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Introduction
Health is defined as a complete state of physical, mental and social wellbeing1. In the occupational setting, disease and wellbeing are respectively associated with burnout syndrome and the concept of engagement2. The term burnout is refers to chronic stress in the workplace, characterised by emotional fatigue (EF), depersonalisation (D) and lack of self-fulfilment (SF)3.
Stress is directly responsible for a wide range of diseases, and it has been shown that professionals working in the medical and social sectors are more likely to develop chronic stress due to direct contact with users4. A prevalence of chronic stress comparable to levels found in other international studies has been encountered amongst prison staff in Spain5,6.
In a study by Caravaca et al. (2018)5the values that make up the three dimensions of burnout were: EF (20.1 ± 11.9); D (10.6 ± 5.0); and SF (27.7 ± 23.2). Somewhat similar and significant values for the first two sub-scales were found by authors such as Bringas-Molleda et al. (2015)7in their study with 222 workers: EF (21.8 ± 12.6) and D (8.5 ± 6.7). These values match the ones obtained in the study by Hernández-Martín et al. (2006)8, with 133 professionals: EF (24.6 ± 11.8) and D (12.6 ± 6.8).
In the study by Bringas-Molleda et al. (2015)7the values for emotional fatigue and depersonalisation are 65% and 70.6%, respectively, while low self-fulfilment stands at 51.5%. It was also found that the working atmosphere and service given to users notably improved in emotionally positive contexts6,9. In such circumstances, what then appears is engagement, characterised by vigour (V) or the amount of energy and resilience, (De) or enthusiastic dedication, pride and inspiration regarding the work in hand, and absorption (A) or the capacity to concentrate on the work10.
Güilgüiruca et al. (2015)11showed that 77% of professionals who used coping strategies for cognitive stress have a moderate to high engagement level, and 88% presented moderate to high personal satisfaction.
There are however very few studies on the use of therapeutic interventions that focus on body awareness and mind-body integration. Such therapies use the term “embodiment”, which from a phenomenological perspective12has been developed by the cognitive sciences13and neurology14to define and reflect the two-way relationship between emotion-cognition and motor behaviour13,15. These premises are used as the basis for the so-called creative therapies, which include Dance Movement Therapy (DMT).
DMT uses the body, non-verbal expression and expressive movement as psychotherapeutic tools16. It makes use of the movement profile, increasing awareness of motor patterns and their links to emotional content. It also uses words to give meaning to experience in movement, enabling a person to increase awareness of him/herself, explore new relational modes and incorporate coping strategies and emotional regulation17. There is evidence for the effectiveness of DMT in health promotion and prevention, reducing levels of anxiety, stress and depression, and improving quality of life18-20.
Systematic literature reviews such as the one by Koch et al. (2019)18show a small, significant, uniform and consistent effect for a level of significance of 95% in 21 studies, with a proven reduction of depression and anxiety and increased quality of life and interpersonal and cognitive skills.
Karkou et al. (2019)19extended the review published in Cochrane in 2015 on DMT and depression. They showed the effectiveness of DMT for treating depression in 192 people of up to 65 years of age in pretest-posttest studies with a significant bias in favour of the group that received intervention with DMT at a 95% level of significance.
Other studies, such as the ones carried out in primary healthcare centres in the UK20, showed improvements in health after intervention with DMT to treat adults with unexplained somatic symptoms, with significant reductions in stress, anxiety and depression, and increased general wellbeing and activity levels.
A study on patients with schizophrenia (Lee et al., 2015)21, also showed a significant decrease in expressions of anger (F1 [1. 36] = 2.26; p <0.05) and levels of depression (F1 [1. 36] = 5.92; p <0.01) in favour of the group that participated in an intervention with DMT. A significant reduction was also seen in negative psychotic symptoms in comparison to the control group (F1 [1. 36] = 5.12; p <0.01) after the intervention.
This exploratory study sets out to show how DMT can encourage body awareness and connection, and enables the appearance of positive emotions and increases engagement. In this case “from within”, behind the walls of an institution that limits freedom, “from within” the work of professionals, and finally “from within” their own bodily experiences.
Material and method
Participants
The initial sample was made up of 15 persons, 6 men and 9 women of between 33 and 59 years of age who all worked as prison staff. Recruitment was carried out online using a convenience non-random and non-probabilistic sampling technique. The participants signed an informed consent form that complied with current legislation on confidentiality and data registration. The exclusion criterion used was the existence of some type of mental illness or treatment with a therapist.
Design and procedure
An exploratory mixed-methodology pilot study was prepared. Information was gathered about level of burnout, affective states and bodily awareness from standardised pre-intervention and post-intervention questionnaires. A participative research-action focus group (FG) was used to obtain the workers’ perceptions of their stress levels. The information was used to design a DMT training programme for prison professionals. At the end of the programme, the participants evaluated their experience anonymously on Google Forms.
Evaluation variables and instruments
The following variables were measured alongside a set of socio-demographic data:
Burnout, via the Maslach Burnout Inventory (MBI)-General Survey test in Spanish22, with the sub-scales of EF, D and SF. A positive diagnosis of burnout comes from high scores in the subscales of EF (>2.9) and D (>2.26), and a low score in SF (<2.83).
Engagement, con la Utrecht Work Engagement Scale (UWES)10,23, categorised into three sub-scales: V, De and A. The existence of medium levels of engagement correspond with values above the ones indicated in parentheses: V (3.20); De (3.00) and A (2.75).
Positive affects (PA) and negative affects (NA), via the Positive and Negative Affect Schedule (PANAS) in Spanish24, the highest value being the one that matches the predominant affect.
Body Awareness (BA), according to the Body Awareness Questionnaire (BAQ)25.
-
Body connection, with the Scale of Body Connection (SBC) in Spanish26, which is divided into the sub-scales of body connection (BC) which evaluates the conscious attention to body signals and body disassociation (BD). The values obtained from the scales correspond to the level of a person's BC and BD. Two qualitative tools were also used:
- A focus group (60 minutes online session) to gather information about the sensations they felt at the start or end of the working day, self-perception of stress, coping strategies and the impact of the healthcare situation. Eight professionals chose to participate.
- Daily reflections, in which each participant freely shared their experiences of the workshop and any bodily and emotional changes that they observed.
DMT intervention programme
The programme consisted of four 90 minute-long virtual sessions, briefly described in Table 1, which ended with a verbal summary and a personal reflection.
Table 1. Issues worked through in sessions and description of dynamics.
| Session | Issue | Dynamics | |
|---|---|---|---|
| 1 | Personal and group body connection. Use of gravity | Working with one's own body weight and resistance; with weight and lightness. Associated emotions. | |
| 2 | Stress in the body: natural rhythm and rhythm when stressed. | Observing rhythm in breathing and spontaneous movements; experiencing physical sensations and associated emotions at different rhythms. | |
| 3 | Personal and general space, limits | Recognising the limits of one's own body. Expanding and containing. Exploring space in non-verbal communication. Observing someone else dancing, their space, and allowing oneself to be observed. | |
| 4 | Flow, the connection with pleasure and vitality | Fast and fluid breathing in movement. Associating working sensations/emotions/situations. Experiencing change in movement: flowing/restricting. Playing with flow in relation to oneself and to others. |
Data analysis
The Statistical Package for Social Science, v. 25.0 (SPSS v25.0) for Windows was used to carry out a descriptive analysis of the variables for burnout, engagement, emotions and awareness and body connection, along with their sub-scales for the initial sample (n=15). Non-parametric tests were applied for the sub-sample (n=4) to obtain a pretest-posttest comparison. After transcribing the FG recording and the daily reflections, a deductive analysis of the information from the FG was carried out, according to the phases of segmentation, categorisation and codification up to saturation and interpretation of the results. The data extracted from the daily reflections was then inductively analysed in line with the previously created grid and applying triangulation between investigators.
Results
The mean age of the initial sample (n=15) of participants was 41.4 years. Most lived with a partner (86.7%) and had children (53.3%). 60% were university graduates, and 33.3%, had post-graduate, master's or doctoral studies. 60% of the sample had worked for more than ten years in the prison, and 86.7% worked in therapeutic roles.
66.7% of the participants played some kind of sport or BA activity in their free time. 53.3% of the sample answered that they had not suffered from any ill health in the previous month, although they declared that they had back pain, migraines and anxiety. The reliability of the tests was analysed with Cronbach's alpha coefficient (Table 2), and all of them presented acceptable psychometric properties (between 0.71 and 0.87). All the variables, with the exception of the BD sub-scale, conformed to normality for a significance level of 0.05.
Table 2. Descriptive statistics and results of Wilcoxon test.
| Mean ± SD* | Mean (RIQ) Pre† | Mean (RIQ) Post† | z§ | P§ | r‡ | ||
|---|---|---|---|---|---|---|---|
| Burnout | EF | 2.40 ± 1.08 | 3.00 (1.70) | 2.30 (1.65) | -1.826 | 0.068 | 0.65 |
| D | 2.85 ± 1.47 | 2.38 (2.31) | 1.63 (2.88) | -1.069 | 0.285 | 0.38 | |
| SF | 4.49 ± 0.67 | 5.08 (1.42) | 5.00 (0.71) | -0.535 | 0.593 | 0.19 | |
| Engagement | V | 3.78 ± 0.93 | 4.00 (1.88) | 4.25 (1.63) | -1.633 | 0.102 | 0.58 |
| De | 3.68 ± 1.03 | 4.40 (2.30) | 4.70 (0.95) | -1.289 | 0.197 | 0.46 | |
| A | 3.16 ± 0.86 | 3.67 (2.04) | 3.67 (1.96) | -0.921 | 0.357 | 0.32 | |
| PANAS | PA | 33.40 ± 7.72 | 32.50 (9.25) | 34.50 (8.00) | -1.604 | 0.109 | 0.57 |
| NA | 18.33 ± 5.88 | 20.00 (2.00) | 17.00 (7.25) | -1.826 | 0.068 | 0.65 | |
| BAQ | BA | 78.27 ± 14.14 | 89.50 (20.25) | 98.00 (6.50) | -1.473 | 0.141 | 0.52 |
| SBC | BC | 30.60 ± 6.04 | 33.50 (12.25) | 38.00 (12.00) | -0.184 | 0.854 | 0.07 |
| BD | 9.00 (5.00)|| | 9.00 (13.50) | 12.00 (6.00) | 0.000 | 1.000 | 0.00 |
Note. *Descriptive statistical data for the initial sample (n = 15).
†Descriptive statistical data for the subject sample of the pretest-posttest study (n = 4).
‡Benchmark for the size of the Rosenthal effect: 0.1 = small; 0,3 = medium; ≥0,5 = large.
§Parameters of the Wilcoxon test of the subject sample of the pretest-posttest study (n = 4).
||Mean and interquartile range when normality not met.
A: absorption; NA: negative affects; PA: positive affects; BAQ: Body Awareness Questionnaire; BC: body connection; EF: emotional fatigue; D: depersonalisation; BD: body disassociation; De: dedication; MD: mean; PANAS: Positive and Negative Affect Schedule; IQR: interquartile range; SF: self-fulfilment; SBC: Scale of Body Connection; SD: standard deviation; V: vigour; BA: Body Awareness.
Table 2 shows the descriptive statistics for the total initial sample (n=15). A high mean value was seen for EF (2.40), with a high value for D (2,85) and medium-low for SF (4.49) in the burnout sub-scales. A diagnosis of burnout could not be confirmed although there were high values for the sub-scales EF and D. For the engagement variable, medium levels were obtained in the three sub-scales of V (3.78), De (3.68) and A (3.16). The data in the scale of affects (PANAS) over a maximum value of 50 showed higher prevalence of PA (33.40) compared to NA (18.33). The variables of BA (BAQ), with an average of 78.27±14.14 and body connection (SBC) in the two sub-scales of BC (30.60±6.04) and BD, with a mean value of 9, presented low values.
Only four of the 15 initial participants answered the questionnaires after the intervention, which meant that the pretest-posttest study was reduced to a sample of n=4.
Table 2 shows the mean and interquartile range. A non-parametric test was used (Wilson test), to analyse possible “pre-post” changes, the results of which are presented inTable 2. Reduction were seen in the sub-scales of EF (changes in the mean from 3.00 to 2.30) and D (from 2.38 to 1.63) for burnout and increases in the scales of V (from 4.00 to 4.25) and D (from 4.40 to 4.70) for engagement.
Increases were also obtained in the sub-scale of PA (from 32.50 to 34.50) along with a reduction in NA (from 20.00 to 17.00). Finally, an increase was observed in the BA values; from 89.50 to 98.00. None of these variations were statistically significant, although the sizes of the Rosenthal effect presented medium and high values for all the previously mentioned variables (Table 2), which might be an outcome of the intervention.
Analysis of the FG showed several categories that were grouped into two meta-categories, called the intrapersonal and interpersonal spheres. The first contained aspects of the persons themselves in relation to stress and included the categories of self-knowledge, BA, emotions and coping strategies. The interpersonal sphere covered stressors, group connection and supports. This categorisation was used for the inductive analysis of the daily reflections, in which new categories that arose were added (self-confidence and personal wellbeing in the intrapersonal sphere, and limits within the interpersonal sphere). Some evidence is presented below, including the codification (FG; session [S] of the daily reflection; participant [P]):
Self-knowledge: the desire to increase self-knowledge to detect burnout appears: “reflecting and thinking here, with everyone else, is the way to find tools or detect the earliest alarm signals” (P4, FG); “...perhaps identify it in time, don’t you think??..., before getting back ache” (P2, FG). The experience provided knowledge about one's own motor patterns and body: “I found out that today I preferred a slow movement to make me relax and so I was able to move more fluidly” (S2, P2); “I like being aware of my space. I can see that my space is very big (...), lots of people can enter” (S3, P1); “The body is wise and sends us signals, you have to know how to interpret them” (S4, P4).
Self-confidence: knowing the body and being aware of its reaction increases self-confidence and enables new modes of expression to be explored: “I’ve noticed that I’m more aware of my body, of what it tells me. I immediately let myself be guided by what it asks me to do, in a comfortable manner” (S4, P2); “I feel that I’ve overcome a new challenge” (S1, P1).
Personal wellbeing: the participants stated that they experienced liberation, bodily relaxation and increased energy: “I haven’t felt sensations like losing stiffness for a long time” (S1, P3); “It's been a liberating experience. I’ve managed to relax the body and lose tension, and find energy to cope with the rest of the day” (S2, P2).
Body awareness: despite the difficulties: “To connect better, I have to close my eyes and stop paying attention to the thoughts that come constantly” (S2, P4). The workshops contributed towards an increase in body awareness: “I’ve been aware of the parts of my body that are most tense and where there is a slight pain. And I’ve been able to focus on them” (S4, P2). Connection with the body can facilitate a change: “I’ve always felt very big and with heavy movements, but today I actually felt light for the first time” (S2, P3); “When I breathed at the start, I really noticed the opening of the stomach, it's as if it didn’t have all the capacity to open the lungs. This sensation didn’t limit me so much at the end” (S2, P5); “I noticed pain on the left hand side of the back, and right now I can’t feel it, it's as if I gave myself a massage with the movement, and the pain has been minimised” (S2, P1).
Emotions: the relationship between movement and emotion is a transformative one: “My movements were slow, I felt a lot of pressure, limitation, sadness, anxiety (…). I feel more in movement than at the start, with more energy and with a bit more freedom and hope; to start with, the feelings were more about loneliness and oppression” (S4, P6); “I visualised pushing out everything that worried me, disturbed me and made me tense” (S1, P2). Positive emotions are generated: “I ended the session feeling happy and in a good mood” (S2, P5).
Internal coping strategies: they discovered the potential to use body work as a tool to cope with occupational stress: “I’ve found that stopping, observing, is positive, it enables you to move more fluidly. I really feel that it can be applied to a working environment”(S4, P2).
Some evidence taken from the interpersonal sphere is shown below:
Stressors: elements appeared that threatened their wellbeing. These could come from the users, the institution or the working hours: “You leave work really anxious because you lived through stuff with inmates, workmates...” (P6, FG); “There are things that weigh you down more, because of administrative issues” (P2, FG); “When I’m very stressed, I feel worn out, very tired, I think it's because of the working hours” (P5, FG). Participants could connect with the body memory during the workshop: “I feel that in our daily lives we are shut off, in pain and tired” (S4, P6); “In the final dance, I connected directly with a working day, where we’re puppets and our movements are involuntary” (S4, P1).
Group connection: here there are elements that relate to working within a team, and the empathy that develops through movement and observing it: “Even though the experience happened on a screen, I was able to connect to students and not feel alone, but rather part of the group” (S2, P2). They mention the potential for movement as a vehicle to transmit emotions: “I loved what my workmates transmitted to me with their movement. And I really felt I could say a lot with the movement and could receive a lot in exchange. It was beautiful” (S3, P2); “At the end, I felt more and more of a need to share and do movements with my colleagues” (S2, P6).
Limits: the online modality of the workshops did not permit physical contact: “I miss the physical contact and being in a setting where this sort of workshop happens” (S2, P4).
Support: humour, group cohesion, trust and coping strategies appeared in the FG: “There's a lot of friendship in the team and there's always the chance to talk about situations that are getting us down, that cause stress” (P6, FG). These strategies also appear in the workshop: “Moving and sharing with workmates (...) and someone else can give you energy or a different way of seeing things, help you and follow their movements when you’re blocked and don’t know where to go” (S4, P6).
At the end of the programme, the participants anonymously declared that they noticed increased wellbeing and that they had learnt strategies to deal with burnout: “Finding a space to become aware of your emotions and body and see how emotional states can be transformed through movement”; “Being more aware of how thinking guides the body. And how movement makes aware of the emotion stored in the body”; “It's helped me to stop and listen to my body, it's something I’m not used to doing and there are times when it's necessary”.
Discussion
The data obtained for burnout in the initial sample of the three sub-scales of EF (medium-high, 2.40), D (high, 2.85) and SF (medium-low 4.49) showed higher levels than the ones in the study by Bresó et al.22, where the results were medium-high EF (2.12), medium-high D (1.50) and medium-low SF (4.4).
In the case of engagement, the values obtained are similar to the ones in other studies (V=3.78±0.93; De=3.68±1.03; and A=3.16±0.86), while the results of the study by Schaufeli et al. (2002)23, showed lower values in the three sub-scales (V=3.82±0.86; De=3.74±1.29; A=3.53±1.00).
The affects scale (PANAS) presents higher values in PA (33.40±7.72) and lower ones in NA (18.33±5.88) in comparison to the studies by López-Gómez et al.24, who obtained results of 32.74±8.31 and 20.08±7.62, respectively. As regards the BA variable (BAQ), lower levels were registered (78.27±14.14) than the ones obtained by Shields et al.25, where the sample of women showed an average value of 106.4, and the one for men showed 97.6. This can also be seen in the BC (SBC) variable of the study by Quezada-Berumen et al.26, where the average obtained in the BC variable was 42.6 along with a mean of 16 in BD in comparison to the values of 30.60 and 9, respectively, in this study.
The low integration and high BD could signify a lack of awareness of a person's bodily and emotional state. Rodríguez-Jiménez et al.27and Payne et al.28)suggest that body work can help in accepting a symptom, and promote emotional self-regulation, self-sufficiency and resilience.
The mean and interquartile range were used for the sub-sample (n=4). The pre data matched that of the total initial sample (n=15) at least in these statistics. The most relevant aspects are the reduced values in the sub-scales EF and D for burnout, an increase in the V and D scales of engagement, an increase in PA and decrease in NA, and an increase in the variables of BA and sub-escale BC. The effect sizes in all these changes are medium and/or large, which, with the necessary proviso that the sample size was a small one, may show the effect of the intervention in reducing stress, which matches the results in other studies18-20.
The qualitative study showed that verbal communication in the FG was the predominant tool. The body work, documented in the diaries, seems to have worked as a way to access unconscious movement patterns, and to the skill of changing and extending them after awareness of them is raised29. The importance of shifting from movement to word, and vice versa, enables cognitive changes to be made17,30. The participants mentioned emotions such as fear, guilt and anger, which are manifested as frustration, fatigue and anxiety.
The dynamics enabled the emotions to be recognised, moved and managed at a physical level. They could also be worked on through creativity in improvisation, positive emotions linked to sensations of freedom, fluidity and vitality31. Fischman32comments that incorporating new proposals in movement encourage emotional modulation and regulation. Experimenting with slowness in movements until stopping, enables work situations to be visualised in which a halt is necessary for a change to take place33.
Although the participants missed the physical contact and being face to face, the online modality was not an obstacle to carrying out work on body awareness. The participants felt part of a group, accepting and returning proposals for movement and experimenting with kinaesthetic empathy32,34.
The main limitation of the study is not having the complete sample to analyse the “pre-post” changes, given that the sample for the study was a very small one. A second limitation was the number of workshops, which in our opinion were too few, and the situation caused by the pandemic, which made attendance and continuity more difficult.
Despite these limitations, the programme proved to be an interesting one. Medium and large effect sizes were seen in most of the variables analysed, and the qualitative analysis shows effects of the work on the participants’ emotional and physical state. It would be very interesting to repeat a programme like this with a larger sample and intervention period, and monitor the variables over a period to time after the intervention.
The implementation of therapeutic and/or training programmes that include body work could be a tool to help in coping with stressful situations, managing and regulating a person's emotional state34, and therefore reducing professional burnout and increasing engagement, which in turn would lead to better care for users.
