The Potential Benefits of Dance Movement Therapy in Improving Couple Relations of Individuals Diagnosed With Autism Spectrum Disorder—A Review

A review of current literature indicates that adults diagnosed with autism spectrum disorder (ASD) feel the need for intimate and sexual relationships and maintain such relationships despite and alongside their difficulties in emotional communication, social interactions, reciprocity, and verbal and non-verbal expression. This understanding calls for the development of intervention programs designed to support the specific needs and address the problems of couples where one partner is diagnosed with ASD. In view of the relevance and significant part played by body and movement in emotional development and psychotherapy, the present article offers a review of studies examining the contribution of dance movement therapy to both the quality of life and functioning of adults with ASD and therapeutic processes in couple therapy. This review aims to establish an infrastructure for the construction of intervention programs and for future studies designed to enhance the quality of life and independence of adults with ASD.

A review of current literature indicates that adults diagnosed with autism spectrum disorder (ASD) feel the need for intimate and sexual relationships and maintain such relationships despite and alongside their difficulties in emotional communication, social interactions, reciprocity, and verbal and non-verbal expression. This understanding calls for the development of intervention programs designed to support the specific needs and address the problems of couples where one partner is diagnosed with ASD. In view of the relevance and significant part played by body and movement in emotional development and psychotherapy, the present article offers a review of studies examining the contribution of dance movement therapy to both the quality of life and functioning of adults with ASD and therapeutic processes in couple therapy. This review aims to establish an infrastructure for the construction of intervention programs and for future studies designed to enhance the quality of life and independence of adults with ASD.
Keywords: autism spectrum disorder, couple therapy, dance movement therapy, dance movement therapy for couples, mirroring The development of adult intimate relationships and the transition into couplehood are part of most people's life cycles, but these transitions become very challenging for individuals diagnosed with autism spectrum disorder (ASD) in as much as social interactions, emotional communication, and reciprocity, which are essential for interpersonal relationships (Le et al., 2010), are made more difficult due to the condition itself (Orsmond et al., 2004).
Research on couple therapy for adults diagnosed with ASD is in its infancy, and the core issues of the studies relate to the need for a better understanding of the unique aspects of intimacy and sexuality for these clients. Studies have examined the prevalence of marital relationships, reporting that 16% of individuals diagnosed with ASD get married (Tani et al., 2012). However, the specific difficulties entailed in the condition are an obstacle to the maintenance of a steady, long-term relationship, and significant support is needed to assist the development of these relationships and, in particular, in preserving them Schöttle et al., 2017;Strunz et al., 2017;Dembosky, 2020).
Current research also explores the experience of typically developed (TD) individuals who are married to partners with ASD. Women married to partners with ASD describe their subjective experience of struggling and loneliness, which all-too-often lead to crises after marriage (Deguchi and Asakura, 2018), and the most problematic areas involve issues of affective communication, problem-solving communication, and quarreling (Roy and Dillo, 2017). Another complexity entailed in these relationships relates to the existence of social stigmas that partners may experience (Naoko et al., 2020).
A recent study which examined the perceptions of adults with and without ASD regarding intimacy found that, among the two groups, intimacy included communication, sharing and similarity, respect and safety for self and other, and working on the relationship. Barriers for both groups included intraand interpersonal conflicts; participants with ASD specifically highlighted uncertainty about relationships and communication, feeling that they did not have the required knowledge and skills. These findings suggest that individuals with ASD and TD individuals have similar notions of intimacy, yet they have different challenges in experiencing it (Sala et al., 2020).
An additional study (Cheak-Zamora et al., 2019) explored the sex and relationship experiences of 27 adults with ASD. The study found that the participants craved a relationship, but only few reported having partners. Among those that did, their actual relationships rarely met ideals. All of the participants expressed the need for tutoring and coaching that cover basic intimacy topics. These studies point to gaps between the desired and the actual life in the realm of intimacy and sexuality for adults with ASD. This gap highlights the need for further studies which would examine specifically tailored intervention programs intended to provide support for marital and sexual issues with this client population.
In spite of the recognition of the particular difficulties described above, the literature survey indicated that there is a distinctive lack of empirical studies that examine interventions for improving couple relationships in individuals with ASD. It is possible that one of the reasons for this lack is the fundamental question as to the efficacy of exclusively verbal work (Koegel et al., 2009;Anderberg et al., 2017) in as much as the clients' communication issues may pose significant problems for reciprocal verbal engagement and emotional reciprocity (Naber et al., 2008;Baron-Cohen, 2010;Eigsti et al., 2011;Vulcan, 2016).
At this point, in view of these lacunae, the manifested need at the clinical level, and the critical role of the body in understanding the complexity of an adult with ASD, we propose to take a step toward addressing these issues by offering a review of studies examining the advantages of dance movement therapy (DMT) to both the quality of life of adults with ASD and processes of couple therapy.We suggest that a specific focus on these two lines of research into ostensibly different "bodies of knowledge, " as offered in this review, constitutes a step toward a research protocol and effective clinical interventions that would support the formation and maintenance of intimate relationships of adults with ASD.
This review was conducted in accordance with the PRISMA Checklist (PRISMA, 2015). The following three criteria were used to select the research studies for this review: (a) use of specific key terms ("DMT, " "Couple Therapy", "Autism Spectrum Disorder, " "Asperger's Disorder/syndrome, " and "Pervasive Developmental Disorder"); (b) publications in international evidence-based English academic journals between 1980 and 2020, and (c) adult individuals identified as having ASD, Asperger's, or pervasive developmental disorder who were involved in DMT and adult individuals in a romantic relationship who took part in DMT-C. The following electronic databases were used to conduct this research study: Medline, Pubmed, Cinahl, and Springer Link.

ASD AND DMT
DMT is based on the assumption that pre-verbal, pre-mentalized bodily memories play an important role in relationships and influence our intimate experience (Shuper Engelhard, 2019b,c,d,e). DMT fosters embodied experiences through bodybased interventions and movement, and words are used to increase self-recognition, self-other distinction, and selfawareness on a bodily level, which positively influence social understanding (Fuchs and Koch, 2014;Koch et al., 2015). Moreover, it has been shown that moving between actions or inner felt experiences and their verbal expressions and practicing these transitions increase the ability to communicate feelings, needs, and emotions (Devereaux, 2012).
DMT interventions include various types of non-verbal mirroring, reflection, use of rhythm, regulatory movement, and movement synchrony-all of which are broadly aimed at helping the client practice relationship skills to attain bodily attunement and empathy and to get acquainted with feelings and needs through the experience of synchronization (McGarry and Russo, 2011;Behrends et al., 2012).
Through the body, DMT addresses issues of emotion and cognition, applying empathic reflection via mirroring of the client's movements in order to form a relationship and enhance emotional understanding of self and other. The assumption underlying this therapeutic modality is that these basic, nonverbal interactions, within the safe and secure clinical setting, serve as a bridge for the formation of relationships and for the enhancement of communicative functioning in relationships outside the clinic in day-to-day context (Baron- Cohen and Wheelwright, 2004).
Studies examining the contribution of DMT with adults diagnosed with ASD have found that their ability to synchronize in open and free movement is limited compared to TD but not completely impaired, and researchers recommend using these tools to develop the social skills of empathic tendency, emotional recognition, and affective engagement (Brezis et al., 2017). Studies, respectively, show that the practice of mirroring, synchronization, rhythm, and reciprocity in movement contributes to social involvement, body awareness (DeJesus et al., 2020), emotional engagement, rapport, and intersubjective communication (Delafield-Butt et al., 2020), emotional empathy (Mastrominico et al., 2018), and the expression of emotions (Takahashi et al., 2019). Several studies in the field describe the effect of 1-h intervention per 6 weeks on regulation, imitation, and interaction (Mateos-Moreno and Atencia-Doña, 2013), for 7 weeks on improvement in psychological well-being, body awareness, self-other awareness, and social skills (Koch et al., 2015), for 8 weeks on the ability to form relationships (Edwards, 2015), and for 10 weeks on emotional expression (Hildebrandt et al., 2016), body image , and cognitive empathy (Koehne et al., 2016b). The interventions in all these studies are based on movement reflection, followed by a verbal discourse that allows the experience to be processed and communicated from the body to the here-and-now. The researchers in all of these studies emphasize the contribution of the practice of empathy in movement (through synchronizing and joining others) to emotional and social understanding ( Table 1).
Following this, our review aims to examine the theoretical basis for a DMT model that could hopefully assist adults with ASD in their intimate romantic relationships by enhancing satisfaction, working toward stabilizing the partnership, and extending its duration.

DMT FOR COUPLES
DMT for couples (DMT-C) focuses on body sensations and movement and lays the ground for symbolic discourse, insight, and processing of psychic materials that influence the couple's relationship (Wagner and Hurst, 2018). The majority of the literature on the subject is based on case studies offering movement experiences combined with verbal discourse during the couple therapy session ( Table 2).
Research in the field of DMT-C found that the experience of expressive movement, synchronization, and mutual attunement through movement had a positive impact on the perceived relationships, an increase of kinesthetic empathy, and an improvement of the participants' ability to attune in relation to their partners' needs (Kim et al., 2013). These skills are precisely those so essential in couple relationships (Le et al., 2010), which may be complex and difficult for adults diagnosed with ASD (Orsmond et al., 2004). Another study found that the imitation of a personal choreography, movement synchronization, and collaboration in resolving incidents of non-synchronization of movement resulted in higher marital satisfaction, more secure attachment, and higher empathy in the relationship (Pietrzak et al., 2017). Furthermore, couples reported experiences of movement with their hands (Wagner and Hurst, 2018), being led in space by their partner (Polo, 2010), mirroring and imitating movement (DeBoer, 2006;Patterson et al., 2012;Lacson, 2020), raised awareness of emotional content from the couples' daily lives, and the ability to understand the emotional needs of the partner. The interventions in the various studies range from 8 h (Kim et al., 2013) of practice to 12 h (Hawkes, 2003;Pietrzak et al., 2017) as similarly described above in DMT interventions with adults diagnosed with ASD.
In a recent research project, nine couples with TD participated in 12 sessions of DMT-C (Shuper Engelhard, 2018, 2019aShuper Engelhard and Vulcan, 2018;Vulcan and Shuper Engelhard, 2019). A total of 126 h of therapy were transcribed and coded. The session began with an invitation to observe the "spontaneous joint movement" (for example, the couple was invited to walk around the room while observing their personal pace and their dyadic pace). As the session continued, the "spontaneous joint movement" was expanded (for example, through the examination of different rhythms). This expansion was designed to meet diverse feelings and emotions evoked through different movement patterns of the partners. The following phase in the session included the "mirroring of movement, " where each partner was invited to move like his/her partner. After each experience of movement, the therapist asked the couple to practice an inner observation of feelings, emotions, memories, and images that emerge after the movement experience. At the end of the session, the couple was invited to share with each other their movement experience in words.
This study found that the participants learned new verbal and non-verbal communication skills, and as a result, they experienced a sense of improved intimacy, and their relationship became more enjoyable. It was also found that the shared body experience helped the partners to increase mutual engagement, responsiveness, and attentiveness (Shuper Engelhard, 2019c). They each learned about the needs of the other, including which bodily experiences bring about a sense of security in the relationship (Shuper Engelhard, 2019d).
In all the studies described, the couples were without any formal diagnosis, except for a single study involving couples with borderline personality disorder (Pietrzak et al., 2017). The review did not find any studies on DMT for adults diagnosed with ASD who are involved in a romantic relationship. All of the interventions offered for DMT with couples are similar to the type of interventions recommended for adults diagnosed with ASD (e.g., synchronization, mirroring, imitation, etc.) in order to enhance social skills and the ability to recognize the other's emotional expression and feelings. Moreover, both studies in DMT-C and studies of DMT for adults diagnosed with ASD suggest the combination of sensory and kinesthetic experience with verbal processing. In couple therapy, the partners reported that their communication improves as the somatic and kinetic information is translated into verbal discourse (Vulcan and Shuper Engelhard, 2019). This is compatible with Bird and Viding's model of empathy (Bird and Viding, 2014;Fletcher-Watson and Bird, 2020), as the contribution of verbalization of the sensory experiences among adults diagnosed with ASD (Hildebrandt et al., 2016) is important to the development of emotional cognition that should be based on learning the connections between emotional action and emotional experience (i.e., identifying the emotion through its expression). These insights reinforce the importance of an intervention that focuses on identifying the other's body gestures as a way to bring about more satisfying communication in the relationship.

DMT-C FOR ASD
We aim to offer this review as a springboard for the development of effective intervention models, which would enhance the ability of adults with ASD to form intimate relations. Further research that can validate the use of DMT-C for ASD is warranted, but based on this review, we would recommend a research plan which, we believe, is likely to generate important and  DMT focused on interpersonal imitation and synchronization changed emotional inference when compared with the control movement intervention group (p = 0.04, η 2 = 0.09).

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Frontiers in Psychology | www.frontiersin.org The observed power by partial squared Eta was high (2 = 0.90, p < 0.001) in the progression of measures in the experimental group.

Evaluation tools Results and conclusions
The value of partial squared omega ω 2 = 0.69 estimates an equally high effect size (Cohen, 1988) of the treatment if systematically applied to the severely affected adult autistic population. The observed power (Cohen's d = 1.18, r = 0.51) suggests a moderate effect size (Cohen, 1988) on the interaction disorder.
The study provides preliminary evidence for the high benefits of jointly using MT and DMT with severely affected autistic adults The time series of embodied interaction was recorded by means of a minimalistic human-computer interface paradigm that has become known as the "perceptual crossing experiment" (PCE) An overall mutual coordination was reached at the dyad level, even in this highly constrained, minimal environment. Research supports the usage of computer-mediated and tactile interactions for understanding the relationship between movement-based coordination and social engagement in patients with ASD novel clinical information and help to reduce social isolation in adults with ASD. The proposed intervention protocol focuses on mirroring, synchronization, and mutual coordination. A DMT-C session for ASD should consist of a warm-up phase, followed by movement experiences and a closing verbal part. This protocol should take place for at least 6 weeks, with two 1-h sessions each week, as all of these were found to contribute to both couple therapy and interventions for adults with ASD.  In this proposed study, the efficacy of DMT-C with ASD will be examined by using an RCT model comparing three groups of couples: two intervention groups [DMT-C, verbal therapy (VT), and a delayed DMT-C group (DG)]. The comparison of the intervention protocol will help determine the unique contribution of each treatment modality to improvements in the subjects' capacity for communication, intimacy, and reflective functioning, whereas the comparison of each modality with the DG is aimed to verify improvement beyond natural maturation. Moreover, literature on music therapy and ASD is continuously growing (Thompson and Elefant, 2019;Epstein et al., 2020;Nielsen and Holck, 2020), and the benefits of DMT may partly be due to the therapeutic effects of music by itself. Perhaps future research could incorporate an experimental design in which DMT-C could be compared with a control group exposed to the same music but without the dance element to determine the effect of dance on its own. Additionally, we would propose DMT as an appropriate intervention designed to raise emotional awareness and social skills and believe that a suitable manualized intervention is likely to be helpful in developing programs for community interventions tailored to the needs of people diagnosed with ASD. By working on the quality of intersubjective communication through DMT, we expect to see an improvement of the quality of the couples' relationship, of the duration of the relationship, and in the partners' satisfaction with each other.

DISCUSSION
Drawing on a number of empirical studies, the aim of this review was to create a comprehensive picture of current research addressing the issues of couple relationships where one partner is diagnosed with ASD in order to understand the potential contribution of DMT in these cases. The survey suggests that DMT-C can contribute to synchronization, adjustment, and familiarity between the partners and that this form of support may be beneficial in terms of the relationship and help the partners cope with the difficulties entailed in ASD.
Both DMT interventions with adults diagnosed with ASD and DMT-C were found to be a valuable mode of supporting interpersonal communication and empathy through movement experiences and may thus be constructively combined to help adults with ASD in engaging with and maintaining intimate relations. The review shows that bodily mirroring has been extensively referenced in the context of working with clients diagnosed with ASD (Baron- Cohen, 2004;McGarry and Russo, 2011;Koehne et al., 2016b;Feniger-Schaal et al., 2018) in order to support social skills and emotional awareness.
As described previously, this is also precisely what is practiced in DMT-C when there is a disruption or difficulty in using these mechanisms. The ability to identify with one's emotion, alongside the establishment of a distinction between the needs and feelings of each one of the partners (Siegel, 2012, p. 6), is the basis for intimate relations, symbolizing the extent of the couple's closeness and the freedom to express the self fully in the relationship while enabling the partner to possess a separate self (Lerner, 2017).
This review emphasizes that heightened emotional awareness is achieved through the transition from awareness of bodily experiences to their verbalization within the DMT session. The articles reviewed emphasize that DMT, which draws attention to the bodily experience and sensations, is helpful for individuals who find it difficult to reflect verbally on their emotions, thoughts, and feelings (Shuper Engelhard, 2019e). It is important to understand the uniqueness of movement for the processing of embodied knowledge as described by Koch et al. (2015, p. 2): "the mind is not hidden but directly expressed in other persons' embodied actions' from the earliest days of infancy." This understanding, alongside the translation of physical and emotional experiences into verbal discourse in order to improve and support intimate relationships, will aid in the development of intervention programs for adults diagnosed with ASD.

CONCLUSIONS
The benefits of integrating movement into couple therapy and into emotional therapy for individuals with ASD are gaining more recognition and scope in research and clinical practice. This review indicates that DMT may contribute to the wellbeing and quality of day-to-day lives of adults with ASD. The ability to identify and express bodily sensations and to relate them to emotions may assist the partners in forming and maintaining adult intimate and sexual encounters, identifying and communicating needs, and feeling understood and loved by another. Moreover, understanding the role of the body and its movement in therapy when emotional discourse is limited can help formulate unique intervention programs for adults diagnosed with ASD as DMT can assist in improving communication and intimacy which may later lead to a higher degree of autonomy when one of the partners is diagnosed with ASD. By offering this literature review, we hope to make a contribution to a better quality of life for adults with ASD by helping them to overcome isolation and engage in meaningful and enjoyable familial and social interactions. The implications of the review will hopefully encourage researchers to take these insights further in future research.

AUTHOR CONTRIBUTIONS
ES and MV have contributed equally to the article and approved the submitted version. Both authors have contributed to the main body of text and to its main ideas.