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 (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) 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).

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 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).

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.

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.

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).

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

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.

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).