Mirroring in Movement Dance Movement The PDF

The Autism Journal
Therapeutic mirroring: Dance movement therapy can

improve individual and interpersonal outcomes in young
adults with Autism Spectrum Disorder
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Journal: Autism
Manuscript ID: AUT-13-0001.R2
Manuscript Type: Original Article

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autism spectrum disorder, embodiment, dance movement therapy,

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Keywords: mirroring intervention, clinical controlled trial, social competence, empathy,

well-being, body awareness, self-other distinction
From the 1970ies on, case studies reported the effectiveness of therapeutic
mirroring in movement with children with Autism Spectrum Disorder
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(ASD). In this pilot study, we tested a dance movement therapy (DMT)

intervention based on mirroring in movement in a population of 31 young
adults with ASD (mainly high-functioning and Asperger autism) with the
aim to increase body-awareness, social skills, self-other distinction,
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empathy, and well-being. We employed a manualized DMT-intervention

implemented in hourly sessions once a week for seven weeks. The
treatment group (n=16) and the no-intervention control group (n=15)
Abstract:
were matched by sex, age, and symptom severity. Both groups did not
participate in any other therapies for the duration of the study. After the
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treatment, participants of the intervention group reported improved well-

being, improved body awareness, improved self-other distinction, and
increased social skills. The DMT-based mirroring approach seemed to
ew
address more primary developmental aspects of autism than the presently

prevailing theory-of-mind approach. Results suggest that DMT can be an
effective and feasible therapy approach for ASD, while future randomized
control trials with bigger samples are needed.
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Page 1 of 34 The Autism Journal
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16 Running Head: MIRRORING FOR AUTISM
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21 Therapeutic mirroring: Dance movement therapy can improve individual and interpersonal
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23 outcomes in young adults with Autism Spectrum Disorder
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The Autism Journal Page 2 of 34
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3 Abstract
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5 From the 1970ies on, case studies reported the effectiveness of therapeutic mirroring in
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7 movement with children with Autism Spectrum Disorder (ASD). In this pilot study, we tested
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10 a dance movement therapy (DMT) intervention based on mirroring in movement in a
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12 population of 31 young adults with ASD (mainly high-functioning and Asperger autism) with
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14 the aim to increase body-awareness, social skills, self-other distinction, empathy, and well-
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16 being. We employed a manualized DMT-intervention implemented in hourly sessions once a
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week for seven weeks. The treatment group (n=16) and the no-intervention control group
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21 (n=15) were matched by sex, age, and symptom severity. Both groups did not participate in
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23 any other therapies for the duration of the study. After the treatment, participants of the
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25 intervention group reported improved well-being, improved body awareness, improved self-
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27 other distinction, and increased social skills. The DMT-based mirroring approach seemed to
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30 address more primary developmental aspects of autism than the presently prevailing theory-
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32 of-mind approach. Results suggest that DMT can be an effective and feasible therapy
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34 approach for ASD, while future randomized control trials with bigger samples are needed.
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Keywords: autism spectrum disorder, embodiment, dance movement therapy, mirroring,
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41 clinical controlled trial, treatment manual, social competence, empathy, well-being, self-other
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43 distinction, body awareness
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3 Therapeutic mirroring: Dance movement therapy improves individual and interpersonal
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5 outcomes in young adults with autism spectrum disorder
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7 Autism is a severe developmental disorder that encompasses body and mind, feeling and
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10 social relating. Social functioning is challenged life-long in autism (Fombonne, 2003; Matson,
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12 Mayville, Lott, Bielecki, & Logan, 2003) with, for instance, only about 8 % of people with
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14 autism reporting having reciprocal friendships (Klinger & Williams, 2009) and only about 6%
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16 hold paid full-time jobs (Child-Autism-Parent-Café, 2012). A major treatment goal is thus to
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improve individual and interpersonal competences of individuals with autism. Since
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21 cognition, emotion, and motor function are all interrelatedly affected by autism there are three
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23 major entries to improve social skills in autism: cognition, emotion and the body. At present,
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25 there is a strong focus on cognitive theories of deficits in autism such as theory-of-mind

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27 (ToM; Baron-Cohen, Leslie, & Frith, 1985; Won & Leung, 2010) and treatment approaches
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30 related to them (Klinger & Williams, 2009; Wood, Drahota, Sze, Van Dyke, Decker, Fujii, et
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32 al., 2009). We argue that from the present state of knowledge – particularly from the findings
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34 of the recent embodiment approaches in cognitive science – a body-oriented treatment
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36 approach to autism is warranted (Gallagher, 2004; Gallese, 2006; Mundy, Gwaltney, &
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Henderson, 2010).
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41 Rather than viewing autism as primarily related to a compromised ToM and consequently
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43 trying to implement therapies on a cognitive level, embodiment approaches support the notion
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45 that due to their developmental and behavioral primacy the nonverbal interaction components
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47 compromised in autism are at the core of the impairment and need to be directly addressed in
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50 autism therapy (e. g., Gallagher, 2004; García-Pérez, Lee, & Hobson, 2007). Existing
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52 embodied treatment approaches such as dance movement therapy (DMT) use deficits and
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54 resources in body movement of individuals with ASD directly as a therapeutic starting point
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56 (e. g., Behrends, Müller, & Dziobek, 2012). Because of the body’s close connection to
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feelings (e.g., Riskind, 1984; Stern, 1985), and the close relation of emotion and cognition
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3 (e.g., Schachter & Singer, 1962), and of body and cognition (e. g., Casasanto & Boroditzky,
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5 2008; Lakoff & Johnson, 1999), movement therapy directly addresses the remaining two
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7 points of entry to treatment in autism – cognition and emotion – with a bottom-up
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10 embodiment approach (e. g., Gibbs, 2005; Koch, 2011).
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12 Resources on the body level in autism
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14 Because of widely functional motor execution and body-feedback mechanisms in autism,
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16 individuals with ASD are able to use the body as a direct resonance tool (re-sound: the other
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re-sonates in us; Froese & Fuchs, 2012; Husserl, 1952) in “face-to-face” interactions – an
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21 important prerequisite to built interpersonal attunement and empathy (e. g., Davis, 1980;
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23 Kestenberg, 1995). By working with the body and the most basic nonverbal interaction skills -
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25 mainly by using direct “in situation” contingencies such as imitation, mirroring, and echoing
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27 (Fraenkel, 1983) with individuals with ASD - one should be able to progressively build
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30 missing anticipatory skills necessary for motor preparation and motor planning (Schmitz,
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32 Martineau, Barthélémy, & Assaiante, 2003). Moreover, the expressive functions of the body
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34 directly relates to communicative functioning and interpersonal competences (Gallagher,
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36 2004). Embodied therapy approaches individually as well as interpersonally affect body
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(expansion of movement repertoire, Fischman, 2008), interpersonal resonance (Froese &
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41 Fuchs, 2012), emotions (perception, expression and communication of affect, Fuchs, Koch &
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43 Summa, 2013; kinesthetic empathy (Fischman, 2008; Kestenberg, 1995), and cognition (e.g.,
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45 perspective taking, metaphoric expression, Lakoff & Johnson, 1999). They thus can be
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47 assumed to work on all levels of the impairment and help to improve symptoms with a
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50 bottom-up approach starting from a developmentally more primary level than ToM
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52 approaches (e.g., Boucher, 2012).
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54 Embodied theories of autism
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56 We are basing our assumptions regarding the effectiveness of DMT in autism on the
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theories of Gallagher (2004) as well as Mundy, Gwaltney and Henderson (2010). According
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3 to the interaction theory of autism (Gallagher, 2004), more primary forms of intersubjective
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5 understanding develop much earlier than the cognitively mediated ToM, which develops by
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7 the age of about four years (e. g., Baron-Cohen, Leslie, & Frith, 1985). Gallagher assumes
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10 that already toddlers acquire a basic knowledge of others’ internal states, and intentions by
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12 observing their movements, gestures or facial expressions. Following this view, the mind is
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14 not hidden but directly expressed in other persons’ embodied actions.
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16 Mundy and colleagues (2010) assume that the social impairments in ASD arise from
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limited simultaneous processing of self-and-other referenced sensory information. The aware-
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21 ness of ones own interoceptive bodily state (heart rate, temperature, proprioception, etc.)
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23 while attending to others is crucial to develop an understanding of others and leads to
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25 empathy, which constitutes the basis of genuine social skills and prosocial behavior (Behrends
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27 et al., 2012). This somatic ability is usually a non-deliberate act (Pallaro, 2006) and its
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30 impairment is assumed to lead to deficient self-awareness and social understanding (Mundy,
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32 et al., 2010). Embodiment theories emphasize that autism therapy should strongly focus on
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34 interaction on the nonverbal level to strengthen intersubjective reciprocity; address timing
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36 issues, and build basic social skills from scratch.
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Dance Movement Therapy: Mirroring in Movement
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41 DMT is an embodied treatment approach that already reported success with mirroring in
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43 movement (e.g., leading and following in movement) for autism in the 70ies (Adler, 1970;
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45 Kalish, 1976). The mirroring approach in DMT uses empathic reflection of the clients’
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47 expressive motor behavior on the therapist’s side (and vice versa) to build a mutual
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50 relationship (e.g., Eberhard-Kaechele, 2012; Fraenkel, 1983; McGarry & Russo, 2011;
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52 Sandel, 1993). The emphasis is thereby on the reflection of the quality of the movement,
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54 rather than its mere form. Kinesthetic empathy can be learned through imitation, however,
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56 imitation alone is not enough to develop interaction skills; attunement (Kestenberg, 1995;
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Keysers, 2011) - as the additional interactional component - is based on body resonance
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3 (Husserl, 1952; Merleau-Ponty, 1962) and is a two-sided process of moment-to-moment
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5 bodily adjustment in tension level, tension patterns and shape flow (Kestenberg, 1995). Under
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7 the assumption of an intact rudimentary ability for attunement in ASD, DMT has the goal to
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10 strengthen this ability and to establish more advanced forms of intersubjectivity. It uses
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12 mirroring of non-stereotypic parts of the clients behavior on the therapists side to the point
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14 where individuals with ASD recognize the contingencies in mutual behavior and they start to
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16 assume a reward quality for them. In the same line, synchrony in therapy has recently been
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shown to be an important predictor of therapy outcome (Ramseyer & Tschacher, 2011).
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21 It needs to be emphasized that mirroring as employed here includes attunement as well as
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23 disruption of attunement. Both serve for boundary recognition and differentiation of self and
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25 other. Following Kestenberg (1995) partial attunement leads to successful differentiation in

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27 normal development. In the same vein, recent experimental studies suggest that inhibition of
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30 imitation enhances self-other distinction (Brass et al., 2009; Santiesteban et al., 2012).
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32 Santiesteban et al. (2012) showed that training of inhibition of imitation directly affected
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34 perspective taking. Those studies did not find support for the role of imitation, they did,
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36 however, not include a focus on movement qualities, where attunement may be of greater
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importance. Mirroring in movement in DMT always includes mirroring of the quality of the
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41 client’s movement as specified in Laban Movement Analysis (Laban, 1980).
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43 The majority of studies using mirroring in movement for ASD have been case studies with
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45 children (e.g., Erfer, 1995; Kalish, 1976; Ruttenberg, Fiese, & Gates, 1988; Siegel, Blau,
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47 Salz-Citron, Rose-Schenck, & Schmitt, 1980). The present state of research suggests that
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50 DMT has a positive influence on attention, social skills, subjective stress perception, and
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52 reduction of stereotypic symptoms (Hartshorn, Olds, Field, Delage, Cullen, & Escalona, 2001;
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54 Weber, 1999); moreover, creative dance was shown to be beneficial for ASD children (Greer-
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56 Paglia, 2006). However, research on adults with ASD as well as research investigating effects
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on empathy, body-, self-/other awareness and well-being is missing.
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3 Research Question and Hypothesis
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5 Because mirroring in movement can strengthen the feeling of attunement with the partner,
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7 which is assumed to lead to a feeling of pleasure and acceptance (Eberhard-Kaechele, 2009),
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10 and of positive affect through the detection of contingencies, we hypothesized that DMT
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12 improves psychological well-being (Hypothesis 1). Thus, participants in the treatment group
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14 were expected to show more psychological well-being (more positive affect, vitality, and
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16 coping, less tension and anxiety) than participants in the control group. Based on the assump-
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tions of Mundy et al. (2010), we hypothesized that DMT improves body-awareness
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21 (Hypothesis 2) and self-other distinction, i.e. the awareness of the borders between self and
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23 other individuals in ASD (Hypothesis 3). Based on studies showing that body awareness and
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25 self-other awareness are preconditions for empathy (Behrends et al., 2012; Brass et al., 2009;
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27 McGarry & Russo, 2011), we hypothesized that DMT improves empathy in ASD, as
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30 operationalized by the Emotional Empathy Scale (EES; Caruso & Meyer, 1998) (Hypothesis
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32 4). On the basis of the theories of Gallagher (2004) and the findings of the connection
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34 between motor and social domain (e.g., Freitag et al., 2007), we hypothesized, that DMT
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36 improves social competence in ASD (Hypothesis 5).
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For the observations of mirroring modalities in the present study, we employed the
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41 concept of co- and self-regulation from Eberhard-Kaechele (2009; 2012). Eberhard-Kaechele
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43 (2009; 2012) put forth a developmentally based category system of mirroring in movement
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45 and related it to the development of mentalization skills (Fonagy, Gergely, Jurist, & Target,
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47 2004). From her category system with twelve mirroring modalities, we selected two easy to
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50 observe developmental stages of concordant mirroring (modal vs. counter movement) related
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52 to the cognitive milestone of perspective taking (ToM) in order to exploratively assess
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54 participants’ developmental stage in terms of mirroring at the beginning of the therapy and
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56 their according development over time (Eberhard-Kaechele, 2012; see Appendix A).
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Method
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3 Sample
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5 Thirty-one individuals with ASD (mostly HFA/AS; 23 men, 8 women) with a mean age
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7 of 22.0 (SD = 7.7, range 16 – 47) participated in this study. The participants were recruited at
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10 the University Hospitals of Heidelberg, at the Central Institute of Mental Health in Mannheim
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12 and at SALO + PARTNER GmbH in Ludwigshafen, a professional rehabilitation institution
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14 of secondary education. All participants were diagnosed with ASD according to the ICD-10
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16 criteria of autism (n=6 early childhood autism, n=3 atypical autism, n=12 Asperger, n=10 no
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specified type of autism, diagnosed as ASD). According to clinical judgment by the patients’
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21 therapist six participants suffered from severe symptom degree of ASD, 15 from moderate
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23 and three from a mild degree of ASD. Clinically not impairing comorbid psychiatric disorders
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25 like mild depressive or anxiety symptoms and any kind of medication were not regarded as
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27 exclusion criteria. IQ of participants was not assessed, but clinically judged to be average. All
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30 participants were required to be older than 16 years and in a health condition to move in
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32 standing position for about one hour. A small number of participants of EG and KG
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34 participants in one of the two settings completed professional internships during the training
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36 (<10%). There were no significant baseline differences between the intervention group and
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the control group at the time of the pretest (for all differences p > .10).
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41 Procedure
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43 Participants were contacted either by posted flyers or by their physician or psychologist.
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45 Since random assignment was not possible due to logistic reasons, treatment (n=16) and
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47 control group (n=15) were matched according to sex, age, and severity of diagnosis. Two
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50 actual therapy groups were run by the same dance movement therapist. Participants in each of
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52 the actual therapy groups came through at least two out of four different cooperating facilities.
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54 No participant took part in any other psychotherapy for the time of the treatment.
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56 The dance movement therapist conducted seven session of the manualized intervention,
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one hour each in a weekly rhythm. The primary co-therapist was a psychology major and the
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3 assistants were psychology students at the University of Heidelberg, trained in the manual and
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5 in monitoring the mirroring modalities of the participants while moving with them. Upon the
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7 first meeting, participants received detailed information about the study and signed and
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10 returned the informed consent sheets. Then, they completed the pre-test, consisting of
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12 different self-report scales (see below). After finishing, a first short version of the therapy
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14 session was conducted.
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16 Intervention. Every session consisted of basically the same sequence of mirroring
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exercises and a verbal processing part.
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21 (a) Warm-Up (about 10 min): For the warm-up, we employed the Chace-circle (Sandel,
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23 Chaiklin, & Lohn, 1993), a loose circle formation where the therapist picks up elements of
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25 each participant and asks the group to try them out (“can we all do what Mr. X does?”, “can
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27 we all be with Mrs. Y?”) and playfully change them (“can we make this bigger / smaller /
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30 louder / softer,” etc.). The Chase-circle creates an atmosphere of being seen and accepted as
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32 one is, and a secure therapeutic space, where participants can try themselves out and express
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34 their thoughts and feelings (Sandel, Chaiklin, & Lohn, 1993). After the warm-up and creation
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36 of an atmosphere of acceptance, all participants split into dyads.
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(b) Dyadic movement part (about 15-20 min): Ideally, a dyad consisted of one
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41 therapist/assistant and one participant. Only in cases when there were less therapists/assistants
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43 than participants, two participants formed one of the dyads amongst each other. Each partici-
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45 pant had the opportunity to choose his or her preferred partner. After choosing the partner, the
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47 therapist explained the task of the session to the participants. First, the participant was asked
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50 to lead (mostly the preferred mode in individuals with ASD; cf. Eberhard-Kaechele, 2009),
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52 then upon the second song the assistant was asked to lead and the participant followed, and
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54 then upon the third song both were asked to move freely but to always stay in contact with
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56 each other, no matter whether they were at the opposite sides of the room. It was emphasized
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that it was not important during mirroring that each person exactly mirrored the shapes of the
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3 other person’s movement, but that it was important that their movements reflected the quality
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5 of the other’s movement, genuinely trying to be with them. For the dyadic mirroring a mix of
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7 slower and faster short pieces of music was used (each at maximum 3 minutes). This free
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10 dancing part also ensured that participants had the opportunity to freely choose the mirroring
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12 modality they preferred.
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14 (c) Baum-circle (about 20 min): After the dyadic movement part, all participants came
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16 together again in a circle. The movement part was then ended with a “Baum-circle” (Koch &
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Harvey, 2012). For this part of the session, participants were encouraged to bring their own
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21 music, which caused a positive response. Then the first volunteer initiated movement to
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23 his/her self-selected piece of music, being asked to basically focus on the expression of his
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25 feelings and not to pay too much attention to the others, while all other participants were
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27 asked to follow in the same kinesthetically attuned way they did before in the dyads. The
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30 Baum-circle aims to establish rapport and empathy in the participants using kinesthetic
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32 attunement and emotional contagion (Hatfield, Cacioppo, & Rapson, 1994; Koch & Harvey,
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34 2012). To be mirrored as a single person by the entire group conveys respect, acceptance
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36 without condition, and a feeling of togetherness. The fact that the Baum-circle worked well in
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the group showed that it was not a strain to confront our participants with a DMT technique
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41 that was created for medium to high functioning populations. Usually, three volunteers
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43 initiated movement in the Baum-circle of one session.
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45 (d) Verbal processing part (about 10-15 Minutes): Finally, all participants sat down to
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47 reflect the session moderated by the therapist. In this context, the participants could express
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50 their actual feelings and their opinion regarding the session. The therapist first encouraged the
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52 participants who initiated an improvisation in the Baum-circle to verbalize how it was to
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54 move, what they wanted to express, and how it felt to be reflected by the other group
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56 members. Then, the other participants were asked about their perceptions and feelings when
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they moved with the person. The aim is to provide and receive feedback suited to increase
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3 body-awareness, self-awareness, self-other awareness, empathy and social skills; and to
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5 verbalize the non-verbal experiences and feelings. The entire DMT session lasted 60 minutes.
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7 Assistants’ tasks. The task of co-therapist and assistants was (a) to verbalize emotions and
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10 support verbalization of emotions, (b) to move in an attuned and appropriate way in dyadic
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12 mirroring, taking up on the movement qualities of the participant, unobtrusively expanding
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14 the repertoire of the participants, and observing their mirroring stage and progress over time;
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16 (c) to encourage participants’ initiative and enhance emotional expression (e.g., by modelling
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in the initial Chace-circle or, if there was no volunteer for the expressive improvisation in the
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21 Baum-circle, to provide a model) and (d) to model authentic expression of sensations,
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23 emotions and cognitions in the verbal processing part of the session.
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25 Questionnaires. Before the first session, participants completed the pre-test, and directly
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27 after the last of the seven sessions, participants completed the post-test, consisting of the
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30 identical self-report scales as the pre-test, supplemented by additional questions about their
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32 experiences during the sessions, their liking of the therapy, and their wish to continue with the
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34 therapy. The control group completed the pre- and post-tests in the same time interval as the
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36 treatment group and did not receive any therapy intervention in that interval.
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Instruments of the Pre-/Posttest (Main Dependent Variables).
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41 Psychological well-being. Psychological well-being was measured by the bipolar 12-item
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43 “Heidelberger State Inventory” (HSI; Koch, et al., 2007), with a range from “1” (“does not
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45 apply at all”) to “6” (“applies exactly”) assessing tension, anxiety, coping, positive affect,
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47 depressed affect and vitality (Goodill, 2006). The internal consistency of the entire scale in
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50 previous studies was Cronbach’s α = .63 - .91. In the present study the internal consistency of
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52 the post-test data was Cronbach’s α = .56 for the tension subscale, for the coping subscale
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54 Cronbach’s α = .70 and for the anxiety subscale Cronbach’s α = .79.
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56 Body-awareness. Body awareness was assessed by the subscale body awareness of the
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bipolar 15-item “Questionnaire of Movement Therapy” (FBT; Gunther & Koch, 2010). This
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3 scale consists of seven bipolar items with a range from “1” (“does not apply at all”) to “6”
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5 (“applies exactly”), which all describe trust in one’s own ability to be aware of the own body,
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7 related affects and the interaction of both. The internal consistency of the post-test data was
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10 Cronbach’s α = .64.
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12 Self-other awareness. Self-other awareness was assessed by a self-constructed scale
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14 comprising the items “I am aware of myself”, “I feel able to engage with others”, “I feel able
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16 to perceive the borders between me and other persons well”, ranging from “1” (“does not
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apply at all”) to “6” (“applies exactly”). The internal consistency in the post-test of the present
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21 sample was Cronbach’s α = .79.
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23 Empathy. The short form of the Emotional Empathy Scale (EES) by Caruso and Mayer
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25 (1998) was used to assess empathy. It ranges from “1” (does not apply at all) to “5” (applies
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27 exactly). We used a self-translated German version that had been validated on n = 80 psy-
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30 chology students by the team beforehand. Sample items are “It makes me mad to see someone
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32 treated unjustly” or “If a crowd gets excited about something, so do I“. The internal consisten-
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34 cy of the entire scale on the post-test data was Cronbach’s α = .77.
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36 Social skills. Social skills were measured by the subscale social skills of the “FBT”
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(Gunther & Koch, 2010) described above. Sample items are ‘I am able to behave appropri-
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41 ately in interpersonal situations’, ‘I am able to accept criticism directed to me’ and ‘I am able
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43 to trust others’. The internal consistency of the post-test study data was Cronbach’s α =.83.
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45 Observations of Mirroring Modalities and Qualitative Measures
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47 The therapists/assistants evaluated mirror qualities of the movement in the free dyadic
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50 dancing part immediately after each session using three items on percentage and type of
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52 mirror activities, the preference of the participant to lead or to follow, and the perceived fun
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54 during the mirroring tasks.
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56 As additional qualitative expressive measures, participants had the opportunity to express
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their feelings about the therapy by painting a picture or writing a short poem about their
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3 experience. These forms of translation of the experiential process into other expressive
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5 modalities were chosen, because of the poor output of the verbal processing circles. The
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7 therapist’s observations of the therapeutic process were additionally considered.
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10 Statistical Analysis
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12 A one-factorial between-group design was employed. The independent variable was
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14 condition (treatment vs. control group). The dependent variables were the difference score of
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16 the pre-posttest data on body-awareness, self-other awareness, psychological well-being
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(positive affect, vitality, tension, coping and anxiety), empathy and social skills. We computed
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21 the means of the items on these dimensions and a difference score ∆ subtracting the pre-test
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23 value of each dimension from the corresponding post-test value. Cronbach’s Alpha’s of
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25 reliability of change scores for the dependent variables resulted between .58 and .67. The
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27 influence of DMT on young adults with ASD was examined with multiple univariate
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30 ANOVA with condition (treatment group vs. control group) as the independent variable and
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32 the difference scores of the outcome measures as the dependent variables. The alpha-level
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34 was set at p<.05. Because we had formulated directional hypotheses, the resulting p-value of
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36 the two-tailed ANOVA was divided by two. In addition, Cohen’s d was computed as an
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estimator for the effect size (Cohen, 1969). Age was used as a control variable, and hence,
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41 entered as a covariate.
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43 Results
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45 Adherence
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47 Out of 16 participants in the intervention ten attended all seven therapy sessions, three
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50 attended six times and three attended five times; given the fact that some participants were
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52 away at some of the dates to do a professional internship this is a very good adherence of
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54 more than 90%. There were no drop outs in the sample.
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56 Main Results: Changes in the treatment group vs. control group
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In the treatment group, all group means changed in the hypothesized direction (all
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1
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3 descriptive and inferential statistics see Table 1; the intercorrelation matrix of all outcome
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5 variables is provided in Table 2; the discrepancies in the degrees of freedom despite the
6
7 unchanged number of participants result from partly missing data in the questionnaires).
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10 Psychological Well-Being (Test of Hypothesis 1). A univariate ANOVA on the average
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12 difference score of all scales of psychological well-being revealed a significant difference
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14 between the treatment group and the control group. Participants in the treatment group
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16 showed a higher increase in psychological well-being in general compared to the control
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group, F(1, 27) = 2.95, p =.049, d = .63 (Figure 1). This effect was carried by the decrease in
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21 tension of the participants of the treatment group. Thus, hypothesis 1 was supported.
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23 Body awareness (Test of Hypothesis 2). A univariate ANOVA on the difference score of
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25 body-awareness revealed a significant difference between the treatment group and the control
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27 group. Participants in the treatment group showed a higher increase in body-awareness
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30 compared to the control group, F(1, 29) = 2.95, p = .049, d = .62 (Figure 1). Thus, hypothesis
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32 2 was supported.
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34 Self-other awareness (Test of Hypothesis 3). A univariate ANOVA on the difference
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36 score of self-other awareness revealed a significant difference between the treatment group
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and the control group. Participants in the treatment group showed a higher increase in self-
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41 other awareness compared to the control group, F(1, 28) = 3.93, p = .029, d = .72 (Figure 1).
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43 Therefore, hypothesis 3 was supported.
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45 Empathy (Test of Hypothesis 4). A univariate ANOVA on the difference score of empathy
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47 did not yield any significant differences between the treatment group and the control group.
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50 Participants in the treatment group showed no significant increase in empathy compared to the
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52 control group on the EES, F(1, 27) = 1.26, p = .271 (Figure 1). Thus, hypothesis 4 was not
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54 supported.
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56 Social Skills (Test of Hypothesis 5). A univariate ANOVA on the difference score of social
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skills revealed a significant difference between the treatment group and the control group.
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1
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3 Participants in the treatment group displayed a higher increase of social skills compared to the
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5 control group, F(1, 29) = 3.49, p = .036, d = .67 (Figure 1), thus, supporting hypothesis 5.
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7 Additional quantitative results
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10 Control variable. The results of the computed ANCOVA indicated that age did not have
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12 a significant influence on any of the dependent variables.
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14 Intercorrelations. The highest correlation we found was that of body awareness and self-
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16 other distinction (r=.60). Body awareness and psychological well-being were positively
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related to empathy (r=.38 and r=.42 respectively; for all inter-correlations see Table 2).
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21 Evaluation of Intervention (Posttest Questionnaire). Thirteen out of 16 participants
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23 reported, that they would like to continue with the therapy, if there was an option (6 “Yes”, 1
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25 “more often”, 6 “less often”, 3 “No”). The mean of the rating on perceived fun during the
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27 DMT intervention was 4.56 (SD = 1.6, range 1 – 6).
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30 Observations of mirroring modalities
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32 On the questionnaire that the therapists/assistants completed at the end of each session,
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34 the descriptive analysis of the mirroring modalities yielded that the participants mirrored
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36 about half of the dyadic time with a constant ratio of 70:30 (modal to contra-lateral). Fifteen
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out of 16 participants used predominantly modal mirroring over all sessions, and there was no
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41 progressive trend observable. The ratio of leading to following was exactly 50:50 across all
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43 participants; all participants were able to do both. Perceived fun increased from M=3.63
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45 (SD=.74) in session two to M=3.91 (SD=1.22) in the sixth session on a scale from 1 to 5.
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47 Qualitative Measures
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50 The therapist observed that all participants were able to use their body movement as a
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52 resource from the beginning of the therapy on. Single participants were able to move from
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54 mirroring to a playful interaction with increasing question and answer structures in nonverbal
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56 behavior (the most advanced mirroring stage according to Eberhard-Kaechele, 2012), others
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were able to use movement metaphorically (e. g., “Tears in heaven”-improvisation of a
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3 participant considered low-functioning), or to express their experience in the form of a poem
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5 (see Appendix B). All participants were able to lead and follow in their own idiosyncratic
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7 ways. The majority of the participants in this study clearly had less problems to attune in
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10 movement to the other persons in the groups than to cognitively and emotionally reflect the
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12 sessions afterwards.
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14 The attempt to translate some of the intense experience in movement to the verbal realm
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16 by inserting drawings as a further nonverbal but more manifest modality than movement, did
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not work in our case. One participant, for example, started to draw a train and was imitated by
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21 several other participants, similar to a stereotypic repetition of what they saw others do and
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23 was presumably something you could do in response to the task. In the same session (the
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25 second-to-last), participants were asked to continue to translate their experience into a creative
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27 artwork, a composition, a dance or a poem at home and bring the result with them in the last
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30 session. The only contributing participant brought the poem that is printed in Appendix B.
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32 Discussion
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34 Our study shows that mirroring in movement improved body awareness, self-other
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36 awareness, psychological well-being, and social skills in young adults with ASD on self-
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report scales. Those outcomes improved significantly in the expected direction with medium
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41 to large effects (effect sizes of .61 to .91); the increase in empathy was not significant. The
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43 increase in body-awareness and self-other awareness showed that the intervention was
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45 accessing those primary embodied interactive skills it aimed to improve. The increase in
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47 social skills in the intervention group was important considering the well-documented grave
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50 restrictions in social interactions in ASD. The increase in well-being additionally indicated
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52 that participants felt more comfortable and relaxed at the end of the therapy sessions. All
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54 findings need to be interpreted with the according caution, particularly the ones missing
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56 measurement validation. In sum, considering the small sample size and the brevity of the
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intervention, our pilot results are encouraging for the implementation of DMT interventions in
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3 the treatment of ASD, however, more studies, particularly randomized controlled trials
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5 (RCTs) are needed.
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7 Additional qualitative process data confirmed these results indicating that DMT
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10 participants were increasingly aware of the self-other distinction and increasingly enjoyed to
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12 participate in the therapy. The mentioning of DMT as a useful therapy in the post-test-
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14 questionnaire clearly increased in the treatment group compared to the control group.
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16 Adherence to and acceptance of the therapy was high. We had no treatment drop-out, instead,
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thirteen out of 16 participants found the intervention useful and stated that they would like to
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21 continue with the therapy. The subjective impression of the therapist and the institutional staff
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23 members converged in experiencing the participants as more outgoing and self-confident after
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25 the intervention. The increasing willingness to bring their own music and initiate movement,
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27 next to being an indicator of the involvement and commitment of the participants, suggested
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30 that the participants felt comfortable, safe and accepted in the group.
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32 The observational results of the mirroring modalities did not yield the expected
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34 progression toward more counter movement – as an indicator of perspective taking in
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36 movement (Eberhard-Kaechele, 2012). To improve the analysis of mirroring modalities and
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their use, future studies may need to take into account more extreme poles of mirroring on the
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41 postulated developmental continuum (Eberhard-Kaechele, 2012). However, the inconclusive
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43 finding may also have come about on the ground of the short intervention duration.
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45 Nevertheless, the therapist and the assistants reported a high degree of nonverbal
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47 resources in the participants: not only were they able use simple forms of mirroring in
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50 movement instantly, but also did they generally use more complex forms of mirroring and
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52 progressively went into playful and teasing interactions. This substantial degree of resources
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54 on the body level yielded an easy and high level access to the participants via movement.
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56 Parts of the results were in line with the findings of previous studies showing that DMT is
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useful for improving diverse bodily, cognitive, and social functions in ASD (e. g., Hartshorn,
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1
2
3 et al., 2001; Weber, 1999). Our study extended the validity of the effectiveness of DMT-
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5 mirroring interventions to the population of young adults with ASD and to a quantitative
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7 design. Unlike most of the other studies that have examined the influence of DMT on ASD in
8
9
10 small samples and case studies, the sample of the present study consisted of a broad range of
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12 individuals with ASD with different diagnoses and degrees of impairment. Consequently,
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14 DMT seems to be a useful treatment method for the entire autism spectrum.
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16 Finally, the chosen method of therapy was anchored in a well-fitting theoretical concept.
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From the recent embodiment approaches, we grounded our reasoning in interaction theory
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21 (Gallagher, 2004) and the individual-interactional model (Mundy et al., 2010). Following
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23 Mundy et al (2010) individual level and interactional level components can be brought
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25 together in a single explanatory model of autism: kinesthetic body awareness (including

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27 interoceptive sensory awareness) needs to be co-activated with visual resonance when in
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30 interaction with others to foster the emergence of self-awareness and self-other distinction. In
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32 our study, body-awareness and self-other awareness showed the highest correlation among all
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34 dependent variables, directly supporting this assumption.
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36 Limitations and future research directions
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One of the most important limitations of the study is the small sample size with n=31. It
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41 limits the power of the test to .60 - .65 (estimated with g*power; Erdfelder, Faul, & Buchner,
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43 1996). The probability of committing a type-II-error, i.e., of falsely rejecting the null-
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45 hypothesis - that treatment and control group do not differ - was accordingly high.
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47 A further limitation stems from the design. Because of the lack of randomization, the
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50 improvement of the symptoms may be due to other factors than the DMT intervention. To
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52 minimize these effects, the control group and the treatment group were matched with regard
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54 to sex, age, and severity of diagnosis. In addition, because the control group did not receive
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56 any intervention, Hawthorne-effects (cf. Roethlisberger, Fritz, & Dickson, 1939), i. e. the
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possibility that the intervention group got better due to increased attention, cannot be
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3 excluded. Moreover, blinding of participants, helpers and researchers in this study was not
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5 possible and thus could have caused expectancy effects.
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7 The exclusive use of self-report scales is another limitation of the study. Regarding the
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10 clinical picture of ASD with the decreased self-awareness and the limited access to affectivity
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12 (Frith, 2003), it could be rightfully questioned whether participants were able to evaluate their
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14 own inner states properly on the self-report questionnaires (Johnson, Filliter, & Murphy,
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16 2009). However, the consistency of the results speaks for an adequate understanding of the
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18
participants here. This was also reported by other authors. Berthoz and Hill (2005) found in
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21 their validity of self-report measures in ASD-study that ASD participants were able to report
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23 about their own emotions using self-reports, in that case on alexitymia (TAS-20, BVAQ-B)
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25 and depression (BDI). In addition, individuals with ASD should on the basis of their condition
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27 be less prone to social desirability bias than non-autistic controls. However, because the
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30 validity of self-report issue is not satisfyingly clarified, future studies should additionally
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32 include other sources of evaluation, such as observational measures or judgment of care-
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34 takers. The heterogeneity of the sample is a problem that needs to be mentioned. However,
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36 effectiveness of the intervention despite of heterogeneity speaks for even bigger effects in
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more homogeneous samples.
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41 More importantly, since there were no sufficient calibrations of the actual mirroring in
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43 movement behavior in the sample of participants, it cannot be determined whether mirroring
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45 was the definitive behavior accounting for the change in self-reports (cf. Ingersoll, 2012).
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47 However, there is a fair chance that mirroring may be the effective mechanisms, since a
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50 variety of other findings clearly show that imitation improves social functioning in children
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52 with ASD (Ingersoll, 2008, 2012). Nevertheless, it needs to be determined whether there are
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54 other factors next to mirroring in movement that influence the outcome measures in such
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56 interventions.
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Moreover, some of the measures such as the FBT (Gunther & Koch, 2010) and the HIS
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1
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3 (Koch et al., 2007) were not yet standardized and cannot be interpreted with as much
4
5 confidence as standardized measures can. This is one of the most severe problems of this pilot
6
7 study. Validation of the instruments is in work.
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9
10 Finally, it is important to note that the three DMT methods employed in the manual are
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12 only a small part of the DMT intervention spectrum in general, and of mirroring methods in
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14 particular. Future studies could either focus on testing other DMT interventions or the effects
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16 of the single specific interventions employed here. Studies with follow-up testing are needed
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to investigate whether observed changes are as stable as in other areas of DMT interventions
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21 (e.g., Braeuninger, 2012).
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23 Conclusions
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25 In sum, the findings increase the understanding of the effectiveness of DMT mirroring
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27 interventions for the treatment of autism. Our pilot results suggest that DMT can be effective
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30 and feasible for the treatment of individuals with ASD, causing improvement in body-
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32 awareness, self-other awareness, psychological well-being, and social skills with all according
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34 limitations discussed and the need for further improved study designs with bigger samples.
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36 In the case of understanding others – next to having theories about their mental states –
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there may be various other ways to form an immediate connection to them such as bodily
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41 resonance. Treatment thus needs to additionally focus on the body and motor level to improve
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43 embodied resonance, kinesthetic empathy, emotional and interpersonal aspects more directly
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45 than by going through secondary cognitive processing. Cognitive therapy approaches may be
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47 helpful to address theory of mind problems, meta-communicative problems, emotion
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50 regulation, and rational behavior in social situations, they can, however, only be implemented
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52 later in life. Embodied therapies – such as DMT – have the advantage that they can be applied
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54 as early as features of autism are detected (e. g., Caldwell, 2009; Schuhmacher & Calvet,
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56 2008); they thus can correct and improve the development early in the course of the
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impairment. In fact, embodied diagnostics can help to detect those features earlier. We
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3 showed in this study that embodied therapy approaches do not cease their effects in the
4
5 treatment of adolescents or adults with ASD. Embodied therapies can provide an important
6
7 building block to a successful integrative treatment of ASD. Since they address emotion and
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10 cognition from a primary developmental basis, the integration of embodied therapies yields
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12 the prospect of a more effective treatment of ASD.
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12 Rating Instrument for Autistic and other Atypical Children. In M. B. Leventhal (Ed.),
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3 Table 1
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5 Means and standard deviations of outcome measures, and results of the univariate ANOVAs
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8 Gro Mean Mean SD SD F-
9 Variables p-value Cohen’s d
10 up pre post pre post value
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12 Body-awareness
13 CG 3.84 3.67 0,78 0,77 2.945 .049* 0.62
(FFT)
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15 EG 4.08 4.35 0,66 0,61
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17 Self-other
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awareness CG 3.76 3.66 0,93 0,84 3.933 .029* 0.72
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20 (SOA)
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22 EG 3.96 4.44 0,86 0,97
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Psychological
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25 well-being CG 3.76 3.77 0,84 0,84 3.123 .044* 0.68

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27 (HIS)
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EG 4.07 4.45 0,52 0,76
er
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30 Empathy (EES) CG 2.96 2.86 0,61 0,60 1.263 .136 0.42
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32 EG 3.12 3.23 0,2 0,52
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Social Skills
34 CG 3.98 3.77 0,44 0,38 3.490 .036* 0.67
35 (FFT)
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37 EG 4.32 4.39 0,68 0,64

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40 Note. EG = treatment group; CG = control group.

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42 * p < .05
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3 Table 2
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5 Intercorrelation matrix of outcome measures
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Variables 1 2 3 4 5
10 1. M (∆) Body-awareness (FFT) (.64)
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12 2. M (∆) Self-other awareness (SOA) .60** (.79)
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14 3. M (∆) Psychological well-being (HIS) .28 .26 (.85)
15 4 M (∆) Empathy (EES) .38 *
.33 .42* (.83)
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17 5. M (∆) Social Skills (FTT) .34 .26 .04 -.17 (.83)
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20 Note. Internal consistencies (Cronbach’s α) are in the diagonal in parentheses.
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22 M (∆): mean difference score derived from post-test minus pre-test.
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24 * p < .05;
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26 ** p < .01.
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3 Figure 1: Pre-/Post Change (∆) in experimental vs. control group
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7 Pre/Post Changes on Outcome Measures
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9 0,60 *
10 *
0,50
11
0,40 *
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13 0,30
14 0,20 *
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16 0,10
17 0,00
18 -0,10
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-0,20
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21 -0,30
CG EG CG EG CG EG CG EG CG EG
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23 Body-awareness Self-other Psychological Empathy (EES) Social Skills
24 (FFT) awareness (SOA) well-being (HIS) (FFT)
_______________________________________________________________________________
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25 Reihe1 -0,17 0,27 -0,10 0,48 0,08 0,41 -0,10 0,10 -0,21 0,07
26 Note. a∆ was computed by subtracting pre-test from post-test scores; positive values signify
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28 an increase, negative values a decrease in the according dependent measure.
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31 CG = control group, EG = treatment group.
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33 *p < .05 for ∆ of FFT, SOA and HSI results, change in empathy (ESS) n .s.
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3 Appendix A
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5 Mirroring Taxonomy of Eberhard-Kaechele (2012)
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22 Note. We compared mirroring modality 3a and 3d in each session to observe the degree to
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24 which participants with ASD used mirroring and to rate their progress (Eberhard-Kaechele,
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27 2012). Observations were done by therapist and assistants for their according mirroring
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29 partners in the free dyadic mirroring part of the session.

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1
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3 Appendix B
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5 Poem of female participant reflecting her experience
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8 We dance
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Everything is dance,
12 so one says.
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15 Even atoms
16 swing and dance.
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18 Electrons circle around protons and neutrons.
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19 Everything swings, all is in harmony.
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21 Only this way
22 the world is kept in an equilibrium
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24 It is an ancient law.
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25 And we also
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circle around each other in our dance.
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29 We dance,
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31 and the music animates us
32 We dance,
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34 and the rhythms permeates us
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We dance,
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38 and find each other.
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40 We dance,
41 and are joyful.
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44 We laugh and dance.
45 We dance and are
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48 … free!
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52 Note. We received the participant’s informed consent to publish the poem in the context of
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54 this study. The therapist had for this purpose translated the poem into English and sent it to
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56 the participant asking her authorization of the translation. Since she did not agree with the
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59 therapist’s translation, she sent back her own translated version (this one).
60

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The Autism Journal

Therapeutic mirroring: Dance movement therapy can

Manuscript ID: AUT-13-0001.R2

Manuscript Type: Original Article

autism spectrum disorder, embodiment, dance movement therapy,

Keywords: mirroring intervention, clinical controlled trial, social competence, empathy,

(ASD). In this pilot study, we tested a dance movement therapy (DMT)

empathy, and well-being. We employed a manualized DMT-intervention

treatment, participants of the intervention group reported improved well-

address more primary developmental aspects of autism than the presently

25 there is a strong focus on cognitive theories of deficits in autism such as theory-of-mind

25 other. Following Kestenberg (1995) partial attunement leads to successful differentiation in

25 together in a single explanatory model of autism: kinesthetic body awareness (including

25 Memory, Metaphor, and Movement. Philadelphia: John Benjamins.

25 cognition and its disruption in autism. Brain Research, 1079(1), 15-24.

25 Adolescents on the Autism Spectrum. Journal of Autism and Developmental

25 well-being CG 3.76 3.77 0,84 0,84 3.123 .044* 0.68

37 EG 4.32 4.39 0,68 0,64

40 Note. EG = treatment group; CG = control group.

29 partners in the free dyadic mirroring part of the session.

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