Fixing the mirrors: A feasibility study of the effects of dance movement therapy on young adults with autism spectrum disorder

Abstract

From the 1970s on, case studies reported the effectiveness of therapeutic mirroring in movement with children with autism spectrum disorder. In this feasibility study, we tested a dance movement therapy intervention based on mirroring in movement in a population of 31 young adults with autism spectrum disorder (mainly high-functioning and Asperger’s syndrome) with the aim to increase body awareness, social skills, self–other distinction, empathy, and well-being. We employed a manualized dance movement therapy intervention implemented in hourly sessions once a week for 7 weeks. The treatment group (n = 16) and the no-intervention control group (n = 15) were matched by sex, age, and symptom severity. Participants did not participate in any other therapies for the duration of the study. After the treatment, participants in the intervention group reported improved well-being, improved body awareness, improved self–other distinction, and increased social skills. The dance movement therapy–based mirroring approach seemed to address more primary developmental aspects of autism than the presently prevailing theory-of-mind approach. Results suggest that dance movement therapy can be an effective and feasible therapy approach for autism spectrum disorder, while future randomized control trials with bigger samples are needed.

Keywords

autism spectrum disorder body awareness clinical controlled trial dance movement therapy embodiment empathy intersubjectivity mirroring self–other distinction social competence treatment manual well-being

Autism is a severe developmental disorder that encompasses body and mind, feeling and social relating. Social functioning is challenged lifelong in autism (Fombonne, 2003; Matson et al., 2003) with, for instance, only about 8% of people with autism reporting having reciprocal friendships (Klinger and Williams, 2009) and only about 6% holding paid full-time jobs (Child-Autism-Parent-Café, 2012). A major treatment goal is thus to improve individual and interpersonal competences of individuals with autism. Since cognition, emotion, and motor function are all interrelatedly affected by autism, there are three major entries to improve social skills in autism: cognition, emotion, and the body. At present, there is a strong focus on cognitive theories of deficits in autism such as theory of mind (ToM; Baron-Cohen et al., 1985; Won and Leung, 2010) and treatment approaches related to them (Klinger and Williams, 2009; Wood et al., 2009). We argue that from the present state of knowledge—particularly from the findings of the recent embodiment approaches in cognitive science—a body-oriented treatment approach to autism is warranted (Gallagher, 2004; Gallese, 2006; Mundy et al., 2010).

Rather than viewing autism as primarily related to a compromised ToM and consequently trying to implement therapies on a cognitive level, embodiment approaches support the notion that due to their developmental and behavioral primacy the nonverbal interaction components compromised in autism are at the core of the impairment and need to be directly addressed in autism therapy (e.g. Gallagher, 2004; García-Pérez et al., 2007). The existing embodied treatment approaches such as dance movement therapy (DMT) use deficits and resources in body movement of individuals with autism spectrum disorder (ASD) directly as a therapeutic starting point (e.g. Behrends et al., 2012). Because of the body’s close connection to feelings (e.g. Riskind, 1984; Stern, 1985), and the close relation of emotion and cognition (e.g. Schachter and Singer, 1962), and of body and cognition (e.g. Casasanto and Boroditsky, 2008; Lakoff and Johnson, 1999), movement therapy directly addresses the remaining two points of entry to treatment in autism—cognition and emotion—with a bottom-up embodiment approach (e.g. Gibbs, 2005; Koch, submitted).

Resources on the body level in autism

Because of widely functional motor execution and body feedback mechanisms in autism, individuals with ASD are generally able to use the body as a resonance tool (re-sound: the other re-sonates in us; Froese and Fuchs, 2012; Husserl, 1952) in what for them are challenging “face-to-face” interactions. Resonance can occur on the autonomic (e.g. raised heartbeat), the individual (e.g. muscular activations, body postures, and related kinesthetic perceptions such as clenching one’s fist or one’s jaws, Fuchs et al., 2014), or on the interpersonal level (e.g. in unconscious mirroring, in touch, such as in handshakes or embraces; Koch, 2011). Resonance, as the basis of sharing perceptual and emotional states, is an important predecessor of interpersonal affect attunement, emotion regulation, and empathy (e.g. Davis, 1980; Kestenberg, 1995; Stern, 1985). By working with the body and the most basic nonverbal interaction skills—mainly by using direct “in situation” contingencies such as imitation, mirroring, and echoing (Fraenkel, 1983) with individuals with ASD—one can progressively build missing anticipatory skills necessary for motor preparation and motor planning (Schmitz et al., 2003). Moreover, the expressive functions of the body directly relate to communicative functioning and interpersonal competences (Gallagher, 2004). Embodied therapy approaches individually as well as interpersonally affect body (e.g. expansion of movement repertoire, Fischman, 2008), interpersonal resonance (e.g. ability to reflect nonverbal or paraverbal expression; Froese and Fuchs, 2012), emotions (perception, expression, and communication of affect, Fuchs et al., 2014), kinesthetic empathy (e.g. ability to move in synchronicity with another; Adler, 1970; Fischman, 2008; Kestenberg, 1995), and cognition (e.g. perspective taking, metaphoric expression; Lakoff and Johnson, 1999). They thus can be assumed to work on all levels of the impairment and help to improve symptoms with a bottom-up approach starting from a developmentally more primary level than ToM approaches (e.g. Boucher, 2012).

Embodied theories of autism

We are basing our assumptions regarding the effectiveness of DMT in autism on the theories of Gallagher (2004) as well as Mundy et al. (2010). According to the interaction theory of autism (Gallagher, 2004), more primary forms of intersubjective understanding develop much earlier than the cognitively mediated ToM, which develops by the age of about 4 years (e.g. Baron-Cohen et al., 1985). Gallagher assumes that already toddlers acquire a basic knowledge of others’ internal states and intentions by observing their movements, gestures, or facial expressions. Following this view, the mind is not hidden but directly expressed in other persons’ embodied actions.

Mundy et al. (2010) assume that the social impairments in ASD arise from limited simultaneous processing of self-and-other referenced sensory information. The awareness of one’s own interoceptive bodily state (heart rate, temperature, proprioception, etc.) while attending to others is crucial to developing an understanding of others and leads to empathy, which constitutes the basis of genuine social skills and prosocial behavior (Behrends et al., 2012). This somatic ability is usually a non-deliberate act (Pallaro, 2006), and its impairment is assumed to lead to deficient self-awareness and social understanding (Mundy et al., 2010). Embodiment theories emphasize that autism therapy should strongly focus on interaction on the nonverbal level to strengthen intersubjective reciprocity, address timing issues, and build basic social skills from scratch.

DMT: mirroring in movement

DMT is an embodied treatment approach that already reported success with mirroring in movement (e.g. leading and following in movement) for autism in the 1970s (Adler, 1970; Kalish, 1976). The mirroring approach in DMT uses empathic reflection of the clients’ expressive motor behavior on the therapist’s side (and vice versa) to build a mutual relationship (e.g. Eberhard-Kaechele, 2012; Fraenkel, 1983; McGarry and Russo, 2011; Sandel, 1993). The emphasis is thereby on the reflection of the quality of the movement, rather than its mere form. Kinesthetic empathy can be learned through imitation; however, imitation alone is not enough to develop interaction skills; attunement (Kestenberg, 1995; Keysers, 2011) —as the additional interactional component—is based on body resonance (Husserl, 1952; Merleau-Ponty, 1962) and is a two-sided process of moment-to-moment bodily adjustment in tension level, tension patterns, and shape flow (Kestenberg, 1995). Under the assumption of an intact rudimentary ability for attunement in ASD, DMT has the goal to strengthen this ability and to establish more advanced forms of intersubjectivity. It uses mirroring of non-stereotypic parts of the clients behavior on the therapists side to the point where individuals with ASD recognize the contingencies in mutual behavior and they start to assume a reward quality for them. In the same line, synchrony in therapy has recently been shown to be an important predictor of therapy outcome (Ramseyer and Tschacher, 2011). The authors define synchrony as general movement coordination—in their case measured with an automatized software detecting pixel changes from films of two persons with similar movements no matter which body part moves within a certain time frame.

It needs to be emphasized that mirroring as employed here includes attunement (e.g. moving together in synchrony, for example, by using the same or complementary movement qualities or shapes) as well as disruption of attunement (breaking out of that synchrony, e.g. by using a different timing). Both serve for boundary recognition and differentiation of self and other. Following Kestenberg (1995), partial attunement leads to successful differentiation in normal development. In the same vein, recent experimental studies suggest that inhibition of imitation enhances self–other distinction (Brass et al., 2009; Santiesteban et al., 2012). Santiesteban et al. (2012) showed that training of inhibition of imitation directly affected perspective taking. Those studies did not find support for the role of imitation; they did, however, not include a focus on movement qualities, where attunement may be of greater importance. Mirroring in movement in DMT always includes mirroring of the quality of the client’s movement as specified in Laban Movement Analysis (Laban, 1980).

The majority of studies using mirroring in movement for ASD have been case studies with children (e.g. Erfer, 1995; Kalish, 1976; Ruttenberg et al., 1988; Siegel et al., 1980). The present state of research suggests that DMT has a positive influence on attention, social skills, subjective stress perception, and reduction of stereotypic symptoms (Hartshorn et al., 2001; Weber, 1999); moreover, creative dance was shown to be beneficial for ASD children (Greer-Paglia, 2006). However, research on adults with ASD as well as research investigating effects on empathy, body awareness, self-/other awareness, and well-being is missing.

Research question and hypothesis

Because mirroring in movement can strengthen the feeling of attunement with the partner, which is assumed to lead to a feeling of pleasure and acceptance (Eberhard-Kaechele, 2009), and of positive affect through the detection of contingencies, we hypothesized that DMT improves psychological well-being (Hypothesis 1). Thus, participants in the treatment group were expected to show more psychological well-being (more positive affect, vitality and coping, and less tension and anxiety) than participants in the control group. Based on the assumptions of Mundy et al. (2010), we hypothesized that DMT improves body awareness (Hypothesis 2) and self–other distinction, that is, the awareness of the boundaries between self and other individuals in ASD (Hypothesis 3). Based on studies showing that body awareness and self–other awareness are preconditions for empathy (Behrends et al., 2012; Brass et al., 2009; McGarry and Russo, 2011), we hypothesized that DMT improves empathy in ASD, as operationalized by the Emotional Empathy Scale (EES; Caruso and Mayer, 1998) (Hypothesis 4). On the basis of the theories of Gallagher (2004) and the findings of the connection between motor and social domain (e.g. Freitag et al., 2007), we hypothesized that DMT improves social competence in ASD (Hypothesis 5).

Method

Sample

A total of 31 individuals with ASD (mostly high-functioning autism/Asperger’s syndrome (HFA/AS); 23 men, 8 women) with a mean age of 22.0 years (standard deviation (SD) = 7.7, range 16–47) participated in this study. The participants were recruited at the University Hospitals of Heidelberg, at the Central Institute of Mental Health in Mannheim, and at SALO + PARTNER GmbH in Ludwigshafen, a professional rehabilitation institution of secondary education. All participants were diagnosed with ASD according to the International Classification of Disorders-10th Revision (ICD-10) criteria of autism (n = 6 early childhood autism, n = 3 atypical autism, n = 12 Asperger, and n = 10 no specified type of autism, diagnosed as ASD). According to clinical judgment by the patients’ therapist, 6 participants suffered from severe symptom degree of ASD, 15 from moderate, and 3 from a mild degree of ASD. Clinically not impairing comorbid psychiatric disorders like mild depressive or anxiety symptoms and any kind of medication were not regarded as exclusion criteria. IQ of participants was not assessed, but clinically judged to be average. All participants were required to be older than 16 years and in a health condition to move in standing position for about 1 hour. A small number of participants in one of the two settings completed professional internships during the training (< 10%). There were no significant baseline differences between the experimental or treatment group (EG) and the control group (CG) at the time of the pretest (for all differences p > .10).

Procedure

Participants were contacted either by posted flyers or by their physician or psychologist. Since random assignment was not possible due to logistic reasons, treatment (n = 16) and control groups (n = 15) were matched according to sex, age, and severity of diagnosis by their primary psychologist or physician. Two actual therapy groups were run by the same dance movement therapist. Participants in each of the actual therapy groups came through at least two out of four different cooperating facilities. No participant took part in any other psychotherapy for the time of the treatment.

The dance movement therapist conducted seven sessions of the manualized intervention, 1 hour each in a weekly rhythm. The primary co-therapist was a psychology major and the assistants were psychology students at the University of Heidelberg, trained in the manual and in monitoring the mirroring modalities of the participants while moving with them. Upon the first meeting, participants received detailed information about the study and signed and returned the informed consent sheets. Then, they completed the pretest, consisting of different self-report scales (see below). After finishing, a first short version of the therapy session was conducted.

Intervention

Every session consisted of basically the same sequence of mirroring exercises and a verbal processing part.

Warm-Up (about 10 minutes): For the warm-up, we employed the Chace-circle (Sandel et al., 1993), a loose circle formation where the therapist picks up elements of each participant and asks the group to try them out (“can we all do what Mr. X does?,” “can we all be with Mrs. Y?”) and playfully change them (“can we make this bigger/smaller/louder/softer,” etc.). The Chase-circle creates an atmosphere of being seen and accepted as one is, and a secure therapeutic space, where participants can try themselves out and express their thoughts and feelings (Sandel et al., 1993). After the warm-up and creation of an atmosphere of acceptance, all participants split into dyads.

Dyadic movement part (about 15–20 minutes): Ideally, a dyad consisted of one therapist/assistant and one participant. Only in cases when there were fewer therapists/assistants than participants, two participants formed one of the dyads among each other. Each participant had the opportunity to choose his or her preferred partner. After choosing the partner, the therapist explained the task of the session to the participants. First, the participant was asked to lead (mostly the preferred mode in individuals with ASD; cf. Eberhard-Kaechele, 2009), then upon the second song, the assistant was asked to lead and the participant followed, and then upon the third song, both were asked to move freely but to always stay in contact with each other, no matter whether they were at the opposite sides of the room. It was emphasized that it was not important during mirroring that each person exactly mirrored the shapes of the other person’s movement, but that it was important that their movements reflected the quality of the other’s movement, genuinely trying to be with them. For the dyadic mirroring, a mix of slower and faster short pieces of music was used (each at maximum 3 minutes). This free dancing part also ensured that participants had the opportunity to freely choose the mirroring modality they preferred.

Baum-circle (about 20 minutes): After the dyadic movement part, all participants came together again in a circle. The movement part was then ended with a “Baum-circle” (Koch and Harvey, 2012). For this part of the session, participants were encouraged to bring their own music, which caused a positive response. Then the first volunteer initiated movement to his/her self-selected piece of music, being asked to basically focus on the expression of his feelings and not to pay too much attention to the others, while all other participants were asked to follow in the same kinesthetically attuned way they did before in the dyads. The Baum-circle aims to establish rapport and empathy in the participants using kinesthetic attunement and emotional contagion (Hatfield et al., 1994; Koch and Harvey, 2012). To be mirrored as a single person by the entire group is geared at conveying respect, acceptance without condition, and a feeling of togetherness. Participants’ use of the Baum-circle showed that it was not a strain to confront our participants with this DMT technique that was originally created for dissociative populations (Baum, 1991). Usually, three volunteers initiated movement in the Baum-circle of each session.

Verbal processing part (about 10–15 minutes): Finally, all participants sat down to reflect on the session moderated by the therapist. In this context, the participants could express their actual feelings and their opinion regarding the session. The therapist first encouraged the participants who initiated an improvization in the Baum-circle to verbalize how it was to move, what they wanted to express, and how it felt to be reflected by the other group members. Then, the other participants were asked about their perceptions and feelings when they moved with the person. The aim is to provide and receive feedback suited to increase body awareness, self-awareness, self–other awareness, empathy, and social skills, and to verbalize the nonverbal experiences and feelings. The entire DMT session lasted 60 minutes.

Assistants’ tasks

The task of co-therapist and assistants was (a) to verbalize emotions and support verbalization of emotions; (b) to move in an attuned and appropriate way in dyadic mirroring, taking up on the movement qualities of the participant, unobtrusively expanding the repertoire of the participants, and observing their mirroring stage and progress over time; (c) to encourage participants’ initiative and enhance emotional expression (e.g. by modeling in the initial Chace-circle or, if there was no volunteer for the expressive improvization in the Baum-circle, to provide a model); and (d) to model authentic expression of sensations, emotions, and cognitions in the verbal processing part of the session. The therapist’s and assistant’s implementation of the manualized therapy was monitored by two of the researchers from a tape of the second to last group session of the bigger group (10 participants present).

Questionnaires

Before the first session, participants completed the pretest, and directly after the last of the seven sessions, participants completed the posttest, consisting of the identical self-report scales as the pretest, supplemented by additional questions about their experiences during the sessions, their liking of the therapy, and their wish to continue with the therapy. The control group completed the pre- and posttests in the same time interval as the treatment group and did not receive any therapy intervention in that interval.

Instruments of the pre-/posttest (main dependent variables)

Psychological well-being

Psychological well-being was measured by the bipolar 12-item “Heidelberger State Inventory” (HSI; Koch et al., 2007), with a range from “1” (“does not apply at all”) to “6” (“applies exactly”) assessing tension, anxiety, coping, positive affect, depressed affect, and vitality (Goodill, 2006). The internal consistency of the entire scale in previous studies was Cronbach’s α = .63–.91. In the present study, the internal consistency of the posttest data was Cronbach’s α = .56 for the tension subscale, Cronbach’s α = .70, for the coping subscale, and Cronbach’s α = .79, for the anxiety subscale.

Body awareness

Body awareness was assessed by the subscale body awareness of the bipolar 15-item “Questionnaire of Movement Therapy” (Fragebogen fuer Bewegungstherapie (FBT); Gunther and Koch, 2010). This scale consists of seven bipolar items with a range from “1” (“does not apply at all”) to “6” (“applies exactly”), which all describe trust in one’s own ability to be aware of the own body, related affects, and the interaction of both. The internal consistency of the posttest data was Cronbach’s α = .64.

Self–other awareness

Self–other awareness was assessed by a self-constructed scale comprising the items “I am aware of myself,” “I feel able to engage with others,” “I feel able to perceive the boundaries between me and other persons well,” ranging from “1” (“does not apply at all”) to “6” (“applies exactly”). The internal consistency in the posttest of the present sample was Cronbach’s α = .79.

Empathy

The short form of the EES by Caruso and Mayer (1998) was used to assess empathy. It ranges from “1” (does not apply at all) to “5” (applies exactly). We used a self-translated German version that had been validated on n = 80 psychology students by the team beforehand. Sample items are “It makes me mad to see someone treated unjustly” or “If a crowd gets excited about something, so do I.” The internal consistency of the entire scale on the posttest data was Cronbach’s α = .77.

Social skills

Social skills were measured by the subscale social skills of the “FBT” (Gunther and Koch, 2010) described above. Sample items are “I am able to behave appropriately in interpersonal situations,” “I am able to accept criticism directed to me,” and “I am able to trust others.” The internal consistency of the posttest study data was Cronbach’s α = .83.

Observations of mirroring modalities and qualitative measures

For the observations of mirroring modalities in this study, we employed the concept of co- and self-regulation from Eberhard-Kaechele (2009, 2012; see Appendix 1). Eberhard-Kaechele (2009, 2012) put forth a developmentally based category system of mirroring in movement and related it to the development of mentalization skills (Fonagy et al., 2004). From her category system with 12 mirroring modalities, we selected two easy to observe developmental stages of concordant mirroring (modal vs counter movement) related to the cognitive milestone of perspective taking (ToM) in order to exploratively assess participants’ developmental stage in terms of mirroring at the beginning of the therapy and their according development over time (Eberhard-Kaechele, 2012).

The therapists/assistants evaluated mirror qualities of the movement in the free dyadic dancing part immediately after each session using three items on percentage and type of mirror activities, the preference of the participant to lead or to follow, and the perceived fun during the mirroring tasks.

As additional qualitative expressive measures, participants had the opportunity to express their feelings about the therapy by painting a picture or writing a short poem about their experience. These forms of translation of the experiential process into other expressive modalities were chosen because of the poor output of the verbal processing circles. The therapist’s observations of the therapeutic process were additionally considered.

Statistical analysis

A one-factorial between-group design was employed. The independent variable was condition (treatment vs control group). The dependent variables were the difference score of the pretest–posttest data on body awareness, self–other awareness, psychological well-being (positive affect, vitality, tension, coping, and anxiety), empathy, and social skills. We computed the means of the items on these dimensions and a difference score Δ subtracting the pretest value of each dimension from the corresponding posttest value. Cronbach’s α’s of reliability of change scores for the dependent variables resulted between .58 and .67. The influence of DMT on young adults with ASD was examined with multiple univariate analysis of variance (ANOVAs) with condition (treatment group vs control group) as the independent variable and the difference scores of the outcome measures as the dependent variables. The alpha level was set at p < .05. Because we had formulated directional hypotheses, the resulting p-value of the two-tailed ANOVA was divided by two. In addition, Cohen’s d was computed as an estimator for the effect size (Cohen, 1969). Age was used as a control variable, and hence, entered as a covariate.

Results

Adherence

Out of 16 participants in the intervention, 10 attended all seven therapy sessions, 3 attended six times, and 3 attended five times; given the fact that some participants were away at some of the dates to do a professional internship, this is a very good adherence of more than 90%. There were no dropouts in the sample.

Main results: changes in the treatment group versus control group

In the treatment group, all group means changed in the hypothesized direction (for all descriptive and inferential statistics, see Table 1; the intercorrelation matrix of all outcome variables is provided in Table 2; the discrepancies in the degrees of freedom despite the unchanged number of participants result from partly missing data in the questionnaires).

Table 1.

Means and standard deviations of outcome measures, and results of the univariate ANOVAs.

Variables	Group	Mean pre	Mean post	SD pre	SD post	F-value	p - value	Cohen’s d
Body awareness (FBT)	CG	3.84	3.67	0.78	0.77	2.945	.049*	0.62
	EG	4.08	4.35	0.66	0.61
Self–other awareness (SOA)	CG	3.76	3.66	0.93	0.84	3.933	.029*	0.72
	EG	3.96	4.44	0.86	0.97
Psychological well-being (HSI)	CG	3.76	3.77	0.84	0.84	3.123	.044*	0.68
	EG	4.07	4.45	0.52	0.76
Empathy (EES)	CG	2.96	2.86	0.61	0.60	1.263	.136	0.42
	EG	3.12	3.23	0.2	0.52
Social skills (FBT)	CG	3.98	3.77	0.44	0.38	3.490	.036*	0.67
	EG	4.32	4.39	0.68	0.64

ANOVA: analysis of variance; SD: standard deviation; HSI: Heidelberger State Inventory.

EG: treatment group; CG: control group.

p < .05.

Table 2.

Intercorrelation matrix of outcome measures.

Variables	1	2	3	4	5
1. M (Δ) Body awareness (FBT)	(.64)
2. M (Δ) Self–other awareness (SOA)	.60^**	(.79)
3. M (Δ) Psychological well-being (HSI)	.28	.26	(.85)
4. M (Δ) Empathy (EES)	.38^*	.33	.42^*	(.83)
5. M (Δ) Social skills (FBT)	.34	.26	.04	−.17	(.83)

M (Δ): mean difference score derived from posttest minus pretest; HSI: Heidelberger State Inventory.

Note. Internal consistencies (Cronbach’s α) are in the diagonal in parentheses.

p < .05; **p < .01.

Psychological well-being (test of Hypothesis 1)

A univariate ANOVA on the average difference score of all scales of psychological well-being revealed a significant difference between the treatment group and the control group. Participants in the treatment group showed a higher increase in psychological well-being in general compared to the control group, F(1, 27) = 2.95, p = .049, d = .63 (Figure 1). This effect was carried by the decrease in tension of the participants of the treatment group. Thus, Hypothesis 1 was supported.

Figure 1.

Pre-/post change (Δ) in the experimental versus control group.

Body awareness (test of Hypothesis 2)

A univariate ANOVA on the difference score of body awareness revealed a significant difference between the treatment group and the control group. Participants in the treatment group showed a higher increase in body awareness compared to the control group, F(1, 29) = 2.95, p = .049, d = .62 (Figure 1). Thus, Hypothesis 2 was supported.

Self–other awareness (test of Hypothesis 3)

A univariate ANOVA on the difference score of self–other awareness revealed a significant difference between the treatment group and the control group. Participants in the treatment group showed a higher increase in self–other awareness compared to the control group, F(1, 28) = 3.93, p = .029, d = .72 (Figure 1). Therefore, Hypothesis 3 was supported.

Empathy (test of Hypothesis 4)

A univariate ANOVA on the difference score of empathy did not yield any significant differences between the treatment group and the control group. Participants in the treatment group showed no significant increase in empathy compared to the control group on the EES, F(1, 27) = 1.26, p = .271 (Figure 1). Thus, Hypothesis 4 was not supported.

Social skills (test of Hypothesis 5)

A univariate ANOVA on the difference score of social skills revealed a significant difference between the treatment group and the control group. Participants in the treatment group displayed a higher increase of social skills compared to the control group, F(1, 29) = 3.49, p = .036, d = .67 (Figure 1), thus, supporting Hypothesis 5.

Additional quantitative results

Control variable

The results of the computed analysis of covariance (ANCOVA) indicated that age did not have a significant influence on any of the dependent variables.

Intercorrelations

The highest correlation we found was that of body awareness and self–other distinction (r = .60). Body awareness and psychological well-being were positively related to empathy (r = .38 and r = .42, respectively; for all intercorrelations, see Table 2).

Evaluation of intervention (Posttest Questionnaire)

Out of 16 participants, 13 reported that they would like to continue with the therapy, if there was an option (6 “Yes,” 1 “more often,” 6 “less often,” 3 “No”). The mean of the rating on perceived fun during the DMT intervention was 4.56 (SD = 1.6, range 1–6).

Observations of mirroring modalities

On the questionnaire that the therapists/assistants completed at the end of each session, the descriptive analysis of the mirroring modalities yielded that the participants mirrored about half of the dyadic time with a constant ratio of 70:30 (modal to contra-lateral). Out of 16, 15 participants used predominantly modal mirroring over all sessions, and there was no progressive trend observable. The ratio of leading to following was exactly 50:50 across all participants; all participants were able to do both. Perceived fun increased from M = 3.63 (SD = .74) in session 2 to M = 3.91 (SD = 1.22) in the sixth session on a scale from 1 to 5.

Qualitative measures

The therapist observed that all participants were able to use their body movement as a resource from the beginning of the therapy on. Single participants were able to move from mirroring to a playful interaction with increasing question and answer structures in nonverbal behavior (the most advanced mirroring stage according to Eberhard-Kaechele, 2012); others were able to use movement metaphorically (e.g. “Tears in heaven” —improvization of a participant considered low-functioning), or to express their experience in the form of a poem (see Appendix 2). All participants were able to lead and follow in their own idiosyncratic ways. The majority of the participants in this study clearly had less problems to attune in movement to the other persons in the groups than to cognitively and emotionally reflect the sessions afterwards.

The attempt to translate some of the intense experience in movement to the verbal realm, by inserting drawings as a further nonverbal but more manifest modality than movement, did not work in our case. One participant, for example, started to draw a train and was imitated by several other participants, similar to a stereotypic repetition of what they saw others do and was presumably something you could do in response to the task. In the same session (the second-to-last), participants were asked to continue to translate their experience into a creative artwork, a composition, a dance, or a poem at home, and bring the result with them in the last session. The only contributing participant brought the poem that is printed in Appendix 2.

Discussion

Our feasibility study suggests that mirroring in movement improved body awareness, self–other awareness, psychological well-being, and social skills in young adults with ASD on self-report scales. Those outcomes improved significantly in the expected direction with medium to large effects (effect sizes of .61–.91); the increase in empathy was not significant. The increase in body awareness and self–other awareness showed that the intervention was likely accessing those primary embodied interactive skills it aimed to improve. The increase in social skills in the intervention group was important considering the well-documented grave restrictions in social interactions in ASD. The increase in well-being additionally indicated that participants felt more comfortable and relaxed at the end of the therapy sessions. All findings need to be interpreted with the according caution, particularly the ones missing measurement validation. In sum, considering the small sample size and the brevity of the intervention, our pilot results are encouraging for the implementation of DMT interventions in the treatment of ASD; however, more studies, particularly randomized controlled trials (RCTs) are needed.

Additional qualitative process data confirmed these results indicating that DMT participants were increasingly aware of the self–other distinction and increasingly enjoyed to participate in the therapy. The mentioning of DMT as a useful therapy in the posttest questionnaire clearly increased in the treatment group compared to the control group. Adherence to and acceptance of the therapy was high. We had no treatment dropout; instead, 13 out of 16 participants found the intervention useful and stated that they would like to continue with the therapy. The subjective impression of the therapist and the institutional staff members converged in experiencing the participants as more outgoing and self-confident after the intervention. The increasing willingness to bring their own music and initiate movement, next to being an indicator of the involvement and commitment of the participants, suggested that the participants felt comfortable, safe, and accepted in the group.

The observational results of the mirroring modalities did not yield the expected progression toward more counter movement—as an indicator of perspective taking in movement (Eberhard-Kaechele, 2012). To improve the analysis of mirroring modalities and their use, future studies may need to take into account more extreme poles of mirroring on the postulated developmental continuum (Eberhard-Kaechele, 2012). However, the inconclusive finding may also have come about on the ground of the short intervention duration.

Nevertheless, the therapist and the assistants reported a high degree of nonverbal resources in the participants: not only were they able use simple forms of mirroring in movement instantly, but also did they generally use more complex forms of mirroring and progressively went into playful and teasing interactions. This substantial degree of resources on the body level yielded an easy and high-level access to the participants via movement.

Parts of the results were in line with the findings of previous studies showing that DMT is useful for improving diverse bodily, cognitive, and social functions in ASD (e.g. Hartshorn et al., 2001; Weber, 1999). Our study extended the validity of the effectiveness of DMT-mirroring interventions to the population of young adults with ASD and to a quantitative design. Unlike most of the other studies that have examined the influence of DMT on ASD in small samples and case studies, the sample of the present study consisted of a broad range of individuals with ASD with different diagnoses and degrees of impairment.

Finally, the chosen method of therapy was anchored in a well-fitting theoretical concept. From the recent embodiment approaches, we grounded our reasoning in interaction theory (Gallagher, 2004) and the individual-interactional model (Mundy et al., 2010). Following Mundy et al. (2010), individual level and interactional level components can be brought together in a single explanatory model of autism: kinesthetic body awareness (including interoceptive sensory awareness) needs to be co-activated with visual resonance when in interaction with others to foster the emergence of self-awareness and self–other distinction. In our study, body awareness and self–other awareness showed the highest correlation among all dependent variables, directly supporting this assumption.

Limitations and future research directions

One of the most important limitations of the study is the small sample size with n = 31. It limits the power of the test to .60–.65 (estimated with g*power; Erdfelder et al., 1996). The probability of committing a type-II error, that is, of falsely rejecting the null-hypothesis—that treatment and control group do not differ—was accordingly high.

A further limitation stems from the design. Because of the lack of randomization, the improvement of the symptoms may be due to other factors than the DMT intervention. To minimize these effects, the control group and the treatment group were matched with regard to sex, age, and severity of diagnosis. In addition, because the control group did not receive any intervention, Hawthorne effects (cf. Roethlisberger and Dickson, 1939), that is, the possibility that the intervention group got better due to increased attention, cannot be excluded. Moreover, blinding of participants, helpers, and researchers in this study was not possible and thus could have caused expectancy effects.

The exclusive use of self-report scales is another limitation of the study. Regarding the clinical picture of ASD with the decreased self-awareness and the limited access to affectivity (Frith, 2003), it could be rightfully questioned whether participants were able to evaluate their own inner states properly on the self-report questionnaires (Johnson et al., 2009). However, the consistency of the results speaks for an adequate understanding of the participants here. This was also reported by other authors. Berthoz and Hill (2005) found in their validity of self-report measures in ASD study that ASD participants were able to report about their own emotions using self-reports, in that case on alexithymia (Toronto Alexithymia Scale (TAS-20), Bermond and Vorst Alexithymia Questionnaire-Form B (BVAQ-B)) and depression (Beck Depression Inventory (BDI)). In addition, individuals with ASD should on the basis of their condition be less prone to social desirability bias than non-autistic controls. However, because the validity of self-report issue is not satisfyingly clarified, future studies should additionally include other sources of evaluation, such as observational measures or judgment of caretakers. The heterogeneity of the sample is a problem that needs to be mentioned. However, effectiveness of the intervention despite of heterogeneity speaks for even bigger effects in more homogeneous samples. Furthermore, the implementation of the manual was only assessed from one session, which does not allow to control for comparable implementation across sessions (fidelity of implementation).

More importantly, since there were no sufficient calibrations of the actual mirroring in movement behavior in the sample of participants, it cannot be determined whether mirroring was the definitive behavior accounting for the change in self-reports (cf. Ingersoll, 2012). However, there is a fair chance that mirroring may be the effective mechanisms, since a variety of other findings clearly show that imitation improves social functioning in children with ASD (e.g. Ingersoll, 2008, 2012). Nevertheless, it needs to be determined whether there are other factors next to mirroring in movement that influence the outcome measures in such interventions.

Moreover, some of the measures such as the FBT (Gunther and Koch, 2010) and the HSI (Koch et al., 2007) were not yet standardized and cannot be interpreted with as much confidence as standardized measures can. This is one of the most severe problems of this study. Validation of the instruments is in work.

Finally, it is important to note that the three DMT methods employed in the manual are only a small part of the DMT intervention spectrum in general, and of mirroring methods in particular. Future studies could either focus on testing other DMT interventions or the effects of the single specific interventions employed here. Studies with follow-up testing are needed to investigate whether observed changes are as stable as in other areas of DMT interventions (e.g. Braeuninger, 2012).

Conclusion

In sum, the findings increase the understanding of the effectiveness of DMT mirroring interventions for the treatment of autism. Our pilot results suggest that DMT can be effective and feasible for the treatment of individuals with ASD, causing improvement in body awareness, self–other awareness, psychological well-being, and social skills with all according limitations discussed and the need for further improved study designs with bigger samples.

In the case of understanding others—next to having theories about their mental states—there may be various other ways to form an immediate connection to them such as bodily resonance. Treatment thus needs to additionally focus on the body and motor level to improve embodied resonance, kinesthetic empathy, emotional, and interpersonal aspects more directly than by going through secondary cognitive processing. Cognitive therapy approaches may be helpful to address ToM problems, meta-communicative problems, emotion regulation, and rational behavior in social situations; they can, however, only be implemented later in life. Embodied therapies—such as DMT—have the advantage that they can be applied as early as features of autism are detected (e.g. Caldwell, 2009; Schuhmacher and Calvet, 2008), and can potentially correct and improve the development early in the course of the impairment. In fact, embodied diagnostics in the first author’s view can help to detect such features earlier (e.g. one possible indicator being that many infants with autism do not show interpersonal shrinking or retreat reactions, when they seriously hurt another person that shrinks away in pain). We showed in this study that embodied therapy approaches do not cease their effects in the treatment of adolescents or adults with ASD. Embodied therapies can provide an important building block to a successful integrative treatment of ASD. Since they address emotion and cognition from a primary developmental basis, the integration of embodied therapies yields the prospect of a more effective treatment of ASD.

Footnotes

Appendix 2

Poem of female participant reflecting her experience.

We dance

Everything is dance,

so one says.

Even atoms

swing and dance.

Electrons circle around protons and neutrons.

Everything swings, all is in harmony.

Only this way

the world is kept in an equilibrium

It is an ancient law.

And we also

circle around each other in our dance.

We dance,

and the music animates us

We dance,

and the rhythms permeates us

We dance,

and find each other.

We dance,

and are joyful.

We laugh and dance.

We dance and are

… free!

Note. We received the participant’s informed consent to publish the poem in the context of this study. The therapist had for this purpose translated the poem into English and sent it to the participant asking her authorization of the translation. Since she did not agree with the therapist’s translation, she sent back her own translated version (this one).

Appendix 1.

Mirroring taxonomy of Eberhard-Kaechele (2012) .

Modalities of interpersonal mirroring in dance therapy
No.	Modality	Characteristics of movement and affect regulation	Development of mentalization
l	Initiation	The ability to initiate, continue, and terminate movement/attention processes (gazing toward something, keeping it in view, diverting one’s gaze). Primary self-efficacy and pre-requisites for regulation.	Discovering contingency, self-discovery, causal thinking.
2	Medial/oceanic mirroring	Totally simultaneous movement between partners or play with controllable objects. Enables interpersonal transcendence, or it is a sign of merging and a lack of differentiation between self and others, or a sign of non-personal. Perception of people as inanimate objects.	“Perfect” contingency, self-exploration, taking control.
3	Concordant mirroring
3a	Modal mirroring	Mirroring in the literal sense, egocentric, along a common axis of movement. Affect attunement. Learning from others, and sense of agency.	High level but not perfect contingency, exploration of the social world.
3b	Cross-modal mirroring	Dynamic/shape is mirrored by voice, another expressive medium, or another body part. Facilitation of exploration.	Medium level contingency, exploring the environment.
3c	Parallel mirroring	Side by side = solidarity, one behind the other = support or leading and following. Joint attention toward a third entity. Shared interest. Social referencing.	Joint attention, teleologic/goal-oriented thought.
3d	Counter movement	Anti-phasic coordination of cyclic movements, for example, open–close versus close–open, up–down versus down–up. Precursor of intersubjectivity, alter-centric versus egocentric, each participant has their own axis of movement.	Perspective taking, differentiation of perspectives.
4	Deferred imitation	Deferred imitation, retention and recall of movement, memory development, identification processes. Replacing one object with another in the repetition of a situation marks the beginning of symbolization and the pretend modality.	Intentional thought, symbolization
5	Contrasting-	The main intention of the movement is reversed, for example, speed: quick versus slow, shape: round versus jagged, direction: up versus down, etc. Ambivalent: doing the opposite serves differentiation, while the common theme/the friction serves connection.	Conceptual thought, for example, opposites, directions, positions, forms, intentional thought IIdifferentiation of self/others beliefs
6	Variation	Simultaneously maintaining contact and serving individuation and expansion of abilities. Self-regulation of affects through “tuning” the dynamic/forms of movement. Adaption to various situations.	Adaptivity, representational thought
6a	Marked variation	Differentiation of one’s own and others affects. Regulation of arousal through mild and possibly humorous exaggeration, containment. Externalization of affects in play or artistic activity, un-coupled from the consequences of reality.	Representational thought, pretend play with mental elements (feelings, intentions, and beliefs)
7	Complementary interaction	The partner’s roles are interdependent and constitute one another, for example, the carrier & the carried, the hunter & the hunted, the protector & the protected, the victim & the perpetrator, etc. Integration of reality and fantasy, self/others abilities, regulation of other people’s affects (comforting, provoking, etc.)	Complete representations and theory of mind, understanding deception. Reflecting mode of thought

ASD: autism spectrum disorder.

Note. We compared mirroring modality 3a and 3d in each session to observe the degree to which participants with ASD used mirroring and to rate their progress (Eberhard-Kaechele, 2012). Observations were done by therapist and assistants for their according mirroring partners in the free dyadic mirroring part of the session.

Acknowledgements

We thank Dr Marianne Eberhard for helpful comments on the manuscript, and all participants and assistants without whom the study would not have been possible. Special thanks to our participant with the poem who in various personal and email communications provided great insights into her way of perceiving the world and created a bridge for us to better understand autistic conditions.

Funding

We thank the German Federal Ministry for Research and Education (BMBF) for grant 01UB0930A to Prof. Dr Sabine C. Koch (PI) and Prof. Dr Thomas Fuchs, University of Heidelberg.

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