68250 • Movement and Dance in Psychotherapy

Table of Contents

68250 • Movement and Dance in Psychotherapy

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS: MOVEMENT AND HEALING

A MULTICULTURAL VIEW OF MOVEMENT AS A HEALING ART FORM

EARLY IDEAS ON MOVEMENT IN THE HELPING AND DANCE PROFESSIONS

MARIAN CHACE AND THE DISCOVERY OF DANCE AND MOVEMENT THERAPY

THE CONSCIOUS DANCE MOVEMENT

3. THE IMPACT OF MOVEMENT ON HEALING

A BRIEF PRIMER ON UNHEALED TRAUMA AND THE LIMBIC BRAIN

HOW MOVEMENT AND RITUAL ENHANCE HEALING

THE ROLE OF MINDFULNESS, MOVEMENT, AND YOGA

4. SIMPLE MOVEMENT TECHNIQUES IN CLINICAL WORK

CLENCH-AND-RELEASE TECHNIQUE/PROGRESSIVE MUSCLE RELAXATION

BILATERAL MOVEMENTS FOR STRETCHING AND CLEANSING

USING HAND GESTURES AND POSTURING FOR TEACHING NEW BEHAVIORS

SITTING AND STANDING WITH INTENTION

RITUAL MOVEMENTS FOR LETTING GO AND RELEASE

DANCING MINDFULNESS

5. FURTHER TRAINING & COLLABORATION

IS FURTHER TRAINING RIGHT FOR MY CLINICAL PRACTICE?

COLLABORATING WITH OTHER PROVIDERS

6. CONCLUSION

7. APPENDIX 1: MULTICULTURAL AWARENESS AND COMPETENCE

BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

CREATING A WELCOMING AND SAFE ENVIRONMENT

8. APPENDIX 2: DANCE IN THE CONTEXT OF EXPRESSIVE GROUP THERAPY

Works Cited

Evidence-Based Practice Recommendations Citations

68250 • Movement and Dance in Psychotherapy

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

For millennia, indigenous cultures around the globe have regarded dance and other movement-intensive activities like drumming to be highly valuable in emotional healing. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. This course will explain how using basic movement strategies (which may or may not include dance) into clinical work represents a return to the roots of how healing arts have been classically used from a global perspective. Special attention is paid to the role of movement in the processing of unhealed emotional trauma. The work of pioneers in Western psychology will be surveyed, and an overview of dance and movement therapy as specific disciplines will be presented. Clinicians will acquire no fewer than five movement-related techniques that they can use alongside of their existing clinical training through reading this course. Options for further training, which also includes a discussion on scope of practice issues with movement, are also presented.

68250 • Movement and Dance in Psychotherapy

Education Category. Alternative Medicine

Release Date. 04/01/2024

Expiration Date. 03/31/2027

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2782 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

For millennia, indigenous cultures around the globe have regarded dance and other movement-intensive activities like drumming to be highly valuable in emotional healing. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. This course will explain how using basic movement strategies (which may or may not include dance) into clinical work represents a return to the roots of how healing arts have been classically used from a global perspective. Special attention is paid to the role of movement in the processing of unhealed emotional trauma. The work of pioneers in Western psychology will be surveyed, and an overview of dance and movement therapy as specific disciplines will be presented. Clinicians will acquire no fewer than five movement-related techniques that they can use alongside of their existing clinical training through reading this course. Options for further training, which also includes a discussion on scope of practice issues with movement, are also presented.

Audience

This intermediate course is designed for psychologists who work with clients on a regular basis or who teach/supervise those working with clients who might benefit from the inclusion of movement in their therapy.

Accreditations & Approvals

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.

Designations of Credit

NetCE designates this continuing education activity for 10 credit(s).

Course Objective

The purpose of this course is to introduce movement therapy as a treatment option that practitioners can incorporate into their work with clients, with the goal of improvement outcomes.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe movement and dance in the context ofpsychotherapy.

2. Describe how various world cultures have used movement, dance, and ritual for emotional healing as a separate entity from modern psychology.

3. Outline the work of earlier pioneers in the psychotherapeutic and dance professions who used movement in healing.

4. Describe how the field of dance and movement therapy emerged as its own discipline.

5. Define conscious dance and explain its differences to dance therapy.

6. Discuss the importance of movement to healing the limbic area of the brain affected by trauma.

7. Summarize the psychotherapeutic profession's research findings and applications for working with mindfulness, movement, and yoga.

8. Describe how to assess clients for the appropriateness of movement-based adjuncts in clinical therapy.

9. Discuss how adding simple movement techniques can enhance traditional, talk-based therapy, and apply basic movement-related exercises to existing clinical work.

10. Decide whether or not further training in movement-related modalities is a good fit for one's own clinical repertoire.

11. Outline special considerations for movement- and dance-related modalities, including cultural competence and group therapy.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margaret Donohue, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

The various disciplines composing the psychotherapeutic profession look to Bessel van der Kolk as a prominent thought leader on issues connected to trauma. Originally from the Netherlands and based in the Boston area, Dr. van der Kolk is an outspoken advocate for the use of creative, innovative, and dynamically body-based interventions in the healing of traumatic stress. In a documentary entitled Trauma Treatment for the 21st Century, van der Kolk speaks on a plethora of issues related to trauma treatment in the modern era [1,46]. One statement in his interview jumps out as a summary position: "The purpose of trauma treatment is to help people feel safe in their own bodies" [1]. He goes on to explain in the interview that some people arrive at this safety through yoga or exercise, while for other people it comes through receiving bodywork, like massage or Reiki. For others, this safety is achieved through a combination of channels, particularly innovative approaches to psychotherapy that honor the mind-body connection.

van der Kolk and his contemporaries have raised awareness about the importance of using the body in the treatment of unhealed trauma and its manifestations, which may or may not include post-traumatic stress disorder, or PTSD. As will be explored in this course, unhealed traumatic memories and experiences generally get stored in the limbic brain, the part of the human brain that cannot be easily accessed using words. Thus, the challenge is to work with the parts of the human brain (i.e., the limbic brain and brain stem) that are deeper than the cerebral cortex, or our talking, thinking, and reasoning brain. If not words, what then?

Remember the adage you likely learned sometime in your youth: Actions speak louder than words. As described in the section of this course on trauma and the brain, there is a great deal of neurobiological wisdom in this statement. Many helping professionals in the modern era trained primarily in cognitive or talk therapy interventions are being asked to engage in a paradigm shift, informed by modern neuroscience. How can we more dynamically engage our clients in their healing, especially when we know that many of their problems are happening in a part of their brain that cannot be easily accessed by talking? The simple answer is to work more fully with action-oriented interventions, and these can include a wide range of movement strategies. Present-day discussions in the psychotherapeutic professions tend to label movement or dance therapy as an "innovative" approach. However, many world cultures have made use of dance, ritual ceremony, aerobic activity, and other forms of movement as part of their healing traditions. Thus, engaging in this paradigm shift of "actions speak louder than words" when it comes to fully healing the brain may involve, more than anything, a back-to-basics approach. As will be highlighted in this course, movement as a healing art is not a new idea—in fact, it is quite ancient. Even after the birth of modern psychology in the 19th century, early thinkers in the field made connections between movement and emotional wellness.

This course will present a brief overview of this history and to consider its relevance to modern-day helping and healing. This course assumes that treating emotional distress is more than a cognitive or medical pursuit. Rather, the optimal pursuit of emotional wellness is more than just treating disease or distress—it requires a holistic approach that looks at the whole person. After examining the history, the impact that movement can have on healing will be explored, especially when healing is framed through a holistic lens. Material on trauma and the brain will be presented, including research from the modern era on the use of movement approaches, specifically yoga. Step-by-step instructions on how clinicians of all backgrounds can implement simple movement strategies to their existing practice without formal or specialized training will also be provided. The course will conclude with information on the specialized training that is available, and learners will have a chance to evaluate if this specialized training is right for them and their practice.

This course offers an overview of many practices and principles that cultures around the globe have used for millennia. Although special attention is paid to highlighting what is most relevant for the modern clinician working in mainstream settings, please understand that if your interest is piqued by any one area of the course, there is more material that you can seek out to expand your knowledge. Throughout the course, recommendations are given for further reading and pursuit of these resources.

2. FOUNDATIONS: MOVEMENT AND HEALING

A MULTICULTURAL VIEW OF MOVEMENT AS A HEALING ART FORM

Eye movement desensitization and reprocessing (EMDR) is one of the most popular and researched therapies in the treatment of PTSD. In brief review, the therapy makes use of back-and-forth eye movements, audio tones, or tapping (of the feet, legs, or arms) to induce emotional and somatic processing more expeditiously. For dancers or drummers, as well as EMDR practitioners, the idea of EMDR and its bilateral mechanism of action makes a great deal of sense. In many Native American traditions, drumming and dancing, typically done in communal ceremony, have been the two most used approaches to treat warriors returning from battle. Many similarities exist in cultures on the Asian continent, from which the tribal nations of North America share a common origin. Traditions of dance as emotional empowerment or communal gathering occur globally: the Haka, a dance of the Maori of New Zealand, the Umoya of South Africa, and even the bouncy circle dances orkolosof Slavic traditions are known to many, even in the modern era.

Rabbi Miriam Maron, a dancer and psychotherapist, summarizes the role of dance and movement as healing art within Judaism [2]. She writes, "The word for dance and the word for illness, taught Rebbe Nachman of Breslav, are related:ma'cho'lfor dance,machah'lahfor illness or affliction. Not by accident do they both share the same root. After all, dancing brings one to a state of joy, and when the body is in a state of joy, the negative energies contributing to illness begin to dissipate" [2]. If one examines texts and traditions from a variety of world cultures, similar themes are evident, making a strong case for dance as a cultural healing universal. Summarizing global research on dance in her book Dance: The Sacred Art, Rev. Cynthia Winton-Henry states [3]:

At the beginning of nearly every culture, dance arose at the foundation of collective spiritual life. Just as inconceivable as separating out deities and goddesses from everyday activities, dancing was intrinsic to the religiosity of indigenous groups. It could not be extricated. It was manna, daily bread. More than mere expression, dancing served as a primary means of knowing and creating the world. It carried technologies of healing, entertainment, and most definitely praying.

Perhaps the most famous story of a Western-trained psychiatrist being affected by the power of indigenous healing traditions is that of Dr. Carl Hammerschlag. In his memoir The Dancing Healers: A Doctor's Journey of Healing with Native Americans, Hammerschlag, trained as a psychiatrist at Yale, relates that when he first traveled to Arizona to work with the Indian Health Services, he believed he was bringing a wealth of knowledge about the human brain to an "uncivilized" people [4]. He soon learned that they had more to teach him about healing than he could ever teach them. He relays a particularly touching story of a tribal elder who, after listening to Dr. Hammerschlag's credentials, asked him if he could dance. To appease him, the doctor did a little shuffle by his bedside. The elder chuckled, replying, "You must be able to dance if you are to heal people." Hammerschlag's memoir offers a glimpse into his own paradigm shift of being trained as a physician, in the traditional Western sense, to being a more holistically rounded healer. He calls for the adoption of the dances and ceremonial customs of indigenous and other cultures generally described as "non-Western" as a way to get clients and patients comfortable with cultivating their own insights. He observes, "Artists and other of creative mind know that the unconscious must be uninhibited to make the associations that produce new understanding" [4].

Gabrielle Roth (founder of the 5Rhythms practice and considered by many to be the mother of the modern conscious dance movement) summarized her work with Native American healers in this anthem of empowerment amongst holistic practitioners [5]:

In many shamanic societies, if you came to a medicine person complaining of being disheartened, dispirited, or depressed, they would ask one of four questions. When did you stop dancing? When did you stop singing? When did you stop being enchanted by stories? When did you stop finding comfort in the sweet territory of silence?

The National Institutes of Health recognize Native American healing approaches as a whole medical system [6]. This system encompasses a range of holistic treatments used by indigenous healers for a multitude of acute and chronic conditions and to promote total health and well-being. Many psychotherapists trained in Western traditions are honoring the holistic missions of their practices by incorporating approaches from the Native American and other healing traditions.

Incorporation of traditional forms of healing into clinical practice can be helpful, but it can be difficult to know where to start. One resource for this integration is Susan Pease Bannit's The Trauma Toolkit: Healing Trauma from the Inside Out [7]. A traditionally trained social worker who completed her internship in the Harvard medical system, Bannit proposes a taxonomy for healing using the five subtle bodies of yoga philosophy. She integrates movement and ceremonial techniques from yoga and Ayurveda (Indian systems of healing), in addition to Native American practices. Bannit's text is an excellent resource for the traditional practitioner working in a North American system wanting to incorporate these multicultural healing traditions in a safe and user-friendly way.

If exploring the cultural roots of dance as a healing art appeals, consider further reading the work of Bannit, Roth, Hammerschlag, Winton-Henry, and Maron. For many clients who have Native American roots, there can be great power in claiming the connection to their lineage, so encouraging them to explore dance and other Native American healing arts may serve as an important adjunct to treatment. This connection does not just apply for Native American clients—truly, encouraging a client to explore their cultural heritage's views on healing can be powerful, whatever that culture may be.

Here are some websites in the area of dance/movement, ceremony, culture, and healing that you and your clients may find useful:

- African healing dance: http://www.wyomadance.com/african-healing-dance.html

- Classical Indian dance: https://www.shaktibhakti.com

- National Center for Complementary and Integrative Health: https://www.nccih.nih.gov

- Various Indigenous cultures: http://www.healing-arts.org

EARLY IDEAS ON MOVEMENT IN THE HELPING AND DANCE PROFESSIONS

Professionals and scholars have been making the links between movement and emotional healing almost since the beginning of modern psychology. These links are not just attributed to psychologists and related psychological professionals—professional dancers and other artists also made connections that we can find valuable as helpers to this day. In this section, we will review some of these modern pioneers. In addition to Lowen, Fritz Perls, Frederick Alexander, Moshé Feldenkrais, Florence Noyes, and Martha Graham will be explored. Some of these leaders and their ideas overlapped, although most of their work represented independent thought that essentially worked with the same ideas: There is great capacity for emotional healing when the body moves itself. These overviews will dovetail into the next section on Marian Chase and the formal discovery of dance therapy, compared with the similar (yet related) conscious dance movement. Then, we will take a look at how the formal literature and practice standards view the use of dance and movement work, both formal and informal.

Alexander Lowen

Alexander Lowen was an American-born physician who originally studied under Wilhelm Reich, a second-generation Freudian psychoanalyst. Like another of Reich's students, Fritz Perls, Lowen added his own ideas to the work of Reich, resulting in the development of bioenergetic analysis (BA) (founding date credited as 1956). According to the International Institute for Bioenergetic Analysis, BA is a body-based psychotherapy rooted in the principles of mind-body connection taught to Lowen by Reich [8]. Some of the core tenants of this therapeutic approach include:

- BA basically combines a bodily, analytic, and relational therapeutic work, based upon an energetic understanding.

- BA helps to release chronic muscular tensions, manage affects, expand the capacity for intimacy, heal sexual trauma or dysfunction, and learn new, more fulfilling ways of relating to others. Tenderness, aggression, and assertion—and their confluence in sexuality—are seen as core life-saving forces. The therapeutic relationship provides a place of safety in which healing begins.

- The therapist reads the body, resonates with its energy, feels the emotions, listens, hears, and answers the words. The language of the body (i.e., posture/gesture, breathing, motility, expression) is the focus, as it indicates the status on the way to personhood, from the past to the present and future.

- Techniques are used to address the energetic aspect of the individual, including their self-perception, self-expression, and self-possession. These also include work with body contact, boundaries, grounding, and the understanding of muscular tensions as indications of somatic and psychological defenses against past trauma. The goal of therapy is more than the absence of symptoms. It is having aliveness, getting a taste of pleasure, joy, love—vibrant health.

- According to Lowen, wellness starts with the reality of the body and its basic functions of motility and expression.

BA is still being practiced throughout the world today, stemming from Lowen's work. During his lifetime, he wrote or co-wrote 14 books on various topics related to health and wellness, explained through the lens of BA. Because it has origins in Freudian psychoanalysis, many view BA as the most classical of the movement and body basic approaches to therapy. The International Institute for Bioenergetic Analysis keeps a catalogue of the latest research and conference presentations on the use of BA as a treatment and wellness approach. For more, visit http://www.bioenergetic-therapy.com.

Fritz Perls

Fritz Perls, regarded as the father of Gestalt Therapy, is typically a more recognizable name than Alexander Lowen, although they studied in the same tradition. Perls developed the Gestalt approach in collaboration with his wife Laura in the 1940s and 1950s, and he also lived in residence at the Esalen Institute in California during the 1960s, where Lowen also completed much of his work. Gestalt is generally considered one of the more classical psychotherapy approaches, with most graduate students in North America receiving some basic training in its principles. Toward the end of his life when an interviewer asked Perls to define the Gestalt approach, he struggled with putting words to it, preferring instead to demonstrate [9]. Perls set out to revise the classic psychoanalysis of his training, and one might observe the Gestalt approach as a more dynamic practice of psychoanalytic principles.

The Gestalt therapist is actively involved with the client, often engaging in their own disclosure, unlike the distance established in psychoanalysis [10]. The Gestalt therapist uses an active array of methods to engage the client, including promoting body awareness and making use of behavioral tools, like movement. Experimentation is encouraged to ultimately allow the client to work through unfinished trauma or issues. Yontef and Jacobs identify Gestalt psychotherapy as the first truly holistic approach to Western psychotherapy, making use of affective, sensory, interpersonal, and behavioral components [10]. The Gestalt approach draws from existential, humanistic, and Zen philosophy, and it can be common for a Gestalt session to work with body alignment, awareness, and movement. It is also common for Gestalt psychotherapists to also work with dance or movement modalities. For an example of a therapist who is integrating the two because of their obvious overlap, visit https://gestaltdance.com.

Although Gestalt psychotherapy is not typically discussed in the new wave of psychotherapies generating attention in the treatment of trauma, many modern approaches (e.g., EMDR therapy, dialectical behavior therapy, sensorimotor psychotherapy, somatic experiencing) draw on many time-honored Gestalt principles. Linda Curran, a psychotherapist, teacher, and director of several educational documentaries on trauma, refers to Gestalt psychotherapy as the "original trauma therapy" [11]. Indeed, many of the newer approaches to trauma and other mental health treatment that appear in the Substance Abuse and Mental Health Services Administration (SAMHSA) Evidence-Based Practices Resource Center make use of coping skills that simply represent a repurposing of many time-honored Gestalt approaches.

Moshé Feldenkrais

Moshé Feldenkrais, a Russian-Israeli engineer and practitioner of the Eastern martial arts, is another name associated with the movement practitioners who taught at the Esalen Institute in the 1960s and 1970s. Feldenkrais was inspired to develop his now trademarked method, described as a type of somatic education, after he was injured playing soccer in his young adulthood. He published his first book in 1949 describing his method. The method is something that anyone interested in learning more about their body and the information it gives them can study. Feldenkrais himself is well-known for giving lessons in his method to the prime minister of Israel. The training program to become a recognized Feldenkrais Method practitioner is extensive, and it is a training program that professionals from many disciplines (e.g., massotherapists, psychotherapists, dance teachers) pursue. Many of the popular conscious dance movements, most notably the Nia movement practice, draw on influences from Feldenkrias. To read more about the method and to pursue a catalogue of current research about the Feldenkrais method, please visit https://feldenkrais.com.

F.M. Alexander

Feldenkrais studied with F.M. Alexander, an Australian actor who explored the somatic connections between body, emotion, and performance decades before doing such became popular within psychotherapy. Despite his early work, Alexander is much less recognized among psychotherapists and counselors. However, many musicians and performing artists are familiar with Alexander's work. According to the public story published about his life, Alexander found himself struggling from chronic laryngitis, which clearly got in the way of his performance as an actor. His healthcare providers were unable to detect an organic cause, so he began engaging in his own inquiry. Alexander discovered that excess tension in his neck and back was causing the problems with his vocalization. Through trial and error, he began making modifications in his movement, which ultimately eradicated his laryngitis. So impressed were the doctors who were unable to help him, they encouraged him to begin teaching his method.

Research conducted on the Alexander technique spans a wide range of academic disciplines. Alexander was also known for promoting the idea of self-discovery with movement, which has led to many individuals engaging in the Alexander technique as a self-study method. Many of the available resources in this area are billed as "Alexander Self-Help." There are many resources available that can assist interested parties in this process. A good first resource to read more about the Alexander technique, its practice, and related research is https://alexandertechnique.com.

Florence Noyes

Like Alexander, Florence Noyes was a performer—a classically trained dancer who regularly performed at New York venues like Carnegie Hall. In her own work as a dance teacher, she began making links between movement and life. She created a system of study now called Noyes Rhythm, described as working with physical technique, improvisational exercises, and building internal awareness. From the days of Noyes, the approach was billed as a something that from which both dancers and non-dancers could derive benefit, if their goal was to open up to greater creativity and ease in life. The work of Noyes can be described as one of the forerunners of modern-day dance therapy. There is an active community of teachers working and sharing the original work of Noyes throughout the world. To read more about Noyes Rhythm and the work being done, please visit https://www.noyesrhythm.org.

Martha Graham

Many present-day teachers of conscious dance and dance therapists look to Martha Graham as a role model. Her inspirational sayings (e.g., "Dance is the hidden language of the soul") regularly make their way around social media pages and other promotional materials. Recognized as the mother of what is now referred to as modern or contemporary dance, Graham clearly extrapolated a great deal of psychological learning about mind-body connection from her own training and work with others. An alumnus of her dance company, Albert Pesso, is well-known in the mind-body circles of psychotherapy for his method, psychomotor psychotherapy, which will be briefly discussed later in this course.

Graham's 1991 autobiographyBlood Memorylargely reads like a study in mind-body-spirit connection, with tremendous insights provided about the role of breath in movement. One such insight about the role of breath can be beneficial to anyone working with the psychological process [12]:

Every time you breathe life in or expel it, it is a release or a contraction. It is that basic to the body. You are born with these two movements, and you keep both until you die. But you begin to use them consciously so that they are beneficial to the dance dramatically. You must animate that energy within yourself. Energy is that thing that sustains the world and the universe. It animates the world and everything in it. I recognized early in my life that there was this kind of energy, some animating spark, or whatever you choose to call it. It can be Buddha, it can be anything, it can be everything. It begins with the breath.

The role of linking breath with movement will be explored further later in this course. Many psychotherapeutic professionals do not realize the powerful connection between the two, yet teaching deep, full breath is a practice that is within our scope as clinical professionals.

MARIAN CHACE AND THE DISCOVERY OF DANCE AND MOVEMENT THERAPY

Although the use of dance as a therapeutic method for healing and wholeness was certainly not new to the 1960s, the founding of dance therapy as a distinct and separate discipline traces here. Marian Chace, like Martha Graham, was a student of Ruth St. Denis and the Denishawn School of Dance during the same era. Chace launched her own career as a dance teacher and was inspired by ideas from Carl Jung about the connection between mind and body. Chace discovered that many of her dance students became more interested in the psychology of movement rather than the technique of dance. Thus, she began further developing her ideas with the support of many in the local medical community of Washington, DC, her home teaching base. She launched into offering her own training programs in what she coined dance/movement therapy, and in 1966, she founded and became the first president of what is now called the American Dance Therapy Association (ADTA).

Although one does not have to be a fully credentialed dance/movement therapist to incorporate movement into the practice of psychotherapy, billing oneself as a dance/movement therapist, at least with the blessing of the ADTA and often credentialing boards, requires specialized training and accredited credentialing. There are now graduate degree programs specifically offered in dance and movement therapy that can count toward ADTA accreditation and toward professional licensure in the mainstream psychotherapy professions (e.g., social work, counseling, marriage and family therapy) in many states. Professionals with a standard Master's degree that is not specific to dance and movement therapy can still become an ADTA-accredited dance/movement therapist through extra training and supervision. Full details about this process can be obtained at https://www.adta.org.

The ADTA's official definition of dance/movement therapy, as stated in their promotional literature and on their website, is as follows [13]:

- Focused on movement behavior as it emerges in the therapeutic relationship. Expressive, communicative, and adaptive behaviors are all considered for group and individual treatment. Body movement, as the core component of dance, simultaneously provides the means of assessment and the mode of intervention for dance/movement therapy.

- Is practiced in mental health, rehabilitation, medical, educational, and forensic settings, and in nursing homes, day care centers, disease prevention, health promotion programs and in private practice.

- Is effective for individuals with developmental, medical, social, physical, and psychological impairments.

- Is used with people of all ages, races and ethnic backgrounds in individual, couples, family and group therapy formats.

The ADTA publishes its own peer-reviewed research journal in dance/movement therapy. Although there is a wide array of research documenting the use of dance and movement therapy approaches in a wide array of physical and medical conditions, the use of such approaches as stand-alone treatments for mental and emotional disturbances has not been fully established [14].

THE CONSCIOUS DANCE MOVEMENT

Those who practice conscious dance (sometimes referred to as ecstatic dance) are well-acquainted with the healing and therapeutic properties of dance, even if they are not practicing healing dance under the formal umbrella of credentialed dance therapy. Mark Metz, founder of the DanceFirst Association and editor of Conscious Dancer Magazine, jokingly states that when you try to define it, it is no longer "conscious dance." Yet for the sake of furthering the academic discussion, Metz offered this definition: movement with an intention toward higher awareness [15].

As noted, Gabrielle Roth is generally credited as the mother of the conscious dance movement. Like Lowen, Perls, and Feldenkrais, much of her work is traced to the Esalen Institute in Big Sur, California. She developed her own practice, which is now called 5Rhythms, because she was asked to put together a movement program for residents and retreatants at the institute while she resided there. In one of her books, Sweat Your Prayers: Movement as Spiritual Practice, Roth wrote (in describing her early years of developing the practice): "Sometimes two hours of moving are as powerful as two years on the couch. I discovered that the body can't lie; put it in motion and the truth kicks in" [5].

Conscious dance practices like 5Rhythms are often associated with places like the Esalen Institute and other retreat centers like the Kripalu School of Yoga and Health and The Omega Institute, as well as music and consciousness festivals like Burning Man. However, mainstream psychological and helping professions have been taking more and more notice of these practices. There are a plethora of dance practices, some developed independently of Roth's 5Rhythms, with most developing in the wake of her legacy, that can be described as conscious dance practices. Many conscious dance practitioners within the helping professions are integrating conscious dance practices as an adjunct to clinical work in clinical settings. Moreover, many professionals are also noticing the value of sending their clients to conscious dance classes as wellness and skills-building technique to help them better manage affect. Even the dance classes that are more fitness-based as opposed to conscious-based, like Zumba fitness, can serve this purpose.

In linking clients with dance resources in the community for their own health and wellness, conscious dance and fitness dance practices are generally more accessible and available than dance/movement therapy. Metz, recognizing this phenomenon, started the DanceFirst organization as a fellowship for those working in movement and dance, designed to be more inclusive than exclusive. This organization publishes a calendar including more than 100 modalities within the scope of conscious dance being taught around the world today and provides a search tool for finding local classes and programs on their website at https://consciousdancer.com.

3. THE IMPACT OF MOVEMENT ON HEALING

Reflection

F.M. Alexander is quoted as saying, “You translate everything, whether physical, mental or spiritual, into muscular tension.” Does this resonate with you and your practice? How might this manifest in your clients?

Recall the previous discussion in this course regarding the age-old adage that actions speak louder than words. When it comes to emotional healing, especially regarding those issues that are deeply entrenched in our more primitive brains, the saying carries a great deal of neurobiological wisdom. Many therapists reach a frustration point in working with traumatized clients because, even if these clients can talk about the trauma, they may not experience much forward movement with their healing. In fact, these clients may end up subjectively worse from talking so much about their trauma. A basic understanding of how unhealed trauma or other adverse life experiences can become stuck in the limbic brain suggests that when it comes to complete healing, talking is not enough.

A BRIEF PRIMER ON UNHEALED TRAUMA AND THE LIMBIC BRAIN

For survivors of trauma and other adverse life experiences, the effects in the neuronetworks of the brain tend to occur at the lower levels of the brain called the limbic brain and the brain stem. These two lower areas in the human brain structure are related to emotion, movement, and the basic functions of human life, but not with concepts like speech, higher-order thinking, or rational judgment. As complicated as the study of trauma neurobiology can get, the most basic concept to grasp in making sense of this material is the human brain is composed of three separate brains, also referred to as the triune brain model.

According to this model, each of the three areas (i.e., the R-complex brain or brainstem, the limbic brain, and the cerebral brain or neocortex) has their own separate functions and senses of time. This model was introduced by MacLean in 1990 and has been used by trauma specialists in the ensuing years to help describe the impact of trauma and trauma processing [16].

The base of the brain contains the cerebellum, and it directly connects to the spinal cord (the brainstem). MacLean terms this as the R-complex (his original name for the basal ganglia), sometimes referred to as the reptilian complex or the "lizard brain." This area is equated with animal instincts. Those basic functions of animal life originate in this lowest part of the brain: reflex behaviors, muscle control, balance, breathing, heartbeat, feeding/digestion, and reproduction. The brainstem is very reactive to direct stimulation.

The paleomammalian complex (limbic system), sometimes called the midbrain, is unique to mammals. According to MacLean, this center of emotion and learning developed very early in mammalian evolution to regulate the motivations and emotions now associated with feeding, reproduction, and attachment behaviors [16]. In MacLean's explanation, everything in the limbic system is either agreeable (pleasure) or disagreeable (pain/distress), and survival is based on the avoidance of pain and the recurrence of pleasure. The limbic brain contains the amygdala and hypothalamus and does not operate on the same rational sense of time we know as humans. The amygdala is a filter and determines if incoming input is dangerous or not [17]. If the amygdala classifies the information as not a threat, it can process through to the neocortex and is integrated with other useful or useless data that have been acquired over the years. In essence, the information integrates into one's existing experience without fallout. As will be discussed later in this course, for many people who go through experiences from which threat or danger is signaled, receiving help, support, or validation sooner rather than later can assist a person with this process of integration, thus decreasing the chances of long-term consequences.

If the amygdala signals threat/danger, other parts of the limbic brain are activated, specifically the survival part of the brain, or the thalamus. These activities can incite one of three reactions, fueled by the lower reptilian brain: the fight response, the flight response, or the freeze response. When these responses are activated and re-activated, the body will respond, regardless of what rational thought might be saying. Even after the danger has passed, the thalamus remains on high alert, activating the same responses if anything reminiscent of the original danger passes through again. Together, the thalamus and the reptilian brain may work extra hard to prevent a similar response the next time. Obviously, these problematic symptoms can keep occurring in a vicious cycle until the limbic-reptilian levels of the brain can return to balance.

The limbic brain has no sense of time. When traumatized people feel "stuck," it is as if their proverbial panic button is not fully functional. When crossed wires get stuck in the limbic brain, they take on a high level of significance, because material was not meant to be stored here long term. When the regulatory capacities of this brain are impaired, it works longer and harder than it was intended to, causing the symptoms associated with traumatic stress.

The goal of successful trauma processing is to move or to connect the charged material out of the limbic brain into a part of the brain that is more efficient in its long-term storage capacities. In the triune brain model, this is referred to as the neomammalian complex (or cerebral neocortex). This is unique to primates, and a more highly evolved version is unique to humans. The neocortex contains the prefrontal lobes of the brain frequently discussed in explaining human behavior. This brain regulates so much of what makes us human: executive functioning, higher-order thinking skills, reason, speech, meaning making, willpower, and wisdom.

Most working in the psychological and behavioral health professions are familiar with attempting to talk reason to people in crisis or to encourage people to leave the past in the past and focus on the present. These types of interventions are common in much of the cognitively focused modern-day training in human services; it is natural to confront a person's negative thinking or to encourage a client to see the "silver lining" or reason. However, talking reason to a person in crisis is often futile. Cognitive (or any reason-based) interventions primarily target the prefrontal regions of the brain. However, the limbic region of the brain was activated during the original trauma to help the person survive (through flight, fight, or freeze responses). Because the frontal lobes were not activated or involved, the individual was never able to link up that limbic activation with frontal lobe functions during the experience. For a person in crisis or intense emotional distress, this process is playing out in real time and/or triggers from earlier, unprocessed experiences fuel the distress.

To summarize, when the limbic brain is activated, the prefrontal lobes are not. For optimal healing to occur, all three brains must be able to work together. Neurologically, unprocessed trauma creates disconnection in the brain. However, it is important to keep in mind that complex interventions are not necessary to encourage whole-brain interaction. Consider that deep breathing is a whole-brain intervention. Breath originates in the primal, reptilian region of the brain. Any movement-based or body-based intervention automatically works with the limbic and reptilian brains. The action parts of one's experience (and conversely the inaction or freeze responses that can result from unhealed trauma) are regulated by the limbic brain and brain stem. Thus, some of the most basic interventions for healing involve taking action.

HOW MOVEMENT AND RITUAL ENHANCE HEALING

Many in Western cultures tend to assume that talking is the best way to process trauma. You may have heard or even used phrases like, "We have to get her talking about it so she doesn't hold it all in," or "Well, he's talking about it, so that's a good sign." In many mental health and addiction treatment cultures, talking is synonymous with processing, and talking can play a role in helping a person to process. However, talking is primarily a function of the frontal lobe. A person can talk about the trauma all he or she wants, but until the person can address it at the limbic level, traumas will likely stay stuck. Being psychologically stuck means that a memory fragment is too large for the brain to process. Thus, something additional is required to help dissolve the fragment. Other healthy modalities of processing that can help with this dissolution include exercise, breath work, imagery, journaling, drawing, prayer, dreaming, and of course, dancing and movement. These experiential modalities are more likely to address limbic-level activity when compared with the classic "talking it out" strategies.

van der Kolk offers a solid summary of how to engage a person in a multi-tiered approach to healing in The Body Keeps the Score [14]. He writes that there are three primary ways for helping survivors feel alive in the present and move on with their lives:

- Top-down methods: Talking, connecting with others, self-knowledge

- Medication and technology: Medications to shut down inappropriate alarm reactions, other therapies/technologies that change the way the brain organizes information

- Bottom-up methods: Allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, and collapse that result from trauma

Usually, a combination of the three approaches is needed. The movement-based strategies addressed throughout this course are designed to help a person work from the bottom up.

THE ROLE OF MINDFULNESS, MOVEMENT, AND YOGA

Evidence Based Practice Recommendation

The Department of Veterans Affairs has found insufficient evidence to recommend for or against dance therapy for the treatment of PTSD.

https://www.healthquality.va.gov/guidelines/MH/ptsd/VA-DoD-CPG-PTSD-Full-CPGAug242023.pdf

Last Accessed: March 25, 2024

Strength of Recommendation: Neither for nor against

Evidence supporting the role of holistic strategies like mindfulness and movement strategies, especially yoga, continues to mount. Research indicates that these modalities provide powerful adjuncts to traditional psychotherapy. Although the field of dance/movement therapy and yoga therapy has existed for quite some time—each with their own journals—van der Kolk made history in 2014 when a psychiatric journal published a study that he and his team completed on yoga and PTSD. Using empirical methodology to study 64 women with described "chronic, treatment-resistant PTSD," the study concluded that yoga significantly reduced PTSD symptomatology, with effect sizes comparable to well-researched psychotherapeutic and psychopharmacologic approaches. Yoga may improve the functioning of traumatized individuals by helping them to tolerate physical and sensory experiences associated with fear and helplessness and to increase emotional awareness and affect tolerance [14].

Many innovators have worked to bring yoga and movement strategies into their work with trauma survivors, recovering addicts, and others who are struggling with problems of living. One such innovator is Nikki Myers, founder of a growing program called Y12SR, the Yoga of 12-Step Recovery. Nikki, a recovering addict and survivor of multiple layers of trauma, launched the program in early 2000. Y12SR meetings are not affiliated with any specific 12-step fellowship; rather, they are independent gatherings that combine the essence of a 12-step discussion meeting with a yoga class. The guiding principle of Y12SR is that "the issues live in our tissues" [18]. As Nikki explains, when one is in the physical posture of a yoga pose or even a simple stretch outside of the context of yoga and they feel muscles quiver, the body is working something out. Myers remembers being a 9-year-old girl watching the news and seeing people of color, people who looked just like her, being hosed and gassed and beaten. She absorbed these images during the social upheaval of the Civil Rights movement, and although she was raised in the northern United States, seeing those images completely shook her sense of authority and self. As Nikki explains, [18]:

Something had to be wrong with me if these people who looked like me were being treated this way. Everything I'd learned in school taught me that government and authority was to be respected, so if government and authority was doing this to children like me, I must be flawed.

She discloses that, to this day, reflecting on that memory brings up a strong visceral reaction in her [18]. These visceral reactions that people experience can rarely be addressed by talking alone, which is why integrating holistic strategies, including movement, are important competencies to weave into clinical skill sets.

In addition to yoga, work with mindfulness meditation and mindful movement programs (some being within the scope of dance therapy) continues to expand in the helping professions. Barton's research on a program she designed called Movement and Mindfulness offers some interesting results and implications [19]. Movement and Mindfulness was a body-based curriculum introduced into a group rehabilitation setting for severely mentally ill clients, using a combination of dance/movement therapy techniques, yoga skills, and traditional group therapy with a focus on mindfulness/Eastern meditation. Using qualitative methods of evaluation, results indicated numerous examples of physical and psychological shifts and experiences of pro-social behavior [19].

Crane-Okada, Kiger, Sugerman, et al. investigated the use of dance/movement therapy paradigms and mindfulness with female cancer survivors [20]. In this randomized design of 49 female participants between 50 and 90 years of age, the program's major benefits included reducing fear and improving attitudes of mindfulness. Another study examined Vipassana meditation and dance as vehicles for promoting somatic and emotional coherence, concluding through empirical measures that the coherence between somatic and cardiac aspects of emotion was greater in those that had specialized training in meditation or dance, as compared with the control group [21].

Since the early 2000s, the field of traumatic stress studies has taken special notice of mindfulness and other Eastern practices like yoga and the martial arts as healing channels. A major reason for this interest relates to neurobiology. Mindfulness practices play a key role in activating the prefrontal cortex and promoting a greater sense of concentration; concentration problems are common among trauma survivors, with the DSM-5-TR identifying them as a heightened arousal symptom [22,23]. Mindfulness can calm a client's inner experience and promote greater introspection, an important feature considering that disorganized memory structure may be one process that impedes access to, and modification of, trauma-related cognitive schema [24,25]. Structured mindfulness practice can cause positive structural changes in the brain related to learning and memory (hippocampus) and can cause a thinning in the amygdala, lessening the charge of fear-based responses [26,27]. There is also evidence that mindfulness meditation practices lead to decreases in ruminative thinking, alter the neural expression of sadness, positively influence change in neural activity, and positively impact working memory capacity and affective experience [28,29,30,31].

In 2012, a task force assembled by the International Society for Traumatic Stress Studies (ISTSS) published a paper on best practices in the treatment of trauma-related disorders. One of the team's conclusions, supported by literature reviews, was that "optimization of outcomes also includes exploration of novel treatment approaches such as complementary medicine strategies that focus on somatosensory experience and the mind-body relationship, for which there is emerging evidence regarding efficacy" [32].

Considerations for Clients Who Fear the Body/Movement

While some clients will be very open to incorporating movement into their therapy, many clients get fearful, skeptical, or otherwise uncomfortable when interventions like yoga, meditation, dance, or other movement strategies are suggested. In trainings, learners often ask, "How do you pitch these interventions to clients? Won't they think they're weird?"

In general, when working with new clients, one can ask general questions about the role of exercise and/or spirituality in their life. If a client is already using exercise, begin discussing some of those benefits and how they can continue working with those as part of their recovery and goals for wellness. In talking about the importance of building coping skills to a treatment plan, also ask if they are open to using simple breathing and movement strategies in the work in the office. If they are amenable, then proceed, and if this results in positive feedback, one can become more proactive about working in yoga, movement, or dance strategies. Sometimes it may be within one's scope to do this in sessions, and other times, it may be appropriate to work to match the client with community resources where they can take classes in these areas.

When clients begin asking the "why" questions about strategies like the ones covered in this course, it can be helpful to respond in one of two ways. The first is to provide a description of the triune model of the human brain, as described earlier in this course, to explain why talking alone may not meet all of their needs. Another approach is to share the following demonstration. A common symptom of PTSD and other trauma-related issues is hypervigilience, or always being on guard for something bad to happen. When one is hypervigiliant, their shoulders tend to creep up a bit toward their ears. Try this now—let your shoulders move up toward your ears and hold them there for a few moments. What are you noticing about your breath when you do this?

If you've held your shoulders up by your ears for even a moment, you probably began to notice a shallowing of your breath. Indeed, when muscles are tense or we are otherwise on guard, we do not breathe as fully as we should. Thus, working on breath and muscle-release strategies can prove to be a radically new, life-changing intervention for people. Most clients are not aware that their muscles are tense or that their breathing is so affected until they do this exercise. This can be a good way to offer a physical/movement-based demonstration instead of just lecturing about the potential benefits.

Of course, clients in therapy have various degrees of receptivity about working with the spectrum of action-based and movement-based strategies, which is why it is important to gauge their readiness and meet them where they are at with interventions. In the next section, a wide range of options that clinicians have at their disposal for integrating breath, movement, and even yoga or dance-related strategies into their clinical work will be presented.

Perhaps the highest degree of resistance from clients will be related to dance. Of course, it is important not to force dance-based interventions on clients or to tell them that they have to seek out a dance class, although it may be worth exploring why a person may be open to other movement strategies like yoga (which is generally more structured) or simple stretching, but closed off when it comes to dance or other more creative movement modalities. Cynthia Winton-Henry, developer of the InterPlay technique and author of Dance the Sacred Art: The Joy of Movement as Spiritual Practice, identifies these primary reasons people tend to be blocked from giving dance a try [3]:

- It is too embarrassing to dance.

- There is no connection between dance and spirituality (a myth).

- The body is a Pandora's box and not to be trusted.

- Dancing is not important.

In some cases, a combination of these factors may be at play. Hence, even while respecting a person's right to say no to dance or creative movement interventions, it may be worth exploring the source of their "no" and using that as grist for the clinical mill.

For those who are scared of or unsure about creative or expressive movement, structured movement exercises can provide for comfort, at least when someone is new to the process of embodiment. Even in approaches in which the goal may be for the group to open up and to explore freely, some clearly show discomfort in this area so they may need more direct physical instruction that feels like stretching. For example, "Open up your arm to the right side, stretch it out away from you, then let the arm float back and across your body to the left side." For this reason, dance or fitness classes that are highly structured may be a better fit for newcomers to dance and movement than classes or techniques that encourage free creative movement.

For the hesitant client, whether in a dance class or group or in an office-based setting, relying on more structure and direction is a solid best practice. Even with the simple breath and movement strategies covered in the next section, letting a person go too long in silence is what causes many to become uncomfortable beyond their window of tolerance. Also, getting continuous feedback from a client is helpful. Let them know that in trying some of these movement and other holistic coping practices, you want to get a sense about what will work for them and what they are not able to handle. Thus, trying six to eight breaths at a time to start with may be too much, so scale it back to two to three. Using the arms for stretching may seem uncomfortable but working with gentle twists from the waist may be a better fit. An axiom that can be helpful in work with movement, either one-on-one or with groups, is that there is always a variation, an adaptation, and alternative movement that can be tried. Additionally, there are ways that movement can be subtly added into favorite, time-honored talk therapy, cognitive therapy, or traditional recovery therapy (e.g., 12-step programs) strategies.

4. SIMPLE MOVEMENT TECHNIQUES IN CLINICAL WORK

Reflection

Consider the following quote from Fritz Perls: “Fear is excitement without the breath.” Does this concept resonate with you? How might it present in your clients?

One of the classical techniques in the broad practice of cognitive-behavioral therapy is thought stopping. Typically practiced as a combination of visualization (e.g., a literal red octagon of a stop sign or any other symbol for stopping) and intentional thwarting of a negative belief (e.g., "I cannot succeed"), the thought stopping approach helps many. However, for some clients, it only goes so far. Many individuals are well aware of what their self-defeating negative cognitions are and even using intention, confrontation, or visualization cannot stop the flow of the negative thought into permeating their emotions and/or behavior.

In these cases, a simple variation on the thought stopping technique using movement can be attempted. Instead of or in addition to visualizing a stop sign, this time bring your hands into a motion that signals stop. For most people, this means raising one or both hands in front of their core body, making some style of barrier motion. By adding this simple movement into the classic technique, the client is automatically working with more functions of the human brain. Clients can continue to make this barrier motion with their hands over and over again, even if it is 50 repetitions, until the negative belief passes. This simple activity in and of itself may not resolve the core negative belief (more intensive processing or cathartic interventions may be needed for that), but as a body-responsive coping skill, it can work wonders for distress tolerance.

Many clinicians (and clients) do not realize that incorporating dance and movement strategies into their work with clients can be done in such a simple fashion. When many clinicians hear "dance and movement work," they fear that this means actually getting clients to dance and engage in other movement activities in the office. Although dance and movement work can involve such strategies, assuming that the clinician feels comfortable and qualified to lead them, they do not have to incorporate that level of intensity. Clinicians who are new to movement work can begin by adding a gesture to the thought stopping technique, see how that works, and then proceed from there.

This section will explore other simple movement activities that correspond well with time-honored counseling and recovery techniques. Specific instructions are given to guide. Clinicians are encouraged to weave them into work with clients in whatever order may make sense. It can also be helpful to try these strategies yourself first, as you read this course. The key to being able to effectively pass these techniques along to clients, whether in an individual context or in a group setting, is to make sure that you have tried and understand the motions.

CLENCH-AND-RELEASE TECHNIQUE/PROGRESSIVE MUSCLE RELAXATION

The time-honored hypnotherapy technique of progressive muscle relaxation dates back to the 1920s. In this technique, recipients are guided to clench and release one muscle group at a time. So, for instance, one may begin by first clenching the left fist, holding it for about 20 to 30 seconds, and then with a nice deep exhale, releasing the contraction. This isometric motion is continued throughout the entire body. There are variations. Some will start with the left fist, and then continue into contracting and releasing the left forearm, then the left upper arm. Some people may prefer, after contracting and releasing the left fist, to move over to the right fist, beginning a pattern of left-right alternation through the body. Some progressive muscle relaxation guided meditation can be very detailed (e.g., challenging you to work with even the smallest of muscular contractions), whereas others are very general.

A full progressive muscle relaxation exercise that covers the whole body, if done slowly and mindfully, can take upwards of 20 minutes to complete. Such an exercise can be an excellent technique for clients who struggle with sleep. However, in most arenas of life, going into a full 20-minute exercise, especially one that may result in complete relaxation and sleepiness, is not optimally realistic. Thus, clients can be encouraged to use the same spirit of isometric muscle contraction used in progressive muscle relaxation in a simplified, "express" format. The following is an example of how one might teach such a skill to a client and work with variations [33].

Have you ever been so angry or stressed you just want to make fists and hit something? In this exercise, you'll be able to make that first…and then practice mindfully, intentionally letting go. Here are the steps:

- Make fists.

- As you focus on your clenched fists, bring to mind something that stresses you out.

- As you reflect on the stressor, really notice the contraction of your muscles. Feel your fingernails dig into your skin, if possible.

- Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly, mindfully let go at any time.

- Notice your fingers uncurling, and feel the trickle of letting go all through your arms, up to your shoulders.

- Notice how it feels to let go.

Clinicians can repeat this basic, core exercise with a client for as many repetitions as necessary and helpful. There is no right or wrong experience that said client should be feeling after the letting-go motion. Rather, this can be a way to help clients cultivate the practice of noticing how certain experiences feel in their body. Alternatively, the client's observations may be used as a channel for dialogue within a standard clinical skill set. For instance, one time I did this exercise with a client who struggled with letting go of things that no longer served her—old memories, old relationships, old beliefs about herself. I guided her through this exercise, using the standard line, "Whenever it feels too uncomfortable for you to keep holding on, know that you can slowly and mindfully let go." My client held on tightly for 15 minutes—the longest I have seen a client hold it. We rode out the experience for a few minutes in silence. She finally broke the ice declaring, "I guess I can really hold on to things for a long time." We ended up having one of the most productive dialogues in our clinical relationship about how holding on to things was a barrier to her health and wellness.

Prior to us doing this exercise, this client was very hesitant about doing anything too deep, explorative, or cathartic with her therapy. Within a few sessions using this simple clench-and-release technique, the client knew that she could no longer stall with her therapy if she wanted to reach her goals.

Clinicians very often talk with clients about the importance of letting go: letting go of the past, letting go of fear, letting go of anger or resentment. The 12-step recovery model places a great deal of emphasis on letting go of resentments. This extensive talk about the virtues of letting go can continue with no results, or clinicians can dynamically, experientially urge clients to work with the concept of letting go, hopefully allowing them to experience how good it can feel to do it.

There are extensive modifications and creative variations that can be made if the basic clench-and-release exercise does not seem to optimally resonate with a client. Some examples include:

- Any muscle group can be clenched and released, especially if clenching the fists is too painful or not possible due to context or physical limitations. Clenching and releasing the stomach and feet are other popular choices.

- A bilateral component can be added to the exercise. For instance, consider clenching the left fist first for a period of time, then move over to the right fist and repeat the motion. Continue alternating left-and-right, giving it a minimum of three sets. Notice if it gets more difficult to "clench" after each sequence of "release."

- Add a relaxing sound (e.g., nature sound, music) in the background or use an aromatherapy diffuser, particularly if using this exercise for sleep.

- The client can be instructed to write down a stressor, resentment, or thing that they wish to let go of on a slip of paper. For some, hearing the drop of the paper to the floor, or releasing it into a recipient (e.g., a trash can, the wind, a flowing river) makes the release experience even more powerful.

In a later section of this course, we will explore how this clench-and-release principle can be used as an actual dance exercise with a client or other recipient.

BILATERAL MOVEMENTS FOR STRETCHING AND CLEANSING

In the clench-and-release variations, adding a bilateral element is noted as a possible option that can be powerful for many. Most clients report a greater sense of relaxation doing the clench-and-release technique bilaterally as opposed to using both fists together. There is something special about the power of bilateral movement on the brain (i.e., back-and-forth/left-to-right), as evidenced by ancient spiritual/healing practices (e.g., drum circles) and modern approaches (e.g., EMDR). Modern research in neuroscience is beginning to support one of the core healing principles in Native American healing arts: moving back and forth has a transformative effect on the brain and the body [34].

Contrary to some misinformation, simply invoking bilateral eye movements or other forms of bilateral stimulation will not cause a person to go into a full-on trauma abreaction. As discussed in the book Trauma Competency, [1]:

Bilateral stimulation is not dangerous, nor is EMDR as a modality. If it were, wouldn't it follow that we should all abreact when walking, snapping our fingers, or playing Miss Mary Mac? However, when administered by clinicians without prerequisite knowledge to effectively address and treat trauma's sequelae, the EMDR protocol proves challenging, fear-inducing and, oftentimes, traumatizing for clinicians and re-traumatizing for clients.

Consider this: If you are pairing bilateral movements together with questions for digging deep into a person's past without training in trauma and its effects, you may be treading into dangerous territory. However, as a basic coping strategy, bilateral interventions themselves are not inherently harmful. It truly comes down to the intention of the movement. If paired with the intention to self-soothe or bring the brain back into balance, as opposed to the intention of inducing deep exploration or catharsis, most clinicians are well within their scope to bring them into the therapeutic context. Within the cannon of EMDR literature, master clinician Dr. Laurel Parnell first introduced the idea of using bilateral tapping, paired with positive imagery, as a self-help strategy [35]. Even the founder of EMDR therapy, Dr. Francine Shapiro, followed suit with a book on using basic EMDR techniques as self-help strategies [36]. Both works serve as excellent supplementary resources to the material provided in this course.

Many clinicians may note that clients who have never heard of EMDR therapy intuitively engage in bilateral "techniques" to help alleviate stress. For example:

Whenever a client feels stressed at work, he goes outside and takes a cigarette lighter and tosses it back and forth from one hand to another. Interestingly, he does not smoke cigarettes anymore; he just uses this self-created technique with the lighter.

Another client was intrigued when EMDR was first suggested to her because she said it seemed like a process she has used to help her calm down over the years. She wears a ring on which a bejeweled bumblebee is set on a spring hinge. When you touch the bee, it rapidly moves back and forth horizontally. This client would stare at the back-and-forth motion of the bee to calm herself whenever she felt agitated or triggered.

Think back to your own experiences in elementary school or preschool. Did your teachers ever use techniques like having the class get up and run in place for a minute or so to work out the stale energy and get the blood pumping? Maybe you have even used such an approach with your own children, telling them to go outside and burn off some of that energy. Conversely, when some are too lethargic or sluggish, engaging in a similar pursuit can generate more productive energy. Such activities bring a greater sense of equilibrium to the brain, opening them up for a greater sense of calm and enhanced learning.

Some of this same logic may resonate with clients. Consider the following cases:

- A client comes into the office. They are so high strung and anxious, they can barely sit down to even give voice to what is happening with them on that given day.

- The session "goes stale"—there is either nothing to talk about, or the client has "hit a wall" from talking too much about a specifically heavy emotion.

In either scenario, consider how bringing some simple movement into standard interventions can make a difference. The following approach may work in either scenario: Instruct the client to stand up tall and encourage them to rotate from the hips, letting their arms fall against the body on each side. The client can keep the motion gentle, especially if their mobility is restricted, simply moving the arms at waist-level from side to side. If the client wants to get more movement into the motion, they can make the hip rotation more vigorous, even moving on to the balls of the feet with each back-and-forth motion.

If you have the option in your setting to do "walking therapy" outside, especially in decent weather, you may take advantage of that experience. In his book The Wounds Within: A Veteran, a PTSD Therapist, and a Nation Unprepared, Mark Nickerson (with Goldstein) shared his experience using this approach with a returning veteran who had a serious case of PTSD [37]. The young man was not only unable to sit still to talk, he had a very difficult time making eye contact because of his intense shame. When the veteran client asked if they could take a walk, my colleague was willing to make some modifications to facilitate and found that the client opened up in a way he was not able to in the office. For many who work in the adventure or wilderness therapy model, similar experiences are regularly observed. Indeed, one of the guiding premises of adventure therapy is that there is healing potential in getting out there and doing instead of just sitting around and talking.

If stepping outside of the office is not a feasible option in addressing either of these two scenarios, or if the client is not open to overt physical movement, clinicians have the option of using only the hands. Some refer to this technique "energetic massage," although the title can be modified to best reach the client. The following is an example of how to teach the exercise [33].

Do you ever feel, quite literally like your brain hurts? Wouldn't it be great if you could give your brain a massage? With a simple exercise that harnesses the power of your own tactile (e.g., touch), you can.

- Rub your hands together for at least 30 seconds (or longer if you want). Really work up some heat!

- Pull your hands apart and bring them to your forehead. You can close your eyes, and place the base of your palms over your eyes; let the rest of your hands curl over your forehead to the top of the forehead. Or you can rest the base of your palms on your cheeks and go around your eyes. Choose a variation that is comfortable and helps facilitate relaxation.

- Settle in and feel the energy you generated in your hands move into your brain. Just allow the head to exist without judgement.

- Hold as long as you like.

This simple strategy, which you may already do inherently when you have a headache, can be used in many ways during therapy sessions. First, when the client comes into session and they seem to be talking rapidly and/or are unfocused, this exercise can be done as a simple ceremony to settling in before beginning talking. This can set a much calmer, more even pace for the session. A second option is as a session closer. If the client has been working on difficult material throughout the session, they may be feeling a little exhausted or too overwhelmed to leave. This option can be presented as a "brain massage" to return the client back to balance before leaving the session. As with many of the exercises discussed in this section, a third option is when/if the session "goes stale." If you've hit a wall with the session content or the client seems too exhausted to continue, this energetic massage movement technique can provide the much needed shift.

Other options and variations on this core exercise include:

- Bringing the energy from your hands to any part of your body that is feeling tense or anxious. Think about bringing the heat energy from your hands to your heart/chest or stomach if you are noticing any tension or pain.

- The "cranial hold" position is an option after generating the energy. To achieve this, horizontally bring one hand to your forehead and the other hand to the back of your head.

- Consider adding another sense into the process for optimal relaxation, like meditative music or an aromatherapy oil of your choice.

USING HAND GESTURES AND POSTURING FOR TEACHING NEW BEHAVIORS

So far in this section, we have covered how to bring the "stop" hand gesture into the classic thought stopping coping skills, how to use clenching and releasing to work with the concept of letting go, and how to use bilateral motion achieved via rubbing the hands together for a simple energetic massage. It should be becoming clear that incorporating movement in the context of traditional psychotherapy can be as simple as working with the hands. The next sections will present a few more ideas for how to bring gestures into therapeutic work to highlight certain principles and begin to explore how advocating certain changes in posture can achieve similar effects.

Regardless of one's primary approach to psychotherapy, clinicians are likely to have worked with clients on setting boundaries. Many clients struggle with boundaries, often as a result of trauma and abuse, with possible connection to codependency or co-addiction patterns. A simple exercise based on a yoga gesture (e.g., a mudra) may be included in this work. The following example is of the mudra of self-confidence, also known as the vajrapradama (or vajra) mudra:

- Interlace your two hands together, allowing your thumbs to point up and away from your body.

- Now bring these interlaced hands over your heart. If touching your body feels too invasive or uncomfortable for you, as a variation, you can bring the gesture over your heart without touching your hand to your skin.

- Hold this gesture over your heart for as long as you are able. Think about this gesture as a fence or a guard for your heart. Consider that you are in control of what comes into your heart, and you are in control of what flows from your heart.

- If you ever need to be reminded of this boundary and that you are powerful, come into this hand gesture and hold it, together with your breath, for as long as you need to.

If a client develops another hand gesture or posture that works better for them based on this original suggestion, this can be a great way of incorporating their feedback and creating a useful variation.

Coming into postures of confidence and power can have similarly positive results. Practitioners of yoga, yoga therapy, and many of the newer somatic therapy approaches that will be briefly discussed in the final section of this course are well-acquainted with this principle. How one sits, stands, and postures oneself overall, in relation to others, can tell a great deal about how one feels and/or perceives oneself in that relationship. For many individuals, having an awareness of this relationship dynamic is the first step of awareness that helps them to renegotiate their own perceptions of the relationship through making an adjustment in the posture. Such adjustments are well-known interventions within the Alexander technique.

Case Example

Client A presents to therapy with several goals, one of which is improved, positive assertiveness in her work setting. The client reports a high degree of stress about an abusive boss. Even after many years in his employ, she continually struggles with feeling heard by him, and she knows that the power dynamic he casts is reminiscent of how she related to a previous spouse with alcohol use disorder. Although she identifies that these older wound issues will need to be addressed and healed later in therapy, her therapist begins, during stabilization, to help her develop some skills to better cope in her work setting. The therapist asks Client A if she is sitting or standing during these difficult conversations with her boss. She replies that he always summons her into his office and that the available chair is lower than the boss's own. When the therapist asks her to visualize herself in this scenario and recall how it makes her feel, she reports that she feels small in his presence, and because of that, she has a natural tendency to curl or cower inward. Inspired by work with trauma-informed chair yoga, the therapist/client dyad spends some time in the session working on how to sit with confidence: sitting forward in the chair so that her feet can remain firmly planted and grounded on the floor, spine upright and straight, shoulders relaxed away from her ears. In the first part of the exercise, Client A simply practices this posture, specifically practicing coming into it from her natural position, which is to sit back in the big chair and cower inward while her shoulders are spiking up toward her ears. After the client feels confident with the posture, she then visualizes sitting in this more confident posture while in her boss's presence. As a homework assignment, the therapist advises her to practice coming into this seated posture every day, pairing it with some of the breath exercises, other safeguard visualizations, and other positive affirmations she is learning in her therapy/healing. When it comes time to actually speak to her boss again, Client A is able to use this simple shift in her posture, which she reports allows her to speak more confidently and feel less affected by the boss's natural critical countenance.

SITTING AND STANDING WITH INTENTION

If Client A had typically interacted with her boss while standing, the exercise could have been easily adjusted to target the standing posture and to practice standing with confidence. A common question in counseling and community settings is what skill can be used when talking to a difficult person. For these situations, it can be most effective to teach one of the foundational poses of yoga: mountain pose (tadasana). To a casual observer, mountain pose may not look very dynamic: it may appear that the practitioner is standing and looking out at the horizon. But there is power in standing with purpose and intention—embodying the power and grace of a mountain. Notice the full surface area of the foot connected to the earth below. Keeping one's gaze to the horizon can help support standing with purpose and confidence. Let the shoulders relax away from the ears, and feel the crown of the head extend to the sky. Allow the hands to rest gently at one's side if practicing this inconspicuously, or if practicing alone or with more intention, consider facing the palms out.

The simple motion of moving from sitting to standing may also be used as a technique for working with clients with movement. Rising from a seated position, assuming physical capacity, is something that most take for granted. Yet even this simple activity of life can be practiced mindfully, allowing one to build an even greater sense of body awareness and empowerment. One example of how this technique (referred to as full body rising) can be taught follows [33].

Whenever one does an activity that is normally automatic in a slow, mindful way, it is a perfect chance to cultivate the attitude of patience. Consider the following exercise:

- While in a sitting position, allow your upper body to fold over your seated, lower body. Your hands do not need to touch the ground, but aim there. Take a few moments and notice how it feels when the blood moves to your head as you fold over.

- Very slowly and carefully, allow your buttocks to lift off of the chair while remaining in the bent-over position. If your hands can touch your feet or the ground, do that; if not, just allow your hands to fall wherever they may on your legs.

- Stay in this folded over, "rag doll" position as long as you are able.

- Slowly, mindfully begin to unfold your spine and rise. Think one vertebra at a time; avoid just rushing up.

- When you have totally unfolded, let your shoulders roll back and keep your gaze straight ahead, with confidence. Notice how you feel.

As with all of the activities presented in this chapter, there are no "rights" or "wrongs" about what a person should (or should not) be feeling. Rather, use the feedback that clients give about the experience to elicit further dialogue within the existing therapeutic context, or use the feedback to make modifications. For instance, if a client is unable to stand, they can still achieve the benefits of this exercise by doing the first part of bending over and then unfolding the spine. The client can be encouraged to take the confidence stance with their upper body, even in a seated position. One can also incorporate music that creates a vibe of rising or emergence to enhance the mood of growing into confidence. This variation can be especially effective in engaging children.

A yogic breathing technique that can be coupled with a confident posture is an approach called lion breathing. Although many adult clients may be initially too self-conscious to try it, they often find benefit if they are eventually able to overcome their reticence, and it can be a useful coping approach for assertiveness training. The following script can be used to teach lion breathing [33].

Although taking on the full character of a lion is optional with this exercise, allowing yourself to make the face of a lion with this breath can help you with letting go of negativity:

- Begin with a healthy inhale with your nose that allows the belly to expand as fully as possible.

- Exhale vigorously, allowing the tongue to hang out. Feel the jaw and cheeks loosen. Open the eyes widely and let them roll back slightly to help with the sensation of letting go.

- Try at least three to five sets, taking time to adjust to the level of your physical comfort. With each set, see if you can allow your tongue to hang out further. Bring your hands up like lion paws to fully get into the character of the breath.

Following attempt of this exercise, individuals should experience a loosening in the jaw on both sides. We often discuss how important it is to stretch the joints, but the jaw, one of the most powerful joints in the human body, tends to be overlooked. It is often said that when a trauma or other stressor has silenced someone, it is felt somatically through jaw pain or throat tension. Doing an exercise like lion breathing, and practicing it with consistently, is a way to promote movement in the somatic and energetic body and resultantly serve as an aid in building confidence. After teaching lion breathing in the office setting, clients can be advised to craft a few minutes each day where they can practice the exercise on their own. As a variation option, adding a musical track that one finds empowering can take the exercise to a new dimension. Although going into a difficult conversation with a boss or other person while doing lion breathing is generally not advised, taking a few minutes to do some lion breaths before going into these types of interactions can make a significant difference.

With lion breathing or any of the strategies, you never want to engage in them to the point of physical pain. Hence, starting with a simple one or two sets of the breath is generally advised until you see how well a person will tolerate the technique. The same spirit of encouraging clients to listen to their body's own limits must also be taken into the next series of exercises.

RITUAL MOVEMENTS FOR LETTING GO AND RELEASE

There can be healing power for many in both ritual and ceremony. For many indigenous cultures, the idea of helping a person to heal without involving ceremony would not be possible. Although one could argue that there is a certain ceremony to the process of coming to an office and sitting down in the therapist's chair, it is a ceremony that has become more of a mindless ritual in modern society. For clinicians committed to bringing in more creativity and movement into their practice of psychotherapy, the essential question is: How can I make the process more dynamic and engaging for my clients?

Reflection

Scan your memory of your practice. What are some of the memories that stick out to you about when you’ve worked with the client to come up with a creative solution to a problem at hand? What role did creativity, specifically invoking some type of ritual or ceremony, play in that solution? Take time to make notes of how these approaches might inform work with your current clients.

A time-honored psychotherapy technique from the Gestalt tradition is the unsent letter technique. In this process, a person writes, in letter form, everything that s/he would like to say to a person who was a source of trauma or offense. When making use of this technique, clients are encouraged to get it all out—avoid censoring language or judging emotional content. Assuming that the client is stable and ready enough to handle this process, they should be supported in really letting it all out. Together, after they've released the emotions through the physical process of writing, devise a method for best releasing the unsent letter. This is where movement, ceremony, and ritual can be introduced to enhance the process. Some people choose to rip their letters up and leave them in the trash bin in the office (again, symbolizing letting go and leaving it behind), whereas others may choose to burn the letter, noticing the rising smoke as a symbolic releasing of the pain in the letter to God/Higher Power/nature. Others may choose to leave unsent letters at a cemetery, if the letter is to someone who has passed away. The options here are endless; the common denominator is that the physical processes involved with these activities powerfully activate the brain to help with the overall sense of release.

Such a ceremonial process may be particularly helpful if a person is struggling with complicated mourning issues, especially if there were words left unsaid or the client/mourner was unable to say goodbye in the way that they would have wished. Taking an unsent letter to a gravesite may be sufficient, but others may want to invite others in to witness the process. Perhaps bringing in the element of fire to burn the letter and setting the intention of it rising to the heavens with the smoke can add to the richness of the ceremony. Bringing in loved ones' favorite songs may also add a dimension to the ceremony.

Experts have also identified a variety of ideas for incorporation of elements of traditional ceremony and ritual into the Western counseling process [4,7]. This can include Native American customs and ceremonies, traditional Chinese medicine practices, and yogic traditions. For example, the text Yoga Skills for Therapists provides examples of how psychotherapists can weave elements of yoga into their own practices without formal training [38].

Although this course will cover direct dance strategies for letting go and release in the next section, a simple movement technique can also be useful as a ritual/ceremony for "shaking off" negativity or stress. Inspired by Cornelius Hubbard, this exercise is referred to as noodling. Like running in place, it can have a similar effect to getting a person whose attention has drifted or who has become overwhelmed to refocus. The following is a sample script for teaching noodling [33].

Haven't you ever envied a cooked noodle? The way it just moves free and easy, without stress, is an admirable quality that can teach us how to practice the attitude of letting go. Think of how fun, and potentially beneficial, it could be to take on the role of a noodle.

- For optimal benefit, rise to your feet (although you can also do this sitting or lying down).

- With your next breath, think of taking on the qualities of a noodle…it is suggested that you begin in your shoulders and then let the "noodling" move through the rest of your body.

- Keep noodling, in an intentional way, practicing beginner's mind, nonjudgment, and non-striving for at least three minutes.

- When you have completed this exercise, allow yourself to be still for a few moments longer (either standing, sitting, or lying down), and notice how it feels.

- Although you can do this in silence, one potential creative modification is to put on some music that can bring out your inner noodle. You can also bring scarves, ribbons, or others props into the action—this is an especially fun exercise to engage children.

As with many of the exercises covered thus far, the dialogue with clients following their attempts of these exercise can be powerful. Comments from clients following an attempt at noodling can lead to an amazing discussion about how hypervigilence plays a role in mental health and body sensations. Clients may begin to get a sense of the extent to which somatic hypervigilence is engrained and how it keeps them from fully "relaxing into" and ultimately enjoying life.

DANCING MINDFULNESS

In 2010, I worked to develop "dance-based" interventions that can be woven into traditional psychotherapy through the lens of a practice called Dancing Mindfulness. Dancing Mindfulness is an approach that uses the human activity of spontaneous dance as a mechanism for teaching and practicing mindfulness meditation. The practice adapts the classic practices of mindfulness in Eastern philosophy for a more Westernized audience using an expressive art form [39]. While various articles and writings within the field of dance therapy reference mindful movement, Dancing Mindfulness exists outside of the structured precepts of dance therapy. Whereas dance therapy approaches may draw upon mindfulness, Dancing Mindfulness is a modern approach to mindfulness meditation that draws on dance as the vehicle for practicing the present-focused meditation. Meditation is any activity that helps one systematically regulate attention and energy, thereby influencing and possibly transforming the quality of experience in service of realizing the full range of humanity and of relationships to others in the world [27]. There are numerous ways to meditate, with different approaches having nuanced effects for individual practitioners [40]. A study consisting of interviews with both nuns and laywomen led Buddhist teacher Batchelor to conclude that the specific techniques of meditation used do not seem to matter as much as one's sincerity in practicing the Dharma, or "the body of principles and practices that sustain human beings in their quest for happiness and spiritual freedom" [41].

Although the phrase Dancing Mindfulness has been coined to describe an approach to mindfulness meditation, cultures around the globe have collectively drawn on the power of dance and present-moment meditation since the dawn of time. Dancing Mindfulness is a wellness practice that grew from my clinical experiences working with trauma and addiction. It can be learned in a group class and practiced in community as well as individually; experience in yoga, meditation, or dance is not required to practice. Participants are simply asked to come as they are with attitudes of open-mindedness. Structured classes begin with a facilitator gently leading participants through a series of breathing and body awareness exercises. Following a mindful stretch series, the facilitator leads participants up to their feet for letting go and dancing with the freedom one might tap into by simply turning on some music and dancing around their houses. Many participants find this practice, especially when supported by the energy of other practitioners who are also taking risks, a cathartic experience. Although some find themselves overwhelmed and intimidated, they are encouraged to just acknowledge their experience, without judgment, and can choose to opt out of a certain dance or use their breath and movement as vehicles for moving through the discomfort. Safety is imperative to Dancing Mindfulness practice—facilitators emphasize that no one ought ever feel forced to participate in any component of the practice.

The primary attitudes cultivated by mindful practice, as identified by Kabat-Zinn in his synthesis of mindfulness research, are used as thematic guidelines in structuring classes: acceptance, beginner's mind, letting go, non-judging, non-striving, patience, and trust [27]. Any of these attitudes may be used as a thematic guide in choosing music for the class, or the facilitator may call upon a series of these attitudes in dancing with an element. The elements of Dancing Mindfulness are networks through which mindfulness can be practiced: breath, body, mind, spirit, sound, story, and fusion of all the elements. A facilitator may elect to start the class working with breath in silence, advising participants that when they use their bodies to come up to their feet and dance, their breaths are with them as a guiding force. Using breath to guide movement is a way, for example, to cultivate the attitude of trust.

Although Dancing Mindfulness was developed within a group context, the attitudes and elements of dancing mindfulness can be used as part of a daily wellness practice and in individual work with clients. Many Dancing Mindfulness facilitators use the practice as an adjunctive activity in clinical settings, bringing moving meditations inspired by Dancing Mindfulness into individual sessions with clients. The following sections will outline versions of some of these mindfulness-informed approaches. Learners are encouraged to try the interventions out first and then determine if they can or should be weaved into work within clients in their existing therapy setting and therapeutic approach. When it comes to physical safety, be sure to advise clients to listen to the feedback that their bodies give them about how far or how fast they are going. In terms of your own clinical scope of practice, if any of these exercises are going to be used for more of a cathartic experience, be sure that you feel comfortable addressing, within your existing therapeutic orientation, what may come up during the movement process.

Clench-and-Release Variation

One Dancing Mindfulness-inspired approach is to take the clench-and-release exercise (discussed previously) to a more dynamic, "dancey" place. The purpose of this dance is to consider whatever it is you are holding onto: anger, resentment, hatred. It is up to the individual to decide what they want to work with. After this selection is made, the dancer is instructed to take two stress balls and grip their hands tightly around them. As the music inspires, they should move through the space and notice the experience of holding on. It is important to allow time for this process. In addition, the choice of music is very important here; "angstier" music can generate more tension in dancers, which is useful here. When the song ends, the client should be instructed to release the stress balls, notice them leave their hands, and drop to the floor. Ask the client to take a moment to notice how good it can feel to let go and to let the earth absorb any of the negativity that arose in the room.

It is generally a good idea to choose the next song as a counterpoint, one that continues to work with the power of release. As a caution: Not everyone likes this dance; some may feel that it is "too much." For those attempting this facilitation in a group or within an individual counseling setting, remind your group or individual client that opting out is always an option. As a variation, the individual could do the same dance without stress balls—simply have people clench their fists and when you invite the release, have them notice how good it feels to release the grip on the hands. Encourage the opening of the hands to trickle into the rest of the body and then dance with that sense of release.

Mindful Music Listening

If an exercise like this seems too advanced or risky for your clients, consider working with the client in the context of a mindful listening exercise and then adding in some movement if it seems organic. Too often, music is in the background. In this exercise, the client can explore how really paying attention to the music in a nonjudgmental manner can usher in a new experience. Clinicians are encouraged to try all four parts of this exercise, in order, before attempting it with clients. It can be an excellent exercise for personal practice in addition to working on it with clients or students.

To start, ask clients to get into a comfortable yet alert position, as if about to do a seated or lying down meditation. Then, cue up a piece of music that the client has never heard before. For the length of the song, their only task is to pay attention to the song, listening mindfully. Just be with the experience.

After a few minutes of silence, cue up the song again and let the music connect with breath. Be open to movement should it happen, and just go with it. Some clients will only be inspired to sway and swivel a little bit; others may break out into a full-on dance routine. Whatever happens, just honor the experience.

Now, find a piece of music that the client knows very well, preferably something that they connect with emotionally. Instruct the listener to return to a sitting or lying meditative position and listen to this piece of music with total awareness, as if it is the first time they are hearing it. Once again, just be with the experience and notice what happens within when listening with mindful ears.

Finally, replay the song, only this time being open to movement. Just go with it, and notice what happens.

5. FURTHER TRAINING & COLLABORATION

Reflection

“Almost all creativity involves purposeful play.” –Abraham Maslow

Consider for a moment how purposeful play in the form of dancing and movement might inspire your clinical practice. How do your own experiences with movement inform your understanding of other individuals and cultures?

IS FURTHER TRAINING RIGHT FOR MY CLINICAL PRACTICE?

If the interventions outlined in this article excite you, there is a chance that you may want to pursue further training in dance and/or movement modalities as part of your continuing education. There are several avenues that you can explore—the conscious dance routes (e.g., 5Rhythms, Dancing Mindfulness); the more structured dance, movement, and expressive arts therapies routes; and finally, approaches to psychotherapy that typically are not viewed as dance/movement therapy, but certainly incorporate movement and somatic work (e.g., EMDR therapy, somatic experiencing). This section will provide a very brief overview of available avenues and resources for further information.

If you are interested in the conscious dance route, consider visiting https://consciousdancer.com, the official website of Conscious Dancer Magazine and the DanceFirst Association. Of particular interest may be the Upshift Guide, which lists summaries and training requirements for more than 100 conscious dance modalities operating around the world. The training lengths for each modality vary, although it is not unrealistic to complete full training in some modalities within several weekend modules. Conscious dance training is generally ideal for those who seek to bring movement practices into the larger community (e.g., yoga studios, churches, schools, wellness fairs, festivals) and not just in a clinical setting. In addition, those who work in a clinical setting that is open-minded to practices like this, having some training in a conscious dance form will generally suffice to support the incorporation of dancing approaches into clinical practice.

For those who are looking for a more structured experience in dance/movement or expressive arts therapy, there are options available through the ADTA (https://www.adta.org) and the International Expressive Arts Therapy Association (https://www.ieata.org). Both entities offer formal training programs, many of which come with continuing professional education. For the ADTA route, to become a registered dance and movement therapist, a period of working with an approved supervisor is required. The ADTA also lists Master's degree programs that they recognize in dance and movement therapy for fulfilling much of these requirements, although a post-Master's training route is available for those wishing to register as a dance/movement therapist after having completed a general clinical Master's degree. The IEATA model allows for individuals to become certified through both traditional and non-traditional models of demonstrating their training and education. These paths are recommended for clinicians who truly want to deepen their educational experience and those who are likely to work in settings where formal accreditations are expected and/or required.

A final, and perhaps the most career-advantageous, path could be to explore the newer wave modalities of psychotherapy that utilize somatic interventions and creative affect tolerance modalities. Many of these, like dialectical behavioral therapy and EMDR therapy, are recognized in the SAMHSA Evidence-Based Practices Resource Center. Others, such as sensorimotor psychotherapy, are increasingly gaining credibility based on their grounding in the latest findings in trauma-informed care and neurobiology. In addition to the traditional modalities in movement discussed in the first section of this course, clinicians should also consider checking out the regulatory websites of these modalities for information about training and formation:

- EMDR therapy: https://www.emdria.org

- Dialectical behavior therapy: https://dbt-lbc.org

- Somatic experiencing: https://traumahealing.org/professional-training

- Sensorimotor psychotherapy: https://sensorimotorpsychotherapy.org

- Psychomotor psychotherapy: https://pbsp.com

- Hakomi mindful somatic psychotherapy: https://hakomiinstitute.com

- Body psychotherapy: https://www.usabp.org

The imperative here is not that all persons interested in incorporating movement into their clinical practice must seek training in every one of these modalities. Rather, they offer a potential avenue for blending somatically informed movement work into a psychotherapy practice. Learners are encouraged to visit the sites, read about each, watch demonstration videos, and if possible, arrange to have some work in each modality done. This process of inquiry will provide a good idea of which approach best resonates and will likely prove to be the best fit for your practice.

COLLABORATING WITH OTHER PROVIDERS

After participating in this course, clinicians should be empowered to, at least, try out some of these movement practices themselves. Even those who do not foresee incorporating movement or dance approaches into work with clients are encouraged to experiment with making them a part of their own self-care. In between stressful meetings or client appointments, consider if you might incorporate a little movement to improve posture or to shake the stress away.

In addition, clinicians should consider the option of collaboration with other professionals. Even if pursuing formal training is not appealing, consider exploring some of the websites and organizations provided. They might be able to direct you to providers in your area who are willing to work with you collaboratively. Especially if it seems like you have exhausted the extent of your clinical repertoire with a certain client, sending them for some supplemental sessions in one of the modalities described here may be a good fit. Many conscious dance or yoga classes offered in communities have a healing spin that is appropriate for clients. Bringing these to clients' attention as resources they can seek out for coping can be helpful, as long as you check back in with them after they sought out the suggestion to make sure that it was not unproductively triggering in any way. This follow-up feedback can be used to continue working with them on wellness measures.

6. CONCLUSION

The intent of this course was to inspire creative thought processes related to how to work movement and dance modalities into an existing psychotherapy practice. There are many options available using various traditions and levels of movement engagement. The creative descriptions are intended to be resources to support work on some of these skills. Before passing them along to clients, it is important to have first tried them. If you have been able to incorporate movement or dance exercises into your daily life and wellness practice, you are in an even better position to be an ambassador for movement.

7. APPENDIX 1: MULTICULTURAL AWARENESS AND COMPETENCE

As discussed throughout this course, dance and movement have long cultural traditions around the world, and the healing properties of movement have been a staple in ancient and modern communities. With this in mind, all clinicians should be mindful of the role of clients' cultural identity, beliefs, and traditions as well as of the cultural roots of modalities.

In its Code of Ethics and Standards, the American Dance Therapy Association has established criteria for providing culturally competent dance/movement therapy [42]. Although this code applies to certified dance therapists, it provides a good guideline for all clinicians incorporating movement, dance, and/or somatic techniques into their practice. The Code includes the following requirements for clinicians [42]:

- Dance/movement therapists should consider the role of cultural context in the practice of therapy and continuously attend to developing the awareness, knowledge, and skills needed to competently work with diverse client groups.

- Dance/movement therapists examine the meaning of their ethnic and cultural backgrounds and how they may affect cross-cultural therapy dynamics.

- Dance/movement therapists develop awareness of their own worldviews, values, and beliefs and seek to understand the worldviews, values, and beliefs of their clients.

- Dance/movement therapists actively engage in broadening their knowledge of all cultures and in particular acquire information about the cultural group(s) with whom they are working, with attention to the inherent strengths of the cultural group. Dance/movement therapists seek this knowledge from multiple sources.

- Dance/movement therapists are sensitive to individual differences that exist within a cultural group and understand that individuals may have varying responses to cultural norms.

- Dance/movement therapists consider the impact of societal dynamics of power, privilege, and oppression on individual client experience and behavior.

- Dance/movement therapists inquire about client concerns, including perceptions of racism, language barriers, or cultural differences, which the client may experience as compromising trust and communication in the therapy relationship or treatment setting.

While these ethical standards do not vary significantly from the codes of ethics governing the various behavioral and mental health professions, there are unique considerations when considering the inclusion of culturally bound traditions. For example, tribal dance has been a vital component of many Native American communities, and clients from these backgrounds (and potentially beyond) may express interest in incorporating indigenous dance into mindfulness practices and/or therapeutic work. Behavioral health service providers should recognize that Native American tribes represent a wide variety of cultural groups that differ from one another in many ways [6]. Each Native American culture has its own specific healing practices, and not all of those practices are necessarily appropriate to adapt to behavioral health treatment settings. However, many traditional healing activities and ceremonies have been made accessible during treatment or effectively integrated into treatment settings. These practices include sacred dances (such as the Plains Indians' sun dance and the Kiowa's gourd dance) [6]. Clinicians from outside of these communities should seek consultation with a Native expert and/or refer clients to a culturally appropriate community or professional resource.

BEST PRACTICES FOR CULTURALLY RESPONSIVE CARE

The U.S. Department of Health and Human Services has outlined steps important to incorporate in evaluation and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills [6].

The first step is to engage clients. In nonemergent situations, it is important to establish rapport before asking a series of assessment questions or delving deeply into history taking. Providers should use simple gestures as culturally appropriate (e.g., handshakes, facial expressions, greetings) to help establish a first impression. The intent is that all clients feel understood and seen following each interaction. Culturally responsive interview behaviors and paperwork should be used at all times [6].

When engaging in any client teaching, remember that individuals may be new to the specific language or jargon and expectations of the diagnosis and care process. Clients should be encouraged to collaborate in every step of their care. This consists of seeking the client's input and interpretation and establishing ways they can seek clarification. Client feedback can then be used to help identify cultural issues and specific needs. If appropriate, collaboration should extend to include family and community members.

Assessment should incorporate culturally relevant themes in order to more fully understand clients and identify their cultural strengths and challenges. Themes include [6]:

- Immigration history

- Cultural identity and acculturation

- Membership in a subculture

- Beliefs about health, healing, and help-seeking

- Trauma and loss

In some cases, it may be appropriate and beneficial to obtain culturally relevant collateral information, with the client's permission, from sources other than the client (e.g., family or community members) to better understand beliefs and practices that shape the client's cultural identity and understanding of the world.

Practitioners should work to identify screening and assessment tools that have been translated into or adapted for other languages and have been validated for their particular population group(s). An instrument's cultural applicability to the population being served should be assessed, keeping in mind that research is limited on the cross-cultural applicability of specific test items or questions, diagnostic criteria, and concepts in evaluative and diagnostic processes [6].

Typically, culturally responsive care establishes holistic treatment goals that include objectives to improve physical health and spiritual strength; utilizes strengths-based strategies that fortify cultural heritage, identity, and resiliency; and recognizes that treatment planning is a dynamic process that evolves along with an understanding of client history and treatment needs. In addition to these general approaches, specific considerations may be appropriate for specific populations.

CREATING A WELCOMING AND SAFE ENVIRONMENT

Ensuring clients feel comfortable enough to participate in therapy, including movement and/or dance approaches, begins with client comfort. This can be facilitated, in part, by providing a welcoming environment. The basis of establishing a safe and welcoming environment for all clients is security, which begins with inclusive practice and good clinician-client rapport. Shared respect is critical to a client's feeling of psychological well-being. Security can also be fostered by a positive and safe physical setting. As such, therapy environments should be controlled in a way to minimize traumatic stress responses. Providers should keep this in mind when structuring the environment (e.g., lighting, arrangement of space), creating processes (e.g., layout of appointments or care systems, forms), and providing staff guidance (e.g., nonverbal communication, intonation, communication patterns). During each encounter, the client's perception of safety is impacted by caretakers and ancillary staff.

Experts recommend the adoption and posting of a nondiscrimination policy that signals to both clinicians and clients that all persons will be treated with dignity and respect [43]. Also, checklists and records should include options for the client defining their race/ethnicity, preferred language, gender expression, and pronouns; this can help to better capture information about clients and be a sign of acceptance to that person. If appropriate, providers should admit their lack of experience with client subgroups and seek guidance from clients regarding their expectations of the visit.

Front office staff should avoid discriminatory language and behaviors. For example, staff should avoid using gender-based pronouns, both on the phone and in person. Instead of asking, "How may I help you, sir?" the staff person could simply ask, "How may I help you?" Offices that utilize electronic health records should have a system to track and record the gender, name, and pronoun of all clients. This can be accomplished by standardizing the notes field to document a preferred name and pronoun for all clients [44]. Persons who identify as nonbinary (i.e., neither or both genders) or with dissociative identity disorder may prefer that plural pronouns (e.g., they) be used.

Questions should be framed in ways that do not make assumptions about a client's culture, gender identity, sexual orientation, or behavior. Language should be inclusive, allowing the client to decide when and what to disclose. Assurance of confidentiality should be stressed to the client to allow for a more open discussion, and confidentiality should be ensured if a client is being referred to a different healthcare provider. Asking open-ended questions can be helpful during a history and physical.

8. APPENDIX 2: DANCE IN THE CONTEXT OF EXPRESSIVE GROUP THERAPY

When practiced as a formal group modality, dance and movement therapy is included in the larger umbrella of expressive groups, which includes a range of therapeutic activities that allow clients to express feelings and thoughts—conscious or unconscious—that they might have difficulty communicating with spoken words alone. The purpose of expressive therapy groups is generally to foster social interaction among group members as they engage either together or independently in a creative activity. These groups therefore can improve socialization and the development of creative interests. Further, by enabling clients to express themselves in ways they might not be able to in traditional talking therapies, expressive therapies can help clients explore their substance abuse, its origins, the effect it has had on their lives, and new options for coping. These groups can also help clients resolve trauma that may have been a progenitor of their current presenting problem. For example, clinical observation has suggested benefits for female clients with substance use disorder involved in dance therapy [45]. Expressive therapy groups often can be "a source of valuable insight into clients' deficits and assets, both of which may go undetected by treatment staff members concerned with more narrowly focused treatment interventions" [45].

The actual characteristics of an expressive therapy group will depend on the form of expression clients are asked to use. Expressive therapy may use music, dance, or free movement. Expressive group leaders generally will have a highly interactive style in group. They will need to focus the group's attention on creative activities while remaining mindful of group process issues. The leader of an expressive group will typically need to be trained in the particular modality to be used (e.g., dance therapy). In some cases, expressive therapies can require highly skilled staff, and, if a program does not have a trained staff person, it may need to hire an outside consultant to provide these services. Any consultant working with the group should be in regular communication with other staff, because expressive activities need to be integrated into the overall program, and group leaders need to know about each client if they are to understand their work in the group. Expressive therapies can stir up very powerful feelings and memories. The group leader should be able to recognize the signs of reactions to trauma and be able to contain clients' emotional responses when necessary. Group leaders need to know as well how to help clients obtain the resources they need to work though their powerful emotions [45].

Finally, it is important to be sensitive to a client's ability and willingness to participate in an activity. To protect participants who may be in a vulnerable emotional state, the leader should be able to set boundaries for group members' behavior. For example, in a movement therapy group, participants need to be aware of each other's personal space and understand what types of touching are not permissible.

After clients have spent some time working on their creative activity (e.g., dance), the group comes together to discuss the experience and receive feedback from the group leader and each other. In all expressive therapy groups, client participation is a paramount goal. All clients should be involved in the group activity if the therapy is to exert its full effect [45].

Another point to consider is the role of touch. Touch in a group is never neutral. People have different personal histories and cultural backgrounds that lead to different interpretations of what touch means. Consequently, the leader should evaluate carefully any circumstance in which physical contact occurs, even when it is intended to be positive. In most groups, touch (handholding or hugs) as part of group rituals is not recommended, though in an expressive therapy or dance group, touch may be acceptable and normative. Naturally, group agreements always should include a clause prohibiting physical violence. Whenever the therapist invites the group to participate in any form of physical contact, individuals should be allowed to opt out without any negative perceptions within the group. All members uncomfortable with physical contact should be assured of permission to refrain from touching or having anyone touch them [45].

Leaders also should make sure that suggestions to touch are intended to serve the clients' best interests and not the needs of the therapist. Under no circumstances should a counselor ask for or initiate physical contact. Like their clients, counselors need to learn that such impulses affect them as well. It is wrong for those providing psychotherapy to allow feelings of attraction to dictate or influence their behavior [45].

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Evidence-Based Practice Recommendations Citations

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