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 GRIFFIN
University College London and Middlesex Hospitals, UK
A B S T R AC T
Chronic Pain without an identifiable organic basis represents a substantial element
of referrals to both medical and mental health professionals. Chronic pain can
compromise independence, school attendance, physical and social activities. The
tendency to label nonorganic pain as having a psychological origin is usually
strongly resisted by parents and young people with treatment creating a significant
challenge for health care professionals. Collaborative, multidisciplinary treatment
programmes 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 the
team in the task of challenging the pain through the use of physiotherapy to
increase strength, stamina and suppleness alongside a range of individual and
group activities that can include relaxation training, hypnotherapy, systemic and
cognitive-behavioural approaches. This article describes how drama and
movement therapy was introduced as an additional component of the treatment
programme of two adolescents who had been long-term inpatients on a medical
adolescent ward. The experiences of adding a complementary therapy to the
programme are described to illustrate a creative way of contributing to established
treatment programmes through the use of sound, movement and gesture in order
to provide a space to explore new ways of being and expanding abilities.
K E Y WO R D S
adolescence, chronic pain, movement therapy, rehabilitation
C H R O N I C PA I N W I T H O U T an identifiable organic basis occurs in 4 to 15% of the
normative adolescent population, and represents a substantial element of referrals to
adolescent medicine and adolescent rheumatology clinics. Chronic pain has a complex
neurological and psychological aetiology, and may supervene in organic diseases that
also cause pain, such as juvenile idiopathic arthritis (Goodman & McGrath, 1991).
Clinical Child Psychology and Psychiatry Copyright 2006 SAGE Publications (London, Thousand
Oaks and New Delhi) Vol 11(4): 569577. DOI: 10.1177/1359104506067878 www.sagepublications.com
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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 11(4)
Extensive investigations followed by a wide range of medical interventions and physical

therapy often produce very little amelioration of symptoms and little understanding of
the cause of the pain. The clinical picture becomes increasingly complicated when there
is 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 medical
care of individuals with pain for which no physical problem can be identified or pain
which is greater than the presenting pathology. For some, the pain marks a gradual but
inexorable downward spiral towards long-term physical disability (Ciccone & Lenzi,
1994).
Chronic pain has a significant impact on the successful completion of the developmental tasks of adolescence. It can compromise successful negotiation of independence
and disrupt school attendance as well as other physical and social activities. Age, gender,
developmental level, previous experiences of pain and situational and psychological
factors 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 often
noted to exacerbate symptoms (Dunn-Geier, McGrath, Rourke, Latter, & DAstous,
1986). There has been and continues to be a tendency to attribute pain of this kind to
psychological problems and in the past it has been labelled psychosomatic or hysterical 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 throughout the centuries with a firm divide between the mind and the body. Western religion
influenced important thinkers and scientific discovery by dictating that an inflexible
partition 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
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 also
like to acknowledge the clinical supervision to Deborah Hood from Rachel Melville-Thomas,
Child Psychotherapist and Dance and Movement Therapist.
D E B O R A H C H R I S T I E is a Consultant Clinical Psychologist and Honorary Senior Lecturer
at University College London Hospitals. She has a background in neurobiology and
neuropsychology. Her current clinical and research interests include helping young people
and their families live with chronic illness.
C O N TA C T : Deborah Christie, Department of Child and Adolescent Psychological Medicine,
West Wing, 250 Euston Road, London NW1 2PG, UK. [E-mail: Deborah.Christie@uclh.nhs.uk]
has a background in the performing arts and through her study of creative
expression led to the realization of the potential of this medium for self-exploration and
transformation. She works as a freelance drama and movement therapist with varying client
groups alongside her practice as a massage therapist.
DEBORAH HOOD
A N G E L A G R I F F I N is a Clinical Psychologist at University College London Hospitals. She

trained at Queens University Belfast and Boston VA Hospital. Her current clinical interests
are neuropsychology and management of pain and chronic conditions affecting children and
adolescents.
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CHRISTIE ET AL.: THINKING, FEELING AND MOVING
time, physicians have viewed illness and disease as the product of abnormalities at the
cellular and organic level, and as such physical evidence became the only marker by
which diagnosis and treatment took place (Salt & Season, 2000). The first person to
challenge the biomedical model was Freud, who suggested that the psychological and
social environment had to be considered in the assessment of physical health but it
wasnt until the 1970s that the biopsychosocial model of health, disease and illness was
put forward by Engel (Salt & Season, 2000). The advances made in understanding
chronic pain have indicated that it is not possible to predict the degree of pain or the
resulting disability on the basis of the injury alone (Turk, 1996). Nevertheless, science
and philosophy of the Renaissance continue to dominate western language and culture.
Schober and Lacroix (1991) state that research has shown that the opinions people hold
regarding health and illness have changed little since the days of Descartes.
This view is mirrored by the difficulty parents and adolescents experience when faced
with physical symptoms in the absence of a specific medical diagnosis and a subsequent
lack of an effective medical treatment. Referrals to mental health professionals are often
resented and resisted by both families and the young people, resulting in a therapeutic
impasse. Psychodynamic approaches which look for underlying family conflict are
strongly resented while cognitive-behavioral approaches may not fit for young people
who cannot make a connection between their thoughts and the experience of pain.
Multidisciplinary rehabilitation approaches explicitly acknowledge the reality of the
pain while emphasizing the necessary involvement of both mind and body in the
recovery process (Calvert & Jureidini, 2003). Parents and young people are encouraged
to stop searching for a cause and find ways of getting on with their life. Acceptance
means taking a proactive approach to challenging pain and encouraging young people
to move forward and collaborate in the multidisciplinary treatment programme. Graded
physiotherapy aims to increase strength, stamina and suppleness complemented by a
range of additional psychological and physical therapies. A range of strategies are used
to engage the young person and parents to join with the team in the task of challenging
the pain. Although cognitive-behavioural therapy remains the most effective psychological intervention for organically mediated pain (Walco, Varni, & Ilowite, 1992) there
is less evidence that these approaches are as effective in nonorganically mediated pain
conditions.
The stance of the team is to keep focused on the potential for future recovery. Young
people work with a multidisciplinary team including a medical doctor, physiotherapist,
occupational therapist, social worker and psychologist. The team uses relaxation, guided
imagery, and systemic, cognitive and behavioural techniques in order to engage with the
young person in order to match the treatment to the individual. Pharmacological
therapies also contribute to the multidisciplinary treatment programme and acupuncture can be offered as a treatment approach (Rusy & Weisman, 2000).
There is a significant increase in the use of complementary and alternative medical
therapies in paediatric and adult populations with adolescent use ranging from 50 to
75% (Gardiner & Wornham, 2000; Wilson & Klein, 2000). This article describes how
drama and movement therapy was introduced as an additional component of a
treatment programme of two adolescents who had been long-term inpatients on our
medical adolescent ward.
A systemic approach makes sense of mind/body problems as being a social
formation involving complex interactions of emotions, knowledge and expression.
Griffiths and Griffiths (1994) describe how physical symptoms are sometimes described
as 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 their
family feels threatened or challenged by attempts the therapist makes to elicit unspoken
information, they are likely to distance themselves or defend themselves. This may be
expressed by an exacerbation of the symptoms we seek to help. There is a need therefore
to create opportunities for reflection and creative problem solving. The aim was to use
creative expression to give each individual an opportunity to explore their experience
of physical disharmony, and the limitations the chronic pain had inflicted on them. The
aim was to encourage the young person to use their body to communicate thoughts and
feelings. It was hoped that the congruence between movement therapy and their
nonverbal style of expression might allow exploration of feelings which were either not
easy 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 treatment
of stress-related muscular tension. Research has shown its effectiveness with chronic
pain 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 an
awareness of psychic energy through physical sensation, and facilitated an explicit
description 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 through
metaphor, 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 expressive use of the imagination through sound, movement and drawing. Working with
movement allows physical impulses to be expressed and gives the client an opportunity
to 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 the
self regardless of physical discomfort. Physical contact has the potential to make an individual aware of basic instincts, highlighting thoughts and feelings (both emotional and
physical) through the senses. Touch plays a crucial role in early stages of human development and can bring awareness to bound, or held, areas of the body and offer a containing space in which to release tension. This is done in conjunction with a focus on
breathing. This then allows a reintegration between bodily expressions, thoughts and
feelings.
Cases
Case 1
C developed lower back pain at 8 years of age. Despite extensive physical investigations
no organic cause for the pain could be found. The pain increased in severity and spread
to other parts of the body until she could no longer walk and required a wheelchair in
order to mobilize. The pain was described as continuous and unremitting with occasional
tremor in the legs and severe radiating attacks of acute pain. A wide range of pain medication produced no significant improvement. Acupuncture was described as helpful and a
course of lignocaine infusions (nerve block) produced limited short-term benefit but no
long-term improvement. Regular physiotherapy, occupational therapy, individual
psychotherapy and family therapy had little impact on reported pain.
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Case 2
B presented at the unit with a 1-year history of shoulder and neck pain which was initially
triggered by a minor sports injury. The pain persisted long after the injury should have
healed. It became worse as time went on and had not been helped by a period of intensive
inpatient physiotherapy at local hospital. Although she was able to walk, B preferred to
use 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 the
opposite ear. She was unable to sit up and was completely dependent on staff and her
parents for every aspect of care. She was visibly distressed by pain at all times. Medical
investigations were abandoned as organic, identifiable causes were ruled out. Treatments
such as nerve blocks by the anaesthetist were not of significant benefit.
Treatment programme
C and B worked with the multidisciplinary team over a period of 14 and 19 months
respectively. The goal was to gradually reduce their experience of pain and increase
mobility. Both girls received regular physiotherapy, occupational therapy, and individual
psychotherapy. Hypnotherapy was also used with both girls. C reported that the
hypnotherapy 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 her
cope during the splinting of her arms which had become locked across her chest. Each
week the splints were used to open up her elbow joint by an extra five degrees until she
was finally able to straighten and flex her arms again.
Systemic family therapy was offered to both families. Following the initial consultations Bs parents continued to attend family sessions. Cs parents did not find these useful
and declined any further sessions.
Following discharge as inpatients both girls returned home and started attending
school using a wheelchair. They returned to the unit one day each week for continued
input from the rehabilitation team. C continued to experience significant pain, used individual psychology sessions to identify ways of getting on with her life and not letting the
pain prevent her from doing things. While B was no longer plagued by her pain she
appeared to have reached a plateau in terms of mobility and continued to use a wheelchair. 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 the
offer of six sessions of drama and movement therapy as an adjunct to their ongoing rehabilitation programme.
The second author (DH) met with the girls and their parents to discuss the rationale
behind the therapy. The sessions were designed to create a space where they could
explore psychological and physiological processes. The goal was to acknowledge and
integrate sensory awareness into the experience of the whole self rather than viewing
the 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 physical
symptoms, 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 therapist
would 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 physical
discomfort the application of massage techniques (body work) at the beginning and end
of the session was of great benefit, not only in relaxation but also by putting them in
touch with their bodies by developing self-awareness and integrating unconscious
knowledge of the body into consciousness. Each physical gesture is seen as an expression
of some part of a persons being therefore every movement, however small, was
acknowledged. If the client appeared stuck, the therapist would ask the client what
sensations, either physical or emotional were being experienced, and if appropriate the
therapist would feed back what she was experiencing in the observation.
Once physical symptoms are felt and acknowledged, exploration is encouraged
through movement, sound and active imagination. This includes the awareness of breath
and rhythm. Movement-observation techniques are used to gain clarity of movement
and gesture. Applying qualities of energy, space, time and flow offers a greater understanding 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 interact
allowing 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 also
anything 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 sessions
with the drama therapist was followed by a weekly psychology session. B invited the
drama therapist to join the first few minutes at the beginning of each session so that she
could 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. Once
it was established that the work was interactive then self-permission to trust and participate seemed to grow from week to week.
Both clients responded very differently. Cs continuing experience of acute and
chronic pain reinforced her, and her familys, view that this was a medical condition that
had been missed, despite repeatedly negative investigations. She was a practical and
capable young woman who remained confused and distressed by the way pain had
stolen 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 the
therapist take the lead. This changed slowly over the weeks with the introduction of
voice work, initially through breath awareness leading into sound, while the therapist
supported physical release through body work. For example, while applying gentle
pressure and passive movement to Cs tense and painful thighs, the therapist asked her
to make sounds that reflected how the legs felt.
At the end of the project C commented that she found the relaxation through massage
to 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 enjoyed
it. She reported the most beneficial experience as creating a space to relax and allow
her 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. She
was very open to exploring the connections between mind and body, the unconscious
and the conscious. This approach reflected her efforts to gain an understanding of what
had 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 the
arm splinting. B had viewed hypnotherapy as a way of releasing the potential of her
unconscious mind to help her body.
B was more actively engaged in the work, being very willing to verbally express how
she 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 feelings
she had previously had limited awareness of. These included anger and also sadness and
affection for her body and mind and what they had endured. She pinpointed her growing
confidence in her feelings and her expressions as being right for her and she found this
liberating. The sessions helped her realize that what she experienced was legitimate and
she 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 hospital
there had been such a focus on her physical symptoms that she felt her body had let her
down or betrayed her. The drama and movement therapy had helped her reintegrate her
mind and body. It helped her feel friendlier towards her body, to regard it as an ally, an
essential and integral component of herself, rather than a foe. The emphasis on the
oneness of mind and body cast a new light on the earlier search for a cause and pointed
her in the direction of a future where unity and wellness of both mind and body are
essential for the health of the whole self. At the end of the sessions she wrote to the
team:
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 sounds
within 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 involved
with the treatment and thoroughly enjoying it! I was given my own scrapbook, so
that 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 into
my 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 support
helpful and useful. She has stopped using a wheelchair, attends school full time and has
a busy and active social life. In contrast C no longer found the programme useful and
the family agreed her support should be transferred to local services. Despite continuing to experience pain, she completed her exams and made plans to go to university and
live 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 identifying ability. Moving from disability to ability also requires the team to think about
treatment 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 and
reported as beneficial by both girls. A dominant story is often that our goal as
professionals is to find a cure, which by definition is to remove the pain. However, it may
be more realistic to focus on ensuring that young people can get on with their lives
regardless of whether we and the young person work out how to ameliorate the ongoing
symptoms. We believe that the adjunctive drama and movement therapy sessions made
a contribution to this holistic approach to pain management and, best of all, made the
young people feel good. The next step must be to develop a way of determining to what
extent it might make a contribution towards symptom alteration and reduction.
Increasing our knowledge of the psycho-physical relationship may provide vital information on the healing process. Both are aspects of the whole individual and intuitively
can be seen to reflect each other. As professionals we need to be open to the new and
the unknown. We must find a balance between the evidence base and our clinical
intuition and try to create space to develop original and possibly better treatments for
young people for whom a limited or no evidence-base exists. We suggest that for some
young people disabled by pain or immobility this approach is a creative way of contributing to established treatment programmes by including the use of sound, movement and
gesture, to provide a space to explore new ways of being and expanding abilities.
References
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chronic pain: The ability to cope. Pain, 26, 2332.
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07 067878 Christie (to_d)

Thinking, Feeling and Moving: Drama and

07 067878 Christie (to_d)

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 11(4)

Extensive investigations followed by a wide range of medical interventions and physical

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

A N G E L A G R I F F I N is a Clinical Psychologist at University College London Hospitals. She

07 067878 Christie (to_d)

CHRISTIE ET AL.: THINKING, FEELING AND MOVING

07 067878 Christie (to_d)

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 11(4)