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STILLBIRTH INTEGRATION: Dramatherapy appliedto unresolved griefRachel Bar-YitzchakPublished online: 14 Sep 2011.
To cite this article: Rachel Bar-Yitzchak (2002) STILLBIRTH INTEGRATION: Dramatherapy applied to unresolved grief,Dramatherapy, 24:1, 8-15, DOI: 10.1080/02630672.2002.9689601
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Dramatherapy Vol24 No 1 Summer 2002 ‘Stillbirth Integration: Dramatherapy applied to unresolved grief
STILLBIRTH INTEGRATION: Dramatherapy applied to unresolved grief Rachel Bar-Yitzchak
ABSTRACT This research is a case study of the effect of Dramatherapy with a client who was suffering from prolonged grief following stillbirth. The assumption was that an analysis of the Dramatherapy sessions could shed light on processes that may assist the client in relief of her unresolved grief and integration of her stillbirth, which were necessary in order to get on with her life. The Dramatherapy was based on Jennings’ (1992, 1993, 1998) EPR model. The analysis focused on the dramatherapeutic processes, specifically, dramatic reworking, retelling and projection, that accompanied theclient’s experience of relief and integration of her loss.
The client, ‘Iris’ (a fictional name), is a career woman, who sought dramatherapeutic treatment in the hope that it might help her overcome her overwhelming feelings of distress and sorrow, which made it difficult for her to function, both physically and emotionally. The research examined the first six sessions of a longer-term therapy, during which the client’s prolonged grief emerged as a major issue for her. The records kept by a participant observer (the researcher), the products of the client’s art work, and audio recordings of the sessions served as the research data. The presentation of the data focused on changes in the client’s appearance, body language, vocal presence, emotionality, and issues raised in the sessions.
When the baby was born she tried to do all she could to look afer the one she loved so much ...
Then, suddenly, the baby stopped growing ... then the child died. And sorrowing, weeping Bunyil held in her arms a tiny, dead baby ....
Her eyes let go tears like mournfil skies the rain ... Time passed, but day and night Bunyil mourned. .. She felt that her child wanted her to be near. She died then. And her people buried her near the baby’s grave.
(Australian aboriginal tale, retold by Gersie, 1992 147-148)
This ancient Aboriginal tale is an extreme example of a mother’s sorrow and inability to integrate the loss of her baby and go on with a new, if changed, life. It has a direct connection to this research. For three years following the stillbirth of her baby, the client “Iris” lived as if ‘dead’, as
well. To the best of my knowledge, there is no research that
addresses the combination of these three areas: grief resolution, stillbirth, and Dramatherapy. This paper, based on my MA dissertation Case Study, represents unique research in this area.
Stillbirth Stillbirth is defined as the birth of a full-term baby who is dead. Death means the separation for-ever from someone we have loved. Pregnancy itself marks adrarnatic transition for a woman in terms of her self-definition. What for most women and their families is one of the happiest events of their lives, becomes a tragic and traumatic event when the baby is stillborn (Rando, 1991). Joy turns to grief; motherhood to mourning; life to death (Gersie, 1992).
The term grief refers to the process of experiencing the psychological, social and physical reactions to one’s perception of loss (Rando, 1991). When a person goes through a typical process of grief, the loss of their beloved is gradually internalised. The individual’s grief workcentres around four basic tasks:
1. recognising the loss
2. releasing the emotions of grief
3. developing new skills
4. reinvesting emotional energy in the present (Leick and Davidsen-Nielson, 1996; Worden, 1991).
By working through these tasks, the grieving individual finds a way to integrate hisher experience of loss and move on with life.
Part of the problem with stillbirth is that it is quite difficult for people outside the first circle of those closest to the woman to affirm her loss. Often, others assume there will be no grief or that it is not as though a ‘real baby’ died.
Some 15-20 years ago the norm in most western countries was to regard stillbirth as a non-event’ and to prevent parents from mourning their child by refusing them access to the dead baby. These are typical hospital procedures in the event of stillbirth and procedures that are similar to those experienced by Iris:
possible. Remove the dead body from the room as quickly as
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about the baby. Discourage the parents from seeing and communicating
think about conceiving another baby. Encourage parents to forget about the dead baby and to
. unmarked mass grave.
Institutional disposal of the baby’s body, often in an
(Mander, quoted in Littlewood, 1996 148-149).
Mothers who have undergone stillbirth report that their trust in life is shattered and overwhelming, devastating mentally distressing emotional changes are common; 20%- 30% of women have appreciable psychiatric long term morbidity. The women are more prone to anxiety after stillbirth (RAdestad, 1998; RAdestad et al., 1998; WiSSP, 1997).
During the past decade, hospital practice has radically changed in most western countries. The routine photographing of all stillborn babies and practices such as giving parents the baby’s name tag. lock of hair, or other mementos have been introduced (Moms, quoted in Littlewood, 1996 149). Parents areencouraged to remember their baby and to talk openly about their loss. In many cases they view the body of their baby and dispose of the body withritual. (StillbirthandNeonatal Death Society-SANDS, 1991). The notion that more details about the stillborn will help resolve the grief has been widely accepted (RAdestad, 1998; WiSSP, 1997).
The most difficult reaction to stillbirth is what is defined as complicated grief.’ As reported by Littlewood (1996), many researchers have documented the complications that may arise during the grieving process after stillbirth, noting that the death of a baby is associated with three key risk factors: relational, circumstantial, and social. The uncertainty of the circumstances surrounding the death, the absence of a body, and the unanticipated and untimely nature of the death are all associated with complicated grief. Losses that are socially unspeakable or socially negated and the absence of a social support network have also been identified as contributing to complicated grief (Littlewood, 1996 148-156).
Dramatherapy and Grief For many people, the death of their child initially makes them feel that they too want to die or at least that they no longer want to live. They may have a sense that their child’s death haskilledtheirfuture(Gersie, 1992 147). Shebelieves that creative-expressive activities are important to the process of healing, because:
... The act enhances the sense of mastery, and allows us to express ourselves directly ... the restoration of the capacity to create ‘symbolic’ utterances results in the easement of tension and contributes to the healing of pain (Gersie. 1992 235-236).
The most important element, is the emphasis on grief work as an active process.
The Client Iris (not her real name) was 40 years old and a new immigrant to Israel at the time of her baby’s death. She was a childless professional career woman, with no family or close friends in Israel, other than her husband. She had very limited communication skills in Hebrew.
This was the couple’s first pregnancy. Subsequently, the couple underwent fertility treatments. These treatments are typically physically and psychologically harrowing. In theprocessoftheferti1itytreatments.Iris’ distress symptoms became more pronounced, and she was not able to control them.
Following the stillbirth of her baby, Iris had sought professional help through traditional psychotherapy. She had not been able to recover from the flashbacks, nightmares, deep insecurity, and ongoing distress evoked by her baby’s death.
Iris made s m e progress during three months of psychotherapy and some symptoms abated. However, one day her psychologist explicitly directed Iris to seek IVF (in- virro fertilisation) treatment immediately in order to conceive again. Iris saw this as a breach of trust and an insensitive violation of her feelings and of her deceased baby. She stopped therapy immediately.
Subsequently, the couple moved to a new home far from their former residence and the symptoms returned. Iris found another psychologist. She stopped seeing this therapist after the therapist recommended that she take Valium for pre-IVF treatment anxiety.
During two years of fertility treatments, the initial symptoms increased after each failed attempt, to the point that her professional and personal life was falling apart. She suffered from increasingly marked hysteria and agitation during any contact with clinics, hospitals, or other medical settings. The sight of an infant made her tearful. She could not bear to be near pregnant women. She was unable to function at work.
Dramatherapy Intervention Several different tools of Dramatherapy were employed in the work with Iris. These included: object sculpting, drawing/ painting, work with clay.
The Dramatherapy continued for a total of 20 sessions, extending to other issues. The main issue of prolonged grief that emerged in early sessions came to a closure and been relieved, by the sixth session as reflected in her report at the beginning of that session. The issue of grief did not arise in any of the subsequent 14 sessions. After coping with this part of her life, Iris could move on in the Dramatherapy, and in her life.
The Case Study Iris called me after a round of failed 1VF treatments, when she could no longer bear her situation. She was in great
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distress during our first telephone conversation, in which she requested an appointment. She started crying as she revealed that her baby had been born dead.
After the first session, I realised that I would like to study this case in depth. At the second meeting, I proposed that she participate in the research for my MA dissertation in Dramatherapy.
Iris was 43 years old at the beginning of the therapy. She worked in advertising and was also a creative writer. When I met her, Iris was unable to write the stories, books, and plays which formed an essential part of her reason for being. Iris impressed me as a woman with great creative potential and imagination who was blocked. Despite these personal strengths, she had been unable to liberate herself from her distress, depression, helplessness and loneliness.
Here follows an overview of the analysis and evaluation of the dramatherapeutic processes during the six sessions.
Session 1 The aim of this session was to develop a contractual agreement regarding the Dramatherapy, to establish a therapeutic relationship and to begin an assessment process (through encouraging Iris to tell her story).
My fmst impression of Iris, as she entered the room, was of someone performing the role of the tragic person. According to Landy’s (1 993) taxonomy, her role reminded me of the tragic hero (200), the zombie (201), or the lost one (230). She seemed to be bearing a very heavy burden, and her facial expression reflected suffering and isolation (Higgins, 1993 64; Jones, 1996 153)
As Iris told her story, I felt 1 was watching a scene of tragedy. Iris’ body state was an indication and a reflection of her mental and emotional distress. This impression was supported by her painfully sad story, repetitive themes and heremotional reactions. Iris seemed like an actor at her first audition in front of a new director. This led me to take a witness role, which I thought would be the most helpful to Iris in this situation Candy, 1992 106; Johnson, 1992 14, 127
Repetitive themes were raised - v u 1 n e r a b i 1 i t y , loneliness, avoidance of close friends who are pregnant or have babies, helplessness, closeness, passiveness, lose direction grief and anger.
At the end of this session, I suggested to Iris that we hold two-hour sessions because of her severe distress I thought one hour would not be sufficient.
Being in several internal states and roles, the most importantdecision1 madewas toletIrisdirectthetherapeutic process and trust her knowing what is good for her following Jennings’ (1998) view that ‘the more you can preserve some autonomy the healthier your clients will become’ ( 122).
Iris’ ‘reworking of her experience’, as a beginning process, was crucial for her.
Session 2 The aims of this session were to continue the assessment process, to reach a diagnosis and focus on Iris’ request for help, to encourage habituation to Dramatherapy, and to help the client express her emotions.
The process of assessment continued in the second session.
When I asked if she would like to express her here and now’ world with objects and not with words, I assumed that this would provide a non-threatening, gentle bridge to the dramatic structure, offering her a means of projection, and providing me with more information for the purpose of assessment. It is notable that whenever Iris was involved in ‘doing’, she stopped crying.
In making and talking about her first sculpted objects, Iris projected her inner world within a dramatic structure (Jennings, 1992 95). She expressed herselfthrough sculpting objects, showing - rather than telling - what her world looked like. (Jones, 1996).
Iris placed her innermost pain on the paper. A big stone, the largest object used in the work, represented not the stillborn infantbut ‘thegriefthatremained‘.Inthisprojection and reworking of her experience, it seemed that Iris admitted to herself, albeit unconsciously, that the stone was a symbol of the primary, main theme that disturbed and distressed her life. The very simple action clarified what she was unable to express in retelling, because of confusion, lack of focus and feeling overwhelmed.
The use of a large stone as a symbol of grief may be associated with the expression ‘from ashes to ashes and dust to dust’ and the fact that Iris’ daughter had been buried anonymously. Thus it might be considered part of a meaningful process for Iris: she had never been to her daughter’s grave, it has no headstone. Within the dramatic structure, Iris was able to make a symbolic and a private ritual of ‘burial’ and integration of her daughter’s death.
I wanted to let her direct the process, to experience a sense of control and feel less passive and helpless.
The other objects in the sculpture and the way she organised them express how she felt and how she perceived her life now - almost colourless and dull. In the work, her husband was smaller than the other objects. Neitherof them were ‘as they used to be’.
When she made the second object sculpture, about her future world, she stopped crying, chose many different shapes, and spread them all over the paper. In doing so, she looked less sad, made more movements, was less frozen, and more focused.
This, in turn, also affected the retelling process. She was able to express her pain more clearly, as well as see a better future. Perhaps the most striking comment on her part was her surprised reaction to the second, more hopeful object sculpture and the observed changes in her voice and
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her facial expression. For amoment the sadness and distress seemed to vanish, and her eyes lit up.
Session 3 The aims of this session were to encourage Iris’ emotional expression through dramatic structure directed toward grief work and expression of emotion, to cope directly with the prolonged grief and identify the main theme.
In this session, I offered Iris a new way of expressing feelings: oil crayons. When Iris began working, I noticed that she handled the crayon gently. As she continued, her hand movement became faster and stronger, and the lines were much brighter, more emphasised.
When Iris finished, I asked her what she wanted to do with her drawing; I wanted to let her direct the process, to experience a sense of control and feel less passive and helpless. Her reaction surprised me. Her facial expression was no longer full of pain and sorrow, but instead reflected surprise. With her eyes opened wide, she looked straight at me, and spoke in a higher, stronger voice. It seemed to me that she had suddenly gained strength throughout her body.
Now she had an opportunity to tell her story; it became a new story and she told it in a new way. She expressed optimism. Her body was more upright. Her facial expressions changed according to the story, she used her hands, her head was straight, her voice was audible and changed tones and rhythms to dramatise the story.
Comparison of Iris’ comments on her drawing with those regarding the two spectograms she made the previous week, reveals a repetition of symbols, colours, and themes. The colour blue and even the stain resemble the button used to represent herself. There are also themes of pain and sorrow created by the fertility treatment, and walls hindering the way to the future, where there is power. These themes recurred in the verbal communication, as well.
In addition to Iris’ projection through drawing and words, she was able, despite her almost frozen embodiment, to use her eyes and her hands. She chose the colours and spread them on the paper, first gently, then less so, observing the shapes and colours. Perhaps the very use of her sensory system helped her return to aprimary stage of development. Like a two-year-old child, she smeared the crayons; this, in turn, began a thawing of her frozen, traumatised embodiment (McMahon, 1996).
The development of the relationship between us, as dramatherapist and client, may also have made it easier for Iris to get in touch with her deepest pain and allowed her to express it. Twenty-five years before, I had suffered a similar tragedy and I had told that to Iris early on. My
explanation that I believe in learning how to live and cope with pain, rather than ‘throwing it away’ may also have provided her with insight.
Irisdrew her ‘memory box’, asmallcedarchest shehad received from her best girlfriends filled with their gifts for mourning and other memorabilia that she kept inside it. She wept - the only time in the course of these sessions that she cried while she worked. Perhaps by drawing her most private and intimate memories connected to her stillborn baby, and coming very close to the core of her grief, she sensed it with all her senses, and continued her weeping that had begun earlier.
Our discussion about a symbolic action related to the grief and Iris’ intention to build a memorial garden led to a new stage in my therapeutic relationship with Iris. For the first time, I spelled out our central issue, telling her that we were dealing with unresolved grief Iris responded with agreement, referring directly to the subject. I used repetition (out of role), as discussed by Johnson (1992 122).
At the end of the session, Ins compared the drawings she had made. She remarked on the expression in her first drawing of sadness and pain, compared to the sunny garden in the last drawing. In Iris’ exploration her emotions and discoveries were very meaningful in terms of grief work. It was the first time she had admitted to the emotions of anger and hate. Again, the projective work, the smearing of colour that evidently expressed rage, was translated by the end of the session into a verbal recognition of this emotion.
Session 4 The aims of this session were to process the last session, to continue the grief work of accepting and recognising the loss, and to express emotion.
This session was completely verbal, concentrating on talking about the previous session. I felt that at that point of her therapy, this unconscious process of symbolic and metaphoric enactment should become conscious (Jones, 1996). Iris herself used the words consciousness and imagination when she tried to understand what had happened to her through the projective process.
It was as if Iris was translating her doing and her reactions into her familiar language - words. This was her way of making order and finding direction in her chaotic inner world. ‘Treading safe ground’ after the last session, enabled her adjustment to the very rapid changes she had experienced through dramatic projection and re-working of her three years past of suffering, and the re-framing of her experience of the dramatic structure. Perhaps this was an important phase inthejoumey toward emotionalequilibrium and intellectual understanding, after her very profound emotional reactions.
Jones (1996) says that ‘closure often takes the form of discussion and reflection upon the work undertaken within the session’ (7). In the nine days since the last session, she had continued the work of that session. Now she had an opportunity to tell her story; it became a new story and she told it in anew way. She expressed optimism. Her body was
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more upright. Her facial expressions changed according to the story, she used her hands, her head was straight, her voice was audible and changed tones and rhythms to dramatise the story. She did not cry the whole session, even when she talked about sad issues.
Shehadtakenaction. Iriswasabletogotoherdaughter’s grave. While there, she had considered our talk about making a symbolic place for her, and she ‘spoke to her’. That day, before coming to see me, she had put a stone in her garden; she saw this as a project, something concrete, to make a place to put all the pains. These two actions represent very important and meaningful processes in grief work, especially where no concrete memories, such as a privategrave, remain. Iris wasable toperformtheseactivities very soon after the Dramatherapy began.
At the end of the session, Iris made another crucial step in terms of grief work, by showing me the memory box. She was capable of touching it, opening it, taking out the presents and the pictures. This kind of sharing is highly recommended in grief work; it represents acceptance, completion, saying good-bye. I did not ask her.to bring the box;itwasherchoice. Sheinvitedmetoparticipatewith her in sharing memories. I responded to her need for confirmation that it was truly happening to her it was not a dream.
Until now, if she did try to express her feelings, the response was advice, solutions, misunderstanding, lack of will to listen.
Session 5 The aims of this session were to continue the grief work, to help Iris express emotions, develop new skills, and reinvest emotional energy in the present. Iris started immediately to tell her story. It sounded as if needed to pour out her heart, to cleanse herself of her anger.
In sharing my feeling with her that we were dealing with the prolonged grief, I took a more directive role of provocateur, using repetition out of role.
Repetition. According to Johnson (1992), the therapist brings back a situation, image, conflict, word, or action again and again, so the client has a number of opportunities to be confronted with it. Instead of moving on and avoiding a situation, the therapist underscores its importance and places some pressure on the client to deal with it’ (122).
Johnson speaks about the therapist “in role” - within a role play with the client. I took the repetition role - not within a role play with Iris, but while we were talking and I called it ‘repetition out of role’.
I wanted to help her stay with the main issue and to enable the continuation of grief work (Johnson, 1992; Landy, 1992). This comment opened a wide and long
retelling about her difficulties and being stuck in prolonged grief. She cried when talking about her baby and fertility treatments, reaffirming my identification of the two main issues.
Iris then recalled her feelings about her painting from the third session. She talked about how shocked she felt upon realizing that the small blue cloud “was me” - “I didn’t know I was in such a state”. This led to a discussion of her talents and blocked creativity, her lack of self-esteem and confidence.
After an hour and a half of verbal communication, I reminded her that she had wanted to work in the sandbox (she chose clay instead), because I thought re-working instead of re-telling might be helpful. When Iris started to knead the clay, she stopped crying; her voice became louder and clear while she continued to tell her story. This was the first time she had worked and spoken at the same time. It seemed she couldn’t stop talking.
In this session, Iris verbally expressed her need and desire for therapy. It is important to remember that writing stories, plays, and novels was her unique talent and greatest strength, but she had not been able to create for a long time. Another important aspect of Iris’ prolonged grief and urgent need to retell her story might be that she had avoided exposing her distress in such a way to friends, doctors, or even psychologists.
Furthermore, until now, if she did try to express her feelings, the response was advice, solutions, misunderstanding, lack of will to listen. Perhaps this increased loneliness and isolation (another theme repeated in almost all the sessions).
It seems that Iris may have felt from the beginning of the Dramatherapy that she could use the whole stage to perform her own monodrama, and her way of playing the roles (without dramatic distancing) was to retell her story.
Inthissession,Iris wasnotinahurrytocreatesomething. She talked about gathering energy from everything she did and starting to become stronger, as she used to be. Her emotional state and embodiment were completely different from the previous sessions and from the beginning of this session. Perhaps her sense of feeling good came from doing something concrete.
Iris herself asked to make the other two clay pieces. This may also reflect a new role and skill; she had never taken such initiative before. These pieces werealsosymbols of herself in the past and her wish to experience her capability and creativity again. The bird might be explained according to Cirlot (1993); ‘it is a symbol of the human soul and every winged being is symbolic of spiritualisation’ (26). In talking about it, she also mentioned the eagle, a symbol of height. Cirlot (1 993) says that ‘the eagle is a bird living in the full light of the sun and it is therefore considered luminous in its essence’ (91). Thus it was as if Iris had unconsciously projected her strong wish to be connected to her soul, spirit, to be able to use her creativity and writing talent as before (‘everything came to me easily, nothing was difficult to me’).
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I n s left with a smile on her face, a straight body, a louder voice. She even laughed several times - a new reaction and she looked more energetic and vital.
Session 6 The aim of this session was to encourage the continuing grief work, expression of emotions, developing new skills, reinvesting emotional energy in the present, as a result of the changes in Iris’ emotional state.
The major changes in I n s ’ overall appearance and the apparent harmony between her physical and emotional state seemed to indicate that Iris was responding to the process. According to Landy’s taxonomy of roles, in this session, she seemed to be a ‘warrior’ (Landy, 1993 226)
In the course of the session, Iris also expressed some new emotional reactions -her sense of humour, laughing, surprise, courage, and strength to deal directly with anger and express it in various ways. New themes emerged and the old ones seemed to vanish. She seemed active energetic, alive, awake, initiating, and open, and reported she had stopped avoiding pregnant friends. Moreover, there seemed to be a major change in one of her most fundamental themes her unresolved prolonged grief. Iris said, ‘After putting the stone in the garden and planting some flowe rs... I feel much, really much more comfortable. I feel as if we finished.’ We shared happiness and joy about this development.
For the first time, Iris identified an issue other than the grief Until today, the themes and e otions she explored always referred to her two major issues - prolonged grief and what was happening to her as a result of fertility treatment.
After recognising her loss and working deeply and intensively, she felt more comfortable with these issues. She was able focus directly on what happened to her when she went to a hospital or a similar place (‘I get crazy and it is not like me, I am not a woman that goes hysterical; whenever there are problems, I find solutions.’) This reminded me of an early feeling that perhaps Iris was suffering post traumatic stress disorder. (The symptoms she reported corresponded to the criteria of DSM IV of the American Psychiatric Association, 1994.) Later, unresolved prolonged grief seemed to be the most pressing and deepest issue.
Iris felt as though she ‘had finished’ her prolonged grief, after an unexpectedly short period of therapy. As audience and witness, I followed her story and her associative way of thinking, which now connected her present state to the distant past.
It seems that Iris had found her hidden roles, such as her embodiment, her dramatic structure of the mind, and her functioning strengths. She became more capable, stronger, and active, enabling her to live with the conflict and the ambivalence.
In all the.sessions, no work had been done directly on roles or embodiment, all the work (including this session) was projective. Perhaps, however, this indirectly affected
f“
her embodiment and role system. This process may also be relevant to her grief work. Iris continued to develop new skills, the third task in grief work, in dramatic language. However, in her case perhaps they were not really new roles, but rather shattered ones. It seemed she was moving towards a more balanced and integrated life, that is, integrating her experience of loss.
When Iris had found her own symbolic and concrete place for her dead daughter, she felt much more comfortable and relieved. This probably enabled her progress in real life - being able to be with her closest friend who was now pregnant.
This session was the first time I had offered Iris a wide variety of dramatic modalities to choose from. She asked for something appropriate for dealing with anger, her hidden theme (mentioned in words only a few times). This was the first time I’d heard her directly address her anger. And yet, she looked very happy energetic joyful and in my terms peaceful and calm.
This dialogue and the work with finger paints was the closest work to embodiment stage she had done. I saw how she used only the tips of her fingers and took small amount of paint, although she felt she was in a whirlpool. I focused on her embodiment, and it seemed that she was handling anger very gently. Encouraged to take more paint by my promise of protection’, she projected her theme of anger both verbally and physically (her expression of disgust). This was another crucial hint for that we should progress very gently and carefully.
This led to deeper discussion of the theme of anger and ways of coping with it. In this dialogue, I decided to take a provocateur role deliberately, to help Iris come closer to her anger.
Her last story about what happened to her was told with satisfaction, smiles, a loud and clear voice, and upright posture. She looked proud and happy.
When I encouraged Iris to express her anger non- verbally, she smeared the paint with large movements. It was the first time I had seen her body move so energetically actively. She used power when hit the paper, and her face expressed anger. The revelation through this drawing was that she felt good when she hit the paper and that she could fight back. It seems that this was made possible because Iris felt contained and safe enough on stage to take the risk.
Her long journey through anger was important to Iris not only in order to learn to fight back. Her problem with anger, one of the emotions related to grief, might have been one of the factors that caused her to be stuck in prolongd grief
When I suggested she write, using her unique talent and creativity to continue feeling stronger and capable, Iris asked instead to make a painting she’d been thinking about
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all week. It was a correction of last week’s work: I didn’t like what I made’. Something new had emerged from Iris’ inner self, with the blue sapphire, she expressed her changed feelings, embodiment, and roles.*
It seems that the process had helped develop her awareness and insight, and review her life. Her remarkable talent and imagination seemed to be restored. She was able to use a new symbol of herself in her real life, to translate it into more concrete action, and to regain her confidence.
Her last story about what happened to her was told with satisfaction, smiles, a loud and clear voice, and upright posture. She looked proud and happy.
The session ended with Iris’ comment on Dramatherapy : ‘I feel that the treatment is very helpful to me, it is concrete and not just words like in psychology and each time I leave our sessions I feel good and I have the power to do things I wasn’t able to do until now’.
Iris’ sadness, pain, sorrow, depression, weakness, nightmares, passivity, helplessness, and loneliness - all major symptoms - were the reason for her coming to Dramatherapy. By the sixth session, they no longer existed. Instead, she expressed energy, liveliness, optimism, satisfaction, laughter, activity, and initiative.
Summary Dramatic retelling and reworking of experience through projection, especially using projective means, may be useful in treating prolonged grief reactions of women experiencing stillbirth tragedy, as it was in this case. Dramatic projection is avery enlightening, enabling, and non-threatening process. It has two major aspects exploring inner conflicts and hidden unconscious issues and, at the same time, allowing the therapeutic healing process itself (Jones, 1996).
In the case of clients who barely move or whose state indicates difficulties with embodiment, and those who are emotionally overwhelmed or depressedllike Iris state at the beginning of her treatment), dramatic projection using sculpting, clay, and paints can be very helpful and effective. Experienced dramatherapists use these means early in the treatment with their clients (Jennings, 1992, 1998; Jones, 1996; Landy, 1993). Jennings (1992) explains that ‘when a client creates a sculpture or other life picture, they have entered into a dramatic structure, created a scene of the drama of their life, like miniature theatre’ (95).
The four dramatherapeutic techniques that the client chose and employed may indicate her condition at the beginning of the treatment - not only her emotional, mental and functional state. but also her EPR development: it was as if she had been stuck for 3 years. Even though she had the ability to use embodiment and roles effectively, in her present state of lack of energy, depression, grief, and frozen body, she was unable to express this ability, and could act only through projection. The impact of using these techniques on this general state of being were profound, immediate, and very meaningful.
The client’s state dictated my suggestions, which were aimed at encouraging her to express herself through drama,
in addition to verbal language. Sculpting, touching, sensing, seeing, smelling - all basic senses and fundamental components - helped Iris express her main issues and promoted the therapeutic process.
It seems that the client’s recovery and the changes she experienced were related to the processes she underwent.
The outcome of this research may contribute to the study of how to treat grief and encourage integration of loss through Dramatherapy. The research may also contribute to the appreciation of some unique aspects of grief after stillbirth and how treatment, in general, and dramatherapeutic techniques, specifically, may assist clients in processing their grief, integrating their loss, and finding the energy to invest in a new life.
This research may be helpful in raising the awareness of gynaecologists and nurses in the delivery room to the deep, painful tragedy of stillbirth, and its mental and emotional implications for women. It may help them to be more empathetic and understanding, to refrain from rushing to give advice (or promises, such as ‘next year you’ll have another baby’) and to address the grieving process.
Professionals working in related field (social workers, psychologists, etc.) might gain an understanding of the healing potential of Dramatherapy for clients with prolonged grief following stillbirth and perhaps other forms of grief Women who experience similar events may benefit from knowledge of this form of therapy, which may help them to achieve recovery, as well. Appropriate early treatment may reduce the need for long-term therapy, the appearance of prolonged grief, and unnecessary suffering.
About six months after the 20 sessions of Dramatherapy hadbeen concluded, Iris decidedto stop fertility treatments. She accepted the fact that she wouldnot be able to conceive naturally, and hoped to live in peace with this and with hersel$
Two years later, she spontaneously conceived a child (at age 46, a medical rarity) and now is mother to an adventuresome, curious baby boy.
NOTES AND REFERENCES 1 Complicated grief can be: delayed grief, when the
recognition of the loss is postponed; chronic grief, which is associated with instances in which theexpected range of reactions is present, but the bereaved person does not recover from them; and absent or distorted grief, in which, according to Raphael (1984), one aspect of grief is emphasised and others often suppressed. Worden (1991) identified complicated grief as (a) chronic grief, (b) delayed grief, and (c) exaggerated grief (7 1-77).
2 According to Cirlot (1995). the sapphire, or ‘lapis lazuli’, as it was called by the Romans ‘was supposed to be able to prophesy by changing its colours’ (313-3 14).
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Dramatherapy Vol24 No 1 Summer 2002 ‘Stillbirth Integration: Dramatherapy applied to unresolved grief
Furthermore, the sapphire is the second-hardest stone, after the diamond.
A Handbook for the Mental Health Practitioner, 2nd ed. (first edition published 1983) London: Routledge
BIBLIOGRAPHY American Psychiatric Association (1994), DSM I V Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Washington, DC: American Psychiatric Association Cirlot, J. E. (1993) A Dictionary of Symbols, New York: Barnes Noble Books Gersie, A. (1992) Storymaking in Bereavement: Dragons Flight in thenlieadow, London: JessicaKingsley Publishers Higgins, R. ( 1993) Approaches to Case Study: A Handbook for Those Entering the Therapeutic Field London and Bristol, PA: Jessica Kingsley Jennings, S., ed. (1992) Dramatherapy TheoryandPractice 2, London and New York: TavistocklRoutledge Jennings, S. (1998) Introduction to Dramatherapy Theatre and Healing: Ariadnes Ball of Thread, London: Jessica Kingsley Johnson, D. R (1992) ‘The Dramatherapist “In-Role”’, in Jennings, S., ed. Dramatherapy: Theory and Practice 2, London and New York: TavistockRoutledge, 112-136 Jones, P (1 996) Drama as Therapy: Theatre as Living, London and New York: Routledge Landy, R. J (1992) ‘One-on One: The Role of the Dramatherapist Working with Individuals’, in Jennings, S., ed. Dramatherapy: Theory and Practice 2, London and New York TavistocklRoutledge. 97-1 11 Landy, R. (1 993) PersonaandPelforrnance - The Meaning of Role in Drama Therapy and Everyday Life London: Jessica Kingsley Publishers k i c k , N. and Davidsen-Nielsen, M. (1996) Healing Pain, New York: Routledge Littlewood, J. (1996) ‘Stillbirth and Neonatal Death’, in Niven, C. A. and A. Walker, eds. Conception Pregnancy and Birth, Oxford: Butterworth-Heinemann, 148- 158 McMahon, L. (1996) The Handbook of Play Therapy, Kiryat Bialik, Israel: Ach (in Hebrew) Rfidestad, 1. (1998) ‘Abstract in English’, in RSldestad, I. Att Foda Ett Dott Barn (Giving Birth to a Stillborn Child), Stockholm: Karolinska Institutet, 4-9 Ri%destad, I. , G. Steineck, C. Nordin, B. SjBgren (1998) ‘Psychic and Social Consequences of Women in Relations to Memories of a Stillborn Child: A Pilot Study, in Rhdestad, 1. Att Fuda Ett Dott Barn (Giving Birth to a Stillborn Child), Stockholm: Karolinska Institutet, 194- 198 Rando, T. A. (1991) How To Go On Living When Someone You Love Dies, New York and Toronto: Bantam Books Stillbirth and Neonatal Death Society (SANDS) (1991) Miscarriage Stillbirth and Neonatal Death: Guidelines for Professionals, London: Stillbirth and Neonatal Death Society WiSSP (Wisconsin Stillbirth Service Program Website) (1997) WiSSP Home Page (http :llwww. wisc. edu/wisp/), 26 October L997 Worden, J. W. (1991) Grief CounsellingandGnef 7kerapy:
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