Tuesday, July 26, 2016

Dance Movement Therapy and Emotional Eating

The roots of dance therapy
can be traced to earliest human history,
when disease was seen as a loss of soul,
and dance was an intrinsic part of the healing ritual.

Joan Chodorow, 2010

Obesity. How big the problem is?

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

Obesity can have a severe impact on people’s health, increasing the risk of type 2 diabetes, hypertension, heart disease, elevated blood cholesterol levels, stroke; and after the menopause cancer of the breast and uterus, osteoporosis and joint problems.  The number of Finished Admission Episodes (FAEs) in NHS hospitals with a primary diagnosis of obesity among people of all ages in 2008/09 was over eight times as high as in 1998/99 and nearly 60% higher than in 2007/08. Consequences of obesity are not just physical; quality of life of obese persons is reduced, because obesity impacts on physical, emotional and social functioning.  There is also a significant burden on health and social services; while precise predictions have been disputed, there is little doubt that without effective action most societies will continue to bear an increasing cost due to a greater prevalence of chronic diseases arising from obesity.

Psychological aspects of obesity 

Some researchers suggest no close relationship between obesity and psychological disturbance or particular features of a personality. However, there are a number of quality studies, which contradict this finding, for obese people who seek medical help and health programs. For example, a relationship has been demonstrated between obesity and psychological disturbance for Caucasian women with high social-economic status, and adolescents who suffer from depression are more likely to become overweight adults than adolescents who are not depressed. Obese people also have significantly lower self-acceptance and self-esteem, are at greater risk of psychological distress and suffer more day-to-day interpersonal discrimination, employment and institutional discrimination compared to normal weight individuals.

A significant causal relationship between obesity and body image disturbance acts as a mediator for increased depression and lower self-esteem. There is a relationship between obesity and poor body image, though not all obese people suffer from body image distress (BID).  The risks for BID include:  high BMI, feminine gender, and emotional eating.  There is thus a clinical need to identify people at risk and to consider developing weight loss programs that aim to prevent BID. BID in overweight individuals decreases with weight loss, but increases as weight is regained; depression decreases with weight loss overall but can increase if the degree of weight lost is lower than expected. Most of the weight lost as a result of following a reducing diet is regained within a few years.

Emotional eating, obesity and diet

Emotional eating can be understood as overeating as a reaction to emotional states.  There is a need for more research on the role of emotions in relation to overeating, as the processes are little understood. One possibility is that awareness of hunger and satiety is reduced in emotional eaters, whereas emotional states (including positive emotions like joy for example) are not tolerated, food providing an opportunity to metaphorically swallow feelings. Emotional eating is closely linked to Binge Eating Disorder (BED); both include the consumption of large amounts of food together with a subjective loss of control over both eating behavior and psychological distress. 

The term emotional eating does not depend on a medical diagnosis but on self-report, and highlights the role of the emotions in determining or maintaining the problematic behavior. Eating in obese persons (especially when combined with emotional eating) often seems to be initiated in the absence of perceived hunger. For example, overweight individuals are more likely to overeat in negative emotional situations than either normal or underweight individuals (underweight individuals being more likely to undereat in similar situations).  A link has been demonstrated between emotional eating and psychological discomfort, low self-esteem, negative body image and affective disturbances. These negative experiences are likely to be exacerbated by the fact that obese people are subjected to stigmatization, discrimination and lower quality of life. The link between self-esteem and eating disorders has been reported in several studies, and negative self-evaluation has been recognized as a risk factor for the development of eating disorders. 

Some studies suggest that low self-esteem predicts the development of eating disorders. A bidirectional relationship has been posited between dieting, emotional eating and negative self-esteem: each dieting failure might decrease self-esteem, which in turn jeopardizes dietary adherence.  Chronic dieters enter a spiral; dieting failures inhibit successful acceptance of the body which in turn leads to decreased self-esteem and decreased self-efficacy (self-efficacy being necessary for dietary adherence).  It has been shown that chronic dieting and negative body image is a combination which leads to negative self-esteem.

An important aspect of appearance and body image is body weight, especially for women; if a woman evaluates her self-worth according to her appearance (self-esteem increasing with body image satisfaction) this poses a potential risk factor for both psychological distress and eating disturbance, including depression. It has been noted that eating disorders and body image dissatisfaction are both common problems, especially in women. Negative feelings about physical appearance are linked with a range of psychological consequences which include low self-esteem and depression for adults as well as for adolescents. Body image disturbances are recognized as a risk factor for women who change their eating habits with the aim of changing their appearance or to lose weight. This can lead to the development of eating disorders, due to the negative spiral identified above. Preventive programs are especially needed in such cases to promote women’s awareness of their body image and its link to possible eating problems.

Living in a Body and Eating Disorder

The eating disorder assumes a powerful role for someone with an eating disorder by providing them with an illusion of control. This illusion allows the individual to avoid facing emotional issues by detaching from their bodily felt experiences.

The quest to distance from the body creates an internal burial ground in which feelings are stored, restricted, stockpiled, and avoided at all costs. Individuals with an eating disorder have a tendency to obsess and pick on their bodies, literally as well as figuratively.

In addition, they may refer to their body as “this body”, thereby depersonalizing their interpersonal relationship even further. It is not uncommon to hear someone with an eating disorder describe the relationship with their body as that of one with a stranger or even an enemy.

Latvian Study

A study led by Bonnie Meekums and conducted in Latvia, explored the effectiveness of DMT in obese women with emotional eating who were trying to lose weight. 158 women were recruited from a commercial weight loss program: 92 with BMI≥28 were identified as emotional eaters and divided into: an exercise control and non-exercisers. The non-exercises were partially randomized to non-exercise control and treatment group.

Using a pre- and post-intervention design, all participants completed all measures on a battery of tests for psychological distress, body image distress, self-esteem and emotional eating. Findings were analyzed for statistical significance. The DMT group showed statistically decreased psychological distress, decreased body image distress, and increased self-esteem compared to controls. Emotional eating reduced in DMT and exercise groups. The authors cautiously conclude that DMT could form part of a treatment for obese women whose presentation includes emotional eating.

Why Dance/Movement Therapy?

Dance and extensive physical activity is one of the best therapeutic approaches we can recommend as efficient and safe methods of recovery. However, sometimes, dance and/or increased physical activity alone is not enough. For those people who struggle with depression, the emotional scars from being teased and bullied, social isolation and poor self-esteem, a psychotherapeutic approach is needed. This is recommended by the U.S. Preventive Services Task Force, with mention of behavioral management and cognitive-behavioral therapy.

Dance/movement therapy is a behavioral health modality that combines physical activity, social
support, creativity and emotional expression.

Movement is not necessarily inherently enjoyable for people who have been too sedentary. When extra weight puts strain on the musculoskeletal system and some organ systems, the body itself can become a dis-incentive to moving more. When guided by a trained dance/movement therapist in the context of a supportive psychotherapeutic relationship, the obese person can overcome fears associated with moving.

Finding one’s own preferred and comfortable ways of moving through gentle improvisation and
movement exploration can increase the person’s investment in the process of moving towards health.

Dance/Movement Therapy, or DMT, is a mind/body integrated form of counseling and creative arts therapy. The American Dance Therapy Association defines DMT as “the psychotherapeutic use of movement to further the emotional, cognitive, physical and social integration of the individual.”

There is still a common misconception that dance is reserved for individuals of a certain body-type or physical ability, however, quite literally, any body can dance. Another common misconception is that in order to participate in DMT, a person must have a background in dance training, when in reality, a person need not ever have set-foot in a dance studio to participate in DMT. There are no criteria for involvement in DMT other than the consent and willingness to participate.

To illustrate the fallacy that only certain body-types or abilities can dance or participate in DMT, one of the recent studies concerning individuals who binge-eat and who are obese, benefited significantly from DMT interventions. Individuals who are obese and engage in binge-eating behaviors may also suffer from low self-esteem and distorted body image. The specific individuals involved in the 36-week longitudinal study exhibited significant improvement in health-related quality of life, body consciousness, and mental representations related to body image. Additionally, all achievements in the study were unrelated to weight-loss, as weight remained largely unaltered throughout the study.

People with eating disorders tend to become socially isolated. The relationship focus of DMT, in group as well as in individual formats, helps the individual risk connecting to others in supported and authentic ways. Discoveries made in DMT about one’s own mind/body connection and about relating to others transfer to other relationships and how one moves through life.

Using carefully monitored movements and breathing techniques, Dance/Movement Therapists help to guide patients in developing body awareness and tolerance. This can be beneficial for individuals with eating disorders because eating disorders, characteristically, interfere with natural body cues such as hunger and satiation. DMT groups may also utilize props and imagery to assist in the therapeutic process. Dancers are encouraged to challenge body image distortions and address destructive behaviors that are sometimes influenced by media or societal pressure. DMT encourages the opportunity for them to welcome and attend to physical and emotional needs, while strengthening their self-esteem and self-worth.

Genuine and Long-Lasting Change

Beginning to feel safe enough to experience, express and understand feelings and sensations as an integral aspect of life is a core task for individuals with eating disorders. However, this is not easy because the fear to avoid connection is so strong. Dance/movement therapy as an integral part of eating disorder treatment can help patients re-claim authentic connection with themselves in both actions and words. This can, over time, lead to the genuine and long-lasting change associated with the ability to sustain recovery.

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