Writing Assignment

Complementary Therapies in Medicine (2012) 20, 377—384

Available online at www.sciencedirect.com

j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / c t i m

Argentine tango dance compared to mindfulness meditation and a waiting-list control: A randomised trial for treating depression

Rosa Pinniger a,∗, Rhonda F. Brown a, Einar B. Thorsteinsson a, Patricia McKinley b,c

a University of New England, Australia b McGill University, Canada c Centre Interdisciplinaire de recherché en réadaptation du Montréal metropolitain, Canada Available online 3 August 2012

KEYWORDS Depression; Mindfulness; Tango dancing; Psychological stress

Summary Objectives: To determine whether tango dancing is as effective as mindfulness meditation in reducing symptoms of psychological stress, anxiety and depression, and in promoting well-being. Design: This study employed analysis of covariance (ANCOVA) and multiple regression analysis. Participants: Ninety-seven people with self-declared depression were randomised into tango dance or mindfulness meditation classes, or to control/waiting-list. Setting: classes were conducted in a venue suitable for both activities in the metropolitan area of Sydney, Australia. Interventions: Participants completed six-week programmes (1½ h/week of tango or medita- tion). The outcome measures were assessed at pre-test and post-test. Main outcome measures: Depression, Anxiety and Stress Scale; The Self Esteem Scale; Satisfac- tion with Life Scale, and Mindful Attention Awareness Scale. Results: Sixty-six participants completed the program and were included in the statistical anal- ysis. Depression levels were significantly reduced in the tango (effect size d = 0.50, p = .010), and meditation groups (effect size d = 0.54, p = .025), relative to waiting-list controls. Stress levels were significantly reduced only in the tango group (effect size d = 0.45, p = .022). Attend- ing tango classes was a significant predictor for the increased levels of mindfulness R2 = .10,

adjusted R2 = .07, F (2,59) = 3.42, p = .039. Conclusion: Mindfulness-meditation and tango dance could be effective complementary adjuncts for the treatment of depression and/or inclusion in stress management programmes. Subsequent trials are called to explore the therapeutic mechanisms involved. Crown Copyright © 2012 Publish

∗ Corresponding author at: School of Behavioural, Cognitive and Social Tel.: +61 2 6773 2410; fax: +61 2 6773 3820.

E-mail address: rpinnige@une.edu.au (R. Pinniger).

0965-2299/$ — see front matter. Crown Copyright © 2012 Published by E http://dx.doi.org/10.1016/j.ctim.2012.07.003

ed by Elsevier Ltd. All rights reserved.

Sciences, University of New England, NSW 2351, Australia.

lsevier Ltd. All rights reserved.

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Introduction.............................................................................................................. 378 Methods.................................................................................................................. 379

Participants ......................................................................................................... 379 Procedure ........................................................................................................... 379 Measures ............................................................................................................ 379 Statistical analysis................................................................................................... 381

Results ................................................................................................................... 381 Group comparisons .................................................................................................. 382

Discussion ................................................................................................................ 382 Limitations .......................................................................................................... 383

Conclusion ............................................................................................................... 383 Conflict of interest statement ............................................................................................ 383 Acknowledgments ........................................................................................................ 383 References ............................................................................................................... 383

ntroduction

ne in five Australians will at some time in their life experi- nce a mental disorder, however, only one-third ever access ffective treatment.1 Some are reluctant to undergo tradi- ional psychiatric treatment or to be identified as mental ealth patients, and therefore avoid treatment. Others may e unaware of available therapies, or find them difficult to ccess; others fail to respond to existing treatments.2,3

Moreover, individuals with self-reported anxiety and epression are reported to use complementary or alter- ative therapies more frequently, rather than mainstream reatments.4 Thus, there is an urgent need for complemen- ary and alternative therapies to address such issues. In this tudy we evaluated tango therapy as one possible alterna- ive approach to alleviate individuals experiencing stress, nxiety and/or depression.

Recreational physical activity reduces disability and psy- hological distress in people with chronic disease, relative o those completing specific rehabilitation exercises but who eport they did no recreational or sport activity,5 suggest- ng that recreational activities may facilitate greater focus n physical and psychological well-being, whereas targeted ehabilitation exercises focus primarily on improving disabil- ty. Activities such as martial arts and dance typically require oncentration on aspects of the present (e.g. learning new hysical skills), and this is argued to indirectly improve psy- hological outcomes.6

Dance, in particular, is reported to be an effective djunct to standard depression therapy.7,8 It is suggested hat the expressive characteristics of dance rather than he exercise itself may assist individuals to deal with feel- ngs otherwise difficult to accept or express.9 Music is also eported to be strongly associated with improvements in hysical and mental health outcomes10; for example, it was ecently shown to decrease patients’ anxieties in an acute are medical setting.11 Even music that is described as being elancholic, such as tango music, is proposed to gener-

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claimed that anyone who can walk can learn the tango.14 It is an absorbing activity that promotes attention by demand- ing a strong connection with a partner,15 since in a dance of about 3 min, the partners must attempt to move as one, a synchronized movement with one partner stepping where the other has just stepped.16 Thus, an awareness of one’s own body and that of the partner is required.

Leaders have to improvise, use leadership skills and take responsibility by selecting adequate steps according to the proficiency and physical characteristics of the partner; fol- lowers mostly walk backwards, and therefore need to trust the leader’s judgement and accept their choice of steps8

by concentrating on their body alignment and maintaining sufficient space between the feet.16

Toneatto and Nguyen17 suggest that any activity requir- ing awareness of current experience is likely to interrupt an individual’s thoughts about their past and fears about the future, so potentially lessening association between nega- tive thoughts and possible affective symptoms. Tango is one activity that could achieve this goal, since it is an absorb- ing activity that requires significant skills acquisition,8,16

and an awareness of current experience.17 It also facilitates an involvement in music, exercise, and touch, all of which have previously been reported to be effective in alleviating psychological distress.18—20 However, as yet tango has not been examined as a possible mindfulness-based treatment for affective symptoms.

Mindfulness is described as a process of observing thoughts and feelings as transient experiences that do not need to be eliminated or reacted to,21 rather than permanent aspects of the self or reflections of reality.22

This approach is suggested to facilitate one’s detachment from negative thoughts, ruminations, and worries,1 thus reducing the contingency between noxious stimuli (e.g. feeling stressed) and habitual distress. Importantly, this approach does not require the person to give up control; rather, it involves shifting attention away from aspects of life that cannot be controlled (i.e. distressing situa- tions), to those which can be managed (e.g. emotional

te positive emotions. However, the combination of tango

usic and partnered dancing is suggested to improve emo- ional state.13

Tango is described as a ‘walking embrace’; a form of ance that evolved in Argentina at the end of the 1800s. It is

r i t s

esponse to situation). It is this change in focus which s thought to underpin the observed reductions in symp- om severity (e.g. depression, pain) seen in several recent tudies.21,23

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Tango therapy for depression

Putative mindfulness activities such as meditation have previously been reported to improve psychological well- being.24 For example, Mindfulness-based Cognitive Therapy, which includes meditation as a component, has been shown to be effective in treating depression and residual depres- sive symptoms.24,25 The intent of these therapies is not to eliminate sadness but to normalise a person’s thinking pat- terns so that mild sadness does not escalate into a more severe state.26

Few potential therapies have been empirically tested as possible mindfulness-based therapies for depression,27

especially those which may be applied outside the clini- cal context. Tango has yet to be examined in this regard, but it does share attributes common to the mindfulness treatments described above. Furthermore, prior research indicates that tango is effective in improving balance, socialisation, and self-esteem in the elderly,28 walking speed, cadence, movement initiation, and motivation in Parkinson’s disease patients,29 and quality of life, adherence to rehabilitation programs, coordination, and equilibrium in myocardial infarction patients.30 Moreover, several pilot studies have examined improvements in psychological well- being in vulnerable populations such as those with mental disabilities.31 Thus, the stage is set to evaluate tango as a means of improving psychological health and wellbeing.

In the present study, we conducted a randomised- controlled-trial (RCT) of tango dance with two control groups: mindfulness meditation and waiting-list controls. In accordance with the limited available literature, we hypoth- esised that: (a) tango and meditation participants will show greater reductions in stress, anxiety, and depression levels between baseline (pre-test) and immediately after treat- ment (post-test), relative to waiting-list controls; (b) tango and meditation participants will show greater increases in self-esteem and satisfaction-with-life between pre-test and post-test, relative to waiting-list controls; and (c) there will be a relationship between group membership (i.e. tango, meditation, and control) and an increase in mindfulness after the 6-week program.

Methods

Participants

This study was conducted with full institutional human research ethics approval. Participants were recruited via advertisements asking for volunteers with self-reported stress, anxiety, and/or depression. They were invited to participate in a RCT evaluating tango dance relative to mindfulness meditation or waiting-listed control. They were advised that they could be allocated to one of those three groups. Advertisements were placed in local newspa- pers, medical centres, and technical colleges in the Sydney metropolitan area, and displayed on two websites (Mental Health Association: www.mentalhealth.asn.au and Univer- sity of New England: www.une.edu.au). Inclusion criteria were age 18 years and over, and self-reported psychologi-

cal distress. Exclusion criteria were pregnancy, and walking or balance problems.

We estimated power based on a previous study,14 and G*Power.32 To get power >.80 given an effect size of f = 0.4,

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ith alpha = .05, and groups = 3 a total sample size of >63 ould be needed.

Ninety-seven people responded to the advertisements. hose who met the inclusion criteria and wished to partic-

pate were randomly assigned (drawn from a hat) to one f three groups: tango dance (n = 33), meditation, (n = 33) r waiting-list control (n = 31). The sample was blinded ince participants filled in the baseline questionnaires prior o randomisation to remove any anticipatory effects. Only 6 of the sample commenced the program (i.e. response ate = 78%). Ten people were unavailable due to work or ther commitments. In addition, 10 people failed to attend 4 r more of the 6 sessions, and were excluded from analysis, eaving 21 tango dance, 16 meditation, and 29 waiting-list ontrols, see Fig. 1.33

rocedure

t the beginning of the study all participants were pro- ided with detailed written information about the study, nformed of the voluntary nature of their participation, and ight to withdraw at any time. They were advised they ould be offered a voucher of their choice for 4 sessions of ither tango or meditation sessions, at the end of the study. aiting-list controls were mailed the consent form and pre-

est survey to be returned in the reply-paid envelope. The ame survey was sent 6-weeks later (i.e. at post-test). articipants in the experimental groups (i.e. tango and med- tation) privately signed consent forms and completed the re-test survey at the beginning of the first class, and again ollowing their sixth session (i.e. post-test).

The meditation and tango classes were each led by an xperienced, registered instructor who volunteered their ime and developed a special program for this study. Med- tation classes were based on the mindfulness exercises roposed by John Kabat-Zinn.34 Tango lessons were based on he Argentinean close-embrace tradition, requiring trained ango-helpers who also volunteered their time. All classes an for 1½ h, as detailed below.

At the start of every meditation and tango session, par- icipants were encouraged to leave the world behind and elax so as to pay full attention in class. They were advised he emphasis was on enjoying the experience rather than chieving a particular outcome (10-min). This was followed y a warm-up period (e.g. low-intensity stretching, 10-min), nd then the 1-h class. Each class introduced new aspects f the activity; for example, the first meditation session ocused on breathing, and later sessions on the mindful- ess of eating, body scan, walking meditation, and music editation.34 In tango dance, each session focused on a dif-

erent aspect of the dance; for example, the consciousness f walking, awareness of one’s own and partner’s body, resis- ance and transference of weight, and close-embrace. At the nd of each session (wrap-up, 10-min), participants were sked to sign the sign-out sheet and if they wished, share heir experiences or ask questions.

easures

articipants were asked demographic information, and bout their participation in exercise over the past month,

380 R. Pinniger et al.

Answered Adv ert isement

N = 97

Tango Dancin g

n = 33

Mindfulness Meditat ion

n = 33

Waiting-list Control

n = 31

Decl ined to pa rtici pate (n= 13)

Discontinue d inte rvention (n=4)

Conti nued in terve ntion (n=16)

Declined to participate (n=6)

Discontinue d inte rventio n (n=6)

Continued in tervent ion (n=2 1)

Declined to participate (n=2)

Return post- test question naires (n=29)

Completed progr amme

n = 29

Completed progr amme

n = 21

Completed pr ogramm e

n = 16

Total number of part icipants inclu ded in t he ana lyses

N= 66

Randomise d

N= 97

F mise

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igure 1 Flow-chart following participants through the rando

r engagement in other physical activities (yes/no); and f so, how often, from 1 (every day) to 7 (<once a onth). To assess the self-reported emotional states of stress,

nxiety and depression, the DASS-21 scale35 was used, mploying a 4-point Likert scale ranging from 0 (did not pply to me at all) to 3 (applied to me very much/most f the time). The structure of the scale and subscales show oderate construct validity.36 In the present study, internal

onsistencies were high with Cronbach’s alphas of .92 for epression, .81 for anxiety and .86 for stress.

Each individual’s judgment of their contentment with ife was assessed using the Satisfaction with Life Scale

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d controlled trial. Revised template of the CONSORT.33

5-items),37 using a 7-point Likert scale, with ratings from 1 strongly disagree) to 7 (strongly agree). The scale has high nternal consistency and excellent test-retest reliability.38

n the present study, internal consistency was high with a ronbach’s alpha of .84.

The Rosenberg Self Esteem Scale (10-items),39 is exten- ively used to assess this construct,40 the items relating o positive and negative attitudes about oneself (5-items ach), every question answered on a 4-point Likert scale

anging from 0 (strongly disagree) to 3 (strongly agree). The cale has high internal consistency41; in the present study, nternal consistency for the scale was high with a Cronbach’s lpha of .84.

Tango therapy for depression 381

Table 1 Means and standard deviations for key variables at pre-test, post-test (N = 66).

Outcome measure Control (n = 29) Meditation (n = 16) Tango (n = 21)

M SD M SD M SD

Measure (pre-test) Self-esteem 16.62 4.82 16.38 3.93 17.90 5.19 Satisfaction with life 15.80 5.73 16.00 5.85 17.79 7.15 Mindfulness 49.65 11.26 52.67 13.69 55.71 11.87 Depression 18.62 11.98 18.50 11.23 16.00 12.35 Anxiety 13.58 9.90 16.00 9.21 12.29 10.03 Stress 21.80 10.45 24.75 10.27 18.67 8.54

Measure (post-test) Self-esteem 17.15 4.93 18.50 4.90 19.30 5.98 Satisfaction with life 17.76 6.65 18.56 6.85 22.24 7.51 Mindfulness 51.81 14.42 57.20 12.77 62.00 12.25 Depression 16.92 9.74 10.63 12.47 8.76 9.64 Anxiety 11.92 10.00 11.25 11.33 5.71 7.05

p ( a

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Stress 19.85 9.85

Mindfulness was assessed using the Mindful Attention Awareness Scale (15-items). This scale assesses the fre- quency of mindful-states in everyday life situations. It distinguishes between people who practice mindfulness and those who do not.42 Items are rated on a 6-point Likert scale ranging from 1 (almost always) to 6 (almost never). The scale has high internal consistency in adult samples.43 In the present study, internal consistency for the scale was high with a Cronbach’s alpha of .88.

Statistical analysis

All statistical analyses were conducted using SPSS version 15. The quantity of missing data was less than five percent in each variable. To answer the first and second hypotheses a one-way between-groups analysis of covariance (ANCOVA) was conducted on each dependent variable, to compare the effectiveness of the activities, relative to waiting-list controls. The independent variables were: group allocation (i.e. tango, meditation, waiting-list), and time (pre- vs. post-test). The dependent variables were post-test scores

on stress, anxiety, depression, self-esteem and satisfaction with life, with the pre-test scores used as covariates. A multiple regression analysis was conducted to answer the third hypothesis; the criterion variable was mindfulness at

p d d

Table 2 Correlations between key variables at baseline (N = 66).

Measure 1 2

1. Self-esteem 2. Satisfaction with life .48**

3. Mindfulness .60** .30*

4. Depression −.66** −.36** 5. Anxiety −.34** −.23 6. Stress −.36** −.26**

* p < .05 (one-tailed). ** p < .01 (two-tailed).

19.00 10.15 12.48 7.53

ost-test and the predictor variable was group membership Tango vs. control and meditation and Meditation vs. control nd tango).

esults

articipant ages ranged from 18 to 80 years (M = 44.39, D = 14.27), and most (90.9%) were female. One-third 33.3%) were living with a partner, one-third (39.4%) were ever married, and the remainder were widowed (9.1%), ivorced or separated (18.2%). Most were well educated: wo-thirds (66.6%) had a university degree (undergraduate r postgraduate), and the remainder had completed a trade ertificate (12.1%), higher school certificate or equivalent 15.2%), or they left school by Year 10 (6.1%). Most were mployed (74.2%, full- or part-time), with the remainder ither unemployed/completing home duties (7.5%), unable o work (4.5%), retired (4.5%), or students (9.1%). A minority f participants (15.2%) indicated they did no regular exer- ise, but most (62.1%) exercised at least once a week, and ome (22.7%) exercised at least once a day.

According to the DASS suggested cut-offs,35 40 of the 66 articipants (60.6%) indicated they had moderate to severe epression at pre-test, with eight (12.1%) reporting mild epression. Forty-four (66.7%) participants indicated they

3 4 5

−.47** −.33** .59**

.−46** .61** .80**

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ad moderate to extreme anxiety, with six (9.1%) report- ng mild anxiety. Thirty-four (51.5%) participants reported oderate to severe psychological stress, with nine (13.6%)

eporting mild stress. Means and standard deviations of dependent variables

re provided in Table 1. The correlations between these ariables indicated that the participants were more likely o exhibit anxiety if they also reported high stress (r = .80,

< .01), whereas those reporting depressive symptoms were ore likely to also report low self-esteem, as indicated by

he negative correlation between both variables (r = −.66, < .01). The next strongest correlation was between mind- ulness and self-esteem (r = −.66, p < .01) in agreement ith other studies that suggest that through mindfulness

person can learn not to judge, rather accept them- elves, their own feelings and circumstances, see correlation able 2.

roup comparisons

fter controlling for baseline depression score, there was statistically significant effect for depression at the end of he program F(2,59) = 6.00, p = .004, partial �2 = .17. Post hoc ests revealed that tango and meditation group participants howed reduced levels of depression at post-test, relative to aiting-list controls [tango (p = .010), meditation (p = .025)]. he effect size (unbiased Hedges’ g [d] measuring the mean ifference between groups in standard deviation units) of oth interventions was large compared to control, tango

= 0.50 and meditation d = 0.54. After controlling for baseline stress score, there was a

tatistically significant effect for psychological stress at the nd of the program F(2,59) = 3.88, p = .026, partial �2 = .12. ost hoc tests revealed that only tango participants showed educed levels of psychological stress at post-test (p = .022), elative to waiting-list controls. The effect size was a bit arger for tango (d = 0.45) than for meditation (d = 0.37). here were no statistically significant results in the remain-

ng dependent variables, although small to moderate effect izes towards improvement were observed for both the ango and meditation groups, but not the waiting-list con- rol group. Improvement for anxiety was larger for tango d = 0.52) than meditation (d = 0.30). The effect size for indfulness was also larger for tango (d = .32) than for med-

tation (d = 0.18). Satisfaction with life improved more in he tango (d = 0.36) than meditation (d = 0.09) while self- steem improved more for meditation (d = 0.35) than tango d = 0.17).

The regression analysis indicated that group member- hip accounted for a significant 10% of the variance in he increase of mindfulness, R2 = .10, adjusted R2 = .07, (2,59) = 3.42, p = .039. Being in the tango classes was a sig- ificant predictor t(59) = 2.61, p = .012 while being in the editation classes was not, t(59) = 1.25, p = .217.

iscussion

his is the first RCT study examining tango dance as possible mindfulness-based intervention for individu- ls with self-reported depression. The first hypothesis is artly supported as tango and meditation participants did

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how greater reductions in levels of depression between re- and post-test, relative to waiting-list controls. The epression change score difference effect sizes were large nd considerably larger than the overall effect size reported or antidepressants (d = 0.31),3 although it is likely that his meta-analysis included a large proportion of patients ith more severe depression. Nevertheless, tango partic-

pants also reported significant reductions in stress levels elative to meditation and waiting-list controls. This sug- ests that dynamic physical activities may be more effective n reducing psychological stress than static activities such s mindfulness meditation, which appears consistent with he results of Rohricht and Priebe,44 who examined body- rientated activities in patients with schizophrenia. The esults are also consistent with prior research indicating he effectiveness of tango dance in the clinical context in anada,28 United States,29 and Argentina,8,45 although no rior RCTs have been conducted in Australia, or have exam- ned the effectiveness of tango in treating depression or ther psychological symptoms. Conversely, results were non- ignificant for anxiety relative to the control group. The mprovement of the tango and meditation participants failed o reach statistic significance, possibly since the control roup showed some improvement. The second hypothesis as not supported as neither self-esteem or satisfaction ith life results were significant, nevertheless, moderate ffect sizes suggest that a larger sample may show differ- nces in these variables and once again the improvements f the control group may have influenced these results. It is ossible that, receiving attention and correspondence dur- ng the program, as well as the prospective free lessons fterwards, may have positively influenced the responses f the control group.

The third hypothesis was partly supported as the regres- ion analysis showed that participants in the tango group eported greater increase in mindfulness at post-test, rel- tive to meditation and waiting-list controls. This is an ncouraging result, since it suggests that tango dance may e a possible mindfulness activity, perhaps more suitable or certain individuals than the putative mindfulness-based enefits of meditation.24,25

From an economic perspective, tango is an attractive ption as a possible first-line or complementary therapy or depression and possible adjunct to stress management rograms, since group-therapy approaches are generally ost-effective.21,46 From a practitioner perspective, tango s a possible alternative, positive and practical approach o working with clients, instead of the usual clinical focus n negative thoughts which need to be changed.47 From a ultural perspective, this and other studies indicate that rgentinean tango can be introduced into non-Latin cul- ures, similar to the way Eastern practices of meditation re now integrated into clinical and psychotherapeutic set- ings.

Finally, 97% of participants in the study chose to receive tango dance voucher after the study, rather than a med- tation voucher, suggesting the popular appeal of tango ance. This is an important consideration, since people

end to adhere to mindfulness-based programs more than ther therapy approaches,22 especially if the experience is ntrinsically positive,25 such as tango dance is reported to e.8

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Tango therapy for depression

Limitations

The results of this study need to be interpreted with cau- tion given several limitations. The sample was relatively small, although the power analysis indicated it was ade- quate, given the planned analyses. Most participants were well-educated females so the results may not be gener- alised to the general population. Information about clinical diagnoses (e.g. depression) or medications (e.g. antidepres- sants) was not collected. People were admitted to the study on the basis of these self-evaluations; however, self-reports have been shown to be more effective than clinical inter- views in capturing sub-threshold anxiety.48 Finally, this was an exploratory trial with restrictions preventing a follow-up being conducted, and therefore it is uncertain whether the benefits gained would continue beyond the cessation of the tango and meditation classes.

Conclusion

In conclusion, preliminary results suggest that tango dance is an innovative and promising approach, as effective as mindfulness meditation in reducing levels of self-reported depression. In addition, participating in the tango program was associated with increased levels of mindfulness and decreased levels of psychological stress. Further research is warranted to fully assess its potential benefits as a well accepted and cost-effective intervention.

Conflict of interest statement

No competing financial interests exist.

Acknowledgments

Jacqueline Simpson (tango teacher) and Tom Jones (clini- cal psychologist, meditation instructor) for giving so much time and dedication preparing and carrying out the program. The tango team: Nga Nguyen, Jean Weiner, Viet Nguyen, Ross Fairhurst and Scott Ross, for their time and profes- sionalism in assisting as leaders at the tango classes. Pedro Colombi (Consul of Argentina, in Sydney) for his support in this project. ‘‘The Kirk’’ (venue at Surry Hills, Sydney) for providing an ideal space to conduct both programs. To all the participants, whose commitment made the study possible, and established grounds for future research.

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