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d is a b il it y

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r e h a b i l i t a t i o n , 1999 ; v o l . 21, n o . 4, 162 174

Clinical e ectiveness of dramatherapy in the recovery from neuro-trauma

Rookwood Hospital, Llanda CardiCF5 2YN, Wales, UK ,

Accepted for publication: July 1998 Abstract

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cation of social relations, described by Duggan and Grainger as keeping ` our balance among the con icting demands and pressure of the social networks that sustain us, but also distort our judgement, circumscribe our awareness and most important of all restrict our freedom to be ourselves. We are pulled this way and that in the present by others present . (p. 105) This study explored the use of dramatherapy in mediating adjustment to neuro-trauma within the hospital setting. The rationale for this lies in the power that subjective perception has to change the individuals relationship to actual or external reality, a relationship currently emphasized in clinical health research. Johnston# in her model of disability described the failure within the health setting of current practice and measures of outcome to allow for this crucial stage in adjusting to physical disability. The medical model of care which has characterized the health service for most of its existence has viewed health mechanistically as a lack of physical in rmity. In rehabilitation terms, this criterion looks to objective physical measures such as mobility, physical strength and lack of physical disability to gauge recovery. The traditional model of disability, current in the health service and embodied in the World Health Organisation model 1980 $ similarly assumes a simple causal link from physical impairment to handicap outlined as shown here :
Disease or disorder ! impairment ! disability ! handicap

Purpose : To investigate the clinical e ectiveness of a short course of dramatherapy (an eclectic term encompassing all the arts therapies), delivered in a one-to-one interaction, in a sample of 10 patients in a neuro-rehabilitation unit. Method : Each participant received ve individual one-to-one sessions of therapy over a 5 week period. A semi-structured interview was carried out with each participant following the course. Results: Qualitative analysis of the taped interviews elicited how the therapy contrasted and complemented the rest of the rehabilitation setting and therapies and how it helped psychological adjustment to severe disabilities resulting from neurotrauma. There were four ways in which it appeared to empower the participants and nurture their self esteem. It provided them with a sense of personal space in an otherwise institutional setting; it allowed escapism and enjoyment; it awakened creativity and a sense of potency; and it provided a metaphor to explore personal issues. Conclusion : Dramatherapy made an important contribution to the healthy adjustment of some patients both to hospital life and to acquired disability. The reports from the patients indicated that this approach to rehabilitation should be further incorporated and developed in neuro-rehabilitation.

Introduction The majority of people in a neuro-rehabilitatio n unit have shared the same trauma of a sudden, life threatening event which leaves devastating sequelae a ecting physical and} or cognitive status. The psychological e of such ects trauma are aptly described by Duggan and Grainger" as ` capable of shattering our equanimity to such a degree that we are cut completely adrift from our existential moorings and thrust into an ocean of fears and inadequacies, a turmoil of existential chaos . (p. 64) At the same time, the individual has to negotiate his} her new role as a patient and meet the expectations of family and sta(as well as their own) in adjusting to disability and in learning new skills. This process is an intensi* Author for correspondence.
0963 8288} 99 $12.00 #

This simple linear relationship does not hold up to clinical experience. A `good outcome following rehabilitation often exists alongside social or emotional misery and distress. In examining and integrating psychological models of adjustment (emotional, behavioural and coping models) Johnston proposed that impairment also gives rise to mental representations which can a coping behaviours and moderate the ect
1999 Taylor & Francis Ltd

Dramatherapy and recovery from neuro-traum a relationship between impairment and disability. Johnston further found that mental representations could predict level of disability when coping behaviours (as taught by therapists) did not. To maximize the chances of a positive adjustment to disability, rehabilitation programmes need to address mental representations and subjective perception in patients. The health service is presently revisiting a psychosocial concept of health which addresses quality of life and which includes a state of subjective well-being. This move is re ected in the World Health Organisation, WHOQOF Group 1994$ which now de nes quality of life as
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`An individual s perception of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept incorporating and a ected in a complex way by the person s health, psychological state, level of independence, social relationships and their relationship to salient features of the environment . In practice, there still remains the problem of how to redress the balance and nurture psychosocial well-being within the healthcare setting. The following project re ects one attempt to supplement the traditional medical model of care with the newly evolving psychosocial model of care within the health service, and within rehabilitation in particular. Dramatherapy refers to the application of all creative, artistic and imaginative activities to produce positive change in people within a focused therapeutic context. Its therapeutic e is attributed to the belief that the ect reality experienced through imagination is capable of providing as much an e on ones being as actuality ect and can provide as potent a vehicle for coming to terms with reality as objective experience.% , & All of these bene ts apply to dramatherapy work, whatever the setting. More speci cally, in the context of working with clients who are having to adjust to physical and} or neuro-disability, traditional therapies (physiotherapy, occupational therapy, speech therapy and neuropsychology) necessarily address the objective world and the fact of disability, continually reinforcing the loss and change. Dramatherapy can release the individual from the immediate present and give time to explore those parts of the subjective world untouched by the present loss. Some anecdotal evidence for bene ts of this in the rehabilitation setting arose when the dramatherapist piloted some experimental sessions within Rookwood on a one to one basis with a heterogeneous group of patients from January to March 1995. This

method of `open sampling produced positive feedback from patients and sta and warranted further exploration of potential bene ts. This study represents an attempt to evaluate formally the e ects of dramatherap y intervention on the recovery process following severe neuro-trauma. The approach best suited to the aims of the study was that of grounded theory, , ( which allows for theoretical formulations to emerge from the process of investigation as an end product. Thus, no a priori hypotheses were formed beyond a general understanding that the therapy would essentially engage the client in a creative process which is understood on some level to be personal and symbolic to them, and that this would be of heuristic value in their adjustment to the hospital setting and their acquired disabilities. Method c h o ic e o f p a r t ic ip a n t s Originally, patients recovering from head injury were to be targeted but this proved too narrow a selection, given the constraints of the research timetable and the availability of patients. In particular, care needed to be exercised in predicting the likely length of hospitalization for each patient. Consequently, the selection criteria were expanded to include any patient with a traumatic event to the central nervous system producing severe and sudden disability. Ten completed the course, six patients were recovering from head injury, one from a cerebral vascular accident, two from removal of a cerebral tumour and one recovering from Guillain Barrie syndrome. st r u c t u r e o f t h e t h e r a p e u t ic in t e r v e n t io n

The introductory session included an interview with the dramatherapist in order for her to prepare an individual programme of activities based on the interests of the participant. The following week therapy was commenced on a one to one basis with the participant and dramatherapist and this occurred for 1 hour each week for 5 consecutive weeks. In the fourth session, a Video camera was positioned in a corner of the room to allow later observation by the neuropsychologist . c o n t e n t o f t h e t h e r a p e u t ic in t e r v e n t io n

The therapy used various artistic forms of creative expression, within an aesthetically pleasing environment, in order to stimulate and release the imaginative and creative ability of the participant. The activities could either be used in self reference to address present concerns and di culties, or could be externally focused and 163

P. McKenna and E. Haste distanced from self, as each participant wished. Using visual images, objects, music, making materials, maps, myths and legends, poems, relaxation techniques and visualization, clients engaged in creating sound recordings, stories, pictures, landscapes and sculptures. Sometimes these involved movement on a small scale, and at others, a combination of the above means were employed. These accomplishments were either purely narrative or were symbolic of personal journeys or were speci cally related to personal issues. Although it was emphasized that the treatment was not performance related, some clients chose to record parts of the process through photos, pictures or the written word (for an example, see Appendix I for Rebeccas poem). m e a su r e m e n t s o f e f f e c t iv e n e s s o f t h e t h er a p y Following session four of the dramatherapy course, both the dramatherapist and the neuropsychologist had lled in the checklist measuring engagement of the participant in the session. The correlation for this was very strong (r 5 0.87) and signi cant at the 0.001 level. This is hardly surprising as most participants were scoring close to, or at, ceiling, indicating that they were able to both carry out the activities and interact appropriately with the dramatherapist. At the end of the entire series of interventions, the dramatherapist was asked to de ne the ways in which she felt the therapy had been of bene t to the patients. She de ned four distinct processes that she perceived during the sessions, which were not mutually exclusive but which did represent increasing levels of involvement: (1) Take control of details in the environment that e or can enhance their ability to be themselves, ect i.e. create a personalized space ; (2) Enjoy or rediscover the nature of play, creativity and spontaneity ; (3) Develop existing skills and discover new abilities and therefore experience the role of creator ; and (4) Gain insights into the nature of their psychoemotional processes. This is achieved by translating their inner world into a concrete manifestation which can then be observed from a new perspective. The ratings of importance from all therapies from each participant were as seen in table 2. in d iv id u a l p r o f il e s o f p a r t ic ip a n t s

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To monitor the responsiveness of each person within the dramatherapy session, the dramatherapist lled in two checklists immediately after each session. One, devised by the neuropsychologist , helped to gauge the responsiveness of the participant. The other, devised by the dramatherapist , aimed to judge the appropriateness of the material for the particular individual (see Appendix II, (a) and (b)). Following the fourth session, the neuropsychologist also lled in these checklists, after observing the session on video. Within a few days following the last session, the neuropsychologist carried out a semi-structured interview, which was tape recorded in most cases (the facility was not available for the rst two). The central questions were how enjoyable or worthwhile the course had been to them and what relationship this had, if any, to the rest of their experience in the hospital. They were also asked to rate the importance of the two main therapies, Physiotherapy and Occupational Therapy as well as Dramatherap y in their rehabilitation programme on a 4 point scale from `not important to `very important . Results Of the 10 patients who entered the course, One patient (John) died just before the nal session and another (Greta) was transferred to another hospital just before the nal session. The patient who was transferred was visited for follow up interview in the other hospital so the database was complete but the course shortened by one session. These two patients were kept in the database as they had completed the bulk of the course. However, interviews were collected for only nine of the group. Table 1 displays the sex, mean ages and medical condition of the group and the mean time for participation in the dramatherapy course. 164

The following descriptions provide background information on each participant and give a brief overview of their experience and attitude to the dramatherapy course. Greta Aged 35, was a young artist who had severely impaired visuo perceptual skills following a brain haemorrhage. For much of the time, Greta s rehabilitation programme reinforced the loss of basic levels of skills in which she
Table 1 Age Mean 34.5 (n 5 10). Range 16 69 Age and sex of group participants and time monitored Sex Male 5 Female 5 Time monitored (days) Mean 38.2 Range 27 42

Dramatherapy and recovery from neuro-traum a

Table 2 Frequency ratings of importance of therapy to treatment (4 5 very important, 3 5 important, 2 5 slightly important, 1 5 not important (n 5 9) Categories: Physiotherapy Occupational therapy Dramatherapy 1 0 1 0 2 0 2 2 3 1 4 4 4 8 2 3 Total 9 9 9

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had excelled before her illness. For her, dramatherapy sessions were comforting and comfortable and allowed her to experience the sheer enjoyment of her creative skills freely, the impairment being irrelevant. In this way, she could again experience continuity of self. She often expressed this during sessions. Of equal importance to her was the space and medium it provided for her to work through problems she needed to solve by using the materials as metaphor. Mike Aged 41, was recovering from the removal of a brain tumour which a ected mobility and coordination. Newly wheelchair dependent, he had also to contend with visual and auditory impairment as well as continuous pain and facial dis gurement. For him, the main bene ts of dramatherapy consisted of restoring self con dence and demonstrating his creative abilities, as well as showing him that he could adapt this facility in other ways than he had in the past, allowing him to express some hope in the future. Mike was naturally e cient and organized and found the inconsistencies in communication and changes in timetables which occurred in the hospital routine very di cult to tolerate and increased his sense of helplessness. He found dramatherapy increased his self esteem and redressed the balance. Mike was also interviewed 7 months later when he was readmitted for routine review. Mike was still very positive in his appraisal of the course and gave his permission for this to be reproduced in its entirety (see Appendix III). Ned Aged 30, was a young man in his early thirties who had su ered a third head injury which left no obvious physical de cit nor primary problems with language, perception or memory and he was above average in intelligence. His personality had become increasingly odd and his awareness of social rules was poor. Ned s overriding cognitive de cit was of the `executive syndrome which had never been recognised before, even though it was suspected that it had rst been acquired in his earlier head injuries. For most of the time, Ned was

dogged by a sense of being disjointed in life and being led by others and he described a part of him that felt helpless, worthless and confused, a feeling that he hadn t `quite got the grip of whats happening all the time. In dramatherapy , he was able to experience a continuity of self that predated his head injuries, when he was happy playing alone for hours in the countryside and on the beach. The contribution that dramatherapy provided was to allow him to clarify what way of life suited his needs and personality. This also allowed him to plan a blueprint for work and living which also became part of his community programme. Some 5 months after discharge, his social worker rang to request a list of dramatherapists in their local area. Sharon Aged 25, was recovering from a head injury resulting in physical disabilities which required wheelchair mobility. Her cognitive di culties were subtle but severe and she was extremely passive, mostly unable to initiate conversation and giving answers which were usually semi-automatic and appeared to be based on what was expected. Sharon s premorbid background included involvement with various social services and o cial agencies ; and wariness of institutional or professional personnel was a long-standing trait. For Sharon, the dramatherapy sessions seemed another element of her rehabilitation which she tolerated but with which she never seemed to engage fully. At initial interview with the dramatherapist Sharon `showed neither resistance nor enthusiasm towards dramatherapy . She seemed willing to take part . At interview, her responses were nearly all mono-syllabic and her strongest reports of its e ectiveness were as a way to get othe ward (the rare response she volunteered, apart from `yes and `no ) and that she enjoyed it. Though part of her inability to elaborate was due to di culties in producing creative thought, she also appeared to remain guarded in all her relationships and activities in the hospital. Graham Aged 17, was still of school age when he had a head injury which left him with a very mild hemiplegia which required a wheelchair for a short time, memory impairment and some generalized intellectual blunting which were resolving quickly. He was also very keen to leave hospital and return to his peer group. Not atypical of his adolescent group, Graham was almost totally invested in his friends and music and it seemed important for him to maintain a stance of indi erence to anything outside this remit. Graham tended to be overtly 165

P. McKenna and E. Haste dismissive of dramatherapy , in keeping with his general attitude to everything in the hospital, apart from physiotherapy which he considered was important in helping him achieve a normal gait. In spite of this, Graham worked in a very focused and engaged way during sessions, discovering a real talent for creative artwork and often showed spontaneous pride in what he had produced. However, positive responses were often followed by dismissive ones to keep in line with his general life script at present. Grahams appraisal of the course consisted mostly of its bene t in allowing him to listen to his music without wasting his own batteries, producing a good picture and passing time instead of `hanging round the ward . Mel (Melissa) Aged 30, was a health professional recovering from a debilitating neurological disease which caused severe paralysis. She still needed wheelchair assistance for attending departments and physical mobility was still greatly reduced. Mel particularly appreciated the opportunity to be in a more individual atmosphere in which she could be free to indulge in whatever form of imaginative play she wished and which did not need to lead to a nished product, conform to a goal or speci cation but to be enjoyed purely in the present. Mel found this very easy and used the session in the fullest possible way. It seemed that she created a space that in the context of her situation, was a healing place. Mel was extremely appreciative of the sessions as both time out from being a patient and for the sheer pleasure of engaging in imaginative experiences. She also valued the contrast in the environmental atmosphere. Maurice Aged 69, was a retired consultant who sustained a head and spinal injury after falling. He preferred to rest most of the time, preferably on his bed. He found it di cult to concentrate on anything for long and was plagued by discomfort, always needing to return to his bed. Consequently, he shortened his dramatherapy sessions and interview to a point where he could interact at a purely socially scripted level, relying on semiautomatic social niceties. Maurice had been very able intellectually and was socially polished. His cognitive de cits prevented him from more complex processing. Consequently, much of his behaviour circumvented any, or real, engagement with the material. Though Maurice was very positive in his appraisal of the course, his account bore little relation to what had actually occurred in sessions. 166 Joanne Aged 36, had sustained a head and spinal injury following a road tra c accident. Her cognitive de cits included an inability to grade her emotional responses to the magnitude of the problem and she was preoccupied and overfocused on many di culties, being both agitated and highly anxious. Joanne needed intensive psychological support from the team which was of limited and transient bene t as her cognitive de cits prevented her from fully incorporating these insights in the long term. The dramatherapy course complemented these approaches by providing her with time out from her preoccupation and the opportunity for physical relaxation which she valued above all other bene ts. Though this aim was simple and very focused, it ful lled Joannes psychological need to experience some measure of peace and tranquillity. John Aged 49, had sustained severe cerebral damage following removal of a brain tumour and had been at Rookwood for nearly 2 years. For almost a year, he had produced very little response to his environment and su ered uncontrolled epilepsy. After 1 year, when the epilepsy had been controlled with medication, John slowly but surely began to recover, rst moving his limbs a little and eventually being able to use a litewriter and, nally, to talk. After another year, John took part in the dramatherapy project. John was very able intellectually before his operation and, though he had a signi cant degree of generalized intellectual impairment, was still able to function at an abstract level and wanted to use the sessions to develop a tape of Bob Dylan s music with a commentary. John died before the last session, an event which was unexpected and traumatic for his family and the rehabilitation sta During the fourth, videoed, . session, John reiterated his intention that the tape was to be made for others to hear. Thus, John left a valuable asset for others to use and the video of the fourth session was given to his family. The dramatherapy course had been uniquely, if idiosyncratically, valuable in Johns case. Rebecca Aged 21, was a young woman who had been involved in a road tra c accident 2 years previously which left her with a severe head injury and long term physical and cognitive de cits. Rebecca had been living in a residential home which was geared to meet the needs of people who were physically disabled where she found the climate to

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Dramatherapy and recovery from neuro-traum a be institutional and unresponsive to her needs as an individual. She took part in the dramatherap y course when she returned to Rookwood for review to help assess her suitability for a place in a transitional rehabilitation unit. Rebecca was still reliant on wheelchair mobility and was very aware of what she had lost in terms of physical and social independence. She described the dramatherapy as `brilliant on several occasions and used it both to rediscover her creativity via writing poems, which she had not done since a teenager, and to work through personal issues. She also emphasized the di erence between it and other therapies as being the rst time that she felt herself to be an equal partner in the exchange. Summary Thus, ve of the nine participants (Greta, Mike, Ned, Mel and Rebecca) were very positive in their appraisals and could provide rich, multi-faceted descriptions of the bene ts of the experience for them. Their self reports also matched the subjective observations of the therapists. A further participant, Joanne, felt positive about the sessions as a form of relaxation therapy, which was observed to be the case by therapists but this seemed to be the extent of its use for her. Although this was only one element of the many potentially available in the treatment, extreme anxiety was the most disabling symptom of her illness and she could easily be brought to the point of sleep in the sessions. Of the remaining three people who were interviewed, Maurice gave very positive feedback about the experience but this did not tally with his observed behaviour during the sessions and it was doubtful that he had really engaged with the activities. The nal two interviewees, Graham and Sharon, were politely positive but unconvincing in their appraisals. In spite of this, Graham had seemed able to engage more than he had expected or intended to but needed to retract whenever he showed enthusiasm. Though John died before he could feed back his feelings about the course, he had, in the fourth session, emphatically reiterated his intention that he was making the tape speci cally for the bene t of other people to use and his creative endeavour speaks for itself to some extent. The overall summary of these self reports are summarized in table 3. Qualitative analysis : the ways in which the therapy was e ective The transcripts of the interviews with the participants were studied at length individually and comparisons across transcripts made. Individual concepts elicited by
Table 3 Self report Greta Mike Ned Mel Rebecca Maurice John Graham Joanne Sharon 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ?? Therapists reports 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 bene cial, 1 a positive experience, ??

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1 1 1 Highly bene cial, 1 1 no data no real bene t.

each participant were grouped into core concepts where they overlapped with concepts from others. From this the following four categories emerged which showed remarkable congruence with those which the dramatherapist had produced independently (see page 164). Thus these categories emerged through a process of initially noting common themes, successively re ned by re-reading each transcript, and considering the strength, commonality and variations across them. The number of patients who reported nding bene ts in each of these four ways are also indicated. c r e a t in g a p e r s o n a l iz e d t r a d it io n a l t h e r a p e u t ic sp a c e :c o n t r a st in t e r v e n t io n s t o

All the ways in which the participants described the therapy as being e ective lay in its contrast to traditional therapeutic interventions. This re ects the rst process described by the dramatherapist as the ability to take control of details in the environment that e or can ect enhance ones ability to be oneself, i.e. create a personalized space. Six of the nine participants who were able to feedback at interview gave clear accounts of this process, part of which re ected a balance between freedom and structure woven into activities, tailored to suit the individuals creative needs and personal style, which also empowered the individual and made them feel in control of the procedure. Greta described this as follows: `Eileen had the sensitivity to nd my creative way came from my inner space, which was painting That approach, that Eileen developed concentrated on what you enjoyed . Mike and Graham expressed this as being able to listen to their music as and when they wanted and Mel described this most directly in the following way : `She was quite easy to go along without any 167

P. McKenna and E. Haste structure, but she d also have content to keep it in control and not go wandering o She didn t demand of you. She just let you go, but kept it within thered be times when she d bring it back in you know lead where she wanted to go really . Rebecca described the sensation of empowerment thus : ` it was really peculiar normally with the therapist, you think `they re the therapist, I m the patient . When I was with Eileen it was like she was my friend. The only di erence was that I was in a wheelchair. So that helped me see really ``what di erence does it make? .
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ment, they control when the lights go on and o , when the TV goes on and o the routine of a hospital decrees when you eat you can become overwhelmed in a sense of the routine. (Mel) Beyond the pleasures of the process of empowerment, further bene ts experienced re ected deeper engagement with the process to provide the experience of escapism and enjoyment, the awakening of creative potential and improvement in self con dence as well as a means of gaining insight into one s inner world. These re ected the same processes described by the dramatherapist speci ed on page 164 in terms of rediscovering the nature of play, creativity and spontaneity, experiencing the role of creator and gaining insight. e s c a p is m a n d e n jo y m e n t : r e d is c o v e r in g o f p l a y , c r e a t iv it y a n d s p o n t a n e it y t h e n a t u r e

The feeling of being in control and empowered also engenders a sense of timeless and personal space. This was brought up by Mel: `There was not really any demands on you. It was pure easy going The hour just ew by really we were just here doing what we wanted to do . and Ned `Oh crikey, has the time gone that quickly? I was a little bit sorry that it was nished `It is more enjoyable than the other therapies Part of the contrasting experience of having both freedom and control over the proceedings was due to the non-clinical environment. Mel, who was a health worker and used to the clinical setting, particularly remarked on this: `The atmosphere was really calm and placid and quiet. Also it s nice in there because its just one person in an environment that you want it to be. Eileen says ``do you want the lights on and which music do you like on ? . All of the participants had been in hospital at least several weeks and many for months and some were acutely aware of the ways in which they were vulnerable to becoming institutionalized. Participants listed the opportunity to leave the ward as a bene t in itself. As an antidote to institutionalization, the therapy was much valued : `you get pushed and pulled around a lot in an institution. Clothes, untidy, little things, being woken up too early. Riled me a lot insensitivity. Got me away from the ward . (Greta) ` its time out from being a patient you just felt it was a change from sitting on the ward, the horrible magnolia walls. It gets you out of that rut of routine The nurses control the environ168

This was the most commonly reported bene t, clearly described by eight of the participants. Their awareness of sheer pleasure during the sessions demonstrated for them that subjective experience need not be dependent on, nor re ect, actuality and that pleasure could be accessed on a regular basis even in stressful or distressing life circumstances. Sharons consistent and positive response to whether she enjoyed dramatherapy was always to say `yes . Given that she was not able to give any more elaborate responses beyond the mono-syllabic, this sparse but persistent response could reasonably be taken at face value. Graham was also unable to expand beyond con rming he `enjoyed the experience. Others were more clearly enriched by the process and for some the promotion of a positive state of mind increased their ability to look positively on di cult circumstances. Greta described this as making her feel quite happy and joyful and thus feeling better about herself and more uplifted, Tony was especially surprised at his facility: `It was an hour I could almost forget about my condition I was using my imagination, I was forgetting. When I was taking the photograph and making up my vision in 3D using what she had in the bag string, pebbles, shells, I found it rather silly but a good laugh and that made me feel good. The ve sessions went very quick I had thought that it was a long time but in no time the ve had gone already In contrast, I cant concentrate on the ward, I cant read a book or do anything on the ward because the pain distracts me. But there I could.

Dramatherapy and recovery from neuro-traum a Ned, in comparing it to the work he was doing for the rest of the time in the hospital, described his experience as follows: `Its more enjoyable in a lot of ways. It s lovely music, its nice and relaxing. Got to sort of poodle around and paint. I love looking through bagfuls of di erent artefacts. I nd that quite fascinating, beautiful shells and things. I could sit there and make pictures and use my imagination. Mel experienced escapism most acutely: `I actually forgot I was sat in the [wheel] chair and almost at one point went to stand up and go It s more than an hour away from the ward. Its an hour in a di erent doing something that you want to do its something that you could totally enjoy and not really know at the time how much e its ect having on you until you, like I said, until you get back. And then you realise ``here we are again . A more passive form of enjoyment might be thought of as relaxation and this was most valued by Joanne for whom the sessions could provide physical as well as psychological release from the agitation and anxiety of obsessional preoccupation with minor problems centring on her health and interactions with sta In relaxing, she . could escape her present situation and, with the help of pictures, immerse herself in imaginary scenes of her choice (at the seaside with her children). Ned also bene ted from the relaxing e which lasted beyond ect the sessions and helped in his general interactions with sta : `Because it was nice relaxing music. I was sort of just relaxed. Ive found actually since then, I ve kind of learnt how to relax a bit better. a w a k e n in g c r e a t iv e p o t e n t ia l w o r t h a n d c o n f id e n c e a n d im p r o v in g se l f ` and it was nice to express what I thought never done that not since I was in school `Though I can t do those things again [referring to impaired coordination preventing playing on a keyboard] this reminded me that I was still ne in my head, I can still be creative. The chance of being even a little bit creative because I can t play music any more, make anything, basically can t do anything, and therefore can t express myself, it is reassuring that haven t really lost it up there. `I dont know why but like exercise and when I leave the premises I m still exercising, feel more con dent. Therapy apart from body and mechanics is important. Brain still needs something . Ned : `I got to sort of poodle around, do some painting, get some sticks and things and make things and generally it was good. It encouraged me to use my imagination. Greta and Mel were also very much at home in the act of creation and for Greta the experience was an extension of her everyday life as an artist. Though she used the process to gain insight into her present coping mechanisms, it was clear that she also relished the creative act in its own right enjoying the aesthetic sensuality of the medium. Greta had marked visuo-perceptual impairment and was often devastated by her consequent reduced skill in visual artistic ability when engaged in her other treatment sessions. Dramatherapy provided her with new ways to experience her creativity: `by working with other modalities, touch and texture I had to pick up objects and understand them through touch. Mel, who described becoming estranged from creative activities in the normal course of her very busy life as a working mother, was delighted with the opportunity to re-explore the experience and consequent empowerment : `And it was nice to be able to do something that looked lovely and was nice to do and was very textural, which helped a lack of sensation in my hands. `As we get older we just get so involved with going out to work, earning money, doing housework. [On creativity] I can still do it, its okay to do it. You always think ``Oh art, Im not going to be very good at that . But the positive thing is theres always something creative in everybody. Whether it s, not exactly draw or paint, but just use objects to make a picture, or make a story or poems or something like that. I really enjoyed doing the 169

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Seven of the group actually produced creative works, ve of whom described a consequent process of feeling empowered which contrasted with their previous feelings of dependency, worthlessness and sometimes hopelessness. While the previous level of engagement led to a positive state of mind this level of engagement provided concrete evidence of an ability to make a positive contribution and be of use and worth in sometimes novel and experimental ways. Thus, it became apparent that a negative and unproductive future does not inevitably follow the fact of disability. Mike particularly bene ted from discovering his creative talent and described how this cascaded to enrich his self image:

P. McKenna and E. Haste pictures. It wasnt something that you had to do. I liked using the fabric. It was nice to be able to do that. To take that away that you are still able to do something worthwhile in the community. Rebecca was delighted to discover she could still write poetry and had been sceptical at rst. By examining poems she had written as a teenager (5 years ago and 3 years before her accident) she rst identi ed similar feelings between now and then. She was surprized at the ability she had demonstrated and did not feel that she still had the creative ability and had no conscious intention to attempt a poem. After using word maps in earlier sessions, Rebecca produced a poem spontaneously and e ortlessly in the fourth, videoed session. (see Appendix 1). Rebecca s head injury had a ected the motor control of her vocal apparatu s and she was very di cult to understand, so that conversation was slow and Rebecca often had to repeat herself and even spell out words before they could be understood. Through poetry, Rebecca could have a potent voice. Johns case, perhaps most clearly, embodies the act of creation, empowerment and usefulness for the community in producing a piece of work clearly speci ed to be made available and used by others, as a gift outlasting his mortality. p s y c h o t h e r a p e u t ic p r o c e s s Three of the group, Greta, Ned and Rebecca, were able to both engage in the creative aspect of the therapy and direct it towards examining personal issues. Mel saw this potential but did not wish to use it in this way. She also pointed out that the limited number of sessions could curtail this aspect of the therapy. For Mel, the other three aspects were what she needed at that time and she was able to clearly articulate this: `It s too short a time to have a counselling relationship as such, but like I said she s very easy to talk to and very understanding. You could use it in that sense if you wanted to, but I didnt use it in that sense . Greta, whose artistic nature needed no time for reacquaintance with the creative process, almost immediately focussed the sessions on salient issues in her life: `Helped me work out things from being here after my illness things from the past. Quite therapeutic. It helped me to see the pressure I was putting on myself before the illness by shifting what objects stood for in the session it showed me how I could shift things in life. Whole way of 170 working was very interesting, very clear. It helped me to gain insight into the past and has far reaching consequences for the future . Ned took a little longer to discover this potential of the therapy but was able to clarify certain areas of confusion in his life: `It made me sort my thoughts out a little bit. It made me realise that there s two de nite sides to my character There was a small stone in the shape of a heart which I ended up putting in the countryside which made me realise that s where I really wanted to be. It made me kind of realize things about myself which I suppose I d always known, but I hadn t really though about. I think it helped me realize aspects of my character. I think it actually helped me know what I wanted which is half the battle. Because to be honest with you I ve had no idea for a long time what I wanted to do. Basically I ve just gone from the one job to the next job and then I ve got frustrated because it hasn t really been what I really wanted to do, but it was just because it was paying the bills and so I was doing it . Rebecca was caught up in the struggle to acknowledge a degree of permanent disability and was still nding it di cult to fully invest herself in the present, looking always to the future when she would walk again. Her poem expresses the frustrations brought about by the promise of normality `in time , the scale of which is never speci ed. Her poetry writing is a potent vehicle for her to both express her feelings in a positive and creative way and as an excellent focus for therapy to help Rebecca nd a way to adapt to her present level of disability. Not uncommonly after the devastating e of head injury. ects Rebeccas frustration had begun to be expressed in destructive ways which threatened her well-being and self image. st a t u s a s a t h e r a p y Finally, with the exception of John, each participant was asked whether they thought dramatherapy was a luxury or an essential element in their treatment. Only three people (Joanne, Graham and Sharon) described it as a luxury or irrelevant to their treatment and progress. Joanne described it as `nice but not essential , Graham thought of physiotherapy as the only relevant treatment for his needs, Sharon tended to give mono-syllabic answers or to say `don t know but rated all therapies as equally important and gave no real indication of having valued dramatherapy . Maurice described it as being `not

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Dramatherapy and recovery from neuro-traum a a luxury, could be an essential part of treatment but this appeared not so much a conclusion from his personal experience (given he had not really engaged in the process) as the semi-automatic stance of the cultured professional. The remaining ve participants thought it was an essential element in treatment. Their responses were as follows: `not only a good complement but stands alone, more bene cial than OT at Rookwood . (Greta) `I think it s not [only] a complementary element but a necessary element . (Mike)
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`For me, yeah. For people certainly with my character, it gave me the space and the time . (Ned) `I think people will really bene t from it. Because it is time out in more senses than just time away from the ward, it s time out from being a patient. Its time out doing something creative. Doing something that you want to do. Listening, just quiet. I think it will get people, especially people whove been here for a long time, it gets you out of that rut of routine. It makes you think a bit more . (Mel) `It should [be an essential part of treatment] because it makes you feel better about yourself . (Rebecca) Discussion Qualitative data from a small group of participants provides some promising evidence that dramatherapy can be an e ective method of intervention for some individuals in their rehabilitation following neurotrauma. In describing, in depth, the e ects of dramatherapy on a few carefully studied participants it has been possible to gain some insight into the psychological mechanisms of adjusting to neuro-trauma. The semistructured interview was drafted in a loose format to allow each participant to say whether or not the course had been useful and if so, to describe how it had been useful. In the analysis of the responses, a clear symmetry between the ways in which the participants bene ted and those de ned by the dramatherapist emerged, increasing the validity of these conclusions. These were to redress the balance of power within the hospital setting so that patients were allowed to experience control over their environment, to experience fun as an antidote to the negative circumstances of their illness, to be empowered by their own creativity and to examine their own psychological processes by using the materials as props.

These are equivalent to core categories in terms of grounded theory( but their validity would also require further instances beyond the handful of cases presented in this series to achieve saturation point. The results also support Johnstons claim that mental representation of impairment in uences level of disability and mediates coping behaviours. For instance, Mike and Rebecca both fed back that the course acted as a spur to aid them alter their perceptions of the nature of their impairment. Mike recognized he still had power to be creative and e ective in his life and felt more detached and less of a victim to the vagaries of bureaucratic timetabling and organization, a view he was still expressing 7 months later. Rebecca gained a perception of herself as no di erent from others, apart from being wheelchair dependent. Notwithstanding these positive reports on the therapy, not all the participants bene ted to the same extent nor in a homogeneous manner. It was not possible to predict in advance who would bene t maximally and who would bene t least nor in what way each would use the therapy. Within the research framework of this project, the amount of dramatherapy these patients received had to be uniform and delineated by the constraints of the research protocol. The dramatherapist had originally envisaged 10 treatments as being a reasonable exposure to the medium, particularly as most adults express a lack of con dence and some wariness of involvement in the creative arts. This wariness was increased by the term `dramatherapy which was in fact a misnomer and misleading for both the participants and stawho could often not override the belief that it was to do with acting. This occurred even with the full written description of therapy at the introductory stage and a direct announcement at every chance that it was a misnomer. In this series, Greta, the artist, initially `thought of drama as not pleasing to her. Ned described `having reservations and `not being really sure what it involved. The fear of having to perform also occurred for artistic endeavour as expressed by Mel: `First of all, I thought ``Im not going to be any good at this art stuand whatever initially I ve always felt that Im not very good at arty things. I thought ``will I be able to do this? Most of the patients were thus taken on `cold and at a very vulnerable and disrupted time in their lives. It is of note that with such little exposure and in so short a time the participants were able to respond so well. However, as the number of participants was small and the form of therapy challenging, further studies are needed to explore how well these ndings can be 171

P. McKenna and E. Haste replicated in the larger population of patients in post acute rehabilitation for neuro-trauma. The constraints posed by certain cognitive de cits and by pre-morbid personality traits also needs consideration in appraising the therapy at an individual level. These interactions were not systematically explored in this small sample nor were they the focus of this study which sought to assess the bene ts of the therapy. The question of boundaries of application is an important one in targeting the subset of patients who will maximally bene t. Setting these boundaries is not easy. Though it would appear reasonable to assume that compromised insight might impair ability to bene t from the therapy this was not necessarily the case. Some participants who had impairments of the executive system which did compromise their ability to integrate and monitor their intellectual and psychosocial behaviour at the higher and subtler levels of functioning, bene ted particularly well. Others with more pronounced di culties in ability to monitor their thinking processes had greatly restricted or dubious bene t. Pre-morbid personality factors also appeared to in uence motivation within the therapy but how far previous experience, or lack of it, in creative activities can in uence outcome needs to be determined. Similarly, the amount of exposure to the therapy needs to be explored in terms of how well the four posited ways of bene t can be developed. Overall, the participants rated the importance of dramatherap y as equivalent to occupational therapy but not so important as physiotherapy. Yet their exposure to these therapies were not equal. In contrast, each participant would have received almost daily physiotherap y and occupational therapy often for some weeks before the dramatherap y commenced and for very many weeks after. They received only ve single sessions of dramatherapy spread over some weeks (usually ve, sometimes four). The parameters of exposure needed to achieve maximum creative, psychotherapeuti c and long term bene t, also need to be mapped so the timescale of sessions can be tailored to suit the needs of individuals. This project demonstrated how addressing the inner, subjective world of a small group of patients and allowing them to experience their own creativity could give them access and insight into their own strengths and intrinsic worth. This process appeared to boost successful coping within the hospital setting but how well this extends to the community which is arguably more important is a further avenue needing exploration. It is within the setting of the community that coping mechanisms are really tested for long term adjustment to disability. Psychological coping is so intimate a part of physical coping that any physiotherapy gains made in 172 hospital can easily be lost if psychological coping is inadequate. Hospital life does not prepare patients for the attitudes of society to disability and the e these ect attitudes have on disabled people. Fitzgerald) describes how science, bureaucracy and organized religion have played an important role `in shaping the construction of disability as the broken, incomplete and imperfect self, as the case requiring management, and as the object of pity or charity , and how, in the face of disability, the individual s self image, which is determined by the interaction of internal resources and the external in uences, shapes who he} she becomes. De Rozario* highlights the increasing evidence to show how `it is the individual s volitional system, that is, that persons inner and interactionist world of values, beliefs, attitudes and inspiration, that helps to mediate, bu and determine the process of er successful coping . Conclusions This study demonstrated how dramatherapy can help some patients cope with both the hospital environment and acquired disability following severe illness or accident. In particular, it highlights the role of the subjective world of the individual in successful coping and adaptation to disability. However, the machinery within the NHS and within the rehabilitation specialism has evolved to service physical well being under the medical model of care. These results support the case for further incorporation and development of this therapy in the acute rehabilitation setting and to explore how it might impact on longer-term coping and adaptation. In particular, it provides a starting point for further investigation of the emerging themes that a personalized space within the rehabilitation setting, play as a form of therapy, creativity, and the use of dramatherap y to examine intra-personal psychological processes, can be important for patients well-being, empowerment and self esteem.
Acknowledgements This research was funded by a Clinical E ectiveness grant awarded by Bro Taf Health Authority, without which no therapy could have occurred. We are especially grateful to all the patients who agreed to take part in this project. We would also like to thank the nursing sta and the multidisciplinary team at Rookwood Hospital for their enthusiasm, support and cooperation in the smooth running of the project. We would also like to express our gratitude to Torgeir Bruun Wyller and Mark Edwards for their very helpful and constructive comments in reviewing this manuscript.

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Dramatherapy and recovery from neuro-traum a

References 1 Duggan, M, Grainer R. Imagination, Identi cation and Catharsi s in Theatre and Therapy. London: Jessica Kingsley, 1997. 2 Johnston M. Modes of disability. The Psychologist 1996 ; May : 205 210. 3 Patrick DL, Erickson P. Health Status & Health Policy : Allocating Resources to Health Care. New York : Oxford University Press, 1993. 4 Jennings S. Dramatherapy. Theory and practice for teachers and Clinicians. London: Routledge, 1987. 5 Cattanach A, Mitchell S, Chesner A, Meldrum B. The handbook of dramatherapy. Routledge. England. 6 Glaser, BG, Strauss, AL. The Discovery of Grounded Theory : Strategies for Qualitative Research. Chicago: Aldine, 1967. 7 Strauss AL, Corbin J. Basics of Qualitative Research : Grounde d theory Procedures and Techniques. Newbury Park : Sage, 1990. 8 Fitzgerald J. Reclaiming the whole: self, spirit and society. Disability and Rehabilitation 1997 ; 19 : 407 413. 9 De Rosario L. Spirituality in the lives of people with disability and chronic illness: a creative paradigm of wholeness and reconstitution. Disability and Rehabilitation 1997 ; 19 : 427 234.

Appendix II (a) : behavioural response to dramatherap y session

(1) He} she uses hands, arms and upper body to gesture appropriately almost never 1 sometimes 2 often 3 (2) He} she initiates the use of hands and arms to manipulate the environment appropriately almost never 1 sometimes 2 often 3 (3) He} she uses head, eyes, facial expressions appropriately almost never 1 sometimes 2 often 3 (4) He} she shows some attending when engaging with therapist. 1 orientating 2 continuous focussing 3 passive responding 4 initiation (5) He} she shows some non-verbal emotional responsiveness when engaging with therapist. 1 none 2 smile} frown 3 laugh} tears (6) He} she shows some verbal emotional expressiveness when engaging with therapist. 1 none 2 cadence} some} prosody positive} negative 3 expresses pleasure} anger (7) He} she shows recognition} familiarity of therapist 1 none 2 something (positively} negatively) 3 often (positively} negatively) (8) He} she is responsive to environment 1 hardly ever 2 sometimes 3 often

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Appendix I : example of an activity during therapy session : Rebeccas poem

Appendix II (b) : engagement in dramatherap y session

Is the client able to engage in the material mostly at times not at all At what level is the client engaging his} her mind seems focused is physically involved is vocally involved is engaging with the dramatherapist Does the client seem inhibited frustrated confused willing to engage relaxed resistant apathetic anticipating} curious


P. McKenna and E. Haste Appendix II (b) (cont.)

Is the material therefore too abstract too complex not relevant enough not appropriate for this client Outline of patients potential opportunities within dramatherapy. Outline of patients needs within dramatherapy. Pat `So ``are you glad you did the dramatherapy ? thats obvious isn t it? Then the other question was ``did you enjoy the thing itself apart from getting away from the ward ? Youve answered that. Do you think it provides a positive sense of your ability to adjust disability? Does it give you something to help you ? `Yes. Well it after the Dramatherapy I realised that I could do something as an activity at home. And keep my mind on it. And to escape. I ve never done it before. Since I ve been ill I really havent had the patience to do anything. Even at Physiotherapy I couldnt keep my concentration very long. I ve been told that. I was miles away. I used to get involved for so long, but I wouldnt be interested then. `When you were doing Physio in Rookwood? `Yes. Right from the beginning. Mind you I ve only been here since last December. I did have a lot of hurt, as far as I m concerned is grief. Because I think I lost my life then. Basically I did at the end of the day, thats my livelihood gone. Dramatherapy helped me, made me believe that I could do things which dont actually connect me with being disabled or my disability. I can escape out of it. `You re not just your disabilities? `No. `Well when I used to come to dramatherapy I used to escape being misunderstood and come in and doing my stu , listening to music and talking in general I realised then I m not just a patient. I m a human being as well. I m being understood on that level. Because it may have been a therapy, but I wasnt being a patient here I wasn t being treated as such. So I behaved as such. So I didnt feel so helpless any more really or misunderstood. So when I went back to the ward I wasnt a patient. I was a normal human being that wasn t very well. `Did it change your ability to assert your needs while you were in hospital or to negotiate decision making processes in your treatment? Did it give you con dence, I suppose ? `Yes it did. Yes in the same way as being misunderstood before. Its hard to explain it, but knowing that I d been very ill and very restricted. I couldnt move, I couldn t move the wheelchair at all. I was very dependent. But like I said before knowing that when I came here afterwards I realised I wasnt just patient after patient. I was a comparatively normal person who has just maybe begin to rationalise things that had gone wrong as far as my treatment. My appointments, my let downs had been concerned and if I hadn t come to dramatherapy I think I would have still been the same. I would have still felt put upon. I would have still been the patient. The underdog. But now as far as treatment is concerned. I m not saying now, but after the dramatherapy I didnt actually call the shots, but I had a voice in making those decisions. And because I had more con dence in myself I was able to do that. I was able to do that more con dently.


Appendix III : Mike: Excerpts from Interview 2 : 7 months post dramatherap y course (September 1997)
Pat ` So its actually seven months on. Have you thought much about that dramatherapy you did since ? Mike `When I looked through my drawers at home which I keep for my cassette tapes and my photographs from drama group I remember then of the times I used to come up for those sessions. I sometimes think about the things I ve done and what was involved and look at those lessons. When I had to make a layout of what was supposed to have been the landing space on the Planet Jupiter with all rocks and bits of string and everything. I must admit it looked good. On the photograph it looked as if it was okay fair enough it looked a bit toyish, manufactured, but it looked quite good, really. It was surprising. Yes I do remember. What it did for me was me personally it gave me I remember it did give me at the time, during the day when I really didnt think so much about my condition I mean when I went to Occupational Therapy I was working to improve my condition because of my condition. And when I went to Physiotherapy I was doing the same there, but when I went to Dramatherapy it was nothing to do physically with my treatment. And well being in this place I found it was much a social thing as well. I didn t consider it as a treatment. It was nice to know that after having gone through all this and feeling the way I did it was nice for me to think that I could get out of my system. I knew I could come up here and I wasn t depressed. I wasn t angry. In fact I used to get lost in my subject. Pat `So you know when you said that when you were home youd open your drawer and you d see what youd done and it reminded you of it, what was the feeling that accompanied it whenever you thought of those sessions within the context of your hospital stay ? What was the feeling? Mike `Happiness I think. Well say I m in my drawer and I pull out an appointment card or a letter and I go through these things with a serious mind, but when I pull out anything from the Drama I see the photographs and my book as such. My book of one page. I smile !

Pat Mike

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Pat Mike