Dance movement therapy for obese women with emotional eating: A controlled pilot study

The Arts in Psychotherapy 39 (2012) 126–133

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The Arts in Psychotherapy

Dance movement therapy for obese women with emotional eating: A controlled pilot study Bonnie Meekums, PhD c,∗ , Ieva Vaverniece, Mg.sc.sal., Mg.soc.sc. a , Indra Majore-Dusele, Mg.psych., Mg.sc.sal. b , Oskars Rasnacs, Mg.math. d a

Arts Therapies Centre, Institute of Health, Latvia, Blaumana 32-8, Riga LV-1050, Latvia Riga Stradins University, Faculty of Rehabilitation, Dzirciema Str. 16, LV-1007, Latvia c University of Leeds, School of Healthcare, Leeds LS2 9JT, UK d Riga Stradins University, Faculty of Medicine, Department of Physics, Dzirciema Str. 16, LV-1007, Latvia b

a r t i c l e

i n f o

Keywords: Obesity Dance movement therapy Emotional eating Controlled study psychological distress Body image distress

a b s t r a c t This study explored the effectiveness of dance movement therapy (DMT) in obese women with emotional eating who were trying to lose weight. 158 women were recruited from a commercial weight loss programme: 92 with BMI ≥ 28 were identified as emotional eaters and divided into: an exercise control (n = 32) and non-exercisers (n = 60). The non-exercises were partially randomised to non exercise control (n = 30) and treatment group (n = 30). Using a pre- and post-intervention design, 24 of the DMT treatment group, 28 of the exercise control and 27 of the non-exercise control completed all measures on a battery of tests for psychological distress, body image distress, self-esteem and emotional eating. Findings were analysed for statistical significance. The DMT group showed statistically decreased psychological distress, decreased body image distress, and increased self-esteem compared to controls. Emotional eating reduced in DMT and exercise groups. The authors cautiously conclude that DMT could form part of a treatment for obese women whose presentation includes emotional eating. Further research is needed with larger, fully, and blindly randomised samples, a group exercise control, longitudinal follow-up, a depression measure, ITT, and cost analyses. © 2012 Elsevier Inc. All rights reserved.

Introduction The number of obese people (body mass index (BMI) above 30) is increasing in the whole world. Reducing obesity is thus a global challenge. Worldwide, the number of obese people has more than doubled since 1980 (World Health Organisation, 2011). Data from The National Health and Examination Survey of 2010 confirm that about 1/3 of USA adults (33.8%) and approximately 17% (or 12.5 million) of children and adolescents aged 2–19 years are obese (Centers for Disease Control and Prevention, 2010). The latest Health Survey for England (Craig & Hirani, 2010) data shows that in 2009, 23.0% of adults and 14.4% of children were obese. The Foresight report, the implications of which are discussed by Aylott, Brown, Copeland, and Johnson (2008) predicted that if no action was taken, more than half of the UK adult population would be obese (60% of men, 50% of women) by 2050. More than one-third of citizens of the European Union (EU) are overweight and one in ten is obese. 400,000 children of school age become overweight each year. Eight per cent of health care expenses are directed towards solutions for the obesity problem (European Parliament, 2008).

∗ Corresponding author. Tel.: +44 113 343 9414. E-mail address: [email protected] (B. Meekums). 0197-4556/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2012.02.004

Obesity can have a severe impact on people’s health, increasing the risk of type 2 diabetes, hypertension, heart disease (Craig & Hirani, 2010), elevated blood cholesterol levels, stroke; and after the menopause cancer of the breast and uterus, osteoporosis and joint problems (Twigg, 2006, chap. 6). The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity amongst people of all ages in 2008/09 was over eight times as high as in 1998/99 and nearly 60% higher than in 2007/08 (NHS, 2010). Consequences of obesity are not just physical; quality of life of obese persons is reduced, because obesity impacts on physical, emotional and social functioning. There is also a significant burden on health and social services; whilst precise predictions have been disputed, there is little doubt that without effective action most societies will continue to bear an increasing cost due to a greater prevalence of chronic diseases arising from obesity. Psychological aspects of obesity Some research suggests no close relationship between obesity and psychological disturbance or particular features of a personality (Salinsky & Scott, 2003). But there are a number of studies which contradict this finding, for obese people who seek medical help and health programmes (Friedman, Reichmann, Costanzo, &

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Musante, 2002). For example, a relationship has been demonstrated between obesity and psychological disturbance for Caucasian women with high social-economic status, and adolescents who suffer from depression are more likely to become overweight adults than adolescents who are not depressed (Stunkard, 2003). Obese people also have significantly lower self-acceptance and selfesteem, are at greater risk of psychological distress and suffer more day-to-day interpersonal discrimination, employment and institutional discrimination compared to normal weight individuals (Carr, Friedman, & Jaffe, 2007). A significant relationship between obesity and body image disturbance acts as a mediator for increased depression and lower self-esteem (Friedman et al., 2002). There is a relationship between obesity and poor body image, though not all obese people suffer from body image distress (BID). The risks for BID include: high BMI, feminine gender and emotional eating. There is thus a clinical need to identify people at risk and to consider developing weight loss programmes that aim to prevent BID. BID in overweight individuals decreases with weight loss, but increases as weight is regained (Sarwer & Thompson, 2002 cited in Schwartz & Brownell, 2004); depression decreases with weight loss overall but can increase if the degree of weight lost is lower than expected (Faulconbridge et al., 2009). Most of the weight lost as a result of following a reducing diet is regained within a few years (Shaw, O’Rourke, Del Mar, & Kenardy, 2005). Emotional eating, obesity and diet Emotional eating can be understood as overeating as a reaction to emotional states (Van Strien, 2002). There is a need for more research on the role of emotions in relation to overeating, as the processes are little understood. One possibility is that awareness of hunger and satiety is reduced in emotional eaters, whereas emotional states (including positive emotions like joy for example) are not tolerated, food providing an opportunity to metaphorically swallow feelings. Emotional eating is closely linked to Binge Eating Disorder (BED), (American Psychiatric Association, 1994); both include the consumption of large amounts of food together with a subjective loss of control over both eating behaviour and psychological distress. The term emotional eating is used in the present study as it does not depend on a medical diagnosis but on selfreport, and highlights the role of the emotions in determining or maintaining the problematic behaviour. Eating in obese persons (especially when combined with emotional eating) often seems to be initiated by the absence of perceived hunger. For example, overweight individuals are more likely to overeat in negative emotional situations than either normal or underweight individuals (underweight individuals being more likely to undereat in similar situations) (Geliebter & Aversa, 2003). A link has been demonstrated between emotional eating and psychological discomfort, low self-esteem, negative body image and affective disturbances. These negative experiences are likely to be exacerbated by the fact that obese people are subjected to stigmatisation, discrimination and lower quality of life (Annis, Cash, & Hrabosky, 2004). The link between self-esteem and eating disorders has been reported in several studies, and negative self evaluation has been recognized as a risk factor for the development of eating disorders (French et al., 2001). Some studies suggest that low self-esteem predicts the development of eating disorders (Zalta & Keel, 2006). A bidirectional relationship has been posited between dieting, emotional eating and negative self-esteem: each dieting failure might decrease self-esteem, which in turn jeopardises dietary adherence (Heaterthon & Polivy, 1992, cited in Baumeister, Campbell, Krueger, & Vohs, 2003). Chronic dieters enter a spiral; dieting failures inhibit successful acceptance of the body which in turn leads to decreased

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self-esteem and decreased self-efficacy (self-efficacy being necessary for dietary adherence). It has been shown that chronic dieting and negative body image is a combination which leads to negative self-esteem (Matz, Foster, Faith, & Wadden, 2002). An important aspect of appearance and body image is body weight, especially for women; if a woman evaluates her self-worth according to her appearance (self-esteem increasing with body image satisfaction) this poses a potential risk factor for both psychological distress and eating disturbance, including depression (Crocker & Garcia, 2005). It has been noted that eating disorders and body image dissatisfaction are both common problems, especially in women (Cash, 2000). Negative feelings about physical appearance are linked with a range of psychological consequences which include low self-esteem and depression for adults as well as for adolescents. Body image disturbances are recognized as a risk factor for women who change their eating habits with the aim of changing their appearance or to lose weight. This can lead to the development of eating disorders, due to the negative spiral identified above. Preventive programmes are especially needed in such cases to promote women’s awareness of their body image and its link to possible eating problems (Cash & Fleming, 2002). The research problem and questions Commercial weight loss programmes are a popular product in Western culture, created in response to ongoing concerns in society about overweight and obesity. However, the results are only evaluated short-term. Most people regain the lost weight over the years following their involvement in the programme. Many are trapped in a cycle of attempting to lose weight, losing control and then feeling bad about themselves, leading to further psychological distress, disordered eating and weight gain. It has therefore been suggested that weight loss programmes should work towards the dual goals of weight loss and increased self acceptance (Devlin, 2001). Complex relationships between emotional eating, body image distress and psychological consequences suggest the need for a non-stigmatising therapy that allows participants to safely access their emotions and which encourages self-reflection, includes diet and physical exercise and addresses the complex relationships identified in obesity with emotional eating. An optimal therapy for this client group focuses on psychological issues associated with weight loss, because overeating is seen as a symptom of deeper emotional problems and permanent changes in eating behaviour are unlikely without addressing these underlying issues (Van Strien, 2002). Dance movement therapy (DMT) was thus envisaged as a potential psychological treatment because it encompasses awareness of and reflection on body image and emotional states, whilst also offering the benefits of an exercise programme. The present study was needed because although the case has made the case for scientific evidence based DMT research, there was no existing research to test the possible effectiveness of DMT for women with obesity and emotional eating (Meekums, 2005, 2010). Research questions were as follows: 1. Is DMT effective in increasing wellbeing and self-esteem and decreasing psychological symptoms for obese women with emotional eating? 2. Is DMT effective in decreasing body image distress for this patient group? Methods Design This research design was based on a previously published review (Meekums, 2005). The four treatment groups were facilitated by

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the first two authors (two groups each), who also conducted data collection and analysis as part of their Masters dissertations. The dual roles necessary for completion of a Masters thesis in a new discipline within Latvia are acknowledged to be a design weakness (this was the first cohort to complete a newly validated and state accredited MSc in arts therapies at a European University). The third author was involved in research design, acted as critical friend, and substantially contributed to writing up, and the fourth author provided statistical support. The original proposed design was for a randomised controlled trial. However, full randomisation was not possible due to the limitations of sample size.

Sampling strategy Inial recruitment N = 158

Met criteria and consented N = 92

Sampling The sample was taken from women who participated in a commercial weight loss programme in Latvia, thus ensuring that all participants were following a similar diet. Inclusion criteria were originally as follows: engaged in the weight loss programme either face to face or online; body mass index (BMI) 30 or above (obese); emotional eating. Demographic data were obtained and all participants were asked about physical problems and mobility restrictions, in order to provide a safe environment. They were also asked whether or not they engaged in physical activity twice or more times a week in order to facilitate selection into one of three groups: control group exercising (Cont1); control group not exercising (Cont2); or treatment group not previously exercising (Exp). Permission for the study was granted by the head of the weight loss programme in the cities of Riga and Jurmala (a seaside city about 25 km west of the capital Riga). This resulted in 158 participants being recruited both in person, at local classes and via an announcement in the organisation’s local web page. Insufficient numbers were obtained in the BMI 30 or above range, and so this was reduced to 28; whilst most of the research on health risks has been conducted using the BMI criterion this is an arbitrary measure and so the reduction to 28 is not seen as jeopardising the study. It is also likely that several of these women had reached a BMI of 30 or above before they started their weight loss programme. 92 women were selected as fulfilling the criteria of emotional eating with a BMI 28 or more, and gave their informed consent. The sample was divided pragmatically into the following three conditions: 1. Treatment group (Exp): women with BMI 28 and above with emotional eating, involved in a Weight loss programme who were not already participating in other physical activities and who attended 10 group DMT sessions twice a week during a period of five weeks (n = 24). 2. Control group (Cont1): women with BMI 28 and above with emotional eating, involved in a Weight loss programme, who were already voluntarily participating in physical activities at least twice a week but did not attend DMT (n = 28). 3. Control group (Cont2): women with BMI 28 and above with emotional eating, involved in a Weight loss programme who were not already participating in other physical activities and who also did not attend DMT (n = 27). Fig. 1 shows the sampling process as a flow chart. Some women self-selected into the second (non exercise) control group because they chose not to participate in DMT, despite being offered a group that was accessible geographically. Those women who were not selected into the treatment group were, however, offered the chance to participate in 10 DMT sessions after completion of the study. The three groups did not differ significantly in terms of average age (Exp = 38.5, Cont1 = 40.1, Cont2 = 38.7). Most of the participants

Cont1 Exercise control

Cont2 Non exercise control

Exp Treatment group

N = 32

N = 30

N = 30

Completed all measures

Completed all measures

Completed all measures

N = 28

N = 27

N = 24

Fig. 1. Sampling strategy.

Sample characteristic by age

60,0% 50,0% 40,0% 30,0%

20-35

20,0%

>50

36-50

10,0% 0,0%

Exp

Cont1

Cont2

Fig. 2. Sample characteristics by age.

at the treatment group were in the age group 20–35 years, whereas most of both control groups were in the age group of 36–50 years. However, the treatment group also included more participants over the age of 50 (see Fig. 2). The intervention The two therapists (authors 1 and 2) each facilitated two DMT groups of seven and eight women. One and two respondents from the groups of each therapist left the treatment DMT programme (see Table 1). The programme composed 10 sessions each with duration of 1.5 h, twice a week over five weeks. The aims were to increase: (1) body awareness; (2) emotional awareness, (3) self-reflection and (4) self-acceptance. Directive and non-directive approaches were combined in order to complete the short-term DMT programme in 10 sessions. These approaches were based on the theoretical and empirical research DMT literature available for relevant client groups (eating disorders, body image, self-esteem, short-term DMT, etc.), (Bloom, 2006; Brauninger, 2006; Frisch, Franko, & Herzog, 2006; Krantz, 1999; Lewis & Scannell, 1995; Pylvanainen, 2003). The theoretical frame used for the programme was Meekums’ understanding of the central importance and use of movement metaphor and the WISE/EMPoweR model for creative change, which includes phases of warm-up, immersion in the creative activity, insight and

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Table 1 Attrition rates for Treatment groups and each control Key: Groups 1 and 2 facilitated by therapist A (in Riga centre), Groups 3 and 4 facilitated by therapist B (in Riga also, but less central).

N at start of study N completing all measures

Group 1

Group 2

Group 3

Group 4

Cont1

Cont2

8 6

7 6

8 7

7 5

32 28

30 27

o Body awareness (attention to the body; breathing, body boundaries, sensitiveness, space) o Body language and self-acceptance in both verbal and non-verbal communication o Investigation of movement symbolism and movement metaphor o The body-mind connection o Dance and self-expression, work with props o Grounding, relaxation, positive body experience o The importance of the group and the understanding that there are others with similar problems

Fig. 3. Basic principles guiding the DMT treatment programme.

evaluation within a defined therapeutic relationship (Meekums, 2002, 2006). The DMT programme included the basic principles identified in Fig. 3, and the programme structure is shown in Fig. 4.

Formative, warm-up stage (sessions 1-2): 1. Rhythm; responding to music of different nationalities/ movement characteristics

Measures and their analysis Participants completed a battery of tests before and after the DMT group. All measures were adapted according to test adaptation guidelines for usage in Latvian or had been previously adapted and used in Latvia. A direct translation method was applied: three translators who were educated in philology (philology is the study of language, tracing developments over time or comparing languages or varieties of language), psychology, and sociology translated into Latvian and then conducted back translations into English. The tests were then piloted to check the coherence of the questions. The measurements used were as follows, both pre- and post-treatment and at analogous times for each control group:

2. Movement qualities (space, time, weight, flow) and their psychological function

Differentiation and intimacy stages (sessions 3-8): 3. Different body parts, body boundaries, space 4. Personal space and others; stop and go 5. Giving-taking-holding-letting go 6. Emotions and feelings: embodiment and expression; safety and comfort

Dutch eating behaviour questionnaire (Van Strien, 2002) To gather data about eating behaviour and BMI and to select respondents with emotional eating, the DEBQ was used. This measures individual eating behaviour (emotional eating, external eating, restrained eating). This is a valid instrument with three scales relating to emotional eating which help to distinguish diffuse emotions (loneliness, etc.) and clear emotional states (anger, etc.). The Cronbach’s alphas in a sample of this study confirmed satisfactory validity with ˛ = 0.72–0.89.

7.My body image: how I do see it and how it is seen by others 8. Self-acceptance – my sunny and shadow side; integration

Separation and closure stage (sessions 9-10) 9. Me: present and future 10. Parting

Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) (Evans et al., 2002) This Questionnaire is widely used in the UK for service evaluation before and after treatment. CORE-OM has been used in research to evaluate treatment efficacy (Barkham et al., 1998, cited

Fig. 4. Structure of DMT programme.

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in Core System Group, 1998) and in personality disorder research (Howey & Ormrod, 2002; Whewell & Bonanno, 2000, cited in Evans et al., 2002). Three of the four scales were used for this study: subjective well-being, psychological problems/symptoms (including depression, anxiety and physical and trauma symptoms) and general functioning (including everyday productivity, close and social relationships). In this study data relating to the well-being and general functioning scales was inverted to reflect an intuitive understanding for the international reader; an increased score is thus associated with an increase in well-being and functioning, whilst a decreased score remains for decreasing symptoms. In statistical analyses Cronbach’s alphas for the scales in a sample of this study were ˛ = 0.70–0.88.

Acceptability of the treatment Table 1 shows the attrition rate for each group. The low attrition rate appears to demonstrate a level of acceptability for this form of treatment. However, this result must be viewed cautiously due to the short time scale over which the study was conducted. Well-being, general functioning and psychological symptoms Clinical outcome measurements show significant improvement in the mean scores of well-being and significant decrease in psychological symptoms in the treatment group from before (1Exp) to after (2Exp) completion of treatment (see Table 2). In both control groups there were no significant changes in well being and psychological symptoms during the intervention period. There were no significant changes in general functioning in any of the three groups.

The Situational Inventory of Body Image Dysphoria (SIBID) This scale measures body image, which is a multifaceted psychological construct that includes the subjective attitudinal and perceptual experiences of one’s body, particularly its appearance. The questionnaire assesses negative body-image emotions in specific situational contexts, for example: situations involving body exposure, social scrutiny, social comparisons, wearing certain clothing, looking in the mirror, eating, weighing, exercising, etc. (Cash, 2000). Validity is appropriate for evaluation of therapeutic changes. The Cronbach alphas in a sample of this study were ˛ = 0.87–0.94.

Body image distress The results shown in Table 2 demonstrate a statistically significant difference for the means of body image distress before and after DMT treatment and that there were no significant differences in the means pre- and post-intervention measures for either of the control groups. Self-esteem Table 2 shows significant improvement in self-esteem in the treatment group after DMT. In both control groups there were no significant changes during the intervention period.

The Rosenberg self-esteem scale This is one of the most widely used scales for the evaluation of self-esteem. The one-dimensional structure has been used in this research to measure global self-esteem. This scale has been used in earlier Latvian research (Miltuze, 2003). SPSS software was used for the analysis. Descriptive Statistics, the T-test for paired and independent samples and the ANOVA were applied using p < 0.05 as the benchmark of statistical difference between means.

Eating behaviour Eating behaviour was not a focus of the study, but it was observed. Results showed a significant decrease in emotional eating after the intervention in the treatment group and in the control group with physical activities Cont1. Control group Cont2 did not show significant changes in comparison of before and after the intervention (see Table 2). Also the ANOVA (Analyses of Variance) has been applied to compare the means of the difference of the first and second measures in the two and more groups of the survey (see Table 3). Results confirm statistical significance in the comparisons where the Exp group is included and no significance in the comparison of the both

Results 24 women completed the DMT programme and all measures, 28 of Cont1 completed all measures, and 27 of Cont2 completed all measures. Table 2 Summary statistics. Paired samples

1Exp 2Exp 1Cont1 2Cont1 1Cont2 2Cont2 Paired samples

1Exp 2Exp 1Cont1 2Cont1 1Cont2 2Cont2 *

Well-being

Psychological symptoms

Mean

SD

t

˛

Mean

SD

2.30 2.95 2.51 2.58 2.46 2.60

0.94 0.56 0.74 0.75 0.75 0.62

−3.94

0.001*

−0.33

0.774

−0.35

0.726

1.42 0.79 1.28 1.15 1.33 1.33

0.84 0.55 0.64 0.79 0.59 0.57

Self-esteem

General functioning

Body image distress

˛

Mean

SD

t

˛

Mean

SD

t

˛

4.32

0.000*

0.097 0.396

0.97

0.386

−0.69

0.494

0.461

0.648

14.28 14.33 11.19 11.59 11.89 13.44

0.004*

−0.862

41.95 31.41 32.60 29.46 41.44 37.77

3.02

0.562

0.63 0.33 0.45 0.35 0.46 0.44

−1.73

0.58

2.69 2.94 2.78 2.82 2.59 2.61

1.07

0.289

t

Emotional eating

Body mass index

Mean

SD

t

˛

Mean

SD

t

˛

Mean

SD

t

˛

18.66 22.83 20.32 20.14 19.74 19.77

4.07 4.13 4.98 3.56 5.18 3.95

−6.86

0.000*

3.43 2.54 3.26 2.91 3.26 3.04

0.60 0.63 0.50 0.67 0.73 0.78

6.26

0.000*

0.000*

0.001*

4.64

0.000*

1.86

0.074

3.58 4.26 3.17 3.20 4.59 4.68

4.10

3.75

32.78 31.37 31.14 29.54 30.74 29.63

4.86

0.000*

0.208 −0.03

0.837 0.972

p < 0.05 statistically significant difference in the means of samples.

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Table 3 Comparison of the difference of the means of the first and second measures for emotional eating in general scale (DEBQ scores), psychological distress (CORE – Outcome measure total scores), self-esteem (Rosenberg Self-Esteem Scale scores) and body image distress (SIBID scores) in the all groups: p-values of the ANOVA.

Exp Cont2 Cont1 Exp Cont2 Exp Cont1 Cont2 Cont1 *

Emotional eating

Psychological distress

Self-esteem

Body image distress

0.002*

0.025*

0.030*

0.000*

0.002*

0.007*

0.017*

0.001*

0.002*

0.185

0.026*

0.000*

0.920

0.139

0.858

0.485

p < 0.05 statistically significant difference in the means of samples.

control groups. For comparison of the CORE scores the difference of the all scales in total has been compared; results confirm significance in all comparison except the Exp with control group Cont1. All the other comparisons, for emotional eating, self-esteem and body image distress demonstrate significance for the Exp group. Weight loss Whilst weight loss was not a focus for this study, data about weight were collected before and after the duration of the treatment group. The data concerning body mass index (BMI) (see Table 2) demonstrate that there were statistically significant changes in BMI before and after the treatment period in all three groups; the treatment group and both controls lost weight. The statistics for all parameters are summarized in Table 2. This shows that, whilst all groups lost weight, only DMT and exercise were associated with a reduction in emotional eating, and only the DMT treatment (experimental) group demonstrated improved well being, raised self-esteem and reduced body image distress. Discussion The results of this study do not support previous research linking weight loss to psychological well-being, since all groups lost weight but only the treatment group improved on a range of psychological measures; this challenges the predominant discourse supported by the weight loss industry linking weight loss to happiness. One of the limitations of this study is that the sample size is limited; there was a need to redefine the target sample as BMI 28 and above instead of BMI 30 and above in order to achieve a target size that could be analysed statistically. BMI remains a crude measure of obesity, though the cut-off point of 30 and above has been used in most of the literature concerning obesity, making comparisons in terms of effect size problematic. The necessity of multiple roles for two of the authors (including acting as therapists, allocating participants to treatment and control conditions, data collection and analysis) introduces a bias to the research. As explained above, this was necessary in order to fulfil the requirements for the Masters dissertation, and was partially overcome by the introduction of the third author as critical friend. The failure to fully randomise was due to the need for sufficient numbers for each of the DMT groups in given geographical locations. However, randomisation would have been easier to achieve if all volunteers for the study had received adequate information and preparation in order to give informed consent at the outset to participation in any of treatment and control conditions. In future studies, greater confidence in the results could be obtained through an intention to treat analysis; however, since similar numbers dropped out from the control groups combined as in the treatment group, it is possible that any effects due to adherence to the study requirements of those who lost weight over those who did not are ironed out in the present study.

Despite methodological shortcomings, some significant results were obtained to suggest a possible superiority (in this study) of DMT over exercise and non exercise controls in the reduction of body image distress and psychological distress and in the increase of self-esteem, and over non exercise controls for reduction in emotional eating. These results should be viewed cautiously however, since the control groups were found by asking volunteers about their existing exercise habits and no attempt was made to provide further exercise intervention to either of the two control groups. The differences between the two control groups are worthy of comment. Those women (Cont1) who regularly participated in exercise had higher scores at baseline on self-esteem and lower body image distress than those who did not participate in any physical activities (Cont2) or the group (Exp) allocated to DMT, as one might expect. This group (Cont1) also significantly decreased their emotional eating over time, despite no intervention. These results allow no conclusions as to cause and effect between selfesteem, body image and physical activities, though they do suggest a correlation. It may be that, as has been suggested elsewhere in the literature, women with higher self-esteem will find it easier to become involved in physical activities (Meekums, 2005); if they evaluate their appearance more highly they might have less body shame and be more open to visiting of public places. Recent research has shown that women with higher self-esteem exercise most often (Puhl, Moss-Racusin, & Schwartz, 2007). Baseline body image distress measurement of Cont1 (the control group who already exercised regularly) resembles the intervention group measurement after the DMT, thus offering an intriguing possible link between increased physical activity in the DMT group and decreased body image distress. Physical activity has been shown to have a positive impact on self-concept, body image and self-esteem (Fox, 1999). Women in the exercise control group (Cont1) had been engaged in physical activities prior to the start of the study and are likely to have already benefited from increased positive feelings regarding the self and the body associated with regular involvement in physical activity, which may have been further potentiated through their own efforts to lose weight and associated increased confidence to engage in increased physical activity. Although self-esteem was higher in the exercise control group than in the treatment group at the start of the study, no differences were detected in the scores of subjective well-being in baseline measurements between conditions; despite previous research linking Subjective well-being and self-esteem have been linked (Diener & Diener, 1995). One possible explanation for this anomaly is that the exercise control participants in the present study provided socially desirable answers when completing the self-esteem measure; alternatively it is possible that CORE does not measure the same aspects of well-being that were measured by Diener and Diener (1995). The considerably lower body image distress score in the exercise control group at baseline measurement could also reflect either

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the effects of exercise or increased awareness of social desirability associated with participation in exercise environments; the greater the BMI, the more the individual is aware of the need to give socially desirable responses (Cash, 2000). Larger samples and randomisation of conditions are needed in order to test this hypothesis. The results of this study offer some support to other research that demonstrates effectiveness of DMT in addressing a range of emotional issues related to long term physical health conditions. Amongst these is research carried out by Mannheim and Weis in the Tumour Biology Centre Freiburg (Germany) using short-term, focused DMT process (5–9 sessions) with cancer patients. Results of this mixed methods study demonstrated positive changes in the scores of emotionality, physical and social functioning (Manheim & Weis, 2006). Also randomised waiting list controlled study has also be conducted of the effects of a six (3 h) session Authentic Movement programme for women with a history of breast cancer. This latter research demonstrated increased vigour and reduced fatigue and somatisation in the treatment group; a qualitative analysis indicated improvements in body image, mood, distress and selfesteem, suggesting that the instruments used may not have been sufficiently sensitive to detect all changes during a short-term programme (Dibbell-Hope, 2000). These results with cancer patients may be partially explained by effects on depressive symptoms. DMT has been shown to have a positive effect on both depressive symptoms and biomarkers including serotonin levels in adolescent girls (Young-Ja, Sung-Chan, Myeong, & Min-Cheol, 2005), and a circle dance using jumping movements has also been shown to be superior to both exercise and music controls in a single intervention for depressed adults (Koch, Morlinghaus, & Fuchs, 2007). Future research concerning DMT for obesity and emotional eating should therefore include a depression measure. The present study suggests a complex relationship between eating behaviour, body image distress, well-being and self-esteem. It is possible that DMT leads to increased awareness of body and emotional states and that this in turn might assist the individual in making changes to eating behaviours associated in particular with emotional eating behaviour. In turn, this might assist the individual in losing weight and maintaining weight loss. However, it has not been possible to demonstrate this hypothesized relationship with any certainty from such a small study with the methodological compromises that were necessary in order to conduct this innovative pilot. This is the first study of its kind and benefits from a unique partnership between the UK and Latvia. It is hoped that this will form the basis for further research with larger samples on multiple international sites and blind randomisation; multiple roles will be avoided where possible and those allocated to a control group will, as for this study, be offered a post-study intervention to avoid negative effects associated with disappointment at not being selected for the treatment group. Data collection will ideally (subject to appropriate funding) be carried out by a research assistant who is not involved with either the treatment or design and who is blind to the research aims. Intention to treat and cost analyses are also needed. Confidence in the results would be improved by the inclusion of follow-up measurements for example three, six and 12 months after the end of treatment. Recidivism in weight management programmes is high and it is therefore likely that a longer therapeutic intervention is needed to achieve stable changes. Twenty sessions over 20 weeks have been proposed for this client group, though dose response effects have not yet been tested (Meekums, 2005). However, acceptability of the treatment could be further tested in a longer intervention; a qualitative study arm may offer greater insights into this important aspect of treatment. It might be cautiously concluded that in this study DMT offered a specific therapeutic effect that offers outcomes in terms of

psychological well-being, body image, self-esteem and eating behaviour that are at least as good as ongoing physical activity and are seemingly independent of weight loss. These encouraging results are worthy of further research. In particular, the difference between the DMT and physical activity groups at post-intervention measurement may be explained in part by the positive effects of the development of self-reflection skills on self-concept (Franken, 1994 cited in Huitt, 2004). Conclusions Despite methodological limitations, the present study suggests that DMT could offer an effective and acceptable treatment option for women who are obese, eat for emotional reasons and are motivated to lose weight by participating in a weight loss programme. This proposition requires further testing in a well designed study using several sites, and also requires health economics analysis in terms of cost effectiveness. In particular, this study demonstrated superiority in a DMT intervention group over both exercise and non exercise controls in increasing self-esteem and body image satisfaction for women defined as obese and emotional eaters. Women participating in the DMT group also had significantly decreased levels of psychological symptoms (depression, anxiety and trauma symptoms) by the end of the programme. Comparative results of control groups showed that losing weight and physical activities per se did not have any significant impact on the psychological well being and self-esteem of obese women. Further research is needed with a longer treatment programme, larger samples, blind randomisation and measurement, an intention to treat analysis and waiting list controls, with follow-up measurements to investigate long-term effects. Greater complexity could also be addressed through a mixed methods design in which perceptions of the treatment programme are examined. Further investigations could build on the present collaboration and broaden it to include dieticians and medical practitioners to maximize the use of evidence based treatments, including for those obese patients suffering diagnosed eating disorders. It might also be desirable to investigate the applicability of this form of treatment to children and adolescents who are obese. An integrated healthcare programme of this nature could assist dietary adherence and optimal physical activity whilst offering the possibility to address emotional issues that might otherwise sabotage efforts to lose and then maintain weight; in short, it might be possible to break the cycle of dieting and bingeing and above all help those adults and children who want to lose weight to do so in a way that promotes self-awareness and self-esteem rather than relying on behavioural change alone that may ultimately reinforce self-denial, failure and self-loathing. References American Psychiatric Association. (1994). DSM IV: Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: American Psychiatric Association. Annis, N. M., Cash, T., & Hrabosky, J. I. (2004). Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: The role of stigmatising experiences. Body Image, 1, 155–167. Aylott, J., Brown, I., Copeland, R., & Johnson, D. (2008). Tackling obesities: The foresight report and implications for local government. Sheffield: Faculty of Health and Wellbeing, Sheffield Hallam University. Baumeister, R. F., Campbell, J. D., Krueger, J. I., & Vohs, K. D. (2003). Does high selfesteem cause better performance, interpersonal success, happiness, or healthier lifestyles? Psychological Science in the Public Interest, 4(1), 28–44. Bloom, K. (2006). The embodied self: Movement and psychoanalysis. London: Karnac Books. Brauninger, I. (2006). Dance movement therapy groups process: A content analysis of short term DMT programs. In S. Koch, & I. Brauninger (Eds.), Advances in DMT theoretical perspectives and empirical findings (pp. 87–102). Berlin: Logos Verlag.

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