Patient Education and Counseling 89 (2012) 525–528

Contents lists available at SciVerse ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Dance therapy improves self-body image among obese patients

Solange Muller-Pinget a, Isabelle Carrard a, Juan Ybarra b, Alain Golay a,*
a
Service of Therapeutic Education for Chronic Diseases, WHO Collaborating Centre, Department of Community Medicine, University Hospitals of Geneva, Geneva, Switzerland
b
Institute of Advanced Cardiology, Medical Center Teknon, Barcelona, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Obesity and disturbed eating behaviors are both associated with low self-esteem and distorted
Received 6 June 2011 body images. The aim of this study was to assess the influence of a dance therapy program on the
Received in revised form 28 June 2012 evolution of mental representations linked to body image among obese patients. Changes in body image
Accepted 7 July 2012
were evaluated in terms of four parameters: physical, psychological, cognitive, and social.
Methods: In total, 18 obese patients were enrolled in a longitudinal dance therapy workshop (DTW)
Keywords: program lasting 36 weeks. Patients danced for 2 h per week and were evaluated three times: at baseline,
Obesity
after 18 weeks, and at the end of the study (36 weeks). Evaluation was performed using questionnaires
Dance therapy
addressing health-related quality of life, sensorial-motor perception, and mental representations linked
Body image
to body schema and self-body image.
Results: Obese patients enrolled in the DTW displayed a significant improvement in health-related
quality of life (p < 0.03), body consciousness (p < 0.001), and mental representations linked to self body
image (p < 0.001).
Conclusion: DTW allowed obese patients to reset both their somatic and psychic consciousness of their
body image.
Practice implications: Patients are usually reluctant to practice physical activity. Dance therapy improves
not only body image, but also psycho-social aspects of their personality.
ß 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction often has the sensation of being a rigid mass, moving as a block.
Thus, bodily tensions occur in posture and gait, and a poor
Low self-esteem and distorted body-image frequently accom- sensory–motor perception prevents them from accessing their
pany obesity and altered eating behaviors, actively contributing to body schema and building a positive body image [7–11].
the vicious circle of restrictive diets and binge eating [1,2]. Enriching the vocabulary of movement in this obese population
More often than not, obese individuals are cut off from feelings provides an opening to other ways of being and existing [5,12–14].
and emotions coming from their bodies due to their sometimes Our research hypothesis as illustrated in Fig. 1 is that dance
traumatic familial or social background [3]. They cling to their therapy would allow obese patients to develop their body
body envelope which according to them, shelters and protects. consciousness and improve their mental representations
Whenever these individuals lose weight too quickly, they perceive [15–17]. Furthermore, they would become capable of owning
a threatening gap and lose their bearings. This often leads to a and transforming these latter issues to improve their psychic and
resumption of weight to feel safe [4]. somatic self-body image [18–20].
The body language of obese individuals is commonly restricted The amendment process, starting from a body with vague
to a few movements, and obese people feel that they have little definitions, would awaken the patient’s senses in terms of
ability to move their bodies. Thus, they feel little or no desire to do kinesthetic, exteroceptive, proprioceptive, and interoceptive sense.
so. Moreover, their perception of the body at rest or in motion is Thus, being more aware of themselves, obese patients would be
distorted, translating as a negative image [5,6]. An obese person able to access phenomenal knowledge, enabling them to be more
conscious of their mental representations [20].
Hence, these changes would tend to improve the self-image of
obese patients and help them to develop improved self-esteem.
* Corresponding author at: Service of Therapeutic Education for Chronic Diseases, Moreover, the motivation to look after their bodies and health,
Department of Community Medicine, University Hospitals of Geneva, Rue
Gabrielle-Perret-Gentil 4, 1211 Geneva 4, Switzerland. Tel.: +41 22 372 9726;
change their eating behavior, and ultimately lose weight would be
fax: +41 22 372 97 15. strengthened. Becoming aware of sensory–motor perceptions
E-mail address: Alain.Golay@hcuge.ch (A. Golay). would help these individuals define their own body boundaries

0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pec.2012.07.008
526 S. Muller-Pinget et al. / Patient Education and Counseling 89 (2012) 525–528

sensory–motor connections, phylogenic and ontogenetic move-

ment history, and movement analysis [10,11,15]. This technique
led to understanding how thoughts and feelings of the mind are
expressed through body in the movement.
Finally, there was an exploration phase during which patients
used the authentic movement technique [19], where they
improvised dances based on a personal theme, learning to inhabit
their personal space and interact with the surrounding space
[16,18,19]. Patients discovered and welcomed the sensations,
memories, emotions, and mental representations that emerged
from their body perception during the improvised dance and in
turn, nourished their body image. Following a verbal summary,
Fig. 1. Process of body image amelioration through dance therapy.
which was often accompanied by drawings to express the content
of patient experiences, the meeting was adjourned.

and set limits, as well as differentiate themselves from the 2.2. Evaluation
environment and so act alone or with others. They would be better
able to communicate with others and the surrounding space. 2.2.1. Data collection methodology
Quality of life related to health, body consciousness, and mental
1.1. Aim representations were assessed on three occasions: at baseline,
after 18 weeks, and at the end of the study (36 weeks). Quality of
The purpose of this study was to determine the influence of a life was assessed using the Impact of Weight on Quality of Life
dance therapy workshop (DTW) program on the development of (IWQOL)-Lite measure [22], a self-administered questionnaire
mental representations associated with body consciousness and specifically designed for obese patients. This survey specifically
self-image in obese individuals. Changes in body image were highlighted how weight affected the patient’s social and profes-
evaluated according to four parameters: physical, emotional, sional life, self-esteem, sexual life, and physical function.
cognitive, and social. Body consciousness and mental representations were evaluat-
ed using Laban movement analysis [23] and developmental
2. Methods movement patterns from Cohen [24]. These coding approaches
were previously used by several authors [25–27], assessing the
The patient population involved 18 females, with a mean age of following criteria:
44.6  2.4 years and a mean body mass index (BMI) of
36.7  1.2 kg m 2. These obese patients were recruited into the study - Posture: body alignment, foot support, and foot position;
via physicians working in a standard obesity weight loss program. - Mindful walking: foot support, foot position, and body part
Dance therapy was proposed to patients instead of conven- mobility;
tional physical activity workshops. All patients remained in the - Muscular tensions: location in the body and context in which the
study until the end of the program, with the compliance rate tensions appeared;
exceeding 90%. - Relaxation: means and frequency;
Inclusion criteria were BMI > 30 and being able to walk 10 m - Developmental movement patterns: navel radiation as well as
without assistance. Exclusion criteria were patients with unbal- spinal, homologous, homolateral, and contralateral patterns;
anced mental diseases such as psychosis that would interfere with - Mental representations through movement analysis: maximum
group therapy, foot ulcers at the moment of data acquisition, and score of 74 and minimum of 17.
orthopedic surgical or neurological problems (other than diabetic
neuropathy) that affected gait.
Our patient population presented several obesity co-morbid- 2.3. Statistical analysis
ities, notably type 2 diabetes mellitus, arterial hypertension,
coronary artery disease, hyperlipidemia, depression, and bipolar Quantitative variables were expressed as means and standard
disorder, while some of the patients had suffered sexual abuse. deviation. Due to the limited sample size, the evolution of each
Protocol: Patients participated in group workshop sessions for variable over time was evaluated using Friedman’s test, while
2 h per week for 36 weeks. During the 36-week program, they comparing the results at three different time-points. The level of
worked on posture, mindful walking, tension relaxation, body statistical significance was set at p < 0.05. Data was analyzed and
image, and movement reeducation based on sensory–motor figures were constructed using the SPSS 15.0 statistical package
connections and developmental movement therapy. During these (SPSS Inc.).
workshops, patients learned to evaluate their body image in their
daily lives using observation tools. 3. Results

2.1. Example of a workshop Body consciousness and mental representations improved

significantly throughout the study, with the results summarized
Initially, a warm-up was offered with fast movements, so that in Table 1.
patients did not have the time to think about their body and what
they should be doing. The aim of this warm-up was to achieve a - Posture showed a significant improvement from baseline
state called ‘‘mobile’’ [21], where only bodily sensations are (13.8  2.9) to the end of the study (22.3  3.5; p < 0.001).
paramount. - Mindful walking improved significantly from baseline to the end
In the second stage, patients became aware of their muscle and of the study (p < 0.001).
psychological tensions, and worked on relaxation and breathing - Despite a significant improvement in tension scores, patients had
exercises. They also worked on movement re-education based on difficulties in releasing tensions on a daily basis. However,
 S. Muller-Pinget et al. / Patient Education and Counseling 89 (2012) 525–528 527

Table 1 and were more likely to perform a sequence of motion. Self-body

Body consciousness and mental representations.
image was hence strengthened. Patients found pleasure in
Baseline 18 weeks 36 weeks p performing the exercises and expressed positive feelings that in
Posture 13.8  2.9 18.7  2.7 22.3  3.5 0.001 turn enhanced them.
Mindful walking 9.0  2.0 11.3  1.6 12.3  1.7 0.001 Patients had to go through the lengthy process of unwinding
Tensions 3.0  0.7 3.8  0.1 4.0  0.8 0.001 past associations around body perceptions in order to construct
Relaxation 3.0  1.0 3.8  0.1 4.0  0.8 0.001 new relations, which would motivate them to change their self-
Patterns of motor development 5.3  1.0 8.1  1.5 8.3  1.4 0.001
representation. Dance therapy in a peer group reassured
Mental representations 4.9  1.0 7.2  1.1 7.6  0.8 0.001
Total score 37.6  6.1 52.6  5.1 58.2  5.8 0.001 patients. They did not fear the gaze of others, but instead
developed a sense of belonging, which changed their attitude
toward themselves. Hence, they developed social skills and
self-care competencies.
Table 2 Body consciousness and mental representations improved
Quality of life assessment using the IWQOL-Lite.
significantly throughout the study (Table 1). Patients became
Baseline 18 weeks 36 weeks p gradually aware of their body parts. They went through a process
Self-esteem 34.9  30.0 38.5  36.3 44.1  30.4 0.08 of analyzing their body movements and language, perceiving their
Physical function 50.5  25.9 55.8  27.5 55.8  28.8 <0.05 bodies as articulated and fluid rather than as a rigid mass.
Work 69.2  27.5 72.8  24.8 75.1  23.1 0.17 Gradually, patients were able to free themselves from the psychic
Public distress 80.4  15.7 75.4  19.9 80.4  15.1 0.65 and motor block preventing them from developing a positive self-
Sexual life 60.7  37.9 60.7  39.8 61.2  33.7 0.87
perception.
Total score 52.3  22.6 55.0  26.1 59.9  22.2 <0.03
The IWQOL-Lite (Table 2) only revealed a significant improve-
ment in two out of the six items assessed throughout the study,
patients were able to relax with the help of someone while namely physical function and total score. Surprisingly, self-
negative thoughts disappeared, and in turn, they observed the esteem as well as professional, social, and sexual life failed to
sensations of relaxation and had positive mental representations. show any significant improvement during the study period. We
Some of them started to relax only 3 times per week on average. believe that this lack of significance should be considered in the
Tension scores peaked at 36 weeks. context of our preliminary study, which was not sufficiently
- Patterns of motor development displayed a significant improve- empowered due to the small sample size. The primary endpoint of
ment throughout the study (p < 0.001). this study was nevertheless reached. Further studies with a larger
patient population, longer duration, and presence of a control
The results of the health-related quality of life analysis are group are warranted, particularly when combining dance therapy
provided in Table 2. As shown, both global scores (p < 0.03) and with a multifaceted approach integrating diet and psychological
mobility subscale scores (p < 0.05) significantly improved after 36 supervision.
weeks. Upon these findings the doctor–patient communication will be
Body weight remained globally unchanged throughout the facilitated as it gives information on the patient’s abilities to
duration of the study. Nevertheless, among the 18 patients, five observe his functioning and it gives the opportunity to the
lost 5.0  1.0 kg on average, five maintained their body weight, while therapist–doctor communication to develop a global approach of
the remaining eight gained 4.2  1.5 kg on average. their patient. Dance therapists are able to share information with
professionals on health care self competences and psychosocial
4. Discussion and conclusion competences.
They are able to throw light on the patients’ capacities to be
4.1. Discussion more in tune with their body sensory perceptions, on their ability
to express one’s needs and feelings about their health and their
The vast majority of obese patients suffer from low self-esteem ability to use their own natural body and mind resources.
and distorted body images [1–3]. The main purpose of this study
was to assess the influence of a particular DTW on the evolution of 4.2. Conclusion
mental representations linked to self-body image among obese
patients. DTW allowed obese patients to improve their body conscious-
Our data showed that obese patients enrolled in the 36-week ness, self-body schema, and mental representations. In addition,
DTW program exhibited a significant improvement in health- they improved both somatic and psychic consciousness associated
related quality of life (p < 0.03), body consciousness (p < 0.001), with their body image.
and mental representations linked to body image (p < 0.001).
These achievements were independent of body weight, which 4.3. Practice implications
remained unaltered.
Posture and mindful walking evolved significantly throughout In obesity treatment, DTW would appear to benefit patients
the study (Table 1). As patients learned to correct their posture rather than physical activity training. As patients are usually
when sitting or standing, it became easier for them to adapt their reluctant to practice physical activity, dance therapy improves
posture when practicing mindful walking. Although the pelvis did not only body image, but also psycho-social aspects of
not shift easily from one hip to another, the sensations in the feet their personality. Following DTW, some patients even have
became more attuned to the ground and therefore, their weight the confidence to participate in dance classes in the
was better distributed on both feet. The mobility in the arms and community.
spine remained restricted and limited.
The significant improvement in motor development patterns Funding
throughout the study (Table 1) was likely the consequence of work
performed on the sensory–motor connections, which helped This project has been supported by the Swiss Art-therapy
movement reeducation. Patients had a clearer body perception Foundation.
528 S. Muller-Pinget et al. / Patient Education and Counseling 89 (2012) 525–528

Conflict of interest [12] Kestenberg Amighi J, Loman S, Lewis P, Sossin KM. The meaning of movement:
development and clinical perspectives of the Kestenberg Movement Profile.
New York: Routledge; 1999.
The authors declare no conflict of interest.
[13] Jeong YJ, Hong SC, Lees M, Park MC, Kim YK, Suh CM. Dance movement therapy
improves emotional responses and modulates neurohormones in adolescents
Acknowledgements with mild depression. Int J Neurosci 2005;115:1711–20.
[14] Muller-Pinget S. La thérapie par la danse Dance therapy In: Richard J, Rubio L,
editors. La thérapie psychomotrice. Paris: Masson; 1995. p. 137–47.
We wish to thank Mrs. Nuria Flores for her skillful secretarial [15] Eddy M. Body–mind dancing. In: Loman S, Brandt R, editors. The body mind
assistance and Dr. Gabrielle Cremer for the revision of the English connection in human movement analysis. Keene, NH: Antioch New England
language. Press; 1992. p. 203–27.
[16] Berrol CF. Neuroscience meets dance/movement therapy: mirror neurons,
the therapeutic process and empathy. Arts Psychother 2006;33:
References 302–15.
[17] Hervey L. Artistic inquiry in dance/movement therapy: creative alternatives
[1] Fossati M, Rieker A, Golay A. Thérapie cognitive en groupe de l’estime de soi chez for research. Springfield, IL: Charles C. Thomas; 2000.
des patients obèses Self-esteem cognitive group therapy with obese patients J [18] Leventhal M. In: Rowe P, Todelle E, editors. Structure in dance therapy. A
Thér Comport Cogn 2004;14:29–34. model for personality integration. New York: CORD-Dance Research Annual X;
[2] Volery M, Carrard I, Rouget P, Archinard M, Golay A. Cognitive distorsions in 1979. p. 173–82.
obese patients with or without eating disorders. Eat Weight Disord [19] Adler J. Offering from the conscious body: the discipline of authentic move-
2006;11:123–6. ment. Rochester, VE: Inner Traditions; 2002.
[3] Anzules C, Haenni C, Golay A. An experience of art therapy for patients [20] Muller-Pinget S. Dance therapy improves body image in obese people. Int J
suffering from obesity. Eur Diab Nurs 2007;4:72–6. Obes 2008;32:S174.
[4] Corcos M. Le corps absent: approche psychosomatique des troubles des [21] Laban R. The mastery of movement. London: Mc Donald&Evans; 1971.
conduites alimentaires. The absent body: a psychosomatic approach of eating [22] Kolotkin RL, Meter K, Williams GR. Quality of life and obesity. Obes Rev
disorders Paris: Dunod; 2000. 2001;2:219–29.
[5] Muller-Pinget S, Golay A. La danse thérapie dans les soins Clinical applications [23] Warner MJ, Warner FE. Laban Notation Scores: an international bibliography.
of dance therapy In: Patrick P, editor. Le rôle de l’art dans les éducations en Ohio, Columbus: The Ohio State University; 1984.
santé. Paris: l’Harmattan; 2008. p. 69–87. [24] Payne H. Pilot study to evaluate dance movement psychotherapy (the body
[6] Lestienne F, Gurfinkel V. Réflexion sur le concept de représentation interne, mind approach) in patients with medically unexplained symptoms: partici-
Science et Motricité. Reflections on the concept of inner representation, pant and facilitator perceptions and a summary discussion. Body Mov Dance
science and motricity Liège: de Boeck; 2002. Psychother 2009;4:77–94.
[7] Corraze J. Schéma corporel et Image du corps. Body scheme and body image [25] Koch S, Muller S. Assessments with KMP questionnaire and the brief KMP-
Toulouse: Privat; 1973. based affect scale. In: Koch S, Bender S, editors. Movement analysis-Bewe-
[8] Neumann R, Strack F. Approach and avoidance: the influence of proprioceptive gunganalyse: the legacy of Laban, Bartenieff, Lamb and Kestenberg. Berlin:
and exteroceptive cues on encoding of affective information. J Pers Soc Psychol Logos Verlag; 2007.
2000;79:39–48. [26] Loman S, Sossin MKM. Current clinical applications of the Kestenberg Move-
[9] Raab M, Green N. Motion as input: a functional explanation of movement ment Profile. In: Chaiklin S, Wengrower H, editors. Life is dance: the art and
effects on cognitive process. Percept Mot Skills 2005;100:333–48. science of DMT. New York: Routledge; 2009. p. 237–64.
[10] Ayres AJ. Sensory integration and the child. Los Angeles: Western Psychologi- [27] Cruz RF, Koch S. Issues of validity and reliability in the use of movement
cal Services; 1987. observations and scales. In: Cruz RF, Berrol C, editors. Dance/movement
[11] Mills M, Cohen BB. Developmental movement therapy. Amherst, MA: The therapists in action: a working guide to research options. Springfield: Charles
School of Body–Mind Centering; 2005. C. Thomas; 2004.