Renee Loved to Dance
Dance/Movement Therapy

By Sarah Campbell Arnett, M.A.,A.D.T.R., N.C.C

Renee was 4 1/2 years old when she walked stiff-legged into my office. She was born with arthrogryposis, a congenital disease where the elbows and knees can't bend, and the feet are often malformed. Renee had a milder form of arthrogryposis so that her arms moved, but her knees wouldn't bend. People with arthrogryposis have difficulty with simple tasks like brushing their teeth or combing their hair. They have difficulty with walking because of foot placement. Not being able to bend the knee makes climbing, jumping or running difficult. But Renee loved to dance.

Renee was unable to attend regular dance classes due to her limited abilities. She had worked with another dance/ movement therapist for about a year before I met her. Renee had learned how to fall safely by using her arm strength, because when she fell she could not break her fall with her knees. She came to the dance/movement therapy sessions in many costumes. She had various tutus and leotards that she put together as only a 4-year-old can. She came ready to dance.

We worked on improving balance, building strength and developing a wider range of movements. Renee enjoyed the dance as she expressed her joy, fear, anger and frustration. The drumming African music allowed her to express her anger by using her strength. While the Nutcracker music played, she danced as a princess with grace and confidence. But it was the Little Mermaid music Renee and I danced through more than any other. I played the parts of the Sea Witch or the Prince, but Renee was always Ariel, the young mermaid who longed to have legs so she could join the humans. Ariel was willing to trade her voice for the ability to have working legs. The analogy between Ariel and Renee was beyond Renee's 4-year-old understanding, but we danced the mermaid story together for a year and a half. Renee is now an adolescent, very active in her school where, like Ariel, she continues to develop her musical ability and play four musical instruments.

Dance/movement therapy helped her to find her own creativity and ways to cope with a body that wouldn't always do as she wished. Dance/movement therapy was one method that worked with Renee. Her mother also provided her with equestrian therapy. The warmth of the horse relaxed her leg muscles and gave her increased flexibility. Now that I am trained in massage therapy, I can look back and see that relaxation through massage could have been beneficial to Renee's health. There are many body therapies available today, sometimes making it hard to know which is most appropriate or helpful for a given situation.

Here, I will highlight some of the similarities and differences between the two fields of dance/movement therapy and massage therapy, so that the reader can better understand the skills and knowledge of dance/movement therapy and how it can interface with your practice.

What is Dance/Movement Therapy?
The American Dance Therapy Association defines DMT as "the psychotherapeutic use of movement as a process which furthers the emotional, cognitive, physical and social integration of the individual." Those trained in this field are psychotherapists who use the body as the medium for exploration, diagnosis, healing and growth. Body movement is both the assessment tool and the tool for intervention. DMT works in both private practices and clinical settings.

The training for a dance/movement therapist requires an academic master's degree. Study includes anatomy/kinesiology, research, group dynamics, dance/movement therapy skills, group and individual therapy skills, nonverbal observation and assessment skills, psychopathology, cultural issues and family dynamics. Knowing that the body and mind are connected, dance/movement therapists work the body as a direct expression of the unconscious self. They maintain a focus on developing the healthy parts of the patient as a foundation for resolving any apparent dysfunction. Dance/movement therapists, like massage therapists, can work with most categories of people.

Dance/movement therapists use the expressive movements of the body to address emotional issues, which may include cognitive and/or physical aspects. Therapists can work within a wellness model for people who want to use movement opportunities to deepen and better integrate personal growth and health. They also work with people of all ages and with a variety of physical abilities. Work can be done with individuals, couples or groups.

The therapist may work with people who have blocks in movement patterns, or who have an altered perception of the body from emotional problems, or who have issues related to physical situations. This may sound similar to other body therapies. However, dance/movement therapists use body movements to help identify the problems, establish a treatment plan or "contract," and then use the body to focus on developing new, expressive, communicative or adaptive patterns. Most bodyworkers focus specifically on the body and leave therapists/counselors to work with the emotions. Dance/movement therapists bridge the gap by working with the interconnection of body, mind and spirit.

What Does a Session Look Like?
Since dance/movement therapy sessions develop spontaneously, they are usually different each time. Groups can be active or quiet; they can be fun and playful or very serious. The session is about what the person needs at the time of the session. Sometimes the sessions may look like an exercise class, a dance class or a meditation class. The dance/movement therapist observes the client and makes clinical decisions along the way based on treatment goals. What actually happens in the group is not as important as the client's relationship to the process during the group. So, if a passerby looked in on the session she may say it looked like a simple dance class. But within the session someone may be enjoying free movement for the first time, perhaps risking vulnerability by taking leadership, or expressing the grief, anger or fear they have harbored for years.

Touch is an obviously important part of the body therapy world. Bodyworkers know the power of touch and at times the feelings that touch can evoke. Touch can be intrusive and intimate, yet touch is an expected part of the massage "contract." Draping and explanation of the process help address the intimacy.

During a DMT session, touch may occur to connect, to push, to pull, to engage or to resist. Touch may not always occur in a session. Each time touch is used there needs to be careful consideration of how it is used and with what intention. In some clients, hidden memories of abuse can emerge around touch, which will be helpful in the diagnostic and healing process. Touch, too soon or without permission, can be detrimental to the healing process. A trained therapist must make clinical decisions many times during the session. A dance/movement therapist may need to seek permission from the clients when touch is part of a session. Clear documentation should occur regarding touch in the sessions for ethical and legal purposes.

The Work of a Dance/Movement Therapist
There are many kinds of work for the dance/movement therapist. Here are just a few:
* In psychiatric hospitals -
Dance/movement therapists address the fragmentation of the body of the schizophrenic, the limpness and immobility of the suicidally depressed patient, or the fragility of mood swings with the bipolar patient. They help educate the client/patient about the body/mind connection related to their illness.
* With chronic pain patients -
During the initial stages, a therapist works on the patients' ability to feel more comfortable within their body, and helps them develop body awareness through muscular tension release and breath flow. Later stages may include addressing the relationship of pain with the client's body image and acquiring tools to give a sense of control of the pain while positively affecting their body.
* With infants, children and adolescents -
Movement is the language for children. Dance/movement therapists working with this population bring additional skills in developmental work and group process. Movement observation may identify the flaccidity of a failure-to-thrive child, the quickness and impulsivity of a hyperactive child, or absence of expected motor sequences in a developmentally delayed child.
* With substance abuse patients -
DMTs pay attention to cues and sensations from the patients' bodies to help identify self-destructive feelings and urges. The therapist helps the patient recognize and rely on their inner strengths, releasing them from external dependence.
* In medical hospitals -
The clinician can facilitate movement and touch for the amputee to identify their new body boundaries and their change in weight and balance. The therapist may work with the cardiac patient to decrease fear of his body "attacking" him and to teach him more about self-awareness, self-monitoring and self care.
* With head-injured patients -
Here the therapist might work to decrease the patient's spasticity, to reintegrate new/altered brain messages to the rest of the body, and to help the patient increase his functioning level.
* In prisons -
Dance/movement therapists might address tension patterns related to being incarcerated. By using dance/movement therapy, prisoners can be taught to re-establish trust in their own actions and opportunities to develop better relationship patterns.
* With developmentally challenged -
The dance/ movement therapist would use the nonverbal medium to help clients express themselves, enhance relationships and learn helpful behavioral patterns.
* With eating disorder clients -
The dance/ movement therapist might help the client establish more realistic body perceptions, learn to appreciate the body and enhance their body boundaries. The client would also learn to recognize tension patterns as a sign of unexpressed feelings.
* With sexual abuse survivors -
Often after abuse, survivors lose their mind/body connection by dissociation. The task for the dance/movement therapist is to help the client use movement to identify feelings as they arise in the body, to regain control over confusing thoughts and feelings, and to share difficult emotions that remain nonverbal.
* Dementia and the older adult -
The DMT can use rhythmic and repetitive movements with combinations of soothing, calming and activating movements to enhance body awareness. Deep breathing, sequential movements, and touch may be used to replace isolation and confusion with a sense of belonging and meaning.

A dance/movement therapist often works with other professionals in the clinical setting. A therapist may share their nonverbal observations with the team to help with diagnoses and progression of treatment. I have sometimes identified the organic body movements in a demented patient (which appears as bizarre patterns around the midline of the body) before the dementia shows up in the cognitive process. These unique methods of assessment from the dance/movement therapist can be very helpful in a treatment team.

Referring to a Dance/Movement Therapist
Recently, a psychotherapist sent me a referral for massage. On our first meeting it was clear the client was ambivalent about massage, yet she thought she needed "bodywork" to help her recover from sexual abuse issues. She was extremely nervous and her posture was tense and guarded. She said she was uncomfortable disrobing for the massage.

Together, we decided that during our next three sessions she would lay on the table fully dressed while I sat across the room teaching her basic relaxation skills (deep breathing, progressive relaxation, etc.). She had told me she coped with difficult situations by dissociating (losing touch with reality by a sense of leaving her body). She continued to dissociate during our sessions (she couldn't remember parts of the session even though she was "awake" the entire time). From my perspective, the client cannot integrate the bodywork, if, during the massage, the person is "out of their body." The music triggered more anxiety in one particular session. It seemed clear to me that her body was not ready for that type of bodywork just yet. I referred her to another dance/movement therapist for body-related psychotherapy since I do not do outpatient dance/movement therapy. We discussed keeping massage therapy in mind for future bodywork.

When touch brings up too many issues which interfere with the massage process, a massage therapist may want to make a referral. Psychosis, dissociation, uncontrollable tears or anger may surface during a bodywork session which need to be addressed in psychotherapy. Dance/movement therapy may be more appropriate when a client identifies and wants to integrate body image issues. Often DMT is helpful when the client needs to use his/her body as a nonverbal medium to explore or enhance self-awareness.

When Might a Dance/Movement Therapist Refer to a Massage Therapist?
A dance/movement therapist may want to work with a massage therapist when a client has tension or postural problems which interfere with movement. If a client is focused on pain in the body which may not be directly connected to emotional issues, direct soft tissue work may be indicated. A referral may be helpful if the client/patient wants more experience with relaxation, including more hands-on work.

I work in an inpatient adult psychiatric hospital. I lead daily dance/movement therapy groups. Sometimes in these DMT sessions patients begin to address tightness and tension they feel as they begin to move. If massage comes up as part of the group process, and is initiated by the patients, I may teach groups of patients about shoulder massage and ways to relieve stress. I usually do not tell the patients that I am a massage therapist unless they ask. At times the unit psychiatrists have written orders for me to give head and shoulder massage to patients to decrease tension or headaches. I do not receive massage referrals to my private practice from the psychiatric patients on my unit since that can be seen as soliciting and as a conflict of interest. If a patient asks about massage therapy or responds well to massage, I help the patient find a local therapist. Because I am employed as a movement therapist, it is important to keep my roles clear. I certainly bring the massage skills to the job, but massage is not my primary function at the hospital. When I do massage on referrals, I get a physician's order and work on my "off" time. Patients or their families pay me directly - so there is no billing. When I was assigned to rehabilitation services, I did massage as part of my work hours, but there was no fee charged to the patient, and I did not get additional compensation.

While at rehab services, I would get physician orders to work with patients with head injury, sickle cell patients, spinal cord patients, and patients with Guillain-Barre. I had the freedom to decide how I would use movement and/or massage therapy skills. Once I was referred to an 81-year-old patient with Guillain-Barre, a neurological disease. This left him paralyzed primarily in the lower extremities. The patient and his wife had done ballroom dancing together for years. The physical therapist asked me to consult as a dance/movement therapist. Occasionally, I would co-treat with another rehab therapist. The patient and I used familiar dance-like movements to enhance his physical therapy and recovery from the illness.

My sessions were usually later in the day and the patient was often fatigued from the other therapies, so I changed my sessions to massage for muscle fatigue and sensory stimulation. This patient had a tremendous support system from his family, demonstrated a lot of emotional strength, and was able to talk about his recovery process. He did not need psychotherapy as much as he needed massage therapy. I decided my massage skills would be more beneficial to the patient at that time.

I was also consulted to work with a 6-year-old patient who was having difficulty in physical therapy. She was lethargic and weak in some sessions, while in others she was extremely sensitive to touch and had pain sensations that blocked therapy. The physical therapist and occupational therapist asked for my help in using new ways to work with this child. The whole team was working with the child to determine the diagnosis. The differential diagnoses were meningitis, encephalitis or Guillain-Barre. The movement patterns continued to decrease and the flaccidity increased. I did not see this deterioration as any acting out behavior or resistance to therapy. The deterioration continued and the child was eventually diagnosed with Guillain-Barre.

The child became paralyzed in both upper and lower limbs. At that point I talked with the neurologist and the rest of the team and recommended that massage might be more beneficial for recovery than the dance/therapy skills. I began massage to stimulate the nervous system and to provide pain relief from a long day of therapies. Many days the child had been through lots of painful procedures so massage became the "treat" for the day. I worked with this patient for weeks until she was discharged. The patient returned to the hospital months later to demonstrate her abilities on her new bike, which she rode down the hallway in the hospital.

Melding Them Together
As I began my training in massage therapy, people often asked me how it was related to my current skills as a dance/movement therapist. I believe the massage training complimented my DMT skills. My focus for my dance/movement therapy training was with group process and human development. The massage training gave me specific information about the body and the body systems that enhanced my current skills as a DMT. I translated these body-based skills into presentations I could offer the community. I get many requests within the hospital and from the general public asking for presentations about stress management, conflict resolution and relaxation skills. The content I share comes from my knowledge base of both massage therapy and dance/movement therapy.

Both professions, massage therapy and dance/movement therapy, utilize the body-mind connection. It's important to discuss with one another how we can work together and share the wealth of information we all have. Each discipline has its own unique expertise to offer. When both professional groups work cooperatively, I believe the therapists and the clients will benefit enormously. Just as Renee had to learn at age 4 to cope with a body which wouldn't do as she wished, we all have the opportunity to integrate the body, mind and spirit in order to reach our fullest potential.

What's the ADTA?
The American Dance Therapy Association (ADTA) is the international organization which helps credential professionals and educate the public about dance/movement therapy. Marian Chace is seen as one of the founding mothers of the ADTA. She had danced with the Denishawn Dance company in the 1930s, and lived in the Washington, D.C. area where she was well-known as a dance teacher and choreographer. By the 1940s her classes had gained popularity and she was asked to take special needs children who seemed to respond to her teaching and to the dance. They kept returning to her classes. She wondered what was it about the dance that was helpful.

Chace was asked to dance with patients at St. Elizabeth's hospital and at Chestnut Lodge. She began to teach dance in the back wards of psychiatric units at a time when most of the psychotropic drugs were not in use. The patients she saw had been considered unremediable for 30 to 50 years, and were often catatonic, isolated and nonverbal for years. Chace found that as she danced with these patients they began to interact, speak and move with her. Again, she asked what was it about the dance that was healing?

In response to the large number of World War II veterans returning home, there was an explosion in the work being done in psychiatry to care for these large groups of patients. During her time at St. Elizabeth's Hospital (which in its prime capacity had a census of 8,000 patients), Chace worked with some of the best psychotherapists of the day. Harry Stack Sullivan, known for his group work, emphasized the importance of the therapist's presence as part of the therapeutic environment. Sullivan greatly influenced Chace's work.

Chace also worked with Jacob Moreno as he was developing psychodrama. Dance/movement therapy was also developing on the West Coast about the same time. Chace began to train students in leadership skills, nonverbal assessment, group synchrony, rhythmic patterns and group process. Eventually there seemed to be a need to organize this newly forming modality, so in 1966, the founding mothers organized ADTA to further educate and promote dance/movement therapy. Today, there are approximately 1,000 dance/movement therapists around the world. The ADTA produces several timely monographs, a quarterly newsletter and the American Journal of Dance Therapy. The association has a code of ethics and a standing board of directors. There is no licensure at this time, but the ADTA's professional members have a two-level credentialling process: DTR (Dance Therapist Registered) represents the entry-level professional and ADTR (Academy of Dance Therapist Registered) identifies the advanced clinician who can then teach and supervise. In February 1999, the National Board of Certified Counselors, Inc. (NBCC) and the ADTA outlined a formal affiliation which designated the ADTR credential in dance/ movement therapy as a counseling specialty credential. This allows dance/movement therapists who meet the educational and training standards under the agreement to have a special application option for taking the National Counselors Exam (NCE), thereby allowing ADTRs to apply for the National Certified Counselor's (NCC) credential. For more information about the organization, graduate schools or research, visit the ADTA Web site at www.adta.org.

Sarah Campbell Arnett is a registered dance/movement therapist, a nationally certified massage therapist and a nationally certified counselor. She received her master's degree in dance/movement therapy from Goucher College in 1984 and served for eight years on the board of directors of the American Dance Therapy Association. Arnett trained in massage therapy at the Body Therapy Institute in 1991 and now works as a program coordinator for the Moses Cone Behavioral Health Unit in Greensboro, N.C. She continues to provide dance/movement therapy groups at the hospital, and maintains a private massage therapy practice in Greensboro as well. Arnett can be reached at smcmonty@aol.com.

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