patients, enabling trust and stability to develop. The last aim was to set out preliminary foundations for the development of theory and practice in DMT with the elderly. These are summarised in three closing statements: i. DMT with the elderly improves QOL. ii. DMT with the elderly fosters participation. iii. DMT with the elderly strengthens resilience. Limitations and suggestions for future research It could be argued that a study of practitioners’ opinion produces a low hierarchy of evidence with regard to effectiveness, appropriateness and feasibility (Behrens & Langer, 2004). One could also question whether practitioners can be the right ‘judge of skills’. On the other hand, non-practitioners cannot be asked for an expert opinion as that would make them an expert (Walton, 2010, p. XIIV). Further research could include a mixed methods design combining qualitative and quantitative approaches. One of the emerging themes in sessions was suicidality. Future research could focus on the support of DMT dealing with suicidality, as it is not well explored in scientific publication. Despite the study’s reasonable amount and diversity of participating practitioners the sample corresponded to a specific geographical area. Results should therefore be seen in this cultural context. Also, the author has transcribed original quotes and categories from German into English. Further research would be enriched by another a survey including a greater variety of therapists’ working in more countries to control for cultural differences. Additional resources for blind raters analysing data in future studies could reduce the risk of bias. Conclusion Results of the study presented here elicit how therapists’ judge the benefits of DMT for the elderly. Practitioners agreed that DMT supports the elderly to improve QOL through self-awareness by stabilising physical health, reducing physical limitations and increasing psychological health, social relationships, autonomy and


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participation, and this is not only true for the elderly. Furthermore, they point out that DMT stabilises cognitive functions, respects the dignity of the elderly and is an economical approach. Consequently, DMT may be suitable to be integrated as a standard treatment in all health service and facility settings for the elderly. DMT in the community may promote hope, joy and a sense of belonging. Acknowledgements I would like to warmly thank all the colleagues who participated in the survey and generously shared their expertise. Many thanks go to Elizabeth Marks who proofread the English manuscript. Special thanks go to my colleagues Fritz Frauenfelder and Bernhard Frey who kindly gave important feedback.

Note 1.

Cronbach’s Alpha for Psychological Health is insufficient (a ¼ .45); therefore, both items are calculated separately: Reduction of Suicidal Thoughts (n ¼ 59, M ¼ 4.6 SD ¼ .55), Improvement of Mental Well-Being (n ¼ 58, M ¼ 4.9, SD ¼ .26).

Notes on contributor Dr Iris Braüninger is a researcher at the Department for Research and Development, University Hospital of Psychiatric Zurich, a DMT supervisor with the German and Spanish Association, a registered dance therapist with the ADTA (DTR), a KMP notator and she holds the European Certificate for Psychotherapy (ECP). She was a post-doctoral researcher at the Stress and Resilience Research Team at the University of Deusto Bilbao. Iris teaches internationally and at the DMT Masters Program Autonomous University Barcelona and is a Master thesis tutor. Her research focuses on DMT efficacy, improvement of quality of life, stress management and resilience through DMT, and the development of movement assessment tools (KMP). She has published extensively on DMT.

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