Dance Movement Therapy in the times of Coronavirus Disease of 2019:

A summary of 5 qualitative interviews in understanding Tele-DMT in India by:

Tripura Kashyap

Co-Founder of Creative Movement Therapy Association of India

Dance Educator  

Movement Therapist

and 

Neha Christopher

Board-Certified Dance Movement Therapist, American Dance Therapy Association

Licensed Creative Arts Therapist, New York State Office of Professions 6 Co-Founder,

Indian Association of Dance Movement Therapy Correspondence: Neha Christopher, Ms, LCAT, BC-DMT

(Licensed Creative Arts Therapist, New York State, Board Certified Dance Therapist, American Dance Therapy Association) 

Conflict of Interest: None

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Abstract From its onset, Novel Coronavirus Disease of 2019 (COVID-19) has drastically and rapidly changed the way people across the world have been communicating, socializing and living.

It has brought some people closer to each other and driven some far apart. As a result of being in quarantine through recurring lockdowns in India, fear, anxiety, and restlessness have taken over people’s lives. This, coupled with uncertainty, lack of reliable information/trust in the medical infrastructure, rumors and genetic predisposition to mental illnesses have caused a rise of mental health concerns due to COVID-19 in India. This rise in the prevalence of mental illnesses in India is projected to be two-three fold; keeping in mind the limited resources/trained professionals this puts India at risk of a mental health crisis. Accessibility to seek help and potentially mitigate such a crisis has also been negatively impacted due to COVID-19. 

Art is inherent to Indian culture and is, therefore, one of the most natural coping mechanisms that can be adopted by Indians. However, creative arts therapists continue to struggle in establishing a standardized way of functioning across the country primarily due to stigma around mental illness. Dance movement therapy is one such healing tool which is rooted both in Indian culture and in the western prognosis of mental illnesses. While there is no doubt that the dance movement therapy sessions positively impacts one’s mental health, this article attempts to identify and collate data on the different adaptations made in the practice of dance movement therapy while addressing mental health concerns that have arisen/been amplified due to COVID-19 in India. PubMed, PsycINFO, Google Scholar and MEDLINE were screened to gain current literature. Authors contacted twelve registered dance/movement therapists of Indian ethnicity and received consent for participation from 5 dance/movement therapists. Data was collected through virtual interviews, eleven recurrent and eleven variant themes were found. 

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Introduction

Dance, awareness of the mind-body nexus and holistic health are core components of Indian culture. Dance movement therapy (DMT) is an amalgamation of these along with western theories of psychology. Even prior to DMT’s formalization 60 years ago, principles of dance movement therapy were being used by various indigenous cultures as a way to celebrate life, community living and cope with adversity. Currently, the entire globe is waddling through the adversity caused due to Novel Coronavirus disease of 2019 which has thrown humanity completely out of gear! 

The first case of human infection was reported in Wuhan, China in December 2019 and was named 2019nCoV by the Chinese Center for Disease Control and Prevention (CDC) on January 7th 2020 (Chen, Zhou et. al.,2020, p. 507. It was later termed COVID-19 by The World Health Organization on February 11th 2020 (WHO, 2020). Although coronaviruses (CoVs) have affected birds and mammals in the past, Schoeman, & Fielding (2019) believe, “It also began infecting humans in the last few decades” (p.21.). “In humans, coronaviruses are among the spectrum of viruses that cause the common cold as well as more severe respiratory disease-specifically SARS and MERS”(Lu, Stratton, & Tang, 2020, p. 420). 

Masters (2006) describes coronaviruses as, “large enveloped RNA viruses with the ability to replicate involving ribosome frame-shifting during genome translation” (Masters, 2006, p.193.). The genetic sequence of SARS-CoV-2 was officially recognized by The World Health Organization (WHO) on January 12th 2020, which eventually led to polymerase chain reaction-based diagnostic testing globally (Corman et al., 2020). Along with an emphasis in increased testing, rigorous and intensive research on the virus’ origins and potential cure has been rampant in the medical field since the outbreak in December 2019. 

Currently, COVID-19 is speculated to have its origins from wild animals particularly the Coronaviridae family which includes two subfamilies, the Coronavirinae and Torovirinae (Lu, Stratton, & Tang, 2020, p. 420; ). While Coronavirinae itself can cause a remarkable variety of diseases, including pneumonia, Torovirinae, contains pathogens of both terrestrial and aquatic animals which can cause haemorrhage and ulcers in their hosts; Together they create a dangerous combination (Lu, H., Stratton, C. W., & Tang, Y., 2020, p. 420; Tekes & Thiel, 2016). 

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Due to COVID-19’s novel and highly infectious nature, it has rapidly evolved from an epidemic to a pandemic, as declared by The World Health Organization in February 2020, only months after its first outbreak in Wuhan, China. Upon said outbreak, the government issued a strict lockdown which forced everyone’s life to move online. While the Chinese civilians stayed indoors, “Chinese health authorities employed rapid public health measures like intensive surveillance, epidemiological investigation and closure of markets” in the interest of public welfare (Chen, Zhou, et al., 2020). 

Here in India, COVID-19 was declared a national health emergency by the government in March 2020. Since then, social (physical) distancing, restricting people’s movement to avoid crowding in public spaces, the closing of malls, schools, theatre’s, etc., have been employed to promote safety and reduce the spread of COVID-19 amongst community members. While some individuals have felt isolated as a result of such measures, others have felt solidarity with their neighbours and have experienced the true support of community living for the first time in their own residential areas! Similar to Wuhan, many people in India also experienced a complete shift of their professional and personal life to the virtual world, in an abrupt manner. 

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The trauma that accompanies COVID-19 is both physiological and psychological. Mental well-being can be heavily affected during a health crisis, such as the current pandemic (Sim & Chua 2004; Ćosić, Popović, Šarlija , Kesedžić, 2020; Moore RC, Depp, Harvey, Pinkham, 2020). Therefore, apart from physical suffering, it is not uncommon for confirmed or suspected cases of COVID-19 to suffer from great psychological pressure and other health-related problems” (Li et al., 2020, p. 1733.). Xiang et al., (2020) point out that patients might also suffer from a “fear of contagion while those in quarantine might experience boredom, loneliness, and anger.” In addition to this, individuals might also experience social stigma and rejection when it is time for them to reintegrate back into society (Brooks et al., 2020). Li, Wang, Xue, Zhao, & Zhu (2020) attribute COVID-19’s negative impact on mental health to its uncertainty and low predictability. 

Considering the global trauma, fear and distress caused by the outbreak of COVID-19 along with the subjective nature of coping skills in individuals, communities and cultures; there is little benefit in identifying a definitive statistical projection of COVID-19’s mental health impact. Regardless, mental health care needs to be given prime importance as part of every government's response to this pandemic. Due to this, dance movement therapists in India were amongst the various mental health professionals that began making this shift and subsequent adaptations in order to continue providing mental health support to both existing and new clients beginning in March 2020. (Torales, O'Higgins, Castaldelli-Maia, Ventriglio, 2020). 

Literature Review

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In the mental health field, COVID-19 creates barriers in both seeking help due to fear of getting infected and maintenance treatments for individuals already enrolled in long term hospitalization programs (Li et al., 2020). The latter is particularly true for individuals in substance abuse recovery programs. Some factors negatively impacting mental health during this pandemic include:

(i) Rumours: Rumours fuel feelings of uncertainty (Usher, Durkin & Bhullar, 2020, p. 316). Due to the widespread and easy use of smartphones, false information spreads quickly causing a subsequent increase in anxiety. Various governments posed strict advisories against COVID-19 related rumours in an attempt to reduce unnecessary panic. China and Russia issued a code of conduct on disinformation that tech. giants, including Twitter, Facebook and Google agreed to adhere to in The United States (Bloomberg, 2020). Likewise in India, strong advisories against false information especially on WhatsApp was issued by the Indian Government in March 2020. 

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(ii) Panic buying and hoarding behaviours: Arndt, Solomon, Kasser & Sheldon (2004) highlight how current anxiety is compounded by people being reminded of their own mortality and lack of control. The pandemic has created a surreal space-time warp in which heavy questions like, ‘What is the meaning of life? What is my purpose on Earth and Who am I? are being intensified and asked more frequently. People are compensating for this lack of control and hopelessness by giving in to the ‘urge to splurge’ and creating an illusion of control which makes them feel safe, in some way. These splurging and hoarding behaviours are precarious as it only furthers the gap between the demand and supply of limited resources, perpetuates anxiety and sets off a vicious cycle of panic buying, hoarding and further reactionary panic in motion. ​

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(iii) Lack of trust in medical infrastructure: In addition to the novel, mysterious and highly infectious nature of COVID-19, the inability of the current global medical infrastructure to quickly understand, address and curb the spread of the disease is problematic and negatively impacts the mental health of all. In some hospitals, health professionals have access to the same amount of information as the general public. “This dubious situation has created a large scale of disturbances in the lives of people across the globe and calls for the need for research...based on the learning of past outbreaks” (Shah, Kamrai, Mekala, Mann, Desai & Patel, 2020, p.2 of 8 in 7405.). Varshney, Parel, Raizada & Sarin (2020) identified the initial stages of COVID-19 to have a significant psychological impact on the respondents. This potentially points to the impact of confusion, lack of information and transparency as attributors of poor mental health especially during the onset of the outbreak in India (Varshney, Parel, Raizada & Sarin, 2020). Additionally, the lack of structured information in communication only further perpetuates the common man’s mistrust in the medical infrastructure (O’Neal, Lin, Devlin, & Ely, 2020). 

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(iv) Predisposition: The stress-vulnerability model suggests that human beings are sometimes born with a genetic predisposition to certain mental illnesses. This predisposition can be activated upon experiencing stressful life events, like this pandemic. Stress often increases one’s cortisol levels. Consequently, continuous exposure to stressful events or “Chronic stress can result in persistently elevated levels of cortisol” which is dangerous to both physical and mental health in the long run (Goh, & Agius, 2010, p.199.). 

Individuals with a predisposition to specific mental illnesses as well as those who have not yet experienced mental illness but are genetically predisposed will be more likely to face the negative psychosocial impacts of COVID-19 than those without a predisposition. In the context of India, Dubey et al. (2020), identified 6 categories of people who are most vulnerable and will require increased psycho-social attention during this pandemic; one of which are psychiatric patients. Individuals with pre-existing suicidal ideations who used to rely on meeting people/ engaging in outdoor activities as a way to avoid rumination or harmful thoughts might be at a greater risk than individuals who have always enjoyed spending time alone (Gokul, 2020). Individuals who suffer from pre-existing mental health conditions like obsessive-compulsive disorder, generalized anxiety disorder, and high level of health anxiety are also at a greater risk of experiencing psycho-social distress/trauma due to COVID-19 (Asmundson & Taylor 2020). The specific type of pre-existing illness/predisposition along with personality types and available support systems will impact the extent to which said predisposition matters. 

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These factors (the spread of rumours, panic buying, hoarding, lack of trust in medical infrastructure and predisposition) are not limited to recipients of care alone but also apply to providers of care. Additional stressors such as compassion fatigue, physical exhaustion, secondary trauma and burnout negatively impact the mental health status of healthcare providers. In a study conducted by Lai (2020) to assess mental health outcomes of health care workers treating patients exposed to COVID-19 in China, it was found that the extent of psychological burden experienced was inversely proportional to how well equipped the hospitals were in Wuhan, China. Lai (2020) also identified nurses, women, and frontline workers’ mental health to be most negatively impacted. 

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Mental health concerns in India due to COVID-19 

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As of 2017, one in every seven Indians experienced some form of mental illness; in May 2020, Dr. Mahesh Gowda, a consulting psychiatrist in Bangalore projected a two/three-fold increase in mental health struggles in India; given the current mental health systems in place, India runs the risk of a mental health crisis as a result of COVID-19 (Porecha, 2019; Krishnaswami, 2020). 

A concern specifically in the Indian context includes the 74 million people who are homeless in the country. Housing is considered to be the first line of defence in fighting this pandemic (Farha, 2020). Lack of proper housing drastically increases the percentage of Indians who can be both physiologically and psychologically impacted by COVID-19. 

Varshney, Parel, Raizada & Sarin (2020) conducted an online survey to understand the psychological resilience of Indians. The researchers received a total of 1106 responses from 64 cities in India and identified that (i) approximately one-third of respondents had a significant psychological impact (ii) Higher psychological impact was predicted with younger age, female gender and co-morbid physical illness and (iii) Presence of physical symptoms and contact history predicted higher psychological impact, but did not reach statistical significance (Varshney, Parel, Raizada & Sarin, 2020, p.5.). 

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India’s Mental Health Response to COVID-19

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Digital support: The use of and support for digital mental health trackers has seen an increase since quarantine measures were put in place in India. Some digital applications which promote virtual mental health support in India are (i) InnerHour, an app created by Dr Shefali Batra and Dr Amit Malik designed for self-help and digital therapy (ii) Trijoj, an app created by Anureet and Arushi Seth designed to offer various mental health solutions; it is also affiliated with the Rehabilitation council in India (iii) Epsychlinic, a 24/7 online chat support started by Shipra Dawar (iv) Yourdost, another digital therapy app created by actor, Risha Chadha and (v) Wysa, an app created by Jo Agarwal designed to provide mental health welfare and currently offering support to those experiencing anxiety and vulnerability (Pothula, 2020). More avenues of digital support are being consistently set up in India. 

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Covid distress Helplines: In response to an anticipated mental health crisis, psychological distress helplines were set up to provide tele-support to callers by the Indian government., NGO’s, trusts and unaffiliated mental health organizations/practitioners. In only 11 days after the first lockdown was instituted, the Indian government’s distress helpline number received a total of 3,07,000 calls, “30% were pertaining to protection against abuse/ violence on children, 11% related to the physical health of callers, 8% related to child labour, another 8% related to missing/runaway children and finally 5% regarding homeless individuals and families (The Economic times, 2020). 

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Online Creative Arts Therapy Training programs, workshops and on-going sessions: In order to enhance training and capacity building of therapists, teachers and students of DMT as well as other allied mental health professionals, many have offered online training programs through the pandemic. Creative Movement Therapy Association of India (CMTAI) conducted a series titled ‘Self-Care through Movement’ to encourage participants in different age groups to release distress held in their bodies and create movement rituals that could be practiced by them daily. Organizations across India such as Artsphere, Synchrony, The Muktha Foundation, The Arts Therapists co-lab, The Mental Health Foundation, The well-being centre, The Colour of Grey cells (COGC) and others have and continue to offer a variety of pedagogical and self-development programs for participants to update their skillset and increase their surge capacities. Although the aforementioned programs ran online, the sessions were dynamic due to the ingenuity of the facilitators and active involvement of the participants during movement experiences and verbal reflections. Participants underwent movement experiences based on Self and group awareness, stress release, movement energizers, emotional expression and resilience and movement meditation. 

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Creative Movement Therapy in India

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Movement is humanity’s universal language everyone can speak and understand it. In many primitive cultures, the dance of medicine men, priests or shamans are believed to be the oldest form of medicine and psychotherapy that facilitated a release of tensions and nursed one’s mental suffering back to health (Levy, 1988). As an art form dance has penetrated the human soul for generations before and has kept many mentally stable through this current pandemic as well. Yet, dance and other art forms are deemed as ‘non-essential services/items’ in India. Dancers across India are faced with many pertinent questions like, “Should we be paying more attention to recollecting forgotten dances and chiseling the craft of dance in our attempt to halt the process of dance forms becoming extinct? Do we need to strengthen dance by witnessing and experiencing it for ourselves more?” Creative movement therapy (CMT) does just that! It allows and invites its participants to recall the universal language of movement. 

The Creative Movement Therapy Association of India (CMTAI) was formed in 2014 and defines CMT as the “Psychotherapeutic framework that works with the mind-body connection to use personal movement language and dance for health and wellness of an individual’s physical, emotional, cognitive, social and behavioural aspects” (CMTAI, 2018). Participants undergoing CMT are encouraged to discover their personal movement vocabulary and explore specific movement ideas and elements from dance forms and other physical traditions in India (Kashyap 2005). 

Examples from classical Indian dances include, (i) hand gestures or Hastas from Bharatanatyam or Odissi which are used to develop fine motor skills and enhance gestural communication (ii) footwork from Kathak promote grounding, centering, increase in movement reflexes and fostering of rhythm development (iii) Prefabricated body movements specific to Mohini Attam or Kuchupudi help improve imitation skills, gross motor movements, eye-hand coordination and movement precision (iv) Navaras - the 9 emotions from Kathakali can be used to help individuals project as well as embody their feelings (v) Certain Challis and Uflis from Martial dances like Mayurbhanj Chhau can be is used to help clients balance on a single leg and increase body-self awareness and focus (vi) Movement props such as dupattas, scarves, cymbals, dandiya sticks and body-based rhythms (like clapping, stamping and snapping) from Indian folk and social group dances are used to vary movement qualities, increase attention span, body coordination and group awareness. 

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Overall, head, neck and eye movements from Indian classical dances along with the recitation of Sanskrit Shlokas have been used to enhance verbal-physical synchronicity by some CMT practitioners. Some of the above-mentioned elements and movement ideas have also been adapted to the virtual medium and are typically carried out through 5 stages of therapeutic encounters; which are, movement seeding, movement exploration, movement expression, resolution and integration. 

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Dance Movement Therapy in India

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Dance and creative movement therapy are both two of several approaches that can assist individuals in dealing with trauma, stress and anxiety. Formally, Dance/movement therapy (DMT) falls under the umbrella of creative arts therapy (CAT) which is best understood as a combination of creativity and clinical theories that tap into and expand the clients’ health; CAT involves 4 branches, art, dance, drama and music therapy. 

The concept of the mind-body nexus and its use in holistic wellness and healing is not a new phenomenon. However, The American Dance Therapy Association (the first formal association of DMT in the world) was only formed in 1966. Since then, several associations have followed. The Indian Association of Dance Movement Therapy was formed in 2020 and defines DMT as a “Psychotherapeutic method that uses movement and creative expression to further socio-emotional, cognitive and somatic integration (IADMT, 2020).” 

Universally, the use of DMT in healthcare is still in its nascent stages. Although current literature shows DMT to be a potentially low-risk and high benefit intervention in alleviating symptoms of mental illness (Karkou, Aithal, Zubala, & Meekums, 2019). Yet, standardization of its use has not been possible. Chiang, Reid-Varley & Fan (2019) attribute this to a lack of methodological rigour in prevalent literature. In spite of this gap, dance movement therapy is becoming increasingly popular as a mental health intervention in medical centres across India. 

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While many treatment methods focus on ‘understanding the problem or reasons’ behind a specific mental illness, DMT is a strength-based model that focuses on working with the healthy/ creative parts of individuals which is typically forgotten or neglected especially while formulating a diagnosis. 

Jeong et al., (2004) conducted a study to assess the impact of 12 weeks of DMT intervention on middle school seniors in Korea. They found that DMT had the potential to stabilize the sympathetic nervous system and can be beneficial in altering concentrations of serotonin and dopamine; ultimately improving psychological distress in adolescents with mild depression (Jeong et al., 2004). The sympathetic nervous system gets activated when individuals feel threatened in any way. In the current pandemic, there is a constant on-and-off engagement of the sympathetic nervous system. In such cases, DMT can prove to be a helpful intervention. 

In a meta-analysis carried out by Koch, Kunz, Lykou & Cruz (2014), they identified that DMT had “small but consistent effects for improvement of well-being, mood, affect, and body image” and “moderate effects on quality of life”. Although most literature is based on the direct link between DMT and elevating low mood, Pylvänäinen, Muotka & Lappalainen (2015) argue that DMT might also have indirect effects on a patient's overall mood by aiding in increasing psychological flexibility. These study findings from 2014 and 2015 are still relevant and remain the need of the hour, especially as society navigates through COVID-19. 

A few recommendations for the overall betterment of mental health in the midst of this crisis include 1) Knowing and managing anxiety and fear in patients 2) Assessing possible de-compensation of patients with previous mental problems; 3) Knowing and managing effects of quarantine and social distancing, and 4) Knowing and managing possible truncated mourning. (Turabian, 2020, p.39.). Dance movement therapy has the inherent ability to address all 4 recommendations made. 

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Dance Movement Therapy in the age of the ‘New Normal’ in India

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For years now, the possibility of working online has existed however, many dance movement therapists deliberately resisted using the medium unless it was to work with clients and students in another city, country or continent. Due to the nature of COVID-19, most dance therapists have begun to lead a full-time online professional life. For many, this includes, teaching, facilitating therapy sessions, attending meetings, delivering webinars, providing/ receiving supervision etc.

As a therapy model, dance movement therapy was designed to be carried out in neutral spaces that neither belonged to the client or the therapist. The shift to the virtual world has caused an increase in certain amounts of self-disclosure which therapists can no longer control. Therapists have had to re-imagine their modality and its purpose in this context. It has become essential to re-construct a plethora of individual and group-based approaches, tools and techniques of DMT to this ‘new normal’. Along with this constant re-ideating, therapists are also faced with the question of, “Does the virtual world have the capacity for neutrality or kinesthetic empathy,” “Can it ever fully replace a studio space and/or clinic?”

In adapting DMT to tele-health practices, dance therapists have used techniques like creative visualization, combining breath and movement patterns, movement-based rituals, self-affirmation practices, body preparatory exercises and relaxation routines in their online sessions. The following method was used to obtain qualitative data on the experience of dance therapists in India on navigating and working in the ‘new normal' in India. 

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Methods

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Authors contacted 12 dance movement therapists of Indian ethnicity asking to participate in a five-question interview. Authors received interest for participation from 5 dance/movement therapists currently practicing in India. Data was collected through virtual interviews (questions asked can be found in Appendix I). Questions were based on understanding therapists’ struggles, adaptations and best practices in Tele-DMT. Interview answers received virtually, were transcribed and analyzed to tabulate results.

Authors define Tele-DMT as, “The practice of dance movement therapy via virtual portals where dance therapists circumvent the impersonal quality of online mediums and offer psychological support via kinesthetic empathy; Tele-DMT emphasizes on movement experiences designed to contribute positively to an individuals’ or groups’ mental and emotional well-being.”

Selection criteria for this qualitative interview was being a registered dance/movement therapist (having a Masters level training in DMT/P) and being of Indian ethnicity. Authors received five responses and five signed consent forms. Responses have been included in the next section and are tabulated as recurrent and variant themes.

For the purpose of this article

(i) recurrent themes were defined as those which appeared in three or more of the participants’ responses

(ii) variant themes were defined as those which appeared one or two times in the participants’ responses