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. 2022 Sep 14;44(2):186–209. doi: 10.1007/s10465-022-09369-y

Combining Dance/Movement Therapy with Cognitive Behavioral Therapy in Treatment of Children with Anxiety Disorders: Factors Explaining Therapists' Attitudes

Naomi Weitz 1,✉, Adrian Opre 2
PMCID: PMC9472729  PMID: 36124161

Abstract

Anxiety disorders (ADs) are among the most common psychiatric disorders and they may appear as early on as in childhood. The current study addressed the combination of two treatments approaches for ADs: Dance/movement therapy (DMT) and cognitive behavioral therapy (CBT), focusing on factors that explain the therapists' attitudes towards actually combining the two therapies. The study utilized a quantitative design, with a perceptions survey administered via an online questionnaire. Ninety-nine therapists participated in the study (DMT-only n = 35, CBT-only n = 42, and DMT + CBT, n = 22). Following preliminary analysis (comparison between the groups, correlations and factor analysis), the structural equation model (SEM, confirmatory factor analysis) revealed a good fit between the theoretical model and the empirical data. First, it was found that the reported actual use of the combined approaches (DMT + CBT) in treatment of children with ADs, was significantly explained by therapists who had experience practicing DMT but not CBT perceiving this combination as efficient. Second, the therapists' use of the combined therapy (DMT + CBT) approaches was not related to their sense of efficacy as therapists of children with ADs. The model represents concordance between the components of the therapists' attitudes: Affective—belief that it is efficient, cognitive—perception of it as effective, and behavioral—their actual use.

Keywords: Cognitive behavioral therapy, Dance movement therapy, Combining therapies, Anxiety disorders in children, Therapist’s attitudes

Introduction

During the last century major developments in the field of Anxiety in children (Banneyer et al., 2018; Ramsawh et al., 2010) have enabled effective treatment for Anxiety Disorders (ADs) (APA, 2013). These developments include the use of various traditional, new treatments, and combinations of treatments.

Anxiety Disorders Among Children

Anxiety disorders (ADs) are among the most common psychiatric disorders and they may appear as early on as in childhood (Costello et al., 2004; Higa-McMillan et al., 2016). Although they often may be adaptive and related to the child's development (Gullone, 2000), in some cases they may reach high levels of severity bearing negative impacts on many aspects of the children's functioning and lives.

In general, about 5% of children and youth in the Western World meet the criteria for ADs (Rapee et al., 2009; Robichaud et al., 2019). Despite their high prevalence, ADs in childhood are under-diagnosed and therefore, often are not treated properly (Chavira et al., 2004). The COVID-19 epidemic has affected the health, social, and material well-being of children around the world, increasing their anxiety and stress (OECD, 2020). In Israel, about a fifth of the children and adolescents suffer to some extent from various types of ADs (Regev & Snir, 2016). The following ADs among children aged 6-12 were referred to in the current study: generalized anxiety disorder (GAD), social anxiety, and specific phobias.

The current study focused on two treatments for ADs: Dance/movement therapy (DMT) and cognitive behavioral therapy (CBT). The most effective treatments of ADs cited in the literature are based on CBT (Higa-McMillan et al., 2016). The need to research a combined approach integrating these two approaches has arisen for several reasons: the impact of CBT treatments in some cases is not sustained over time and about 40% of youth remain anxious (Walczak et al., 2019), CBT might not lead to improvement of the patients' conditions thus CBT alone is not always sufficient (James et al., 2013).

The literature review revealed reasons that justify the need to investigate therapists' attitudes regarding the combined effect of DMT with CBT. First, findings demonstrate that there are many physical symptoms in ADs (Beidel et al., 1991; Dorn et al., 2003; Ramsawh et al., 2010). Thus, treatments that rely on the body-mind connection can be an important part of the healing process. CBT does refer to the physical aspect of the body, but only that related to a narrow aspect of body-mind connection. The reference includes learning to identify physiological symptoms as primary signs, and integration of relaxation strategies (Warner et al., 2009). Therefore, DMT may complement CBT, strengthening the body-mind connection by imbedding movement into therapy.

Second, in treatment among children, there may be a need to use nonverbal expression as a method of bypassing words while expanding possibilities of expression, according to the children's varying needs, such as: age, interest, and their verbal and nonverbal expression and communication. CBT is direct, goal oriented, and verbal. It focuses directly on the anxiety problem. However, children with ADs can have difficulties in verbally expressing their feelings and may avoid recognizing and talking about their problems. Referring directly to their ADs might elicit dissociative responses, causing the child to experience high levels of tension, fearful reactions, and avoidance that might be manifested in therapy. Thus, these children need safe ways of accessing their inner world that may encourage and motivate them to deal directly with their ADs. The expression of worries and fears at their own pace, through their own authentic language (including movement, arts, play), is enabled and strengthened by using DMT as an additional form of Creative Arts Therapy.

Third, due to their tendency for avoidance, children with ADs might lose interest in significant activities and their ability to play might diminish. Hence, there is a fundamental need to gradually regain their motivation for taking part in their natural activities-using movement, creativity and playfulness, alongside openness for acquiring practical coping tools. DMT has the potential to address this need.

Fourth, so far, therapists' attitudes towards the combined effect of CBT with DMT for treatment of children with ADs has not been investigated, although in the last decade this combination is being used more frequently and becoming more accepted.

The objective of this study was examining the factors affecting therapists’ attitudes to using combined treatments, to open a path towards introducing a combined model for treating children with ADs. Furthermore, the researchers hoped that the results of this study would promote further research towards establishing an integrated model of DMT with CBT.

Dance/Movement Therapy (DMT)

Dance/movement therapy (DMT) is a psychotherapeutic use of dance and movement, based on the connection between body and mind, and the healing power of dance (Chaiklin, 2016). Dance/movement therapists have tried to find and establish a theoretical basis for their work, while employing different therapeutic methods. Bernstein (1979) identified eight different theoretical approaches embedded in DMT, including the Freudian, Jungian, Gestalt, and Transpersonal approaches. Koch (2017) characterized mechanisms that apply to DMT and are suitable for children with ADs: (a) hedonism (playfulness and joy); (b) aesthetic experience (experiencing unity) and its authentic expression; (c) non-verbal expression; (d) enactive transitional space; and (e) creation. In addition, in movement and dance, specific body feedback mechanisms and techniques of DMT, such as mirroring and imaginative techniques are available.

Although dance is one of the most ancient forms of healing, DMT was established as a profession in Western countries in the 1940s, and began to achieve worldwide recognition from the 1990s (Chaiklin, 2016). Research on DMT has been mostly qualitative, but in recent years, quantitative research has been conducted as well and is continuing to develop (Koch et al., 2019). According to a recent meta-analysis (Koch et al., 2014, 2019), evidence-based research found that DMT consistently and with a high homogeneity improved affect-related psychological conditions by decreasing anxiety and depression levels.

More research is needed to deepen and focus the knowledge on the therapeutic mechanisms of DMT and dance interventions, especially those that combine other types of therapies such as CBT (De Witte et al., 2021).

Cognitive Behavioral Therapy (CBT)

The concept of CBT includes many types of evidence-based therapies, which all have a common base. The integration of cognitive concepts with behavioral therapy is based on the theories of Ellis (1962) and Beck (1976). According to Kendall (2012), CBT among children with ADs is focused on behaviors and relationships in the external reality, including cognitive and behavioral interventions, especially: psycho-education, thoughts' and emotions' identification, cognitive structuring, relaxation, gradual exposure, rewards, and additional home assignments. CBT has a number of observation-based protocols for treatment of ADs (e.g., Chorpita, 2007; Kendall & Hedtke, 2006; Rapee et al., 2009), which are fairly similar to each other but with different emphases.

Usually, in CBT, training and skills sessions relate to: awareness of physical and emotional reactions and specific physical symptoms of anxiety; identifying and evaluating anxious “self-talk”; skills of problem solving, such as the ability to introduce changes in the anxious self-talk together with developing self-esteem, sense of self-efficacy, and coping methods. Play is combined in CBT as an additional intervention that helps the child learn and understand the basic concepts of the treatment, ways to implement them, and use them in their efforts to reduce their anxiety (Kendall & Hedtke, 2006).

CBT is one of the most widely used forms of child psychotherapy for ADs (Higa-McMillan et al., 2016). Evidence-based studies on treatment of ADs among children found that treatments that centered on acquisition of skills and on the principles of CBT are highly effective (Banneyer et al., 2018; Farrell et al., 2019; Kendall, 2012; Rapee et al., 2009). However, CBT alone may not always be effective enough (James et al., 2013). Therefore, over recent decades several attempts have been made to combine CBT, as a structured establish treatment approach, with other therapies.

The Combined Treatment

The use of combined therapies in treatment of anxiety disorders (ADs) is becoming more common. Four primary types of integrative approaches are mentioned in the literature: technical eclecticism (the use of techniques from various theoretical approaches), common factors (characteristics that are shared across various theoretical approaches), assimilative integration (working primarily from one theoretical approach while incorporating techniques from other psychotherapeutic approaches), and theoretical integration (combining theoretical concepts into a unified theory) (Stricker, 2010). In the qualitative part of the current broad study, it was found that therapists who combined DMT with CBT used three of the four combination methods (technical eclecticism, common factors and assimilative integration), but not theoretical integration (e.g., Wachtel, 1977). They did actually combine DMT with CBT, but not on the basis of a systematic body of knowledge or following an organized model of treatment that guided them in combining these approaches (Weitz & Opre, 2019a). Rather, they tended to lean on other well-established integrative approaches (e.g., Linehan, 2018; Weiss, 2009; Young et al., 2003).

The current study focused on two treatments for ADs: Dance/movement therapy (DMT), and cognitive behavioral therapy (CBT). There have been different attempts to integrate CBT with components of DMT from the embodied-CBT model (ECBT); a model that integrates CBT, neuroscience, and embodied cognition, using embodiment techniques such as movement synchrony and imitation (Pietrzak et al., 2017). Another framework for a new pluralistic 'meta-approach' of therapy for depression combines active elements from talking therapies, such as CBT principles, with creative approaches, particularly DMT (Parsons et al., 2019). Other studies relate to the integration of CBT with Expressive Arts (Czamanski-Cohen, 2014; Malchiodi & Rozum, 2012; Rasmussen, 2001; Sarid & Huss, 2010). There are also models from other Creative arts therapies, for instance CBAT (cognitive‐behavioral art therapy, Rosal, 2001), CBT-ARTS (Sharon, 2018), CBMT (cognitive-behavioral music therapy, Hilliard, 2001), CBPGT (cognitive-behavior psychodrama group therapy, Treadwell at al., 2016).

Combining DMT with CBT leans on the added values of DMT to CBT and of CBT to DMT. However, as Fig. 1 presents, top-down approaches (such as CBT) do not always succeed in relieving the somatic and biological symptoms of ADs, while bottom-up interventions bear the potential to help regulate the physical symptoms of ADs, and as a result, improve treatment outcomes by synchronizing the endocrine system to enhance balanced functioning (Goggin, 2018; Homann, 2010; Pietrzak et al., 2017).

Fig. 1.

Fig. 1

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Combining of DMT (bottom-up) with CBT (top-down) leading to improve treatment outcomes

According to the findings of the broad mixed-methods study (Weitz & Opre, 2019b), the added values of DMT to CBT are: use of nonverbal expression of feelings and sensations, emphasizing the connection with the body, constant assimilation of patient and therapist movement and dance in the treatment process by creating a flexible and meaningful therapeutic experience. The added values of CBT to DMT are use of CBT as an "anchor", a "road map" for treatment (Weitz & Opre, 2019a), because it is structured and based on protocols. CBT helps by emphasizing cognitive processes defining targeted and practical goals.

An essential step for evolution of DMT approaches and advancing the integration according to psychotherapy professional demands, is the ability to rely on assimilation of CBT principles that validate the DMT therapist’s combined-approaches' work.

Effect of the Combined Treatment

Regarding the combined effect of DMT with CBT, in the current study, the conclusive term effect was refined into three distinctive components of the therapy: the therapists' sense of efficacy, the efficiency of the treatment process, and the effectiveness of treatment—positive results for the patient indicated success of the therapy.

Self-efficacy relates to the person’s level of confidence that they are able to successfully organize, perform, and execute tasks (Bandura, 1993, 1997). In terms of self-efficacy, counselors, teachers, and nurses have been studied most commonly, and Creative arts therapists have only rarely been studied. Findings indicate that art therapists had low-levels of burnout and high-levels of self-efficacy. A higher sense of self-efficacy enabled therapists to set higher goals and enhanced their ability to adopt changes and innovations (Gam et al., 2016). Qualified and experienced therapists, with strong self-efficacy usually managed to focus on their patients and the therapeutic process (Levenson & Davidovitz, 2000; McGuire et al., 2019). In the current study, the therapists' experience of working with each approach was measured by the number of years they have practiced each approach.

Treatment efficiency and effectiveness related to determining whether an intervention produced the expected result. Studies have focused on trying to determine the treatment factors that bring about changes in emotions and symptoms, for example, according to Vocisano et al. (2004), the primary emphasis had been placed on researching the efficiency and effectiveness of different therapeutic approaches, despite studies showing that the therapist’s characteristics impact upon the treatment’s outcome beyond a specific treatment method. Therefore, the aim of the current study was to explore factors explaining the therapists' attitudes towards combining DMT with CBT in treatment of children with AD's.

The Proposed Model

Based on the literature review and the findings of the interviews that were conducted in the first study, the following model is suggested (Fig. 2).

Fig. 2.

Fig. 2

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The proposed model for explaining the variance of actual combining DMT with CBT

Research Objective

The current study is the third part of a doctoral thesis (Weitz) based on a mixed methods research paradigm which combined qualitative and quantitative research methods (Creswell & Creswell, 2018). Using semi-structured interviews, the first study examined the therapists’ attitudes towards the combined effect of DMT with CBT on the treatment of children with ADs. The second study described the procedure of the development and validation of a new questionnaire which was based on the first study's findings: “Therapists’ attitudes towards treatment of anxiety disorder among children with ADs”.

The aim of the current third study was to propose a model that explained the variance in therapists' reported use of the combined dance/movement therapy (DMT) with cognitive-behavioral therapy (CBT) treatment of children with ADs.

Design

The current study utilized a quantitative design (Creswell & Creswell, 2018), i.e., an attitudes and perceptions survey via an online questionnaire (Eagly & Chaiken, 1993; Harmon-Jones et al., 2018). The independent variables were the groups of participants for DMT-only, CBT-only, and DMT + CBT therapists. The dependent variables were: therapists' efficacy in treatment of ADs among children (attitude's affective component), the perceived added value of CBT to DMT, the perceived added value of DMT to CBT, and the extent to which the combination of DMT with CBT was perceived to be efficient (attitude's cognitive component), reported use of DMT with CBT combination in treatment of children with ADs (attitude's behavioral component).

Methodology

Participants and Sampling

The quantitative data was gathered through an online questionnaire, which was distributed among 120 Israeli therapists who treat children with ADs and are all registered psychotherapists or registered dance/movement therapists, who qualified in professional institutionss. They were chosen using a purposive sampling procedure (a non-probable sampling method), based on the researcher's knowledge of their treatment approach, qualifications, expertise, and experience, and in line with the purpose of the study. Ninety-nine therapists completed the entire questionnaire (83% response rate) and were classified into three groups according to their types of treatment: DMT-only (n = 35), CBT-only (n = 42) and DMT + CBT (n = 22).

Instrument

Following the literature review and the findings of a systematic content analysis of the interviews conducted in the first study (Weitz & Opre, 2019a), the new questionnaire—"Therapists' Attitudes towards Treatment of Anxiety Disorders among Children (ATAD-Q)"—was constructed, developed, and validated. The aim of the new instrument was to measure the therapists' attitudes towards the combined effect of DMT + CBT treatment among children with ADs. The questionnaire included five categories: Therapists' efficacy in treatment of ADs among children (6 items, α = 0.91) —which represented the affective component of their attitudes; the perceived added value of CBT to DMT (6 items, α = 0.88), the perceived added value of DMT to CBT (6 items, α = 0.92), and the extent to which the combination of DMT with CBT was perceived as efficient (8 items, α = 0.91)—which represented the cognitive component of their attitudes; reported use of DMT with CBT combination in treatment of children with ADs (9 items, α = 0.89)—which represented the behavioral component of their attitudes. For each category, item analyses revealed that the corrected item-total correlations are above 0.40 (i.e., all items measure the same content realm). The level of agreement with each statement was ranked on a Likert-type scale, from 1 (Do not agree at all/never) to 5 (Strongly agree/always). Statements regarding the added values of each treatment to the other offered an option to check "I don’t know".

Results

Data Analyses

The data analyses included reliability coefficients (Cronbach α), descriptive statistics (frequencies and percentages, means and standard deviation), and Pearson’s r correlation coefficients. Exploratory factor analysis was conducted to reveal the structure of the questionnaire (allocation of each of the statements to its pre-defined category according to the findings of the interviews conducted in the 1st study, see Weitz & Opre, 2019a). Finally, structural equation modeling (SEM) path analysis was run (on AMOS 16) to test the fit of the theoretical model (five categories and years of experience in DMT/CBT treatment among children with ADs), i.e., construct validation (Byrne, 2001; Harrington, 2009; Hox & Bechger, 1998).

Exploratory Factor Analysis

The first step for construction of the model was performing an exploratory factor analysis using varimax rotation (which aimed to maximize the sum of the variance of the squared loadings), to confirm that the allocation of the 40 statements to each category in accordance with the model produced from the findings of the qualitative interviews (1st study). The results are presented in Table 1.

Table 1.

Factor analysis results—explaining the variance of therapists' attitudes towards combining DMT with CBT in treatment of children with anxiety disorders

Category B. The added value of CBT to DMT E. The combination of DMT and CBT A. Therapists efficacy, in treating children with ADs C. The added value of DMT to CBT D. Is the combination of DMT with CBT efficient (The quality of treatment)
Factor 1 2 3 4 5
13. CBT defines applicable and measurable targets for the therapeutic process 0.829 − 0.071 0.197 0.195 0.212
9. CBT emphasizes the cognitive and behavioral components of therapy 0.820 0.047 0.063 0.091 0.231
14. CBT focuses the treatment 0.803 − 0.022 0.149 0.165 0.106
17. CBT combines psycho-educational explanations to enhance patients' understanding of the diagnosis and treatment 0.768 0.033 0.267 0.166 0.118
12. CBT provides a defined structure for the therapeutic process 0.761 − 0.114 0.184 0.167 0.080
11. CBT validates the importance of body sensations and physical expression of the patient's feelings and thoughts 0.754 0.109 0.313 0.123 0.085
16. CBT provides tools (such as: questionnaires, case formulation, etc.) to establish a diagnosis and choose treatment ways 0.700 0.175 0.110 0.064 0.269
10. CBT strengthens the physiological aspect (working with the body) of treatment processes according to the DMT approach 0.649 0.167 0.080 0.298 0.128
15. The advantage of the CBT approach is that it offers short-term treatment 0.582 − 0.054 0.083 0.051 0.114
35. I combine both approaches according to the stage of the treatment − 0.021 0.906 0.153 0.076 0.200
34. I combine both approaches according the targets of the therapy 0.019 0.902 0.107 0.171 0.150
32. I combine both approaches according to the patient 0.059 0.850 0.174 0.085 0.212
33. I combine both approaches according to the patients age 0.013 0.844 0.127 0.114 0.184
36. I combine both approaches when therapy in a single approach does not advance change in the child 0.002 0.808 − 0.008 0.121 0.006
37. I combine both approaches: begin with one, and then continue with the other − 0.015 0.806 − 0.027 0.061 0.125
40. I partially combine: I treat in one major approach (DMT or CBT) but also intervene using the other approach (CBT or DMT) 0.142 0.700 − 0.163 0.082 − 0.050
38. I combine both approaches, − 0.040 0.541 − 0.307 0.161 − 0.013
3. The tools I use are suitable to treat children with ADs 0.239 0.077 0.851 0.051 − 0.015
1. I know how to treat children with ADs 0.155 0.126 0.847 − 0.041 − 0.021
4. My approach enables efficient treatment of anxiety in children 0.159 0.050 0.844 0.171 0.011
5. Treatment of anxiety in children according to my approach – succeeds (diminishes anxiety and improves functioning) 0.250 − 0.019 0.786 0.063 − 0.002
7. My therapeutic approach does not provide sufficient tools for efficiently treatingchildren with ADs 0.086 − 0.021 0.769 − 0.202 − 0.095
6. I am not sure that I know how to treat children with ADs 0.097 − 0.145 0.731 − 0.137 − 0.074
2. I am capable of treating any child with AD 0.050 0.084 0.719 0.036 − 0.072
8. Treatment of anxiety in children with ADs according to my therapeutic approach does not ensure diminishing of anxiety and improvement of the child's functioning 0.193 − 0.041 0.665 − 0.086 − 0.090
23. DMT enables a meaningful experience of creation which advances coping and change 0.136 0.152 0.013 0.895 0.156
21. DMT enables realization and understanding of abstract concepts and processes of therapy 0.144 0.086 − 0.113 0.851 0.136
20. DMT enables non-verbal expression of feelings and sensations, which create a combined language, emotional and physical 0.308 0.185 − 0.078 0.818 0.156
22. DMT enables flexibility of the therapeutic process in accordance with the patient 0.157 0.200 − 0.061 0.810 0.185
19. Because DMT stems from a primary and natural source for children, it enables to combine movement in all of the therapy's components 0.125 0.075 0.043 0.786 0.049
18. Focusing on the body according to DMT expands the behavioral and physiological aspects of CBT 0.312 0.183 − 0.015 0.770 0.134
27. The combined therapy process is based on research and concurrently experiential 0.147 0.003 0.104 0.297 0.802
29. The combined therapy is efficient because it includes both verbal and nonverbal expression 0.108 0.239 0.012 0.293 0.801
28. The combination raises interest, encourages rethinking and sets challenges for the therapists 0.121 0.173 − 0.029 0.291 0.769
26. In order for the combined treatment to be efficient, the therapist acquire professional experience in both approaches 0.166 0.114 − 0.159 0.120 0.760
25. In order for the combined treatment to be efficient, the therapist must have appropriate professional training in both approaches 0.127 − 0.016 − 0.119 0.168 0.715
24. The combination of both approaches is efficient because it sets defined targets and provides clear and precise tools along with pleasure and fun for the children 0.290 0.288 0.220 0.165 0.647
30. The combined therapy is effective when the child has the ability to connect to their body and movements 0.264 0.061 − 0.113 − 0.179 0.577
31. The combined therapy is effective 0.133 0.086 − 0.201 − 0.117 0.510
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N = 99

Bold values indicate items loaded on the factor presented in the column

The factor analysis revealed five factors that together explained 67% of the variance in the therapists' attitudes. This construct was in exact accordance with the a-priori division to five categories, which were determined according to the findings of the qualitative interviews (first study). These results indicated strong content and constructs validity of the validated ATAD-Q new questionnaire (Weitz & Opre, 2019a). The distributions (total and each group) and correlations of the five categories are presented in the next two sections.

Therapists Attitudes Towards Combining DMT with CBT—Distributions and Correlations of the Five Categories

In order to examine therapists' attitudes towards combining DMT with CBT in treatment of children with anxiety disorders, according to their type of treatment, the differences in their level of agreement with the statements were tested by one-way Analysis of Variance (ANOVA) with multiple comparisons (Scheffe test, significance level set to at least p < . 05). The means, standard deviations in the five categories, the level of agreement with the statement “the approaches are inherently contradictory”, years of experience in treating according to the CBT approach, and the DMT approach, are presented in Table 2.

Table 2.

Therapists' attitudes towards treatment of ADs among children and years of experience with DMT and CBT, by type of treatment (CBT and/or DMT)

Category DMT (n = 35) CBT (n = 42) DMT + CBT (n = 22) Total (N = 99) F P Scheffe
M SD M SD M SD M SD
E. Use of the combination of DMT and CBT 2.66 0.99 1.43 0.91 3.21 0.53 2.35 1.13 30.14 0.000 CBT <  DMT, DMT + CBT
D. The extent to which the combination of DMT with CBT is perceived efficient 4.12 0.63 3.83 0.81 4.07 0.64 4.01 0.70 1.49 0.231
C. The added value of DMT to CB 4.47 0.72 3.37 0.94 4.32 0.83 4.18 0.90 9.97 0.000 CBT, DMT + CBT < DMT
B. The added value of CBT to DMT 4.08 0.71 4.32 0.71 4.50 0.51 4.28 0.68 2.69 0.073
A. Therapists’ efficacy, efficiency of the treatment, and effectiveness among children with ADs 3.41 0.69 4.24 0.61 4.15 0.55 3.93 0.73 18.60 0.000 DMT <  DMT + CBT, CBT
Number of years treating according to t P
 DMT 12.7 6.5 – – 14.2 6.9 13.3 6.6 – 0.85 0.400
 CBT – – 5.8 7.1 4.3 3.3 5.3 6.1 0.947 0.347
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Analysis of variance with multiple comparisons—Scheffe test, t-tests. Categories: A, B, C, D—Range 1–5 (1 = Do not agree at all–5 = Strongly agree). Category: E—Range 1–5 (1 = Never–5 = always)

N = 99

DMT + CBT and DMT-only therapists reported greater use of the combined approaches (DMT with CBT) in treatment of children with ADs, and they also perceived it as more efficient. The added value of each approach was perceived to be higher by its therapists, as expected. Yet, DMT + CBT and CBT-only therapists perceive their efficacy among children with ADs as higher than DMT-only therapists. In addition, the number of years of experience treating according to each approach was found similar between the combining therapists and therapists who treat according to one approach only (DMT or CBT). Additionally, all therapists do not agree with the statement "In my opinion, the approaches are inherently contradictory (M = 1.59, SD = 0.79). Due to the relatively small sample sizes of the three groups and unequal number of participants in each group, the following analyses were conducted on the entire sample (N = 99).

Correlations Among Five Categories of Therapist's Attitudes Towards Combining DMT With CBT

The second step for construction of the model, was examining the correlations among the five categories, years of experience in DMT and/or CBT and agreement with the statement "the approaches are inherently contradictory" (Table 3).

Table 3.

Pearson correlation coefficients matrix among the five categories, years of experience in DMT and/or CBT and agreement with the statement "the approaches are inherently contradictory"

Category 2. Years DMT 3. Efficacy 4. Added value CBT 5. Added value DMT 6. Efficient 7. USE 8. Contra-dictory
1. Number of years treating according to the CBT approach − 0.23* 0.45*** 0.11 − 0.23* − 0.04 − 0.22* 0.00
2. Number of years treating according to the DMT approach − 0.12 − 0.01 0.50*** 0.18 0.64*** − 0.29**
3. A. Therapists efficacy in treatment of children with Anxiety Disorder 0.35*** − 0.21* − 0.07 − 0.08 0.16
4. B. The added value of CBT to DMT 0.22* 0.42*** 0.13 − 0.04
5. C. The added value of DMT to CBT 0.39*** 0.47*** − 0.20*
6. D. To what extent, is the combination of DMT with CBT efficient (The quality of treatment) 0.32*** − 0.17
7. E. Use of the combination of CBT with DMT − 0.01
8. 39. In my opinion, the approaches are inherently contradictory
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N = 99

Significance level *p < .05; **p <. 01; ***p <. 001

Based on the results of these correlations, the SEM path analysis was conducted.

Confirmatory Factor Analysis

The third and final step for construction of the model was based on a confirmatory factor analysis using structural equation modeling (SEM). The results are presented in Tables 4 and 5.

Table 4.

Fit measures for SEM MODEL

Measure Value
χ2 16.26 ns
df 11
χ2/df 1.48
RMSEA 0.07
CFI 0.97
TLI 0.93
NFI 0.92
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RMSEA root mean square error of approximation, CFI the comparative fit index, TLI the Tucker-Lewis coefficient, NNFI non-normed fit index, NFI the Bentler-Bonett normed fit index

N = 99, ns – p value not significant

χ2 (CMIN) the minimum value of the discrepancy (depicting overall fit) between a suggested theoretical model and the covariance matrices based on the samples' data (non-significant value indicates good fit between the theoretical model and measurement data)

Table 5.

Estimates and standardized estimates of regression weights

Estimate (B) S.E C.R Standardized estimate (β) P
Perceptions of the efficiency of the combined treatment
 The approaches are inherently contradictory − 0.081 0.070 − 1.147 − 0.099 0.251
 Added Value—DMT to CBT 0.227 0.068 3.318 0.294 0.000
 Added Value—CBT to DMT 0.340 0.085 4.017 0.356 0.000
Use of the combined approaches (DMT with CBT)
 Efficacy of therapist 0.327 0.363 0.899 0.220 0.368
 Efficiency of DMT & CBT combination 0.288 0.136 2.115 0.175 0.034
 Years as a CBT therapist − 0.026 0.024 − 1.068 − 0.132 0.286
 Years as a DMT therapist 0.078 0.010 7.778 0.592 0.000
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N = 99

According to the fit indices, the suggested model (based on the theoretical literature and the interview results) has good fit to the empirical data drawn from the questionnaires (χ2/df = 1.48, NFI = 0.92, TLI = 0.93, CFI = 0.97, RMSEA = 0.07) (Fig. 3).

Fig. 3.

Fig. 3

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SEM explaining the variance of actual combining DMT with CBT among therapists

The results of the path analysis revealed that 28% of the variance in therapists' perceptions of the efficiency of the combination of DMT with CBT was explained significantly by recognizing the high added value of each treatment to the other.

Although significant, the perception of the approaches as not contradictory was related positively to perceiving the combined treatment as effective.

Forty-three percent of the variance in therapists' reported use of DMT with CBT in treatment of children with ADs was significantly explained by their perception the combined treatment as effective, as well as having more years of experience with DMT but not with CBT. Nonetheless, the therapists' use of the combined approaches was not related to their sense of efficacy in treating children with ADs.

Discussion

The aim of the current research study was to propose a model explaining therapists' use of the combined DMT with CBT treatment in accordance with their attitudes and perceptions of its efficiency. The perception of the combined treatment as efficient not only relied on therapists being aware of the treatment approaches, knowing their principles and studying them—but they also had to recognize their specific added value to each other. These attempts to form novel integrated treatments, based on perceptions of the added value of each approach to the other, have been reported in other studies (Linehan, 2018; Stricker, 2010; Wachtel, 1977; Young et al., 2003).

The reported actual use of the combined approaches, DMT with CBT in treatment of children with ADs, was found to be significantly explained by perceiving this combination as efficient, alongside with experience practicing DMT but not CBT. This can be explained by the expected concordance among all components of one's attitudes (cognitive, affective, and behavior; Harmon-Jones et al., 2018). Therapists' positive attitudes and perceptions of combined treatments as effective (cognition) and belief in its efficiency (affective) may result in actual using them in treatment (behavior) (Eagly & Chaiken, 1993). Nevertheless, CBT principles are better known and regarded as more evidence based than DMT principles. Therefore, therapists should be encouraged to use and explore their own approach before combining it with other therapies while maintaining its uniqueness. Thus, experience in practicing DMT influenced its use as well as using additional combined treatments that attempted to integrate DMT principles, e.g., Mindfulness, body-mind psychotherapies, CBT 3rd generation and more (Hayes et al., 2004; Weiss, 2009).

An important finding revealed that therapists' use of the combined DMT with CBT approaches is not related to their sense of efficacy as therapists of children with ADs. Two explanations may account for this finding: (a) effective performance demands competence and knowledge that are still in early stages of development (Bandura, 1993, 1997); (b) the therapists who participated in the current study were chosen according to relevant and sufficient experience with treatment of children with ADs, and not with regard to the therapeutic approach they use (Gam et al., 2016; Weitz & Opre, 2020). In summary, the model represents concordance between all three components of the therapists' attitudes: The affective component (belief that the combined treatment is efficient), the cognitive component (perception of the combined treatment as effective), and the behavioral component (reported actual use). Therefore, theoretical and methodological contribution may be drawn from this study, as depicted in the following sections.

Theoretical Contributions

The findings of the study may provide novel knowledge to integrative therapy theory as well as practice, which may be applied also to other combined approaches from the Creative Arts Therapies with CBT. The research shed light on the well-established CBT approach, by highlighting aspects and gaining insights which have the potential to facilitate an integration of CBT with DMT. DMT has originated and developed from psychodynamic theories. However, combining DMT with CBT, opens a path to new innovative forms of DMT that lean on evidence-based theory. DMT culture, as a treatment and research approach, appears to be developing in small steps, both in terms of its use as a single treatment method and as part of a combination with other therapies. This development creates practical latent knowledge that could develop into a well-established theory.

Methodological Contribution

The current study may contribute to research on DMT using quantitative methods and validated tools to empirically study the field of DMT. Moreover, based on our literature review, this seems to be the first attempt to study empirically DMT combined with CBT.

The grounded theory model, which was produced according to the interviews' findings, served to create a new validated instrument, the questionnaire—"Therapists' attitudes towards treatment of anxiety disorders among children (ATAD-Q)".

Practical Applications and Recommendations

In some countries, including Israel, no organized legislation for Creative Arts Therapies, including DMT exists. According to the findings, combining CBT into DMT enables validation of DMT principles and therapeutic processes, based on an evidence based theory with proven efficiency—may lead to important legislation.

The study emphasizes the importance of specialized professional training for combining adapted treatments according to the unique needs of children with ADs.

Following this study, a professional community of combining therapists should be founded, in order to collect and share practical experience and empirical, evidence-based knowledge (to date, most of them work separately without an affiliation group).

Limitations and Suggestions for Further Research

There is a need for future studies examining the unique characteristics of children with ADs as well as the existing treatment methods whose efficiency has been proven. Also, the scope of the current study should be broadened to better understand ways in which therapists treating children with various ADs identify and determine the most effective treatment. Additional studies should map the tools available to each approach, research and document their latent theory, and review existing studies that demonstrate the efficacy of the tool in treating children with ADs.

In order to validate the self-report questionnaire's findings and conclusions, additional research should be conducted, by observing and documenting therapeutic sessions (DMT-only, CBT-only and DMT + CBT). In other words, self-reports should be validated by qualitative approaches, e.g., collection, organization and documentation of the cumulative experience and successes (or failures) of combined treatments in children with ADs using action research studies, interviewing professional, parent and the children, and documentation of therapy sessions (observations, video recordings and documental analysis). Additionally, the grounded theory model may be applied on other age groups and additional disorders.

Conclusion

The primary conclusion of the research is that therapists, who work with both approaches and combine them, are aware of the added value of each approach to the other. Therefore, they constantly and continuously create experiences that could promote the integration of these approaches. Additionally, the integration of theory and practice of both approaches yields new evidence-based knowledge and a basis for practice, which allow more precise, optimal and efficient responses for treating children with ADs.

It is essential to close the gap between theory and practice, to create in the near future an integrative treatment based on theory and research, in addition to the cumulative practical experience in DMT with CBT. A new comprehensive theoretical and practical model of combining DMT with CBT as an integrative treatment for children with ADs requiring additional research. The connections and common principles of the two approaches, alongside the differences between them, can form an integrated treatment in which each approach complements the other and may form in the future, with further research, a whole which is larger than the sum of its parts—DM-CBT. This integration is highly important and significant for effective treatment of children in general and children with ADs especially.

Biographies

Naomi Weitz, Ph.D

is a lecturer and mentor at the “David Yellin” Academic College (Jerusalem), in the DMT Masters’ Degree Program, and at the Open University of Israel (“Psagot”)—leading the CBT training program of the School of Cognitive Behavioral Psychotherapy. Additionally, she works as a mentor and supervisor of Expressive and Arts Therapies and CBT, in the Israeli Ministry of Education. Her research interests involve the connection and integration of CBT with DMT in treatment, especially in treatment of anxiety disorders. She is an experienced child and adolescent psychotherapist, integrating CBT with Expressive and Arts Therapies in her work. She creates and develops tools for children’s therapy (including games and books).

Dr. Adrian Opre

is a tenured professor in the Department of Psychology of the Babeş-Bolyai University of Cluj-Napoca. His areas of expertise are: cognitive psychology (fundamental and applied research), personality psychology (theory, research, diagnosis and intervention) and applications of the cognitive sciences in education and organizations. Over the past 7 years, Professor Opre’s preoccupations have focused primarily on the socio-emotional development programs for children and young persons. The most relevant outputs are Self kit and Yourself Programs. Adrian Opre has participated, as director, coordinator or member, in over 15 national and international research and research-development projects and has published, as author or coauthor, over 70 scientific studies in scholarly journals (ISI ranked, indexed in international databases, nationally agreed ones, etc.). He is the author of 4 books, co-author of 6 books, has edited and coordinated 3 volumes (of international contributions), 15 chapters in collective volumes, 8 teacher’s manuals, etc. (see http://psychology.psiedu.ubbcluj.ro/index.php/ro/).

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders (DSM-5®) American Psychiatric; 2013. [Google Scholar]
  2. Bandura A. Perceived self-efficacy in cognitive development and functioning. Educational Psychologist. 1993;28(2):117–148. doi: 10.1207/s15326985ep2802_3. [DOI] [Google Scholar]
  3. Bandura A. Self-efficacy: The exercise of control. Macmillan; 1997. [Google Scholar]
  4. Banneyer KN, Bonin L, Price K, Goodman WK, Storch EA. Cognitive behavioral therapy for childhood anxiety disorders: A review of recent advances. Current Psychiatry Reports. 2018;20(8):65. doi: 10.1007/s11920-018-0924-9. [DOI] [PubMed] [Google Scholar]
  5. Beck AT. Cognitive therapy and the emotional disorders. New American Library; 1976. [Google Scholar]
  6. Beidel DC, Christ MAG, Long PJ. Somatic complaints in anxious children. Journal of Abnormal Child Psychology. 1991;19(6):659–670. doi: 10.1007/bf00918905. [DOI] [PubMed] [Google Scholar]
  7. Bernstein P, editor. Eight theoretical approaches in dance movement therapy. Kendall Hunt; 1979. [Google Scholar]
  8. Byrne BM. Structural equation modeling with AMOS. Lawrence Erlbaum; 2001. [Google Scholar]
  9. Chaiklin S. We dance from the moment our feet touch the earth. In: Chaiklin S, Wengrower H, editors. The art and science of dance/movement therapy: Life is dance. Routledge; 2016. pp. 35–44. [Google Scholar]
  10. Chavira DA, Stein MB, Bailey K, Stein MT. Child anxiety in primary care: Prevalent but untreated. Depression and Anxiety. 2004;20(4):155–164. doi: 10.1002/da.20039. [DOI] [PubMed] [Google Scholar]
  11. Chorpita BF. Modular cognitive-behavioral therapy for childhood anxiety disorders. Guilford; 2007. [Google Scholar]
  12. Costello EJ, Egger HL, Angold A. Developmental epidemiology of anxiety disorders. In: Ollendick TH, March JS, editors. Phobic and anxiety disorders in children and adolescents. Oxford University; 2004. pp. 61–91. [Google Scholar]
  13. Creswell JW, Creswell JD. Research design: Qualitative, quantitative, and mixed methods approaches. 5. Sage; 2018. [Google Scholar]
  14. Czamanski-Cohen J, Sarid O, Huss E, Ifargan A, Niego L, Cwikel J. CB-ARTS-The use of a hybrid: Cognitive behavioral and art-based protocol for treating pain and symptoms accompanying coping with chronic illness. The Arts in Psychotherapy. 2014;41(4):320–328. doi: 10.1016/j.aip.2014.05.002. [DOI] [Google Scholar]
  15. De Witte M, Orkibi H, Zarate R, Karkou V, Sajnani N, Malhotra B, Hung Ho RT, Kaimal G, Baker FA, Koch SC. From therapeutic factors to mechanisms of change in the creative arts therapies: A scoping review. Frontiers in Psychology. 2021;12:1–27. doi: 10.3389/fpsyg.2021.678397. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Dorn LD, Campo JC, Thato S, Dahl RE, Lewin D, Chandra R, Di Lorenzo C. Psychological comorbidity and stress reactivity in children and adolescents with recurrent abdominal pain and anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 2003;42(1):66–75. doi: 10.1097/00004583-200301000-00012. [DOI] [PubMed] [Google Scholar]
  17. Eagly AH, Chaiken S. The psychology of attitudes. Harcourt Brace Jovanovich College; 1993. [Google Scholar]
  18. Ellis A. Reason and emotion in psychotherapy. Lyle Stuart; 1962. [Google Scholar]
  19. Farrell LJ, Ollendick TH, Muris P, editors. Innovations in CBT for childhood anxiety, OCD, and PTSD: Improving access and outcomes. Cambridge University; 2019. [Google Scholar]
  20. Gam J, Kim G, Jeon Y. Influences of art therapists’ self-efficacy and stress coping strategies on burnout. The Arts in Psychotherapy. 2016;47:1–8. doi: 10.1016/j.aip.2015.09.005. [DOI] [Google Scholar]
  21. Goggin, C. (2018). The efficacy of Dance/Movement Therapy for trauma affected youth: A literature review. Expressive Therapies Capstone Theses, 93. Retrieved September 1, 2021, from:https://digitalcommons.lesley.edu/expressive_theses/93
  22. Gullone E. The development of normal fear: A century of research. Clinical Psychology Review. 2000;20(4):429–451. doi: 10.1016/s0272-7358(99)00034-3. [DOI] [PubMed] [Google Scholar]
  23. Harmon-Jones E, Armstrong J, Olson JM. The influence of behavior on attitudes. In: Albarracin D, Johnson BT, editors. The handbook of attitudes, volume 1: Basic principle. Routledge; 2018. [Google Scholar]
  24. Harrington D. Confirmatory factor analysis. Oxford University; 2009. [Google Scholar]
  25. Hayes SC, Follette VM, Linehan MM, editors. Mindfulness and acceptance: Expanding the cognitive-behavioral tradition. Guilford; 2004. [Google Scholar]
  26. Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF. Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child & Adolescent Psychology. 2016;45(2):91–113. doi: 10.1080/15374416.2015.1046177. [DOI] [PubMed] [Google Scholar]
  27. Hilliard RE. The use of cognitive-behavioral music therapy in the treatment of women with eating disorders. Music Therapy Perspectives. 2001;19(2):109–113. doi: 10.1093/mtp/19.2.109. [DOI] [Google Scholar]
  28. Homann KB. Embodied concepts of neurobiology in dance/movement therapy practice. American Journal of Dance Therapy. 2010;32(2):80–99. doi: 10.1007/s10465-010-9099-6. [DOI] [Google Scholar]
  29. Hox JJ, Bechger TM. An introduction to SEM. Family Science Review. 1998;11:345–373. [Google Scholar]
  30. James, A. C., James, G., Cowdrey, F. A., Soler, A., & Choke, A. (2013). Cognitive behavioral therapy for anxiety disorders in children and adolescents. Cochrane database of systematic reviews, (6). Retrieved September 1, 2021, from: https://www.ncbi.nlm.nih.gov/pubmed/23733328 [DOI] [PubMed]
  31. Kendall PC. Anxiety disorders in youth. In: Kendall PC, editor. Child and adolescent therapy: Cognitive-behavioral procedures. 4. Guilford; 2012. pp. 143–189. [Google Scholar]
  32. Kendall PC, Hedtke K. Cognitive-behavioral therapy for anxious children: Therapist manual. 3. Workbook; 2006. [Google Scholar]
  33. Koch SC. Arts and health: Active factors and a theory framework of embodied aesthetics. Arts Psychotherapy. 2017;54:85–91. doi: 10.1016/j.aip.2017.02.002. [DOI] [Google Scholar]
  34. Koch S, Kunz T, Lykou S, Cruz R. Effects of dance movement therapy and dance on health-related psychological outcomes: A meta-analysis. The Arts in Psychotherapy. 2014;41(1):46–64. doi: 10.1016/j.aip.2013.10.004. [DOI] [Google Scholar]
  35. Koch SC, Riege RFF, Tisborn K, Biondo J. Effects of dance movement therapy and dance on health-related psychological outcomes. A Meta-Analysis Update. Frontiers in Psychology. 2019;10:1806. doi: 10.3389/fpsyg.2019.01806. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Levenson H, Davidovitz D. Brief therapy prevalence and training: A national survey of psychologists. Psychotherapy: Theory Research Practice Training. 2000;37(4):335–340. doi: 10.1037/0033-3204.37.4.335. [DOI] [Google Scholar]
  37. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. Guilford; 2018. [Google Scholar]
  38. Malchiodi CA, Rozum AL. Cognitive behavioral and mind-body approaches. In: Malchiodi CA, editor. Handbook of art therapy. Guilford; 2012. pp. 89–102. [Google Scholar]
  39. McGuire JF, Caporino NE, Palitz SA, Kendall PC, Albano AM, Ginsburg GS, Birmaher B, Walkup JT, Piacentini J. Integrating evidence-based assessment into clinical practice for pediatric anxiety disorders. Depression and Anxiety. 2019;36(8):744–752. doi: 10.1002/da.22900. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. OECD (2020), OECD Policy Responses to Coronavirus (COVID-19): combatting COVID-19's effect on children. Retrieved September 1, 2021, from https://www.oecd.org/coronavirus/policy-responses/combatting-covid-19-s-effect-on-children-2e1f3b2f/
  41. Parsons A, Omylinska-Thurston J, Karkou V, Harlow J, Haslam S, Hobson J, Lewis J, Haslam S, Griffin J. Arts for the blues—a new creative psychological therapy for depression. British Journal of Guidance & Counselling. 2019;139:137–146. doi: 10.1177/1757913919826599. [DOI] [PubMed] [Google Scholar]
  42. Pietrzak T, Lohr C, Jahn B, Hauke G. Embodying cognition in cognitive-behavioral therapy. Preprints. 2017;2017:2017090065. doi: 10.20944/preprints201709.0065.v1. [DOI] [Google Scholar]
  43. Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: Prevalence, phenomenology, and a research agenda. Archives of Pediatrics & Adolescent Medicine. 2010;164(10):965–972. doi: 10.1001/archpediatrics.2010.170. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Rapee RM, Schniering CA, Hudson JL. Anxiety disorders during childhood and adolescence: Origins and treatment. Annual Review of Clinical Psychology. 2009;5:311–341. doi: 10.1146/annurev.clinpsy.032408.153628. [DOI] [PubMed] [Google Scholar]
  45. Rasmussen LA. Integrating Cognitive-Behavioral and expressive therapy interventions: Applying the trauma outcome process in treating children with sexually abusive behavior problems. Journal of Child Sexual Abuse. 2001;10(4):1–29. doi: 10.1300/J070v10n04_02. [DOI] [PubMed] [Google Scholar]
  46. Regev D, Snir S. Arts therapies in the Israeli education system: An update. Arts Therapies: Research and Creativity in the Therapeutic Process. 2016;6(1):575–591. [Google Scholar]
  47. Robichaud M, Koerner N, Dugas MJ. Cognitive behavioral treatment for generalized anxiety disorder: From science to practice. Routledge; 2019. [Google Scholar]
  48. Rosal, M. (2001). Cognitive-behavioral art therapy. Approaches to art therapy theory and technique.‏ Routledge
  49. Sarid O, Huss E. Trauma and acute stress disorder: A comparison between cognitive-behavioral intervention and art therapy. Arts in Psychotherapy. 2010;37(1):8–12. doi: 10.1016/j.aip.2009.11.004. [DOI] [Google Scholar]
  50. Sharon Y. Tipul cognitivi hitnahaguti b’emtzaut omanuyot [Cognitive behavioral therapy using the arts] In: Snir S, Regev D, editors. K’shehatipul b’emtzaut omanuyot pogesh et ma’arexet haxinux b’israel [When treatment with the arts meets the Israeli educational system] University of Haifa; 2018. [Google Scholar]
  51. Stricker G. Psychotherapy integration. Psychotherapy Bulletin. 2010;410:25. [Google Scholar]
  52. Treadwell TW, Dartnell D, Travaglini LE, Staats M, Devinney K. Group therapy workbook: Integrating Cognitive-Behavioral therapy with psychodramatic theory and practice. Outskirts; 2016. [Google Scholar]
  53. Vocisano C, Klein D, Arnow B, Rivera C, Blalock JA, Rothbaum B, Vivian D, et al. Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients. Psychotherapy Theory, Research, Practice, Training. 2004;41(3):255–265. doi: 10.1037/0033-3204.41.3.255. [DOI] [Google Scholar]
  54. Wachtel PL. Psychoanalysis and behavior therapy: Toward an integration. Basic; 1977. [Google Scholar]
  55. Walczak M, Breinholst S, Ollendick T, Esbjørn BH. Cognitive behavior therapy and metacognitive therapy: Moderators of treatment outcomes for children with generalized anxiety disorder. Child Psychiatry & Human Development. 2019;50(3):449–458. doi: 10.1007/s10578-018-0853-1. [DOI] [PubMed] [Google Scholar]
  56. Warner CM, Reigada LC, Fisher PH, Saborsky AL, Benkov KJ. CBT for anxiety and associated somatic complaints in pediatric medical settings: An open pilot study. Journal of Clinical Psychology in Medical Settings. 2009;16(2):169–217. doi: 10.1007/s10880-008-9143-6. [DOI] [PubMed] [Google Scholar]
  57. Weiss H. The use of mindfulness in psychodynamic and body orientated psychotherapy. Journal of Body, Movement and Dance in Psychotherapy. 2009;4(1):5–16. doi: 10.1080/17432970801976305. [DOI] [Google Scholar]
  58. Weitz, N., & Opre, A. (2019a). The effectiveness of DMT-CBT combination in Anxiety Disorders treatment: therapists' perceptions. The European Proceedings of Social & Behavioural Sciences, LXIII (June 2019a). Future Academy
  59. Weitz N, Opre A. Therapists’ perceptions: Added values of DMT and CBT for children with ADs. Psychologia-Pedagogia. 2019;64(1):5–22. [Google Scholar]
  60. Weitz N, Opre A. Therapists' attitudes towards the combined DMT and CBT treatment of children with anxiety disorders. Cognition, Brain, Behavior. 2020;24(1):35–66. [Google Scholar]
  61. Young JE, Klosko JS, Weishaar M. Schema therapy: A practitioner's guide. Guilford; 2003. [Google Scholar]

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