drama and movement therapy

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Thinking, Feeling and Moving: Drama and

Movement Therapy as an Adjunct to a

Multidisciplinary Rehabilitation Approach for

Chronic Pain in Two Adolescent Girls

DEBORAH CHRISTIE , DEBORAH HOOD &

ANGELA GRIFFINUniversity College London and Middlesex Hospitals, UK

A B S T R A C T

Chronic Pain without an identifiable organic basis represents a substantial elementof referrals to both medical and mental health professionals. Chronic pain cancompromise independence, school attendance, physical and social activities. Thetendency to label ‘nonorganic’ pain as having a psychological origin is usuallystrongly resisted by parents and young people with treatment creating a significantchallenge for health care professionals. Collaborative, multidisciplinary treatmentprogrammes encourage families to find ways of getting on with their lives by taking

a proactive approach to challenging pain. The family is invited to join with theteam in the task of challenging the pain through the use of physiotherapy toincrease strength, stamina and suppleness alongside a range of individual andgroup activities that can include relaxation training, hypnotherapy, systemic andcognitive-behavioural approaches. This article describes how drama andmovement therapy was introduced as an additional component of the treatmentprogramme of two adolescents who had been long-term inpatients on a medicaladolescent ward. The experiences of adding a complementary therapy to theprogramme are described to illustrate a creative way of contributing to establishedtreatment programmes through the use of sound, movement and gesture in orderto provide a space to explore new ways of being and expanding abilities.

K E Y W O R D S

adolescence, chronic pain, movement therapy, rehabilitation

C HR O NI C PA IN W IT HO UT an identifiable organic basis occurs in 4 to 15% of thenormative adolescent population, and represents a substantial element of referrals toadolescent medicine and adolescent rheumatology clinics. Chronic pain has a complexneurological and psychological aetiology, and may supervene in organic diseases thatalso cause pain, such as juvenile idiopathic arthritis (Goodman & McGrath, 1991).

Clinical Child Psychology and Psychiatry Copyright © 2006 SAGE Publications (London,ThousandOaks and New Delhi) Vol 11(4): 569–577. DOI: 10.1177/1359104506067878 www.sagepublications.com

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Extensive investigations followed by a wide range of medical interventions and physicaltherapy often produce very little amelioration of symptoms and little understanding of the cause of the pain. The clinical picture becomes increasingly complicated when thereis no underlying disease process or the injury site has healed but the pain persists.Goldberg and Huxley (1992) talk about the frequent appearance in primary medicalcare of individuals with pain for which no physical problem can be identified or painwhich is greater than the presenting pathology. For some, the pain marks a gradual butinexorable downward spiral towards long-term physical disability (Ciccone & Lenzi,1994).

Chronic pain has a significant impact on the successful completion of the develop-mental tasks of adolescence. It can compromise successful negotiation of independenceand disrupt school attendance as well as other physical and social activities. Age,gender,developmental level, previous experiences of pain and situational and psychologicalfactors all play a role in the impact of pain on daily living.

Low perceived levels of control over the pain, particularly in young women, are oftennoted to exacerbate symptoms (Dunn-Geier, McGrath, Rourke, Latter, & D’Astous,

1986). There has been and continues to be a tendency to attribute pain of this kind topsychological problems and in the past it has been labelled psychosomatic or hysteri-cal pain although there is a push to move away from using this terminology (Rutter,Taylor, & Hersov, 1994). The treatment of chronic pain has been referred to as ‘one of the most widespread and difficult challenges facing health-care professionals’ (Pearce& Mays, 1995).

A dualistic approach to physical and psychological problems has persisted through-out the centuries with a firm divide between the mind and the body. Western religioninfluenced important thinkers and scientific discovery by dictating that an inflexiblepartition was maintained between the body and the mind (Williams & Erskine, 1995).

This can be seen particularly in the writings of the 17th-century philosopher, Descartes,who proposed that the body could function successfully without the mind. Since this

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 11(4)

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A C K N O W L E D G E M E N T S : We would like to thank both of the young women who agreed to join us in our search for a greater understanding of ways to challenge pain. We would alsolike to acknowledge the clinical supervision to Deborah Hood from Rachel Melville-Thomas,Child Psychotherapist and Dance and Movement Therapist.

D EB O RA H C HR I ST IE is a Consultant Clinical Psychologist and Honorary Senior Lecturerat University College London Hospitals. She has a background in neurobiology and

neuropsychology. Her current clinical and research interests include helping young peopleand their families live with chronic illness.

C O N T A C T : Deborah Christie, Department of Child and Adolescent Psychological Medicine,West Wing,250 Euston Road, London NW1 2PG, UK. [E-mail: [email protected]]

D EB O RA H H O OD has a background in the performing arts and through her study of creativeexpression led to the realization of the potential of this medium for self-exploration andtransformation. She works as a freelance drama and movement therapist with varying clientgroups alongside her practice as a massage therapist.

A N GE L A G R IF FI N is a Clinical Psychologist at University College London Hospitals. She

trained at Queens University Belfast and Boston VA Hospital. Her current clinical interestsare neuropsychology and management of pain and chronic conditions affecting children andadolescents.








time, physicians have viewed illness and disease as the product of abnormalities at thecellular and organic level, and as such physical evidence became the only marker bywhich diagnosis and treatment took place (Salt & Season, 2000). The first person tochallenge the biomedical model was Freud, who suggested that the psychological andsocial environment had to be considered in the assessment of physical health but itwasn’t until the 1970s that the biopsychosocial model of health, disease and illness wasput forward by Engel (Salt & Season, 2000). The advances made in understandingchronic pain have indicated that it is not possible to predict the degree of pain or theresulting disability on the basis of the injury alone (Turk, 1996). Nevertheless, scienceand philosophy of the Renaissance continue to dominate western language and culture.Schober and Lacroix (1991) state that research has shown that the opinions people holdregarding health and illness have changed little since the days of Descartes.

This view is mirrored by the difficulty parents and adolescents experience when facedwith ‘physical symptoms’ in the absence of a specific medical diagnosis and a subsequentlack of an effective medical treatment. Referrals to mental health professionals are oftenresented and resisted by both families and the young people, resulting in a therapeutic

impasse. Psychodynamic approaches which look for underlying family conflict arestrongly resented while cognitive-behavioral approaches may not fit for young peoplewho cannot make a connection between their thoughts and the experience of pain.

Multidisciplinary rehabilitation approaches explicitly acknowledge the reality of thepain while emphasizing the necessary involvement of both mind and body in therecovery process (Calvert & Jureidini, 2003). Parents and young people are encouragedto stop searching for a cause and find ways of getting on with their life. Acceptancemeans taking a proactive approach to challenging pain and encouraging young peopleto move forward and collaborate in the multidisciplinary treatment programme. Gradedphysiotherapy aims to increase strength, stamina and suppleness complemented by a

range of additional psychological and physical therapies. A range of strategies are usedto engage the young person and parents to join with the team in the task of challengingthe pain. Although cognitive-behavioural therapy remains the most effective psycho-logical intervention for organically mediated pain (Walco, Varni, & Ilowite, 1992) thereis less evidence that these approaches are as effective in nonorganically mediated painconditions.

The stance of the team is to keep focused on the potential for future recovery. Youngpeople work with a multidisciplinary team including a medical doctor, physiotherapist,occupational therapist, social worker and psychologist. The team uses relaxation, guidedimagery, and systemic, cognitive and behavioural techniques in order to engage with theyoung person in order to match the treatment to the individual. Pharmacological

therapies also contribute to the multidisciplinary treatment programme and acupunc-ture can be offered as a treatment approach (Rusy & Weisman, 2000).

There is a significant increase in the use of complementary and alternative medicaltherapies in paediatric and adult populations with adolescent use ranging from 50 to75% (Gardiner & Wornham, 2000; Wilson & Klein, 2000). This article describes howdrama and movement therapy was introduced as an additional component of atreatment programme of two adolescents who had been long-term inpatients on ourmedical adolescent ward.

A systemic approach makes sense of ‘mind/body problems’ as being a ‘socialformation’ involving complex interactions of emotions, knowledge and expression.

Griffiths and Griffiths (1994) describe how physical symptoms are sometimes describedas ‘the public performance of an unspeakable dread’. It follows that creating a context(or space) within which the young person or their family can freely express previously

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silenced stories may bring dramatic relief. Seeking ways to facilitate this freeing of expression is a challenge for therapists. One difficulty is that if a young person or theirfamily feels threatened or challenged by attempts the therapist makes to elicit unspokeninformation, they are likely to distance themselves or defend themselves. This may beexpressed by an exacerbation of the symptoms we seek to help. There is a need thereforeto create opportunities for reflection and creative problem solving. The aim was to usecreative expression to give each individual an opportunity to explore their experienceof ‘physical disharmony’, and the limitations the chronic pain had inflicted on them. Theaim was to encourage the young person to use their body to communicate thoughts andfeelings. It was hoped that the congruence between movement therapy and theirnonverbal style of expression might allow exploration of feelings which were either noteasy to speak about or not accessible.

Drama and movement therapy

Sessions focused on awareness of movement, and included massage techniques to help

support the process of sensory awareness. Massage has long been used in the treatmentof stress-related muscular tension. Research has shown its effectiveness with chronicpain sufferers (see http://www.centerforhealthstudies.org).

Movement with touch, alongside massage, played a key role due to the amount of physical tension experienced by each individual. The therapist (DH) encouraged anawareness of psychic energy through physical sensation, and facilitated an explicitdescription of where the energy feels ‘bound and stuck’ (Keleman, 1975; McNeely, 1987;Mindell, 1982). The work is based on a view that difficulties can be revealed throughmetaphor, drawing on the work of Jung and the idea of the self-regulating system (Storr,1983). Clients are encouraged to explore ‘presented’ physical symptoms through expres-

sive use of the imagination through sound, movement and drawing. Working withmovement allows physical impulses to be expressed and gives the client an opportunityto look at thoughts and feelings in relation to both psychological and physical symptoms.The aim of these sessions was to become conscious of an experience of ‘being with theself’ regardless of physical discomfort. Physical contact has the potential to make an indi-vidual aware of basic instincts, highlighting thoughts and feelings (both emotional andphysical) through the senses. Touch plays a crucial role in early stages of human develop-ment and can bring awareness to bound, or held, areas of the body and offer a contain-ing space in which to release tension. This is done in conjunction with a focus onbreathing. This then allows a reintegration between bodily expressions, thoughts andfeelings.

Cases

Case 1C developed lower back pain at 8 years of age. Despite extensive physical investigationsno organic cause for the pain could be found. The pain increased in severity and spreadto other parts of the body until she could no longer walk and required a wheelchair inorder to mobilize. The pain was described as continuous and unremitting with occasionaltremor in the legs and severe radiating attacks of acute pain. A wide range of pain medi-cation produced no significant improvement. Acupuncture was described as helpful and acourse of lignocaine infusions (nerve block) produced limited short-term benefit but no

long-term improvement. Regular physiotherapy, occupational therapy, individualpsychotherapy and family therapy had little impact on reported pain.


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Case 2B presented at the unit with a 1-year history of shoulder and neck pain which was initiallytriggered by a minor sports injury. The pain persisted long after the injury should havehealed. It became worse as time went on and had not been helped by a period of intensiveinpatient physiotherapy at local hospital. Although she was able to walk, B preferred touse a wheelchair. Her shoulders were extremely tense and were held shrugged up towards

her ears. She cried constantly and seemed fearful of having anyone touch her.In the first weeks following admission she deteriorated further. She adopted a

permanent waking position of arms crossed over her chest with each hand lying by theopposite ear. She was unable to sit up and was completely dependent on staff and herparents for every aspect of care. She was visibly distressed by pain at all times. Medicalinvestigations were abandoned as organic, identifiable causes were ruled out. Treatmentssuch as nerve blocks by the anaesthetist were not of significant benefit.

Treatment programmeC and B worked with the multidisciplinary team over a period of 14 and 19 monthsrespectively. The goal was to gradually reduce their experience of pain and increasemobility. Both girls received regular physiotherapy, occupational therapy, and individualpsychotherapy. Hypnotherapy was also used with both girls. C reported that thehypnotherapy helped her relax during the sessions but did not find it helpful otherwise.Hypnotherapy was used with B in sessions with the occupational therapist to help hercope during the splinting of her arms which had become ‘locked’ across her chest. Eachweek the splints were used to open up her elbow joint by an extra five degrees until shewas finally able to straighten and flex her arms again.

Systemic family therapy was offered to both families. Following the initial consulta-tions B’s parents continued to attend family sessions. C’s parents did not find these usefuland declined any further sessions.

Following discharge as inpatients both girls returned home and started attendingschool using a wheelchair. They returned to the unit one day each week for continuedinput from the rehabilitation team. C continued to experience significant pain,used indi-vidual psychology sessions to identify ways of getting on with her life and not letting thepain prevent her from doing things. While B was no longer plagued by her pain sheappeared to have reached a plateau in terms of mobility and continued to use a wheel-chair. We were aware that both continued to forge ahead in reestablishing their social,family and school life. Both girls enjoyed drama at school and were keen to take up theoffer of six sessions of drama and movement therapy as an adjunct to their ongoing reha-bilitation programme.

The second author (DH) met with the girls and their parents to discuss the rationalebehind the therapy. The sessions were designed to create a space where they couldexplore psychological and physiological ‘processes’. The goal was to acknowledge andintegrate sensory awareness into the experience of the whole self rather than viewingthe mind, body and emotions as separate and independent entities.

The aims of the sessions were to:

■ Develop a greater sense of self;■ Become more physically conscious;■ Explore ways of expressing thoughts, feelings and emotions;■ Explore how the mind and body relate.

Throughout the sessions they were encouraged to listen to and explore physicalsymptoms, primarily through movement. This inevitably led to dramatization where the


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girls were encouraged to put their thoughts and feelings into ‘motion’. The therapistwould at times mirror back what she saw in a playful and interactive way.

For these two young people who were deeply and profoundly affected by physicaldiscomfort the application of massage techniques (body work) at the beginning and endof the session was of great benefit, not only in relaxation but also by putting them intouch with their bodies by developing self-awareness and integrating unconsciousknowledge of the body into consciousness. Each physical gesture is seen as an expressionof some part of a person’s being therefore every movement, however small, wasacknowledged. If the client appeared stuck, the therapist would ask the client whatsensations, either physical or emotional were being experienced, and if appropriate thetherapist would feed back what she was experiencing in the observation.

Once physical symptoms are felt and acknowledged, exploration is encouragedthrough movement, sound and active imagination. This includes the awareness of breathand rhythm. Movement-observation techniques are used to gain clarity of movementand gesture. Applying qualities of energy, space, time and flow offers a greater under-standing of how to work with the individual (see Newlove, 1993, 2004).

As the client leads the sessions the level of interaction would vary from week to week.At times the therapist acted as a silent observer, and at other times would interactallowing a dialogue of movement to develop. At the end of the session, there was a brief discussion and summary of what happened in the session.

Each client was given a notebook to record what happened in the sessions and alsoanything that happened between sessions that they felt was relevant. It was the clients’decision if they wanted to bring it in and share it with the therapist. Each of the sessionswith the drama therapist was followed by a weekly psychology session. B invited thedrama therapist to join the first few minutes at the beginning of each session so that shecould share anything that had emerged which she was keen to explore further.

Session feedback Trust is an extremely important aspect of this work as some of the creative expressions(e.g., the use of movement and voice) appeared to seem ‘weird’ and ‘embarrassing’. Onceit was established that the work was interactive then self-permission to trust and partici-pate seemed to grow from week to week.

Both clients responded very differently. C’s continuing experience of acute andchronic pain reinforced her, and her family’s, view that this was a medical condition thathad been ‘missed’, despite repeatedly negative investigations. She was a practical andcapable young woman who remained confused and distressed by the way pain hadstolen her adolescence and was preventing her from becoming an independent young

adult.C took a quite passive approach to the work. Sessions consisted primarily of massage

and movement with touch work. She appeared most comfortable when she let thetherapist take the lead. This changed slowly over the weeks with the introduction of voice work, initially through breath awareness leading into sound, while the therapistsupported physical release through body work. For example, while applying gentlepressure and passive movement to C’s tense and painful thighs, the therapist asked herto make sounds that reflected how the legs felt.

At the end of the project C commented that she found the relaxation through massageto be the most beneficial and of being ‘more conscious of tension and holding on, that

is, unclenching jaw’. She reported ‘the hardest part was using the voice. But now enjoyedit.’ She reported the most beneficial experience as creating a space to relax and allowher to become aware of different body sensations.


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In contrast B was less focused on the detection of a medical cause for her illness. Shewas very open to exploring the connections between mind and body, the unconsciousand the conscious. This approach reflected her efforts to gain an understanding of whathad happened to her and also her willingness to take opportunities for further progress.This seemed to be reinforced by her experience of using hypnosis to help her with thearm splinting. B had viewed hypnotherapy as a way of releasing the potential of herunconscious mind to help her body.

B was more actively engaged in the work, being very willing to verbally express howshe felt. Body work was carried out more in the form of holding and breath awareness,also talking her through self-massage. B was very keen to use movement in the sessions.

She was particularly intrigued by the accuracy with which her body expressed feelingsshe had previously had limited awareness of. These included anger and also sadness andaffection for her body and mind and what they had endured. She pinpointed her growingconfidence in her feelings and her expressions as being right for her and she found thisliberating. The sessions helped her realize that what she experienced was legitimate andshe did not need to check out if it was right or wrong with anyone.

B considered the experience beneficial. She observed that during her time in hospitalthere had been such a focus on her physical symptoms that she felt her body had let herdown or betrayed her. The drama and movement therapy had helped her reintegrate hermind and body. It helped her feel friendlier towards her body, to regard it as an ally, anessential and integral component of herself, rather than a foe. The emphasis on theoneness of mind and body cast a new light on the earlier search for a ‘cause’ and pointedher in the direction of a future where unity and wellness of both mind and body areessential for the health of the whole self. At the end of the sessions she wrote to theteam:

This 5-week block of holistic therapy has helped me to understand my body and

its capabilities, by letting me explore and create my own movements and soundswithin my own limitations/abilities.

As an open-minded individual, who was very welcoming to this new treatment,I found it fascinating to interpret what it was, but even more so by getting involvedwith the treatment and thoroughly enjoying it! I was given my own scrapbook, sothat I could record any feelings, memories, or emotions that I felt during my week.Deborah and I would then discuss my drawings/words etc., and translate them intomy own pattern of movement or sound. This was a great way to express myself without feeling saddened by my physical limitations.

A final comment

B continued to make progress and found the continuing multidisciplinary supporthelpful and useful. She has stopped using a wheelchair, attends school full time and hasa busy and active social life. In contrast C no longer found the programme useful andthe family agreed her support should be transferred to local services. Despite continu-ing to experience pain, she completed her exams and made plans to go to university andlive as independent a life as possible.

Both of these young women had part of their adolescence ‘hijacked’ by chronic pain.Intensive rehabilitation support helped them move from a focus on disability to identi-

fying ability. Moving from disability to ability also requires the team to think abouttreatment goals creatively and not allow the pain to restrict our work as professionals.Redefining outcome in collaboration with the young person as ‘getting your life back on


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track’ is an important part of this process. This adjunctive treatment was enjoyed andreported as beneficial by both girls. A dominant story is often that our goal asprofessionals is to find a cure, which by definition is to remove the pain. However, it maybe more realistic to focus on ensuring that young people can get on with their livesregardless of whether we and the young person work out how to ameliorate the ongoingsymptoms. We believe that the adjunctive drama and movement therapy sessions madea contribution to this holistic approach to pain management and, best of all, made theyoung people ‘feel good’. The next step must be to develop a way of determining to whatextent it might make a contribution towards symptom alteration and reduction.

Increasing our knowledge of the psycho-physical relationship may provide vital infor-mation on the healing process. Both are aspects of the whole individual and intuitivelycan be seen to reflect each other. As professionals we need to be open to the new andthe unknown. We must find a balance between the ‘evidence base’ and our clinicalintuition and try to create space to develop original and possibly better treatments foryoung people for whom a limited or no ‘evidence-base’ exists. We suggest that for someyoung people disabled by pain or immobility this approach is a creative way of contribut-

ing to established treatment programmes by including the use of sound, movement andgesture, to provide a space to explore new ways of being and expanding abilities.

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