ATM 208: PERFORMING ARTS THERAPY II

COURSE DESCRIPTION
Components of Creative Arts Therapy:
- Art Therapy;
- Dance/Movement Therapy;
- Drama Therapy;
- Music Therapy;
- Poetry Therapy;
- Psychodrama Therapy;
Practitioners in the Performing Arts Therapy:
Application of each Component of the relevant Therapeutic, Rehabilitative, Community or
Educational Settings;
Emerging Trends in Music Therapy; Dance/Movement Therapy; and Drama Therapy;

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COMPONENTS OF CREATIVE ARTS THERAPY

Many definitions of expressive arts therapy mention its use of distinct features such as Music,
movement, Play, Psychodrama, Sculpture, Painting, and Drawing. If necessary, though,
therapists may choose to combine several techniques in order to provide the most effective
treatment for the individual in therapy.

The components of Creative Arts Therapy are;

1. Art Therapy
2. Dance/Movement Therapy
3. Drama Therapy
4. Music Therapy
5. Poetry Therapy
6. Psychodrama Therapy

ART THERAPY
Definitions
Art therapy is a form of expressive therapy that uses the creative process of making art to
improve a person’s physical, mental, and emotional well-being.

It is a creative process involved in expressing one’s self artistically can help people to resolve
issues as well as develop and manage their behaviors and feelings, reduce stress, and improve
self-esteem and awareness.

Art therapy, sometimes called creative arts therapy or expressive arts therapy is a form of therapy
encourages people to express and understand emotions through artistic expression and through
the creative process.

Art therapy is a form of expressive therapy that uses art materials, such as paints, chalk and
markers. Art therapy combines traditional psychotherapeutic theories and techniques with an
understanding of the psychological aspects of the creative process, especially the affective
properties of the different art materials.

Art therapy involves the creation of art in order to increase awareness of self and others. This in
turn may promote personal development, increase coping skills, and enhance cognitive function.
It is based on personality theories, human development, psychology, family systems, and art
education. Art therapists are trained in both art and psychological therapy.

The Definitions of the Profession:

Art therapy is the therapeutic use of art making, within a professional relationship, by people
who experience illness, trauma or challenges in living, and by people who seek personal
development. Through creating art and reflecting on the art products and processes, people can
increase awareness of self and others, cope with symptoms, stress and traumatic experiences;
enhance cognitive abilities; and enjoy the life-affirming pleasures of making art.
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Art therapists are professionals trained in both art and therapy. They are knowledgeable about
human development, psychological theories, clinical practice, spiritual, multicultural and artistic
traditions, and the healing potential of art. They use art in treatment, assessment and research,
and provide consultations to allied professionals.

Art therapists work with people of all ages: individuals, couples, families, groups and
communities. They provide services, individually and as part of clinical teams, in settings that
include mental health, rehabilitation, medical and forensic institutions; community outreach
programs; wellness centers; schools; nursing homes; corporate structures; open studios and
independent practices.

Who Can Use Art Therapy?

For the most part, anyone can use art therapy. In a world where there is a multitude of ways to
communicate and express one’s self, expressive arts therapy is yet another. One of the major
differences between art therapy and other forms of communication is that most other forms of
communication elicit the use of words or language as a means of communication. Often times,
humans are incapable of expressing themselves within this limited range.

One of the beauties of art as therapy is the ability for a person to express his/her feelings through
any form of art. Though there are other types of expressive therapies (such as the performing
arts), expressive art therapy as discussed here typically utilizes more traditional forms of art such
as painting, drawing, photography, sculpture, or a variety of other types of visual art expression.

You don’t need to be talented or an artist to receive the benefits, and there are professionals that
can work with you to dive into the underlying messages communicated through your art, which
will aid in the healing process.

Art therapy can achieve different things for different people. It can be used for counseling by
therapists, healing, treatment, rehabilitation, psychotherapy, and in the broad sense of the term, it
can be used to massage one’s inner-self in a way that may provide the individual with a deeper
understanding of him or herself.

What does an Art Therapist do?

Art therapists are trained in both therapy and art, and have studied and mastered both psychology
and human development, having received a Master’s Degree. There are various requirements for
becoming an art therapist as well as certifications which means they are masters when it comes
to using art as a springboard for everything from a general assessment of another person’s state
to treatment for aiding serious illness. Art therapists can work with people of all ages, sex, creed,
et al. They can help an individual, a couple, a family, or groups of people and depending on the
situation, there may be numerous therapists working together as a clinical team.

Art therapists are trained to pick up on nonverbal symbols and metaphors that are often
expressed through art and the creative process, concepts that are usually difficult to express with
words. It is through this process that the individual really begins to see the effects of art therapy
and the discoveries that can be made.

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How would I use Art Therapy?
As with most any therapy, art as therapy is generally used as a treatment for something - usually
as a way to improve one’s emotional state or mental well-being. Expressive arts therapy doesn’t
have to be used only as a treatment though. It can be used to relieve stress or tension, or it can be
used as a mode of self-discovery. Many people can stand to use some sort of creative outlet.

Do you need to be Talented?

Absolutely not. And you need not be ‘afraid’ of expressing yourself through art. Though it may
seem different and unnatural at first, it is typically because the individual is not used to
communicating via the arts. The creative process can be one of the most rewarding aspects.
Coupled with an art therapist, you should gradually, if not immediately, feel comfortable with
this newfound form of expression. After all, the goal is not necessarily to create an art
masterpiece.

Art: A wonderful Form of Therapy

Expressive art therapy is the use of creative arts as a form of therapy and is a fantastic field that
has proven to work wonders in many people’s lives. It can help someone express themselves,
explore their emotions, manage addictions, and improve their self-esteem. It really helps children
with developmental disabilities, however; art therapy is awesome because it can help anyone!

Doing an activity like drawing relaxes you after a long day? That is because it is very
therapeutic. If you see a professional art therapist, they can help you interpret the feelings that
pour into your design, and even help work through and resolve problems. Studies have also
proven that colouring, even as an adult, has tremendous benefits. Unfortunately, colouring,
drawing, painting, and playing music is very taboo in the adult world. Break away from that
social expectation, and see how freeing it is to let your creativity flow.

Art therapy can be a mixture of drawing, colouring, painting, sculpting and pretty much
everything else you can think of that is artistic. Besides helping someone better their emotional
being, art therapy is great for many other things. It can help general illness. Art therapy can help
someone who has a cancer diagnosis. Battling cancer takes both a very physical and emotional
toll, and is even a struggle accepting the diagnosis. Art and dance are powerful expressions of
these emotions, and can help relieve a lot of stress, anger, and sadness. Someone in need of
therapy to have some relief after a disaster would also be an excellent candidate for artistic
therapy.

There are so many uses and benefits to expressive arts therapies that can help drastically improve
people’s lives for many reasons. Even if you don’t need serious help, it can be a great way to
release stress after a long work week. Art therapy is a growing field that is being more widely
accepted, so it is also an opportunity as a career field.

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DANCE /MOVEMENT THERAPY

Dance therapy is the psychotherapeutic use of movement and dance as a process to support
intellectual, emotional and motor functions of the body.

As a form of expressive therapy dance therapy looks at the correlation between movement and
emotion.

A typical dance therapy has four main stages:

a) Preparation
b) Incubation
c) Illumination
d) Evaluation

Dance has been used therapeutically for thousands of years.

It has been used in the influence of:-
a) Fertility
b) Birth
c) Sickness and
d) Death

Although dance has been a method of expression for centuries, it wasn’t until the past half of
Century that it was characterized as a form of therapy. The development of DMT can be split
into two waves throughout history.

First wave
Marian Chase spearheaded the movement of dance in the medical community as a form of
therapy. She is considered the principle founder of what is now Dance Therapy in the USA.
In 1942, through her work, dance was first introduced to Western Medicine. Chase was
originally a Dancer, Choreographer and a Performer. After opening her own dance school in
Washington D.C, Chase began to realize the effect of dance and movement had on her students.
The reported feelings of wellbeing from her students began to attract the attention of the medical
community, and some local doctors began sending patients to her classes. She was soon asked to
work at St Elizabeth’s Hospital in Washington D.C and once the psychiatrics too realized the
benefits their patients were receiving from attending Chace’s classes. In 1966 Chase became the
first President of the American Dance Therapy Association, an organization which she and
several other DMT pioneers founded.

Second wave
The second wave of dance movement therapy came around 1970s to 1980s and it sparked much
interest from American Therapists. During this time, therapists began to experiment with
psychotherapeutic application of dance and movement. As a result of the therapists experiments
DMT was categorized as form psychotherapy. It was from this second wave that today’s Dance
Movement Therapy evolved.

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Principles
 The theory of Dance Movement Therapy is based mainly upon the belief than body and
mind interact.
 Both conscious and unconscious movement of the person affects total functioning and
also reflects the individual’s personalities. Therefore the therapist -client relationship is
partly based on none verbal cues. Such as body language.
 Movement is believed to have a symbolic function and as such can aid in understanding
the self.
 Movement improvisation allows the client to experiment with new ways of being.
 Through unity of the Body, Mind and Spirit DMT provides a sense of wholeness to all
individuals
a) The Body
Refers to the ‘discharging of energy’ through muscular-skeletal responses to stimulate
receive by the brain.
b) The mind refers ‘mental’ activities such as memory, imagery, perception, attention,
evaluation, reasoning and decision making.
c) The Spirit
Refers to the ‘subjectively’ experienced state of feeling in engaging or emphatically
observing dancing.

The therapy process

The process has four stages and each stage has a smaller set of goals.
i. Preparation
 This is the warm up stage a safe place is established without obstacles nor destructions.
 Supportive relationship with a witness is formed
 Comfort for participant to be familiar with moving with their eyes closed
ii. Incubation
 Leader verbally prompt participants to subconscious
 Open ended imagery used to create an internal environment that is relaxed atmosphere,
and symbolic movements.
iii. Illuminations
 Process which is integrated through conscious awareness via dialogue with witness,
self-reflection in noted the participant uncovers and resolves subconscious motivations,
increased self-awareness can have positive and negative effects
iv. Evaluation
 Discuss insights and significance of the process, prepare to end therapy.

Dance styles used

A variety of dance styles are used in DMT depending on the needs of the client e.g.
- Modern dance with emphasis on the pure elements of movement,
- Authentic Movement,
- Turkish Dance,
- Ballroom Dance,
- Tango,
- Waltz,
- Foxtrot,

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- Aerobic Dance,
- Line dancing and
- Body Psychotherapy.

Benefits
 Dance therapy works to improve the social skills, as well as relational dynamics among
the clients that choose to participate in it to better improve the their quality of life
 Through this form of therapy clients will gain deeper sense of self-awareness through
meditative process that involves movement, motion and realization of one’s body.
 It is different from other rehabilitative treatments because it allows creative expression
and is more holistic meaning it treats a full person; mind, body and spirit.
 Using dance movement as a form of therapy activates several brain functions at once.ie
kinesthetic, rational, musical and emotional. This type of movement requires mental,
physical and emotional strength to work simultaneously thus causing full body and soul
workout.
 Dance therapy is suitable even for people who are not accomplished dancers, and may
even be good for those who are clumsy in the dance floor.
 Dance therapy can be useful on one to one situation where the therapists works with only
one patient to provide a safe place to express emotions.
 Dance therapy have beneficial results on children who have been abused and/or
neglected.
 Dance therapy combines multiple areas of the brain to work together rather than
stimulating one area at a time.
 Individuals’ feel stronger sense of self confidence and higher view of self-esteem.
 The dance therapy was also beneficial to those who are emotionally disturbed.

Locations
Dance movement therapy is practiced in location such as:-
 Rehabilitation centers
 Medical settings
 Educational settings
 Nursing homes
 Day care facilities
 Disease prevention centers
 Health promotion programs

Other definitions
 Dance therapy is a type of psychotherapy that uses movement to further the social,
cognitive, emotional and physical development of the individual.
 It is a type of psychotherapy in which dance therapists work with people who have
many kinds of emotional problems, intellectual deficits and life threatening illness
 It is a type of therapy that try to help people develop communication spells, a positive
self-image and emotional stability.

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DRAMA THERAPY

Drama therapy is the use of theatre techniques to facilitate personal growth and promote mental
health. Drama therapy is used in a wide variety of setting including hospitals, schools, mental,
health centers, prisons and businesses. Drama therapy, as a form of “expressive therapy” (also
known as creative arts therapies) exits in many forms and can be applicable to individuals,
couples, families and various groups.

Other definitions
Drama therapy is a treatment approach that provides a theoretical platform for people in therapy
to express their feelings, solve problems and achieve therapeutic goods.

According to North America Drama Therapy Association it defines drama therapy as an active
experimental approach to facilitating change. Through storytelling, projective play, purposefully
improvisation and performance, participants are invited to release desired behaviors, practice
being in a relationship, expand and find flexibility between life roles and perform the change
they wish to be and see in the world.

History
The modern use of dramatic process as therapeutic intervention began with Dr. Jacob L.
Moreno’s development of psychodrama in the 1970’s. The field had expanded to allow many
forms of theatrical interventions as therapy including role play, theatre games, group-dynamic
games, mime, puppetry, and other improvisational techniques.

Today drama therapy is practiced around the world and there are academic programs in the
UK, Germany, Netherlands, Canada , Israel and USA. Often drama therapy is utilized to help
a client:
 Solve a problem.
 Achieve catharsis and to dig in and find the truth.
 Deliver in truths about self.
 Understand the meaning of personally resonant images.
 Explore and transcend unhealthy patterns of behaviors and interpersonal interaction.

In practice
 Due to the ‘cathartic’ nature, drama itself tends to promote good that washes mental
health. However drama therapy consists of more than just acting.
 Like art, music and dance therapies drama therapy uses the art form as spring board for
deepened, more meaningful work with participant.
 Drama therapists guide people in therapy through a series of intentional activities
that allow them to enact scene representation of the way they want to live their lives
 Participants may see drama therapy effect changes in their behavior, emotional state,
personal growth and skill adaptation.
 Participants utilizing drama therapy are often able to improve their interpersonal
relationship skills through active participation in activities like:
- Story telling
- Role playing

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 - Puppetry
- Rituals
- Games
- Improvisational Techniques
- Scripts
- Group Dynamic Games
- Mime

 Participants in drama therapy follow roles to tell a story or perform a part thus embracing
a new perspective of the character and themselves.
 Another key element is or where the acting takes place.
 Other components of drama therapy include: ritual, conflict, resistance, spontaneity,
distance and catharsis.
 Drama therapy works to shed light on a feeling and behaviors of a person and helps teach
them ways to manage and overcome obstacles they struggle with. The hope is that by
taking on specific roles a person can gain personal insight and break free from barriers.
 Though this process can be beneficial and rewarding it can be very difficult.
 Though drama therapy can be done individually it is typically done in groups or
community settings
 As a form of counseling drama therapy is usually private and doesn’t involve spectators.

Drama therapy objective

The primary goal of ‘drama therapy’ is to provide people with a safe and secure experience that
encourages the full expression of their emotional voice through playful, dramatic activity.
As a practice drama therapy aims to do the following;
a) Promote positive behavioral changes.
b) Improve interpersonal relationship skills.
c) Integrate physical and emotional well-being
d) Achieve personal growth and self-awareness.
e) Improve overall quality of life.

Drama therapy may be used as a treatment for the following;

a) Post-traumatic stress.
b) Anxiety
c) Depression
d) Interpersonal relationship issues
e) Substances abuse
f) Behavior issues related to autism
g) Rehabilitation
h) Schizophrenia (conflict)
i) Dementia (mental disorder)
j) Hearing difficulties
k) Grief and loss

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Drama therapy session
A typical group drama therapy session may work like this:
1. Check In
This is designed to help the drama therapists understand how you are feeling today. Younger
children may be supported in this with the use of emotion cards.
2. Warm Up
At this point the drama therapist will want to prepare you for the session. A warm up activity is
something that loosens the muscles and engages the imagination; an example of this is the name
game where members of the group introduce themselves by stating their name and miming an
action that represents how they are feeling.
3. Main Activity
This is when the therapists will help the group explore issues through various drama therapy
techniques such as role play.
4. Closing
At the end of the session the therapists may ask for your input into how you think the session
went, or may de-brief the group to let you know what you have achieved.
Drama therapy activities
For the main activity drama therapists can use a range of different activities including the
following:
Role Play
This is when you act the part of a certain character in a certain situation e.g. To act the part of a
child or parent and to explore any emotions this brings to the surface.
Improvisation
To improvise in acting is to make up a scenario on the spot. This technique may require you to
work with others and makes you think on the feet.
Mime
Miming is essentially acting without the use of words. This means that you will have to rely on
your body language alone to portray a certain emotion or scenario. This can cause you to think in
different ways and may tap into feelings you have not experienced before.
Speech
Using speech in drama therapy could involve speaking in ways you don’t normally speak (e.g. If
you have low self-confidence your therapist may ask you to shout rather than whisper) or it may
involve using language to describe the way a character is feeling.
Movement
Similarly to mime, movement therapy requires you to express emotions through your body rather
than through speaking. You may find yourself dancing to do this or indicating a state of mind
through an action

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Acting Out
In some cases your drama therapists may ask you to re-enact behaviors or situations that have
caused you problems in the past. This can be difficult task to undertake as it can cause you to
remember and re-experience difficult emotions. The idea behind doing this is to help you learn
how you can do things differently in the future or simply understand why what happened
affected you the way it deed.
Use of props and masks
Sometimes using props and masks during drama therapy activity can help you to take on
different roles. These can be especially important when working with young children to help
them identify with the character they are portraying or simply to help them express emotions.

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MUSIC THERAPY
Definitions
 Music therapy is the use of music to address a number of emotional, cognitive and social
issues in people of all ages. It is often used with people who have disabilities or illness,
but the healing benefits of music can be enjoyed by anyone and at any age.
 Music therapy is the clinical and evidence based use of music interventions to accomplish
individualized goals within a therapeutic relationship by a credentialed professional who
has completed an approved music therapy programme.
 Music therapy is an established health profession in which music is used within a
therapeutic relationship to address physical, emotional, cognitive and social needs of
individuals.
 Music therapy is the use of interventions to accomplish goals within a therapeutic
relationship by a professional who has completed an approved music therapy programme.
A music therapy session involves the client in musical experiences and there are four basic types:
1. Recreation: The client performs music: he/she sings or plays on an instrument a pre-
composed song or piece of music according to his/her capabilities, either by memory or
using notation.
2. Listening: The client listens to pre-recorded, live or improvised music in any type or
style.
3. Composing: The client creates music, i.e. melodies /lyrics to songs, music for
instruments, musical plays, etc.
4. Improvisation: The client makes/creates music spontaneously with voice, body or an
instrument.
Music experiences are chosen, adapted, and directed by the music therapist to address the
individual client’s needs and ability levels. Since the central feature of music therapy is the
music, many different types of music engagement are integrated into music therapy sessions.
Some other music engagements may include:
 Listening to live or recorded music.
 Learning music-assisted relaxation techniques, such as progressive muscle relaxation or
deep breathing.
 Singing of familiar songs with live or recorded accompaniment
 Playing instruments, such as a hand percussion.
 Improvising music on instruments or voice.
 Writing song lyrics.
 Writing the music for new songs.
 Learning to play an instrument, such as piano or guitar.
 Creating art with music.
 Dancing or moving to live or recorded music.

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  Writing choreography for music.
 Discussing one’s emotional reaction or meaning attached to a particular song or
improvisation
Methods
In general, musical therapy utilizes the power of music to interact with human emotions and
affect wellbeing. Although there are several different types recognized in the world today, there
are various different psychological theories for musical therapy, which define the different types
as we know them.
Bonny Method of Guided Imagery and Music
- Helen Lindquist Bonny was a music therapist who developed an approach to music
therapy that involves guided imagery with music.
- Mental imagery is used to aid patients with physiological and psychological issues they
may be experiencing. The patient is asked to focus on an image, using this as a starting
point to think and discuss any related problems. Bonny added music to this technique,
helping patients to heal and find solutions with increased awareness.
- In this application, music is thought to be a co-therapist, due to the significant role it
plays in the therapy. The music choice is an important consideration for the therapist to
make, with the individual patient and the goals for the session influencing the selection.
Dalcroze Method
- Also known as the Dalcroze Eurhythmics, this is a method used to teach music to
students and can be used as a form of therapy.
- It was developed by Émile Jaques-Dalcroze and focuses on rhythm, structure and
movement expression in the learning process. This type of musical therapy is thought to
greatly improve physical awareness, which helps patients with motor difficulties
significantly.
Kodaly Method
- Zoltán Kodály is considered to be the inspiration for the development of this philosophy
of music therapy. It uses a base of rhythm, notation, sequence and movement to aid in the
learning and healing of the patient.
- It has been observed that this method helps to improve intonation, rhythm and music
literacy and has also had a positive impact on perceptual function, concept formation,
motor skills and learning performance in a therapeutic setting.
Neurologic Music Therapy (NMT)
- NMT is a model of music therapy that is based on neuroscience, specifically the
perception and production of music and its influence on the function of the brain and
behaviors.
- It uses the difference between the brain with and without music and manipulates this to
instigate changes in the brain to affect the patient, even outside the realm of music.
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 - Specialists of this type of musical therapy claim that the brains changes and develops as a
direct consequence of engaging with music. This can be beneficial to train motor
responses, like tapping a foot to music, and to develop related motor skills.
Nordoff-Robbins
- Paul Nordoff and Clive Robbins partnered together for nearly two decades to investigate
the place of music in therapy, with a particular interest for disabled children.
- They piloted projects with children affected by autism, mental disorders, emotional
disturbances, developmental delays and other learning difficulties, using music as the
means of therapy.
- The core aspect of the Nordoff-Robbins approach assumes everyone can find meaning
and benefit from music and focuses on music creation with the help of a therapist. This
technique is widely practiced throughout the world today and can accommodate patients
of all experience and ability levels.
Orff-Schulwerk
- The Orff-Schulwerk approach to music therapy was developed by Gertrude Orff to help
children with developmental delays and disabilities, following the realization that
medicine alone was not sufficient.
- This places an emphasis on education and uses music to improve the learning ability of
children.
Materials for Music Therapy
The basic materials of music therapy include: percussion, voice, string instruments, keyboards,
environmental and body sounds, movement and possibly wind instruments and brass.
Preference should be given to a good selection of quality instruments that sound great and that
are pleasing to the eye, durable, low maintenance and sturdy.
The element of presenting choices to our clients is important. It is believed that it is the person's
feelings, hands and movements that breathe life into the sound of the instrument.
The goal is to provide successful musical experience, helping clients move toward musical
expression and achieving their fullest potential.
Part of properly structuring sessions is to provide excellent quality instruments that sound great,
are inviting to play and facilitate musical process. Most instruments used by clients in therapy,
do not require formal training. They are designed so that, even to non-musicians they sound
good. No traditional music training is necessary to be musical in therapy. There are also
supplemental books, videos and CDs for therapists to use in their own practice or classroom.
Modern life can be complicated, demanding and stressful, but relaxation music is a wonderful
tool that can help you to slow down, breathe deeply and gain perspective. It’s common
knowledge that deep breathing techniques, brief mindfulness, meditations and gentle yoga are all
good ways to release the tension that accumulates on even uneventful days.

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But it can be difficult to shift into relaxation mode after a particularly challenging work meeting.
Music can be a shortcut into a more relaxed, centered way of being. Instead of trying to force
yourself into a state of relaxation (which can actually cause more stress and frustration), you can
use relaxation music to gently guide you into serenity.
Any place that sells CDs will likely have a good selection of relaxation music. Many people find
recordings of nature sounds like birds, running water, and pounding surf extremely relaxing and
calm your mind.
Foundations and Principles
Apply basic knowledge of:

1. Existing music therapy methods, techniques, materials, and equipment with their
appropriate applications.
2. Principles and methods of music therapy assessment, treatment, evaluation, and
termination for the populations specified in the Standards of Clinical Practice.
3. The psychological aspects of musical behavior and experience including, but not
limited to, perception, cognition, affective response, learning, development,
preference, and creativity.
4. The physiological aspects of the musical experience including, but not limited to,
central nervous system, peripheral nervous system, and psychomotor responses.
5. Philosophical, psychological, physiological, and sociological basis of music as
therapy.
6. Use of current technologies in music therapy assessment, treatment, evaluation, and
termination.

Client assessment

1. Select and implement effective culturally-based methods for assessing the client’s
strengths, needs, musical preferences, level of musical functioning, and development.
2. Observe and record accurately the client's responses to assessment.
3. Identify the client's functional and dysfunctional behaviors.
4. Identify the client’s therapeutic needs through an analysis and interpretation of
assessment data.
5. Communicate assessment findings and recommendations in written and verbal forms.

Treatment planning

1. Select or create music therapy experiences that meet the client's objectives.
2. Formulate goals and objectives for individual and group therapy based upon
assessment findings.
3. Identify the client's primary treatment needs in music therapy.
4. Provide preliminary estimates of frequency and duration of treatment.
5. Select and adapt music, musical instruments, and equipment consistent with the
strengths and needs of the client.
6. Formulate music therapy strategies for individuals and groups based upon the goals
and objectives adopted.

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 7. Create a physical environment (e.g., arrangement of space, furniture, equipment, and
instruments that is conducive to therapy).
8. Plan and sequence music therapy sessions.
9. Determine the client's appropriate music therapy group and/or individual placement.
10. Coordinate treatment plan with other professionals.

Therapy implementation

1. Recognize, interpret, and respond appropriately to significant events in music therapy

sessions as they occur.
2. Provide music therapy experiences that address assessed goals and objectives for
populations specified in the Standards of Clinical Practice.
3. Provide verbal and nonverbal directions and cues necessary for successful client
participation.
4. Provide models for and communicate expectations of behavior to clients.
5. Utilize therapeutic verbal skills in music therapy sessions.
6. Provide feedback on, reflect, rephrase, and translate the client's communications.
7. Assist the client in communicating more effectively.
8. Sequence and pace music experiences within a session according to the client's needs
and situational factors.
9. Conduct or facilitate group and individual music therapy.
10. Implement music therapy program according to treatment plan.
11. Promote a sense of group cohesiveness and/or a feeling of group membership.
12. Develop and maintain a repertoire of music for age, culture, and stylistic differences.
13. Recognize and respond appropriately to effects of the client's medications.
14. Maintain a working knowledge of new technologies and implement as needed to
support client progress towards treatment goals and objectives.

Therapy evaluation

1. Design and implement methods for evaluating and measuring client progress and the
effectiveness of therapeutic strategies.
2. Establish and work within realistic time frames for evaluating the effects of therapy.
3. Recognize significant changes and patterns in the client's response to therapy.
4. Recognize and respond appropriately to situations in which there are clear and present
dangers to the client and/or others.
5. Modify treatment approaches based on the client’s response to therapy.
6. Review and revise treatment plan as needed.

Documentation

1. Produce documentation that accurately reflects client outcomes and meet the
requirements of internal and external legal, regulatory, and reimbursement bodies.
2. Document clinical data.
3. Write professional reports describing the client throughout all phases of the music
therapy process in an accurate, concise, and objective manner.

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 4. Effectively communicate orally and in writing with the client and client’s team
members.
5. Document and revise the treatment plan and document changes to the treatment plan.
6. Develop and use data-gathering techniques during all phases of the clinical process
including assessment, treatment, evaluation, and termination.

Termination/Discharge planning

1. Assess potential benefits/detriments of termination of music therapy.

2. Develop and implement a music therapy termination plan.
3. Integrate music therapy termination plan with plans for the client’s discharge from the
facility.
4. Inform and prepare the client for approaching termination from music therapy.
5. Establish closure of music therapy services by time of termination/discharge.

Professional role/Ethics

1. Interpret and adhere to the AMTA Code of Ethics.

2. Adhere to the Standards of Clinical Practice.
3. Demonstrate dependability: follow through with all tasks regarding education and
professional training.
4. Accept criticism/feedback with willingness and follow through in a productive
manner.
5. Resolve conflicts in a positive and constructive manner.
6. Meet deadlines without prompting.
7. Express thoughts and personal feelings in a consistently constructive manner.
8. Demonstrate critical self-awareness of strengths and weaknesses.
9. Demonstrate knowledge of and respect for diverse cultural backgrounds.
10. Treat all persons with dignity and respect, regardless of differences in race, ethnicity,
language, religion, marital status, gender, gender identity or expression, sexual
orientation, age, ability, socioeconomic status, or political affiliation.
11. Demonstrate skill in working with culturally diverse populations.
12. Adhere to all laws and regulations regarding the human rights of clients, including
confidentiality.
13. Demonstrate the ability to locate information on regulatory issues and to respond to
calls for action affecting music therapy practice.
14. Demonstrate basic knowledge of professional music therapy organizations and how
these organizations influence clinical practice.
15. Demonstrate basic knowledge of music therapy service reimbursement and financing
sources (e.g., Medicare, Medicaid, Private Health Insurance, State and Local Health
and/or Education Agencies, Grants).
16. Adhere to clinical and ethical standards and laws when utilizing technology in any
professional capacity.

17
Inter professional collaboration

1. Demonstrate a basic understanding of professional roles and duties and develop

working relationships with other disciplines in client treatment programs.
2. Communicate to other departments and staff the rationale for music therapy services
and the role of the music therapist.
3. Define the role of music therapy in the client's total treatment program.
4. Collaborate with team members in designing and implementing interdisciplinary
treatment programs.

Supervision and administration

1. Participate in and benefit from multiple forms of supervision (e.g., peer, clinical).
2. Manage and maintain music therapy equipment and supplies.
3. Perform administrative duties usually required of clinicians (e.g., scheduling therapy,
programmatic budgeting, maintaining record files).
4. Write proposals to create new and/or maintain existing music therapy programs.

References
Aigen, K. (1997). Here we are in Music: One Year with an Adolescent, Creative Music Therapy
Group. Nordoff-Robbins Music Therapy Monograph Series #2. Gilsum NH: Barcelona
Publishers.
Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C.
Thomas Publishers.
Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: John Day.
Robbins, C. & Robbins, C. (1998). Healing Heritage. Gilsum, NH: Barcelona Publishers.
Alley, J.M. (1978). Competency based evaluation of a music therapy curriculum. Journal of
Music Therapy, .11, 9-14.

Braswell, C. Maranto, C.D., Decuir, A. (1979a). A survey of clinical practice in music therapy,
Part I: The institutions in which music therapist's work and personal data. Journal of Music
Therapy, 16, 2-16.

Bruscia, K., Hesser B., & Boxill, E. (1981). Essential competencies for the practice of music
therapy. Music Therapy, 1, 43-49.

Certification Board for Music Therapists. (1988). Job re-analysis survey of Music Therapy
knowledge and skills.

Jensen, K.L., & McKinney, C.H. (1990). Undergraduate music therapy education and training:
Current status and proposals for the future. Journal of Music Therapy, 18, 158-178.

Lathom W.B. (1982). Survey of current functions of a music therapist. Journal of Music
Therapy, 19, 2-27.

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McGuire, M.G. (1996a). Determining the professional competencies for the National Association
for Music Therapy: Six surveys of professional music therapists in the United States, 1990-1996.
Paper presented at the Eighth World Congress of Music Therapy and the Second International
Congress of the World Federation of Music Therapy, Hamburg-Germany.

McGuire, M.G. (1996b). A survey of all American Association for Music Therapy and National
Association for Music Therapy educators. Unpublished manuscript. Author.

Maranto, C.D., and Bruscia, K.E. (1988). Methods of teaching and training the music therapists.
Philadelphia: Temple University.

National Association for Music Therapy. (Various dates). Surveys conducted from 1991 through
1996.

Petrie, G.E. (1989). The identification of a contemporary hierarchy of intended learning

outcomes for music therapy students entering internships. Journal of Music Therapy, 26, 125-
139.

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POETRY THERAPY

Definition

Poetry therapy is a form of expressive arts therapy that involves the therapeutic use of poems,
narratives, and other spoken or written media to promote well-being and healing. Therapists may
use existing literature as part of treatment or encourage those in therapy to produce their own
literary works to express deep-seated emotions. In either case, they offer a safe, non-judgmental
atmosphere in which people in therapy are able to explore their written expressions and
associated emotional responses.

History and development of poetry therapy

The healing effect of words has long been recognized. As far back as 4000 BC, early Egyptians
wrote words on papyrus, dissolve them in liquid, and gave them to those who were ill as a form
of medicine. In more recent history, reading and expressive writing were employed as
supplementary treatments for those experiencing mental or emotional distress. Pennsylvania
Hospital, the first hospital established in the United States, reportedly employed this approach as
early as the mid-1700s.

In the early 1800s, Dr. Benjamin Rush introduced poetry as a form of therapy to those being
treated. In 1928, poet and pharmacist Eli Griefer began offering poems to people filling
prescriptions and eventually started ‘poem therapy’ groups at two different hospitals with the
support of psychiatrists Dr. Jack L. Leedy and Dr. Sam Spector. After Griefer's death, Leedy and
others continued to incorporate poetry into the therapeutic group process, eventually coming
together to form the Association for Poetry Therapy (APT) in 1969.

Librarians also played a major role in the development of this approach to therapy. Arleen
Hynes, one pioneer in this area, was a hospital librarian who read about poetry therapy and began
reading stories and poems aloud, facilitating discussions on the material and its relevance to each
individual in order to better reach out to those being treated and encourage healing. She
eventually began development of a training program for poetry therapy, around the time other
individuals were doing the same. In 1980, all leaders in the field were invited to a meeting to
formalize guidelines for training and certification. At that meeting, the National Association for
Poetry Therapy (NAPT) formed out of what had been the APT.

As interest grew, several books and articles were written to guide practitioners in the practice of
poetry therapy. Hynes and Mary Hynes-Berry co-authored the 1986 publication Bibliotherapy -
The Interactive Process: A Handbook. More recently, Nicholas Mazza outlined a model for
effective poetry therapy, also discussing its clinical application, in Poetry Therapy: Theory and
Practice. The Journal of Poetry Therapy, established in 1987 by the NAPT, remains the most
comprehensive source of information on current theory, practice, and research.

Today, poetry therapy is practiced internationally by hundreds of professionals, including

psychologists, psychiatrists, counselors, social workers, educators and librarians. The approach
has been used successfully in a number of settings-schools, libraries, hospitals, rehabilitation

20
centers, and correctional institutions, to name a few-with various populations, including children,
adolescents and the elderly.

How does poetry therapy work?

As part of therapy, some people may wish to explore feelings and memories buried in the
subconscious and identify how they may relate to current life circumstances. Poetry is believed
to be beneficial to this process as it can often:

 Be used as a vehicle for the expression of emotions that might otherwise be difficult to
express.
 Promote self-reflection and exploration, increasing self-awareness and helping
individuals make sense of their world.
 Help individuals redefine their situation by opening up new ways of perceiving reality.
 Validate emotional experiences and improve group cohesiveness by helping people
realize many of their experiences are shared by others.
 Help therapists gain deeper insight into those they are treating.

In general, poetry therapists are free to choose from any poems they believe offer therapeutic
value, but most tend to follow general guidelines. It is recommended selected poems be concise,
address universal emotions or experiences, offer some degree of hope, and contain plain
language.

Although the selection of material is usually done by the therapist, those being treated might be
asked to bring to therapy a poem or other form of literature they identify with, as this may also
provide valuable insight into their feelings and emotions.

Techniques used in poetry therapy

A few different models of poetry therapy exist, but the most popular and most frequently used is
the model introduced by Nicholas Mazza. According to this model, poetry therapy involves three
major components: receptive/prescriptive, expressive/creative, and symbolic/ceremonial.

Receptive/Prescriptive
In this component the therapist will introduce a poem or piece of literature and encourage the
person in therapy to react. Material is typically selected based on its ability to describe, explain
and identify issues relevant to the content of the session. Selected material is usually read aloud
by the therapist or the person in therapy so the tone and rhythm of the poem can be fully
experienced. In the case of group, family, or couples therapy, individuals may take turns reading
different stanzas or might be asked to read the entire poem in unison. While the poem is being
read, the therapist notes the verbal and nonverbal reactions of the individual, and these reactions
are generally explored after the reading with questions such as, ‘I noticed you were smiling as
the poem was being read. Can you tell me about your reaction?’ ‘Is there a particular line in the
poem that touched you?’ ‘How does this poem make you feel?’

21
Expressive/Creative
This component involves the use of creative writing-poetry, letters, and journal entries-for the
purpose of assessment and treatment. The process of writing can be both cathartic and
empowering, often freeing blocked emotions or buried memories and giving voice to one's
concerns and strengths. Some people may doubt their ability to write creatively, but therapists
can offer supporting by explaining they do not have to use rhyme or a particular structure.
Therapists might also provide stem poems from which to work or introduce sense poems for
those who struggle with imagery. A therapist might also share a poem with the individual and
then ask them to select a line that touched them in some way and then use that line to start their
own poem.

In group therapy, poems may be written individually or collaboratively. Group members are
sometimes given a single word, topic, or sentence stem and asked to respond to it spontaneously.
The contributions of group members are compiled to create a single poem which can then be
used to stimulate group discussion. In couple’s therapy, the couple may be asked to write a
dyadic poem by contributing alternating lines. .

Letter writing, another effective therapeutic tool, may be a more accessible creative platform for
some. One exercise involves writing a letter to the persona of a poem read in therapy. The letter
may include expressions of approval or disapproval, and this process can clarify the individual's
initial reactions to the poem. A letter could also be addressed to any emotions presently causing
difficulty in order to help a person visualize and externalize these feelings in the hope of gaining
control over them. Individuals might also be encouraged to keep a personal journal during
therapy and record their thoughts after hearing or reading a poem. Those in group therapy may
have the opportunity to share their entries with group members.

Symbolic/Ceremonial
This component involves the use of metaphors, storytelling, and rituals as tools for effecting
change. Metaphors, which are essentially symbols, can help individuals to explain complex
emotions and experiences in a concise yet profound manner. Rituals may be particularly
effective to help those who have experienced a loss or ending, such as a divorce or death of a
loved one, to address their feelings around that event. Writing and then burning a letter to
someone who died suddenly, for example, may be a helpful step in the process of accepting and
coping with grief.

How can poetry therapy help?

Poetry therapy has been used as part of the treatment approach for a number of concerns,
including:

 Borderline personality,
 Suicidal ideation,
 Identity issues,
 Perfectionism,
 Grief.

22
Research shows the method is frequently a beneficial part of the treatment process. Several
studies also support poetry therapy as one approach to the treatment of depression, as it has been
repeatedly shown to relieve depressive symptoms, improve self-esteem and self-understanding,
and encourage the expression of feelings. Researchers have also demonstrated poetry therapy's
ability to reduce anxiety and distress in people diagnosed with a terminal illness.

Those experiencing posttraumatic stress have also reported improved mental and emotional well-
being as a result of poetry therapy. Some individuals who have survived trauma or abuse may
have difficulty processing the experience cognitively and, as a result, suppress associated
memories and emotions. Through poetry therapy, many are able to integrate these feelings,
reframe traumatic events, and develop a more positive outlook for the future.

People experiencing addiction may find poetry therapy can help them explore their feelings
regarding the substance abuse, perceive drug use in a new light, and develop or strengthen
coping skills. Poetry writing may also be a way for those with substance abuse issues to express
their thoughts on treatment and behavior change.

Some studies have shown poetry therapy can be of benefit to people with schizophrenia despite
the linguistic and emotional deficits associated with the condition. Poetry writing may be a
helpful method of describing mental experiences and can allow therapists to better understand
the thought processes of those they are treating. Poetry therapy has also helped some individuals
with schizophrenia to improve social functioning skills and foster more organized thought
processes.

It is important to note in most instances, especially in cases of moderate to severe mental health
concerns, poetry therapy is used in combination with another type of therapy, not as the sole
approach to treatment.

Training for poetry therapists

Poetry therapists receive literary as well as clinical training to enable them to be able to select
literature appropriate for the healing process. While there is no university program in poetry
therapy, the International Federation for Biblio-Poetry Therapy (IFBPT), the independent
credentialing body for the profession, has developed specific training requirements.
Several studies support poetry therapy as one approach to the treatment of depression, as it has
been repeatedly shown to relieve depressive symptoms, improve self-esteem and self-
understanding, and encourage the expression of feelings.

Training, in the form of an independent study program, is provided with the direction of a
Mentor/Supervisor approved by the IFBPT. Individuals can pursue training to become a certified
poetry therapist (CPT), registered poetry therapist (RPT), or certified applied poetry facilitator
(CAPF). Those with a master's degree in a mental health field or a medical degree and
professional licensure can obtain the CPT or RPT credentials. Both the CPT and RPT are
qualified to work with individuals in good health as well as those who are experiencing mental
health concerns. To obtain the RPT certification, a more advanced level of training and fieldwork
is required.

23
To obtain the CAPF certification, a person must have a bachelor's degree. Upon certification,
CAPFs are qualified to work with healthy populations and may be employed by schools or
libraries. They can also work in mental health settings with the supervision of a qualified mental
health professional.

Concerns and limitations of poetry therapy

In spite of its widespread appeal and broad range of application, some concerns have been raised
about the use of poetry therapy.

The content of some poems might have no value or unintended effects for some people in
therapy. Some poems might evoke memories or emotions the individual is not yet ready to
handle, or have significant personal value to one personal in therapy but little application for
others in treatment. The language of some poems may be difficult to understand, and the
message of some poems may be so obscure that little therapeutic value is obtained. However,
therapists who are aware of these factors and take care when selecting literary materials to be
used in session can likely avoid many or all of these potential issues.

Some critics have pointed out it is possible for people to analyze a poem on a purely intellectual
level, without any emotional involvement. This type of intellectualization may be more likely
when complex poems are used, as a person might spend so much time trying to decipher the
meaning of the poem that they lose sight of their emotions and spontaneous reactions. Poems that
are unoriginal or filled with clichés are unlikely to stimulate individuals on a deep emotional
level or challenge them to think in ways promoting growth.

The speech and language abilities of individuals in therapy must also be considered, since poems
will have little value if the words used are not understood. In group therapy sessions, individuals
who have difficulty with reading or writing may be reluctant to share their poems, which can be
a barrier to discussion, and some people who speak English as a second language or lack
advanced linguistic skills may be challenged by the figurative language often used in poems.
Further, poetry therapy may have little or no value for those individuals who simply do not enjoy
poetry.

References:

1. Chavis, G.G. (2011). Poetry and story therapy: The healing power of creative
expression. Philadelphia, PA: Jessica Kingsley Publishers.
2. Gooding, L. F. (2008). Finding your inner voice through song: Reaching adolescents with
techniques common to poetry therapy and music therapy. Journal of Poetry Therapy,
21(4), 219-229.
3. International Federation for Biblio/Poetry Therapy. (n.d.). Summary of training
requirements. Retrieved from http://ifbpt.org/obtaining-a-credential/getting-trained
4. Mazza, N. (2003). Poetry therapy: Theory and practice. New York: Brunner-Routledge.
5. Olsen-McBride, L. (2009). Examining the influence of popular music and poetry therapy
on the development of therapeutic factors in groups with at-risk adolescents (Doctoral

24
 dissertation). Retrieved from http://etd.lsu.edu/docs/available/etd-11102009-
114408/unrestricted/Olson-McBride_diss.pdf
6. Rossiter, C. (2004). Blessed and delighted: An interview with Arleen Hynes, poetry
therapy pioneer. Journal of Poetry Therapy, 17(4), 215-222.
7. Springer, W. (2006). Poetry in therapy: A way to heal for trauma survivors and clients in
recovery from addiction. Journal of Poetry Therapy, 19(2), 69-81.
8. The National Association for Poetry Therapy. (n.d.). History. Retrieved from
http://www.poetrytherapy.org/history.html

25
PSYCHODRAMA THERAPY
Definition
Psychodrama is an experiential form of therapy that allows those in treatment to explore issues
through action methods (dramatic actions). This approach incorporates role playing and group
dynamics to help people gain greater perspective on emotional concerns, conflicts, or other areas
of difficulty in a safe, trusted environment.
People seeking therapy may find psychodrama to be beneficial for the development of emotional
well-being as well as cognitive and behavioral skills.

History and development of psychodrama

Jacob Moreno, a 20Th Century psychiatrist, developed psychodrama in the early 1900s, holding
the first session in 1921. The approach was born out of his recognition of the importance of
the group approach to therapy and his combined interests in philosophy, theater, and mysticism.
In the late 1930s, he founded the Beacon Hospital, which featured a therapeutic theater where
psychodrama could be practiced as part of therapy, and in 1942, he established the American
Society of Group Psychotherapy and Psychodrama. After his death in 1974, his wife, Zerka,
continued to travel, teaching and training others in the approach.

Other notable figures include Martin Haskell, who worked with Moreno in the 1950s and was
one of the earliest pioneers of the approach, Eya Fechnin Branham, a trainer in the Southwest,
Anne Ancelin Schutzenberger, who helped pioneer psychodrama in France and throughout
Europe, Gretel Leutz, an early European psycho-dramatist, and Marcia Karp, who was the
primary pioneer of psychodrama in Great Britain.
Theory and purpose of psychodrama
Moreno described psychodrama as the ‘scientific exploration of truth through dramatic method.’
The approach, which is grounded in principles of creativity, spontaneity, combines sociometry,
group dynamics, and role theory in order to evoke cognitive, emotional, and behavioral
responses in those in treatment and help them achieve new perspective through better
understanding of their roles in life, the ways they interact with others, and things that may be
creating challenges or restricting change in their lives.

Through psychodrama, people in treatment are often able to develop their use of language and
perspective as they use action methods to explore past, present, or future occurrences. Because
psychodrama can help people see themselves and their situations from an outside perspective, the
psychodrama session often becomes a safe place for people to explore new solutions to
difficulties or challenges, whether they are rooted in outside causes or past situations.

Techniques used in psychodrama

Psychodrama sessions are often performed as weekly group therapy sessions, typically
comprised of 8 -12 members. Sessions generally last between 90 minutes and 2 hours. Each
psychodrama focuses on the life situation of one individual, with group members taking on roles
as needed.
A session is typically executed in three phases:

26
  the warm-up phase,
 the action phase,
 the sharing phase.
Through role and drama-based play, the protagonist and other participants develop insight
into past issues, present challenges, and future possibilities.

The goal of the warm-up phase is to help establish trust, group cohesion, and a sense of safety
among members. Without trust, group members may not feel comfortable performing action
methods or exploring raised issues or conflicts. One technique often used in warm-up is role
presentation, where members of the group adopt a certain role in order to introduce themselves.
Because in psychodrama, members of the group often act out roles in other members' lives, this
technique can help provide insight to those in the group. As the members get to know one
another, one member may volunteer to act as the psychodrama protagonist, or the main focus of
the psychodrama.

In the action phase, the protagonist-with the therapist's help-creates a scene based on significant
events in the protagonist’s current life. The therapist directs the session, while other group
members serve as auxiliary egos, or individuals from the protagonist's life. The rest of the group
members act as an audience.

The following techniques are most commonly used as part of the action phase:
 Role Reversal: The protagonist steps out of their own role and enacts the role of a
significant person in their life. This action can help the protagonist understand the other
person's role and help the director (therapist) better understand relationship dynamics. Doing
so may also help increase the protagonist's empathy.
 Mirroring: The protagonist becomes an observer while auxiliary egos take up the part of
the protagonist, acting out an event so the protagonist can watch. This technique can be
helpful when a protagonist is experiencing extremely negative feelings or is feeling
separated or distanced from feelings or emotions about the scene.
 Doubling: A group member adopts the protagonist's behavior and movements, expressing
aloud any emotions or thoughts that member believes to be the protagonist's feelings and
thoughts. This technique can be used to build empathy for the protagonist or to challenge, in
a constructive and non-aggressive way, some aspect of the scene or the protagonist's actions.
 Soliloquy: The protagonist relates inner thoughts and feelings to the audience. This may be
done when speaking to a double, or at the encouragement of the director (Therapist).

During the sharing phase, the director shifts back to a therapist role in order to facilitate the
processing of the scene. Processing the meaning of the feelings and emotions that have come to
light is believed to be essential for transformation to occur. The sharing phase provides time for a
group discussion about the events that took place in the action phase. The audience might
consider, among other topics, how their thoughts or observations could have an impact on
the protagonist’s ways of interacting or relating with others?

Training and certification for psychodrama therapists

The training and certification process in psychodrama is governed, in the United States, by the
American Board of Examiners in Psychodrama, Sociometry, and Group Psychotherapy.

27
Individuals who wish to pursue certification must first have a master's degree in a related field,
complete a minimum of 780 hours of training with Board-certified individuals, have 52 weeks of
supervised, professional practice in psychodrama, sociometry, and group therapy, and participate
in 40 supervised sessions of 50 minutes each. Those seeking training must also participate in
professional activities such as continuing education workshops, throughout the certification
process and certified.
Who can benefit from psychodrama?
The psychodrama approach has been proven successful at facilitating the expression of strong
emotions and feelings. Conversely, it has also been shown to be a helpful approach for
individuals working to better contain their emotions. Because the technique emphasizes body
and action as well as emotion and thought, it is considered a holistic technique and is believed to
be effective for a wide range of concerns. Individuals experiencing: difficulty with relationships,
social and emotional function, trauma or unresolved loss or addiction might find psychodrama a
helpful approach.

Psychodrama might also be beneficial for those who are diagnosed with mood, personality,
or eating disorders and are challenged by identity issues and/or negative self-image, as this
technique may provide those in treatment with a safe space and format to communicate pain and
challenges faced.

One study showed psychodrama to be effective in treating middle school-aged girls who had
experienced trauma. The girls who participated in the study reported being less anxious,
depressed, and withdrawn after participating in a psychodrama group for 20 weeks.

Concerns and limitations

Professionals who offer the psychodrama approach typically report the effectiveness of the
practice based on anecdotal experiences of working with groups and experiencing the
transformations. However, there is little empirical research to date supporting the impact of
psychodrama. Over the past decade there has been a shift to provide more empirical research
demonstrating the effectiveness of psychodrama in motivating change in the participants’ lives.
Current research in psychodrama focuses on the impact of group trust and safety and the
effectiveness of the sharing phase.

Because psychodrama places heavy emphasis on trust and safety, counselors generally prescreen
and prepare group members for the psychodrama process. The purpose of prescreening is
important to psychodrama and any form of group psychotherapy because it ensures the group
members are open to working on sensitive issues. If a person is determined to be not ready for a
psychodrama method, the therapist is ethically bound to refer this person for individual therapy.
Selecting individuals who would be a good fit in a group together may become a time-
consuming process for the counselor.

The experiential component of psychodrama can require a lengthy warm-up phase in order for
group members to develop enough trust in each other to be comfortable spontaneously acting out
aspects of their lives, particularly their concerns and challenges. Counselors are typically

28
required to use specialized skills simultaneously in order to facilitate the trust-building process
and transition into guiding the dramatic scene.
Confidentiality can also be a concern in psychodrama. Whenever a group format is utilized, it is
vital for the counselor to discuss confidentiality with the group members and work to ensure the
psychodrama events are kept within the group. In the beginning of the group psychodrama
experience, each group member will sign a contract of confidentiality. However, there are
currently no legal implications if a group member breaks confidentiality. If a group member does
divulge group information, typically the counselor will hold a group meeting to democratically
decide whether to keep that person in the group or refer them out to another program or therapist.
Any threat to confidentiality can impact trust and safety among the group, which can further
hinder the effectiveness of the psychodrama for those involved.

References:
1. American society of group therapy and psychodrama. (2014). Retrieved from
http://www.asgpp.org/asgpp-education.php
2. Bellofatto, M., & Kirsner, N. (2013). Eating disorders; The IAEDP symposium 2012 reveals
real life benefits for psychodrama experience. Mental Health Weekly Digest.
3. Carbonell, D., & Parteleno-Barehmi, C. (1999). Psychodrama groups for girls coping with
trauma. International Journal of Group Psychotherapy, 49(3).
4. Certified practitioner standards. (2013). Retrieved from
http://www.psychodramacertification.org/docs/CPStandards.pdf
5. Chimera, C., & Baim, C. (2010, August 29). Introduction to psychodrama. Workshop
presented at IASA Conference, Cambridge. Retrieved from http://www.iasa-
dmm.org/images/uploads/Chip Chimera and Clark Baim Workshop on Psychodrama.pdf
6. Chung, S. F. (2013). A review of psychodrama and group process. International Journal of
Social Work and Human Services Practice, 1(2), 105-114.
7. Karp, M., Holmes, P., & Tauvon, K. B. (Eds.). (2005). The Handbook of Psychodrama.
Taylor & Francis.
8. Kellermann, P. F. (1987). Outcome research in classical psychodrama. Small Group
Research, 18(4), 459-469.
9. Kipper, D. A., & Ritchie, T. D. (2003). The effectiveness of psychodramatic techniques: A
meta-analysis. Group Dynamics: Theory, Research, and Practice, 7(1), 13.
10. Photo Directory of Psychodramatists. (2003, June 2). Retrieved from
http://www.blatner.com/adam/pdirec/hist/hist72.htm
11. Propper, H. (n. d.). A concise introduction to psychodrama, sociodrama, and sociometry.
Retrieved from http://www.asgpp.org/pdf/psychodrama.conciseintro.pdf
12. What is psychodrama? (n.d.). Retrieved from
http://www.psychodrama.org.uk/what_is_psychodrama.ph

29
PRACTITIONERS IN THE PERFORMING ARTS THERAPY
Definitions
Client - denotes anyone using the service of a Performing Arts Therapy Practitioner.
Performing Arts Therapy- the intentional use of the healing aspects of Performing Arts Therapy
in the therapeutic process
Good Practice
The following code of practice is intended to act as clear guidance to all Performing Arts
Practitioners but does not supplant any local or other procedure agreed with employing
authorities.
Performing Arts Therapy Practitioners should at all times consider the welfare of clients and
patients by showing respect for their autonomy and welfare.
Good practice follows from standards established through training and maintained by
supervision, further relevant training and continued personal development.
Supervision is an essential component of good practice.
Records should be kept for the purposes of continuity of treatment and clarity of thinking
Performing Arts Therapy Practitioners who are Drama therapists must be registered with the
Health Professions Council. Performing Arts Therapy Practitioners who are trained in various
fields must be registered as appropriate with their professional association.
Self-Regulation
Performing Arts Therapy Practitioners should recognize the need to adhere to the following areas
of good practice:
Performing Arts Therapy Practitioners should not practice under the influence of alcohol or
drugs unless as prescribed by a medical practitioner.
Performing Arts Therapy Practitioners should not practice if they are deemed mentally or
physically unfit to do so.
Performing Arts Therapy Practitioners should ensure that they receive suitable and sufficient
support for themselves in their working practice and in their non-working life in order to avoid
personal issues and/or needs adversely affecting their work.
Advertising
Advertising by Performing Arts Therapy Practitioners is to be confined to descriptive statements
about the services available and the qualifications of the person(s) providing them. Performing
Arts Therapy Practitioners must not claim to possess qualifications they do not have. All
advertising should comply with relevant law.
Fees
Performing Arts Therapy Practitioners have a responsibility to charge fees appropriate to their

30
qualifications and level of experience. Fees should be negotiated with regard to the minimum
current rate recommended by the Performing Arts Therapy body for private practice.
Information on current salary scales in the Health, Social and Community services may be
obtained from the relevant authorities.
Insurance
Unless provided by their employer(s), Performing Arts Therapy Practitioners should ensure they
have professional indemnity and public liability insurance to cover them in the event of a legal
suit. They should ensure they are adequately covered in the event of other claims that might be
made against them or the owners of the premises in which they work.
Working Environment
Performing Arts Therapy Practitioners have a responsibility to ensure that the space in which
they practice and the manner in which they work complies with all relevant Health & Safety
legislation. This specifically relates to the safety of any equipment or materials used, the
temperature of treatment rooms and the possible risks of cross infection.
Performing Arts Therapy Practitioners should carry out a risk assessment prior to starting
therapy with each client. They should ensure that they maintain adequate levels of privacy and
comfort for clients that meet specific needs.
Equality of Opportunity
In all areas of practice Performing Arts Therapy Practitioners should adhere to the Performing
Arts Therapy Practitioners body Equal Opportunities policy and the policy of the institution in
which the therapist is working. Performing Arts Therapy Practitioners should periodically review
their practice to ensure that they are not making discriminatory decisions based upon a client's
race, class, culture, gender, marital status, physical or mental ability, religion or sexual
orientation.
Acceptance of Referrals and Suitability of the Performing Arts Therapy Practitioners Approach
Whatever the course of the referral, the Performing Arts Therapy Practitioners shall at all times
maintain responsibility for deciding the suitability of referrals for Drama therapy (where they are
a Drama therapist) or the suitability of using the Performing Arts Therapy Practitioners
Approach with the client where they are a therapist in another discipline. Performing Arts
Therapy Practitioners should ensure that they establish a clear working relationship not only with
the client but also with medical practitioners and other appropriate professionals involved in their
care.
Professional Relationship
Clients have the right to request information about the therapist's experience, training,
qualifications and level of supervision. Contracts with clients should be explicit regarding fees,
holidays, cancellations and frequency of sessions. The nature and length of the therapy should be
discussed with the client and mutual agreement sought.

31
Performing Arts Therapy Practitioners should conduct their practice in a professional manner.
Performing Arts Therapy Practitioners should not exploit the emotional vulnerability or
dependence of their client. Sexual relationships between Performing Arts Therapy Practitioners
and their clients are prohibited.
The relationship between the Performing Arts Therapy Practitioner and the client must be
confined to a strictly professional basis. Performing Arts Therapy Practitioners recognize the
importance of a good working relationship and the power and influence this can give them. The
Performing Arts Therapy Practitioners should act in a manner consistent with that recognition.
Performing Arts Therapy Practitioners should make it clear to their clients and any other relevant
parties that the therapy may include the client experiencing some distress or measure of upset.
However it should also be made clear the Performing Arts Therapy Practitioners will not engage
in any behavior that is cruel, inhumane or unethical or which is intended to distress the client.
Performing Arts Therapy Practitioners need to be open about their training, qualifications,
experience and other related information regarding their professional competence. Performing
Arts Practitioners should respect the dignity of their clients and their worth as human beings.
They should affirm their clients' right to and need for self-determination, personal growth and
responsibility. They should attempt to enhance their clients' progress in these directions.
Professional Relationship - Post Therapy
The professional relationship between the Performing Arts Therapy Practitioners and the client is
defined by the contract. The professional relationship ends with the termination of that contract.
However certain professional responsibilities continue beyond the termination of the contract.
They include, but are not limited to the following:
Maintenance of agreed upon Confidentiality
Avoidance of any exploitation of the former relationship.
Provision for any follow up care and/or support that might be needed.
Assessment & Review Procedure
Performing Arts Therapy Practitioners should constantly monitor the usefulness and
effectiveness of their therapy practice. This should be achieved through using an organized and
routinely audited process of note making, record keeping and report writing.
Record Keeping
Performing Arts Therapy Practitioners should keep adequate records about their clients, and to
ensure privacy, these should be kept safely under locked conditions. If any information is stored
on computer disks, therapists should ensure they conform to the requirements of the Data
Protection Act. Whatever records are kept should be in a form that can be inspected by clients if
they so request.
The Client's Consent to Treatment-the Therapeutic Contract
Therapy should not normally commence without the client understanding, in broad terms, the

32
nature, purpose and likely effects of the proposed treatments and freely consenting to it
proceeding.
The client has a right to withdraw consent at any time during treatment to the whole or part of
the therapeutic process. The therapy would then be completed in an appropriate way. Where the
client is considered by the Performing Arts Therapy Practitioners to be incapable of giving
consent in the above terms, the Performing Arts Therapy Practitioners should seek the agreement
of all or some of the following persons: the primary therapist, the primary carer or the multi-
disciplinary team concerned.
The contract should include explicit details about time, fees, respective responsibilities of the
client and therapist, rationale of sessions, restrictive and permissive ground rules of the session's
confidentiality.
It should be understood that no one else can give consent for a non-urgent treatment to proceed,
except in the case of:
A minor, where the nearest relative can consent
Award of court, when it is a matter for the court to decide
A child in the care of the local authority when it is a matter for the local authority
Beyond these exceptions the law is uncertain, but it is acceptable practice to proceed in the good
faith of all concerned, exercising duty of care.
Touch
It is in the nature of the Performing Arts Therapy Practitioners Approach that touch may occur
between clients and/or clients and Performing Arts Therapy Practitioner(s). This should be made
clear to clients and, where relevant, to clients' representatives and service purchasers, before
therapy commences.
Professional Development
Performing Arts Therapy Practitioners should continue to develop their professional skills by
attending, where possible, any courses, in service training programmes, lectures, conferences or
workshops offered by appropriate organizations in order to extend their knowledge and range of
skills. This should be, where possible, with the financial support of their employers. Performing
Arts Therapy Practitioners should ensure that they meet the Continuing Professional
Development (CPD) requirements of their governing bodies.
They should also keep up to date in their field by the reading of current literature and by being
informed of and promoting the interests of the Performing Arts Therapy. Performing Arts
Therapy Practitioners whether Drama therapists or other health professionals should endeavour
to keep in contact with fellow professionals through meetings.
Training
If involved in the training of other professionals, Performing Arts Therapy Practitioners should

33
ensure they have adequate experience and supervision, appropriate for the setting of standards
for personal and professional development, for those for whom they are responsible.
Delegation of Duties
Performing Arts Therapy Practitioners have a responsibility to refrain from delegating
professional responsibility to unregistered and/or unqualified persons except in the case of
students in training, in which case, full responsibility for the students must be taken by the
qualified Performing Arts Therapy Practitioner.
Relationships with Colleagues
Performing Arts Therapy Practitioners respect the integrity of other professionals. However, they
should confront a colleague whom they have reasonable cause to believe is acting in an unethical
manner, and failing resolution, to report that colleague to the appropriate professional body.
Legacies and Gifts
Performing Arts Therapy Practitioners should neither offer nor accept tokens such as favours,
gifts, legacies or hospitality, which might be construed as seeking to promote undue influence.
Where relevant, they should adhere to guidelines or procedures published by employing
authorities.
Child Protection
Performing Arts Therapy Practitioners should be aware of, and agree to abide by, the relevant
Area Child Protection Committee (ACPC) Inter Agency Guidelines. Performing Arts Therapy
Practitioners have a duty to pass on information related to adult to child or child to child abuse.
The issue of child protection is important for Performing Arts Therapy Practitioners regardless of
whether their work routinely brings them into contact with children.
Disclaimer
Performing Arts Therapy Practitioners need to be aware of any preexisting guidelines,
procedures or requirements that are defined in their contract(s) of employment.
Performing Arts Therapy Practitioners must abide by the laws of the country in which they
practice.

34
APPLICATION OF EACH COMPONENT TO THE RELEVANT THERAPEUTIC
REHABILITATIVE

Art Therapy in Rehabilitation

Introduction
Some key contributions that art therapy can make to rehabilitation include: sensory experiences,
symbolic expression, emotional expression, life enhancement, cognitive development and social
connectedness.

Defining art therapy in rehabilitation

Art therapy involves the discovery of new connections, relationships and meanings in a safe and
non-judgmental atmosphere, which in turn provides the client with alternative perspectives on
life and relationships with others. Thus, art therapy can work in multifaceted ways involving the
whole person including sensory-motor, perceptual, cognitive, emotional, physical, social and
spiritual aspects. Growth through art is seen as a sign of growth through the whole person
(Karkou and Sanderson 2006).

Art therapy is a fluid, adaptable, and evolving field. Although art has always been an innate part
of human civilization it has only been since the Second World War that it has been properly
recognized for its restorative and transformative qualities (Hogan 2001; Waller 1991). As Jones
(2005) clarified, not only are we still discovering the nature of the arts but, we are also still in the
early stages of understanding what art therapy does, how it does this and why it is effective.

Those who become art therapists have experience in at least one previous field of knowledge,
such as: medicine, psychology, education, visual arts and social work traditions. It is through this
amalgamation of knowledge and theoretical orientation that art therapists often define their
practice with orientations such as, psychodynamic; humanistic (i.e. phenomenological, gestalt,
person centered); psycho-educational (behavioural, cognitive behavioural, developmental);
systemic (family and group therapy); as well as integrative and eclectic approaches (Jones 2005;
Rubin 2001).

Art therapists work in a variety of rehabilitation settings and with a variety of issues including:
mental health problems; learning difficulties, language and communication difficulties,
imprisonment, medical problems, sensory or physical problems, stress, emotional and/or social
problems. Each of these contexts have their own requirements for rehabilitation and art therapists
need to consider what aspects of art therapy can serve within the rehabilitative process (Jones
2005). Therefore, art therapists define what they do by the context they are working in.

Johnson (2008) discussed how art therapy is used in prison settings and identifies this through
four domains of the rehabilitative process: therapeutic, educational, prison quality of life
management and societal (community involvement). He argues that art therapy is used as a form
of rehabilitation that seeks to fulfil the innate desire to be productive, seek creative autonomy
and as an outlet for expression. These qualities of art appeal to prisoners, just like the general
public, and engage them serving as a platform to reform and reduce re-offending. The
recreational nature of art therapy also serves to reduce boredom, ease mood, as well as build

35
relationships between prisoners and staff thus promoting a safer and more cooperative
environment.

How art therapists practice in rehabilitation settings

Overview of Art Therapists' Practices
In general, art therapists avoid using medical terminology and diagnostic labels with their clients,
as this is seen as questioning and limiting the individuality of the client and their individual
needs. They see that the art therapist's role is to ‘prepare the ground for the process to start and
then facilitate the continuation of the process’ (Karkou and Sanderson 2006, p. 54).

The therapeutic dynamic is understood by many therapists through a construct incorporating the
therapist, client and the art work (Schaverien 1990, 2000). This triangular model is most
frequently used by art therapists who value an analytical approach to understand the non-verbal
and verbal interactions taking place within the therapeutic milieu.

Allen (1995, 2008) suggested that the therapist's role is not to change, fix, cure or interpret the
art, but, in collaboration with the client, to witness the flow of expression present in the images
and, should the client desire, to discover inherent meaning in or through art. Thus, transformation
occurs through self-direction as a natural unfolding of the artist's reality as expressed through the
images. The more fully clients come to know themselves, the more they are able to authentically
participate in life and community as well as develop an ongoing motivation towards recovery.

When the art work is complete the art therapist may assist their client to find words to describe
their art work by asking them for concrete descriptions of what they see (refer to Betensky 1995,
2001).

Spaniol (2003) suggested that the therapist's support and respect for the client's reality is critical
in encouraging the client to talk about their art in their own words and personal style. Spaniol
(2003) emphasized three fundamental components of the art therapist's role in psychosocial
rehabilitation, which can be easily applied to other forms of rehabilitation:
- The first is authenticity; the therapist fosters deep relationships with clients that become a
model for clients' relationships with one another.
-Secondly, the therapist fosters creativity in the client's engagement in the arts and understands
the special role that creativity can play in the lives of people with mental illness.
-Thirdly, the therapist supports a climate of recovery through their belief that people with mental
illness can build lives of meaning and purpose despite their illnesses.

The Art-Based Practice Continuum

A recent study auditing art-based activities within the psychosocial rehabilitation sector
developed an art-based practice continuum to explain the diverse range of approaches that were
being adopted. They noted an ongoing tension in how art facilitators and program managers
define art therapy, partly due to art therapists incorporating the practices of community arts, art
education or arts/health, as well as facilitators from other related fields adopting personal growth
oriented practices (Van Lith, Fenner, Schofield, Pawson and Morgan 2009). The modes, context,
levels of structure and aims of the art-based practices employed in these organizations can be
represented along the following continuum.

36
Art-based Practice Continuum
Art making with Program
Studio Individual art
Art making emphasis on skill facilitated and Art
art making with a
individually development and structured art psychotherapy
making healing purpose
mastery groups

As this model highlights, art therapists embrace visual art qualities as well as incorporate
therapeutic elements depending on the clients' needs in their process of rehabilitation. These
varied approaches are not necessarily discretely delivered programs, but provide a range of
methods which can be adapted and applied according to perceived client needs and the
facilitators' training. Although this continuum relates to psychosocial rehabilitation programs it is
applicable to other rehabilitation settings.

Key contributions of art therapy in rehabilitation

Art therapy ultimately works in a strengths-based way to assist in rehabilitation through restoring
the self. These will be explained in the following section under the following headings:
- sensory experiences,
- symbolic expression,
- emotional expression,
- life enhancement,
- cognitive development and
- social connectedness.

Sensory Experiences
The visual and material qualities of art media and the art work are unique elements to art therapy.
These offer alternatives to other strategies in rehabilitation as they work through visual, sensual
and kinaesthetic experiences. This can often be perceived as unconventional in rehabilitation
settings and consequently easily misunderstood.

Kagin and Lusebrink's (1978) expressive therapies continuum demonstrates the commonalities
between various art forms and the defining properties of each medium. The expressive therapies
continuum proposes four levels of experience: kinaesthetic/sensory (action), perceptual/affective
(form), cognitive/symbolic (schema) and creative. Whilst art therapists may use this scale for
evaluative and reflective purposes they remain cautious that a particular quality of a medium is
also dependent upon the individual's interactive style and development or regression. For
example, clay may be resistive for an experienced potter or regressive for a young child.

Symbolic Expression
The use of symbolism and its relationship to our unconscious holds an important place in the
history and development of art therapy (Edwards 2004; Rubin 2005; Schaverien 1990, 2000).
Arnheim (1974) maintained that form and subject matter cannot be separated and states that even
simple line expression is symbolic as it expresses visible meaning. On the other hand,
Dissanayake (1992) argued that the creation of art alone is satisfying and symbolic meaning may
be secondary or absent in its importance. In art therapy, it is the client's preference whether they
see their imagery as visual metaphor and this may depend on whether the image developed

37
inside or outside their conscious awareness. When this type of art is produced in art therapy, the
therapist and client can obtain important information by exploring the deeper meanings. It is
often seen as particularly useful in exploring dreams, goals and aspirations (Kaplan 2000).

Emotional Expression
Art therapy can serve as a means of symbolic speech, which is particularly beneficial for clients
who have a good mastery of verbal communication or words, but are unable to accurately
express their emotions (Liebmann 1990). For example, for clients who have limited verbal
expression or those who are highly articulate but have difficulty with emotional expression, the
visual arts can be employed as a means of speaking from the self. When possible a combination
of verbal and non-verbal communication is encouraged as a way of acquiring new and more
comprehensive understandings of what is being expressed to uncover the significance of personal
meanings (Kaplan 2000; Karkou and Sanderson 2006).

Some art therapists embrace the notion that art taps into the unconscious, which allows thoughts
and feelings to be expressed that may otherwise be restrained or denied (Rubin 2005; Malchiodi
1998). Kaplan (2000) concurs with this by highlighting that art therapy provides access to our
personal and cultural history that would not be available through verbal means. Utilizing this
capacity to access awareness and communicate meaning through art can serve as an alternative to
verbal interventions. Additionally, it has been argued that art is a less threatening method to
disclose private information about one's feelings, allowing for a deep, thorough and yet
contained exploration of the self (Tate and Longo 2002).

Art therapy also allows for the release of emotions in a contained way, referred to as catharsis. It
provides access to and relief of painful or troubled emotions in a safe and therapeutic setting by
creating a physiological response of relaxation or through altering mood. This act can result in
feelings of empowerment as well as the experience of inner peace through art expression (Rubin
2005).

A study of art made in concentration camps during the Holocaust potentially illuminates our
understanding further. Ornstein (2006) explained how prisoners instinctively used art to make
sense of their traumatic experience and gain an insight into their experiences that would
otherwise not have been available to them. She noted the overwhelming need to create in order
to transform these experiences into expression. The image in these situations worked as a mirror
of the internal world and had a confirming and supportive effect, resulting in a feeling of being
understood.

Life Enhancement
The making of art is known to induce the experience of flow as a form of optimal experience
producing quality of life enhancement through feelings of psychological growth, enhanced life
quality and well-being (Csikszentmihalyi 1990, 1996). Being in a 'flow' state through art therapy
enables escapism, distraction and time out from reality, which are highly beneficial for people
with ongoing mental health difficulties such as anxiety, hallucinations, delusions or for those
who are highly stressed (Warren 2006). Research has also found that by being in a meditative-
like state through the art process, clients are not only able to deal with highly traumatic material,

38
but the resolving of these issues in imagery allows for insight and personal growth (Van Lith
Fenner and Schofield 2009).

Dissanayake (1988) also emphasized the life altering qualities by arguing that similar to ritual
and play, it enables us to imagine, fantasize, formalize and distance material as well as provide
cathartic relief to tensions. She highlights that it is not just the 'thoughtless' experience that is
desirable but our direct connection to the immediacy of art that restores the significance, value
and integrity of sensuality and the emotional power of things. This is seen as a stark contrast to
the usual indifference we are used to experiencing. This heightens our awareness making us
more aware of who we are and what we want.

Dissanayake (1988) also highlighted how art assists in developing resilience as it prepares and
trains us for the unfamiliar through the testing of realities. These experiences provide a reservoir
from which to draw appropriate responses to experiences that have not yet been met, providing
us with the strength to face new challenges. She adds that through the use of fantasy and
imagination art also allows us to constantly stretch our minds and be challenged in new ways.

Cognitive Development
Our earliest human experiences are believed to be in aural and visual forms, prior to the
development of verbal skills (Golomb 2004). The development and use of these capacities are
often ignored or undervalued as we engage in a predominantly verbal society. Consequently, art
therapist Kaplan (2000) argued the importance for children to be offered art to enhance and
develop well-rounded cognitive skills that not only activates mind-brain development, but
enhances creative abilities through imagination and play.

Kaplan (2000) also highlighted how art therapy facilitates problem solving. The distance that the
art work provides allows clients to order, reflect, experiment and refine thoughts and
experiences. Kaplan emphasizes the importance of using art therapy for people with cognitive
impairments due to its ability to evoke sensual pleasure and feelings of satisfaction. The
importance of promoting sensory stimulation through art therapy with acquired brain injury
clients has been noted. Sensory stimulation through art therapy enhances clients' awareness and
attention span as well as provides a new focus through the appreciation and exploration of
materials (Chantios 2005). In certain cases, as a person's cognitive impairment may decline,
artistic abilities may increase and serve as compensation (Mell Howard and Miller 2003).

Social Connectedness
The stigma associated with some illnesses such as mental illness, has been identified as a key
barrier to gaining employment, education, feeling like a contributing member of a community
and a sense of social inclusion. In the United Kingdom, researchers have argued for the
importance of maintaining and improving art-based community organizations as a solution to
social exclusion (Moriarty 2002; Secker Hacking Spandler Kent and Shenton, 2007; Smith 2003;
White and Angus 2003).

Parr's study (2005) focused on how art-based community groups play an important role in
developing social relationships and identity beyond that of stigmatized labels. The art group was
valued as an important 'stepping stone' for reintegrating into wider social relationships and

39
situations outside project spaces. Not only was the art group seen as a way to work through
everyday difficulties, but it was also seen as a form of self-validation whereby participants were
able to express without feeling the risk of interpretation by others. In accordance with this study,
Van Lith, Fenner, and Schofield (2009) also identified how the making of art with those who
have chronic mental health problems can have benefits beyond the internal self, which generates
passion and meaning in life. They also highlighted the importance of making art within a group
setting as this enabled clients to develop a sense of being part of a social world and a deepening
of interpersonal relationships.

Importance of a supportive setting in art therapy

Art therapists highlight the value of art as having healing or therapeutic potential through the
context of where it takes place. They see art therapy as a process that, given the circumstances
surrounding its use, may become a powerful and life changing experience (Karkou and
Sanderson 2006). The art therapy setting enables artistic expression by being safe, comfortable
and empathic, which is contained by well-trained and supportive staff. This environment allows
for a culture of openness, empowerment and experimentation to develop (Higgins and Newrith
1999; Waller 1991). A conscious effort from the art therapist is needed to provide and maintain a
supportive psychological and physical environment within which safety and trust are engendered
and nurtured, one that permits an optimal process of creativity to unfold.

Consequently, it is how the therapy takes place, the environment, the development of
relationships and communication during planning and implementation stages that encourages
success and determines whether or not therapeutic transformation is likely to occur (Everitt and
Hamilton 2003). This is substantiated in a report describing guidelines for the practice of art
psychotherapy with people prone to psychotic states (Brooker Cullum Gilroy McCombe and
Mahony 2006).

Conclusion
This article aimed to inform the reader about some of the key areas that art therapy contributes to
rehabilitation. Through this broad overview it was hoped to clarify why and how art therapy is
used in rehabilitation settings. Art therapy is still in the early stages of finding suitable research
approaches to further understand the qualities of its practice and benefits, as well as finding
appropriate methods to evaluate practices. Nevertheless, the restorative and transformative
benefits of art are gaining considerable attention in rehabilitation settings and readily being
adopted as a positive, strengths-based and meaningful activity.

References
Allen P. 1995. Art is a way of knowing. Boston: Shambhala.
Allen P. 2008. Commentary on community-based art studios: Underlying principles. Art
Therapy: Journal of the American Art Therapy Association 25(1):11-13.
Arnheim R. 1974. Art and visual perception: A psychology of the creative eye. Berkeley:
University of California Press.
Betensky M. 1995. What do you see? Phenomenology of therapeutic art expression. London:
Jessica Kingsley.
Betensky M. 2001. Phenomenological art therapy. In: Rubin J, editor. Approaches to art therapy
theory and technique. 2nd ed. Philadelphia: Brunner Mazel. p. 121-134.

40
Brooker J, Cullum M, Gilroy A, McCombe B, Mahony J, Ringrose K, Russell D, Smart L, von
Zweigbergk B, Waldman J. 2006. The use of art work in art psychotherapy with people who are
prone to psychotic states. London: Goldsmiths College & Oxleas NHS Trust.
Chantios E. 2005. Art therapy. In: Victorian Brain Injury Recovery Association, editors.
Proceedings of the Frontiers of clinical practice - environments for recovery (3rd VBIRA
workshop). Melbourne. p. 56-61.
Csikszentmihalyi M. 1990. Flow: The psychology of optimal experience. New York: Harper
Collins.
Csikszentmihalyi M. 1996. Creativity. New York: Harper Collins.
Dissanayake E. 1988. What is art for? Seattle (WA): University of Washington Press.
Dissanayake E. 1992. Homo aestheticus: Where art comes from and why. New York: Free Press.
Edwards D. 2004. Art therapy. London: Sage.
Everitt A, Hamilton R. 2003. Arts, health & well-being - An evaluation of five community arts in
health projects. Durham (UK): University of Durham.
Feldman D, Csikszentmihalyi M, Gardner H. 1994. Changing the world. A framework for the
study of creativity. Westport (CT): Praeger.
Golomb C. 2004. The child's creation of a pictorial world. 2nd ed. Mahwah (NJ)/ London: L.
Erlbaum Associates.
Higgins B, Newrith C. 1999. Creativity and play: Reflections on a creative therapies group. In
Campling P, Haigh R, editors. Therapeutic communities. London: Jessica Kingsley. p. 116-127.

41
Psychodrama therapy in rehabilitation

Becoming addicted to drugs or alcohol is often a slow process that takes hold invisibly so that
that the person involved rarely notices when the line has crossed between regular use and being
controlled by the substance. When it happens, a great number of changes-usually negative-occur
in the person’s life, and this often results in a gradual, downward spiral that can be difficult to
overcome. Many techniques and treatments exist to help people to confront these issues, and one
of the most unusual and effective is known as Psychodrama for addiction.

What is psychodrama therapy?

Everyone is unique, and thus, people will have different responses to different things and
different types of therapy. What will work for someone with strong visual flair, such as art
therapy, may not be appropriate for someone with no interest in art, but strong religious
conviction. In that case, faith-based therapy may be a better alternative. Then there is
psychodrama therapy, which has had a broad application for decades now, and can act as an
effective complementary form of holistic addiction treatment in addition to many other types of
therapy.

Psychodrama is a carefully structured form of art-in this case, the art of acting-that is
incorporated into a treatment plan for therapeutic value. Almost all of us have been a part of a
theatrical experience in some way, whether that’s watching the acting in a play, movie or
television program, or participating in drama ourselves in school, or some other point in our
lives.

How psychodrama therapy for addiction works

It’s important to note that psychodrama therapy doesn’t force anything on anyone. If actually
being an acting participant goes too far beyond the comfort level of a person in recovery, he or
she will not be forced to do it. In fact, if psychodrama is not an appropriate or effective treatment
for an individual, it won’t be used at all.

But it’s often worthwhile to give it a chance. Psychodrama for addiction can reveal many things
that a person never suspected if they are receptive to it. For example, one psychodrama exercise
for people in addictive situations is ‘role reversal,’ where, rather than playing the part of the
addict, which was their personal experience in their life, they take on the role of someone else,
such as a concerned friend or family member. In taking on this part and acting it out, participants
often gain new insights, not just into themselves, but even a better understanding of how and
why a person has behaved in the way they did to the addict. This insight often allows people to
move forward with a greater sense of control about their own situation.

Psychodrama is acting
Sadly, one of the casualties of substance addiction is all too often the relationships people forge
with others. Addiction can create huge divides between people that were formerly very close to
each other. In other cases, addiction, can destroy the trust an addict once had in other people as
the spiral of addiction forces them into contact with people willing to take advantage of their

42
desperation. It’s not uncommon for an addict, at the beginning of the recovery process to have a
lot of work to do in starting-or rebuilding-relationships with other people.

However, once detoxification and withdrawal are over, simply putting a person back in their old
life is not going to repair the damage that’s already been done. That is going to take work, and
often it will also take the acquisition of new social skills, more empathy, and stronger bonds to
make these connections. Equine therapy treatment is a safe way to undergo this process with a
partner that is not judgmental, biased or harboring a personal or ulterior motive; a horse.

Working to build trust

The true purpose of Psychodrama Therapy, as it is with any other form of addiction therapy, is to
take the issues, feelings and obstacles that are central to an addiction, and put them in a place
where they can be safely, openly examined, discussed and dealt with. Physical addiction is just
one component of the addiction cycle, and while the physical addiction can be relatively
‘quickly’ addressed with a supervised detox and withdrawal period, that only requires time and a
little bit of medical care.

To overcome the psychological factors that enable or led to addiction is a completely different
challenge that takes time, effort, knowledge and patience. Psychodrama Therapy is one more
vehicle for enabling this. By allowing people to watching someone else’s experience, or act it
out, it gives them a chance to step beyond their own personal boundaries and, in doing so,
consider ideas they wouldn’t have.

When psychodrama therapy is most effective

Psychodrama therapy can be especially effective in a group therapy setting, where sharing
similar experiences with others, and seeing other people discuss and act out their issues makes it
easier to be open and honest. Psychodrama Therapy shows a recovering addict that he or she is
not alone, and can, in fact, draw strength, encouragement and even friendship from others. While
it’s not the only way to treat addiction, it has proven quite effective over the decades.

43
Music therapy in rehabilitation

Introduction
Music now plays an increasing role in several disparate areas. Music can reduce stress, improve
athletic performance, and improve motor function in neurologically impaired patients with stroke
or Parkinsonism. Moreover, patients who listened to music also experienced less depression and,
to a lesser extent, confused mood after the intervention than patients who received no listening
material.

Since the patient groups did not differ in demographic and clinical variables at the baseline or in
antidepressant medication and rehabilitation received during the intervention, and since any non-
specific effects of therapeutic attention were controlled for, these differences observed in
cognitive recovery can be directly attributed to the effect of listening to music.

Music therapy appears to affect physiological phenomena such as blood pressure, heart beat,
respiration as well as emotional aspects such as mood and feelings. Clinical studies in adults also
demonstrated correlations between the physiological and emotional stimulation effects of music.

Music has been used as a form of therapy for many different diseases and, unless hearing is
totally affected, may indeed be experienced and appreciated by even the most severely physically
or cognitively impaired subjects. Music Therapy has been widely used in the rehabilitation of
handicapped children, providing one of the few ways in which these subjects can attain self-
expression.

In addition, Music Therapy is recommended in geriatric care to improve the social,

psychological, intellectual, and cognitive performance of older people. Depressed older adults, in
particular, can experience the effects of passive Music Therapy. Finally, evidence and clinical
studies show that Music Therapy improves the cognitive functions and quality of life of patients
with Alzheimer’s disease.

Dementia.
According to the World Health Organization report published in 2012, the estimated number of
people living with dementia exceeds 35.6 million worldwide (Alzheimer’s Disease International,
2009). This number is predicted to double by 2030, and more than triple by 2050 (Alzheimer’s
Disease International, 2009). Our results concerning music are of note, as we found that music
produced low levels of interest and pleasure in comparison to other stimuli. To our knowledge,
there are no other studies of music that utilize pleasure as a specific outcome measure in this
population. Several studies have linked music to a decrease in agitation and/or apathy in persons
with dementia, and an increase in positive social behaviors. Gotell et all found that music
increased awareness of/and interest in their environment in persons with dementia.

Our results agree with those findings in that music produced significantly higher levels of
interest and pleasure than the baseline condition. Alzheimer’s disease (AD), the most common
form of dementia, is characterized by a general, progressive decline in cognitive function that
typically presents first as impaired episodic memory. The main goal of the present study was to
determine the extent to which music can be used to enhance memory for associated verbal

44
information in patients with AD and healthy older adults. The results confirmed that patients with
AD performed better on a task of recognition memory for the lyrics of songs when those lyrics
were accompanied by a sung recording than when they were accompanied by a spoken
recording. Musical mnemonics provide an intricate neurophysiologic template for the mapping
of verbal information in temporal and tonal space, and this template may be used during retrieval
to aid in lyric recognition or recall. For healthy older adults with intact cortical memory circuits,
it is possible that the relatively simple nature of the recognition task in the current paradigm does
not produce a need to recruit from these areas of the brain not typically used for recognition
memory, and so results in no difference between the sung and spoken conditions. In other words,
there may be no need to rely on the holistic musical memory ‘backup’ at the part of the
performance scale where control subjects scored. It is also possible that attentional deficits in
patients with AD and the ability of music to moderate these deficits by heightening arousal,
account for the effect of condition in the patient group.

Parkinson’s Disease.
Parkinson’s Disease (PD) is a common degenerative disease dominated by a disorder of
movement, consisting of bradykinesia (slowness of movement), hypokinesia (reduced
movements), tremor, rigidity, and postural and gait abnormalities; mood changes are also a
major component of PD. This study is the first to assess objectively the effect of a systematic
program of active Music Therapy on standardized measures of PD severity using a prospective,
single-blinded design. Moreover, this clinical study compared the efficacy of Music Therapy and
Physical Therapy to highlight any eventual difference between the two methods in their effect on
both physical and emotional functions. Our results demonstrate improvements in motor abilities
and emotional status related to active Music Therapy. The improvement in motor performance
was related mainly to changes in bradykinesia. Although the Music Therapy-related motor
response seemed to decline after each session, a trend of improvement was observed in the
Music Therapy group in the overall evaluation.

Improvement in emotional functions was found both after each Music Therapy session and
throughout the entire study period, but when measured 2 months after completion of Music
Therapy, the values returned to baseline levels. Significant improvements in ADL and quality of
life were also documented in patients undergoing Music Therapy. Physical Therapy, meanwhile,
led to a clear improvement in rigidity but did not induce any major changes in other variables. In
accordance with the clinical literature, it may be argued that the Music Therapy-induced
improvement in bradykinesia could be due to the effect of external rhythmic cues, which, acting
as a timekeeper, may stabilize the internal rhythm formation process in patients with PD. This
motor power of rhythm may be especially strong in various forms of motor and impulse disorder
and music can indeed be therapeutic here. Thus, patients with parkinsonism, in whom
movements tend to be incontinently fast or slow or sometimes frozen, may overcome these
disorders of timing when they are exposed to the regular tempo and rhythm of music.

Fibromyalgia
Fibromyalgia is a chronic disease characterized by sensitive points on the body that manifest
common musculoskeletal pains, fatigue, and low pain threshold. Although there is no clear-cut
data about the prevalence and incidence of FMS in the world, prevalence is generally between
6% and 20%. The aim of the study Demirağ et all was to investigate the effects of sleep and

45
touch therapy accompanied by music and aromatherapy on the symptoms of fibromyalgia and
depression, and the findings are as follows (These results support the study hypotheses):
The TMA (touch therapy accompanied by music and aromatherapy) intervention reduced FMS
symptoms in patients, and the change is statistically significant. The SMA (sleep accompanied
by music and aromatherapy) intervention reduced FMS symptoms in patients, and the change is
statistically significant. The education given to the patients in both the TMA and SMA groups
during the intervention was effective in decreasing the symptoms.

Visual Rehabilitation.
Salvatore et all in publication describes a 74-year-old patient with open angle glaucoma in both
eyes and macular pucker in the right eye underwent visual rehabilitation with acoustic
biofeedback by means of Vision Training Module 10 minutes each eye once a week for 5 weeks.
The patient was asked to move his eyes according to a sound which changed into Mozart’s
Sonata for Two Pianos when the patient locked the fixation target. This is the first time that
Mozart music has been applied to a visual rehabilitation, and the results are worthy of attention.
Music could enhance synaptic plasticity in the brain and affect neural learning and fixation
training. By means of music therapy, we can improve the visual performance in patients with
macular pucker to postpone the surgical time and assure the patient a better quality of life.

Stroke.
During the first weeks and months of recovery after a stroke, the brain can undergo dramatic
plastic changes that can be further enhanced by stimulation provided by the environment. In
stroke rehabilitation, elements of music have previously been used as a part of physiotherapy and
speech therapy to enhance the recovery of motor and speech functions. In addition, nonverbal
auditory stimuli have been shown to temporarily ameliorate left visual neglect after stroke.
However, the knowledge about the long-term effects of everyday music listening itself on the
recovery of cognitive and emotional functions after stroke is very limited. Musical training has
extensive effects on the brain. One aspect that may be relevant for stroke rehabilitation is that
musicians have enhanced subcortical auditory and audiovisual processing of speech and music.

In the study, authors have observed significant motor gains accompanied by plastic changes in
chronic stroke patients who were tested before and after 20 sessions of music supported therapy
(MST). Of note, they found increased motor cortex excitability in the patients’ affected
hemisphere after training, an association between changes in the motor cortex representation on
the injured hemisphere and improved performance of diadochokinetic movements with the
affected upper limb. These results suggest that MST can drive task-dependent cortical
reorganization in stroke patients in the chronic stage. Kim et all in their publication describe in
conclusion: ‘Music therapy has a positive effect on mood in post-stroke patients and may be
beneficial for mood improvement with stroke’.

Aphasia
According to the National Institutes for Health (2008), approximately 1 in 272 Americans suffer
from aphasia, a disorder characterized by the loss of ability to produce and/or comprehend
language. Despite its prevalence, the neural processes that underlie recovery remain largely
unknown and thus, have not been specifically targeted by aphasia therapies. One of the few
accepted treatments for severe, non-fluent aphasia is Melodic Intonation Therapy (MIT), a

46
treatment that uses the musical elements of speech (melody & rhythm) to improve expressive
language by capitalizing on preserved function (singing) and engaging language-capable regions
in the undamaged right hemisphere. In speech, phonemes occur so quickly it is difficult for
severely aphasic and/or apraxic patients to process auditory feedback in time to self-correct.
However, when words are sung, phonemes are isolated and thus, can be heard distinctly while
still connected to the word. In addition, sustained vowel sounds provide time to ‘think ahead’
about the next sound, make internal comparisons to the target, and self-correct when sounds
produced begin to go awry. Recovery from aphasia can happen in two ways: either through the
recruitment of perilesional brain regions in the affected hemisphere, with variable recruitment of
right- hemispheric regions if the lesion is small, or through the recruitment of homologous
language and speech-motor regions in the unaffected hemisphere if the lesion of the affected
hemisphere is extensive. Treatment-associated neural changes in patients undergoing MIT
indicate that the unique engagement of right-hemispheric structures (e.g., the superior temporal
lobe, primary sensorimotor, premotor and inferior frontal gyrus regions) and changes in the
connections across these brain regions may be responsible for its therapeutic effect.

Conclusions
The use of music therapy in the rehabilitation is huge, but little appreciated. Music therapy is a
method of cost-effective, non-invasive where there is no reported side effects. There are small
number of studies and publications on the use of music as a form of rehabilitation.

References
1. Sleight P. Cardiovascular effects of music by entraining cardiovascular autonomic rhythms
music therapy update: tailored to each person, or does one size fit all? Neth Heart J. 2013; 21(2):
99–100.
2. Särkämö T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M, Autti T,
Silvennoinen HM, Erkkilä J, Laine M, Peretz I, Hietanen M. Music listening enhances cognitive
recovery and mood after middle cerebral artery stroke. Brain. 2008; 131(Pt 3): 866–76. doi:
10.1093/ brain/awn013.
3. Standley JM. Music research in medical/dental treatment: meta- analysis and clinical
applications. J Music Ther 1986; 23: 56–122.
4. Peretti PO, Zweifel J. Effect of musical preference on anxiety as determined by physiological
skin responses. Acta Psychiatr Belg. 1983; 83: 437–42.
5. Kim DS, Park YG, Choi JH, Im SH, Jung KJ, Cha YA, Jung CO, Yoon YH. Effects of Music
Therapy on Mood in Stroke Patients. Yonsei Med J. 2011; 52(6): 977–981.
6. Smith DS. Therapeutic treatment effectiveness as documented in the gerontology literature:
implications for music therapy. Music Ther Perspect. 1990; 8: 36–40.
7. Kirk R, Abbotson M, Abbotson R, Hunt A, Cleaton A. Computer music in the service of
music therapy: the MIDIGRID and MIDI-CREATOR systems. Med Eng Phys. 1994; 16: 253–8.
8. Gibbons AC. Music development in the elderly: what are the chances? Designs Clin
Enhancement. 1986; 81: 24–5.
9. Tyson J. Evaluating elderly diseases. Nursing. 1988; 18: 34–41.

47
Drama therapy in the rehabilitation of stuttering patients

Introduction
The therapeutic intervention of people who stutter has been traditionally centered exclusively on
individual logaoedic (speech) therapy, mainly focused on the stuttering speech symptoms.
Logaoedic therapy often has positive results in terms of fluency improvement and still represents
the core of rehabilitation; however, it can be enriched by integrative therapeutic tools able to
intervene on the variables associated with the disorder. Rehabilitation practice has been carried
out through an integrated approach which includes traditional therapy, group activities and
drama-therapy, with particularly encouraging outcomes.

Reasons why theatre has been inserted in the rehabilitation program

The design of a rehabilitation intervention integrates both traditional and drama-therapy,
stimulating the person who stutters to go beyond the static boundaries of the traditional logaoedic
therapy. Patients' needs, in fact, often require a rehabilitation program not limited to the sole
treatment of the symptom, but involving the whole person.

The need for a global approach to the person, aimed at a stimulating and validating of all the
personal dynamics, has been obvious to us from the beginning of our therapeutic experience. It is
necessary to suggest to patients many different activities, aimed at testing both their verbal and
non-verbal skills and allowing them to challenge themselves in different contexts from their
usual ones, thus improving their own self-esteem, which may be particularly compromised in
patients who stutter. In fact, durable outcomes can be obtained only by dealing with their
spontaneous individual defenses. Obviously, in order to motivate patients to practice for several
hours-per-week, the activities had to be captivating and creative, not stressful.

Furthermore, group activities are desirable, since they have a two-fold advantage: they lighten
the therapy burden and they allow patients to emerge in their own identity. On one hand, in fact,
they require group members to accept pre-existent rules and on the other hand to contribute to
create new ones. Group activities also require the ability to evaluate when to take leadership and
when to wait and follow others, according to different situations and dynamics. The ideal
solution, for its therapeutic worthiness, could be nothing but theatre.

According to the definition given by the National Association for Drama Therapy (NADT),
drama-therapy is ‘the systematic and intentional use of drama/theatre processes, products, and
associations to achieve the therapeutic goals of symptom relief, emotional and physical
integration and personal growth. Its earliest applications date back to 19Th century and concerned
treatment of patients affected by mental illness. Through the years, the healing power of theatre
has had many different applications: the use of an artistic medium makes drama an active and
creative kind of therapy allowing an integrated action on diverse variables, such as emotion,
voice, individual characterization and expression, gestures and movement. In fact, theatre allows
work simultaneously on:

 Verbal communication, through the generalization of learned verbal facilitation

techniques;

48
  Non-verbal communication, through improvement in the efficacy of body language, the
use of voice and the ability to express emotions.

Because of theatre, patients gain more knowledge and awareness of their body and of
themselves, learning to accept their own limitations and validating their strengths. Theatre
stimulates individual creativity, by allowing those who practice it to put themselves in someone
else's shoes, playing different roles and facing often demanding situations different from the
everyday. This activity allows patients to experience and acquire more flexibility and ability to
face changes, allowing them grow in self-esteem, making them stronger and, at the same time,
reducing their fears (not just those connected with speaking) and promoting their personal
growth. Last but not least, the benefits also positively affect patients' relationships, since they
become more spontaneous, thus reducing their rigidity which is often typical in their social
behaviour.

Some data about the experimentation

Through the fifteen years of experimentation, 510 patients have been treated according to the
integrated protocol, benefiting from drama-therapy. 360 of them were males and 150 females - in
a proportion male-female of 4:1, as a consequence of the gender difference in the incidence of
stuttering. The treated patients were from all the age groups: children (40%), adolescent (30%),
adults (30%).

The rehabilitation program

The rehabilitation treatment lasts one year. At the beginning, after the therapeutic alliance is
established, the logopedist begins individual work on patient's verbal communication, mainly
aimed at an improvement in the pneumo-and phono-articulatory coordination and the acquisition
of verbal facilitation techniques. As the patient carries out individual logopedic therapy, he/she
also begins, with other people of his age group, some group activities promoting verbal
expression in different contexts, by drawing on everyday situations (phone-therapy and so on).

At the end of this first step, lasting four months, the patient add theatre training to logopedic
therapy. At this stage, logopedic therapy focuses on group activities aimed at solidifying what
patients have learned in the first stage, through therapeutic settings with different subjects and
activities. At the same time, theatre laboratory begins. Patients are not always happy to begin this
new kind of therapy. The fear of facing a new situation produces a typical avoidance reaction,
accompanied by many doubts about/on their participation.

The theatre laboratory is conducted by a professional actor and director with the collaboration of
a logopedist and lasts 7 months, with a schedule of 2-4 hours a week. During this time,
participants work on the development of their non-verbal language, articulation, breath
improvement and vocal strengthening. The exercises are taken from the best international
repertory. All this makes the work style very specific and allows patients to have an experience
which is methodologically sound and stimulating at the same time.

After the first stage of learning the basic techniques, patients practice using pantomimes,
interpretation and improvisation. At this stage it is possible to work in a structured way on
modelling, adapting the acquired techniques and tools addressing the patients' individual needs.

49
Training, aimed at therapeutic purposes, has a motivating goal in preparing and putting on a play
in a real theatre.

Usually the chosen play is a comedy, since it allows patients to test factors useful in therapy,
such as irony. In recent years teams have successfully chosen to use a script open to possible
adaptations made by the patients-players, together with the director, during the rehearsals. In this
way, new cues can be added, as well as performances in line with personal features and talents
(i.e. singing, dancing). The experience is more enriching, since participants can better express
themselves and realize they can customize the script, as they can adjust other scripts connected
with the roles they can choose, or be called upon, to play in their real lives. The performance
experience remains an unforgettable memory in patients' minds.

The time immediately preceding the performance is very delicate to manage, since in many cases
it triggers all the typical fears of the people who stutter: feeling unable to completely rely on
themselves, and now are going to be on a stage and perform before an audience, surrounded by
silence and dark. Once again the reaction of avoidance is a concrete temptation. Psychological
support is necessary, especially for some.

On the day of the play, tension rises - everything is ready: stage, scenery, costumes, and make-
up. Participants have their final rehearsal and then start the play. It's always a great test for them
and they always overcome it. Even when they feel they are about to block, they succeed in
managing. Improvisation frequently supports them, by making them replace the word which
could cause a block with another one, or by inducing them to ask and receive support from other
players on the stage.

While patients act, therapists evaluate their ability to manage time pressure and the difficulties
connected with a speech block, looking for alternative solutions to suggest. In fact, since the play
represents both ordinary verbalization experiences and the purpose of the therapeutic program, it
is always interesting for therapists to observe patients at work and study their behavior.

Once the play is over, an intense adrenaline remains; actors go and celebrate, because they know
they have achieved an important goal for themselves: the experience they went through becomes
a positive reference point in their memory and each time they face other trials, they remember
their success. The play will be debriefed, through a collective session analyzing everything that
occurred. The therapeutic program is coming to an end. During the last two months, patients
work on generalization of acquired techniques and continue logaoedic therapy, integrated with
outdoor verbalization experiences personalized according to individual difficulties.

What patients think of their theatre experience: the findings of a survey

The research team made a qualitative survey of the patients who had taken part in the current
year's play. The most interesting findings are shown below.

Before approaching the theatre laboratory, not all of the participants were for it: 58% of them
had a negative attitude, considering it too difficult for them. The remaining 42% had a positive
attitude, considering it a challenge and pleasant experience. After the initial theatre sessions,
those who had a positive attitude had their expectations confirmed, while the others changed

50
their minds, as they realized that the laboratory was an exciting experience. All participants in
the theatre laboratory affirmed they felt at their ease in the group. Not all the activities during the
theatre laboratory were considered easy to perform by patients. Interestingly, not all the
participants found the activities related to the use of the voice more difficult to perform than
those related to the use body movements: 40% of patients interviewed considered the latter more
demanding than the former.

It is worth noting that those who feared the theatre experience found the activities related to the
use of the voice more difficult than those related to the body. Final evaluations about the
laboratory were positive for all the patients: training improved awareness and the use of non-
verbal communication for all participants allowed them to feel more at ease than before in their
everyday verbalization experiences. In terms of generalization, it was observed that avoidance of
speaking decreased, the use of verbal facilitation techniques improved, as well as the ability to
communicate in everyday situations, with improvement in interpersonal relationships. It is also
worth noting that one patient out of three stated after the theatre laboratory felt he stuttered less
than before.

Conclusions
Through these years of experimentation, the integrated protocol which blends traditional therapy,
group activities and theatre laboratory showed to be a particularly effective therapeutic tool,
producing remarkable results in patients. Work aimed at acquisition of verbal facilitation
techniques, through both individual therapy and group activities, is the first essential step to train
patients in facing the theatre laboratory experience and its difficulties with more self-confidence.
The most relevant outcomes pertain to a general improvement in both verbal and non-verbal
communication, the ability to manage anxiety in stressing contexts and a greater confidence in
one's own communicative and relational abilities. The attested generalization of the learned
techniques into different everyday situations is the most encouraging outcome in terms of
enduring results, after therapy is completed.

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Dance therapy intervention for sub-acute stroke in a rehabilitation hospital setting

Dance can be a promising treatment intervention used in rehabilitation for individuals with
disabilities to address physical, cognitive and psychological impairments. A biweekly 45-
minutes dance intervention was offered to individuals with a sub-acute stroke followed in a
rehabilitation hospital, over 4 weeks. The dance intervention followed the structure of the usual
dance class, but the exercises were modified and progressed to meet each individual’s needs. The
dance intervention, delivered in a group format, was feasible in a rehabilitation setting. A 45-
minutes dance class of moderate intensity was of appropriate duration and intensity for
individuals with sub-acute stroke to avoid excessive fatigue and to deliver the appropriate level
of challenge. The overall satisfaction of the participants towards the dance class, the availability
of space and equipment, and the low level of risks contributed to the feasibility of a dance
intervention designed for individuals in the sub-acute stage of post-stroke recovery.

Introduction
Stroke is a leading cause of disability worldwide. Stroke is a complex medical condition that can
lead to physical, psychological and cognitive impairments impacting on activity and social
participation. Exercise interventions that improve mobility, balance, and quality of life are
needed for individuals with residual movement impairments post-stroke. To address the needs of
individual post-stroke with multiple impairments, many novel rehabilitation interventions are
emerging. One of the innovative interventions that has been used for older adults and individuals
with neurological conditions is dance.

Recently, dance has shown to be a promising treatment modality, because of its pertinent and
lasting effect on psycho-emotional perspectives that may greatly enhance its use as a physical
activity in rehabilitation, in addition to providing cardiovascular benefits. There is increasing
evidence to support the use of dance in rehabilitation to address various impairments. A recent
systematic review by Keogh et al. suggested that the practice of dance can present multiple
physical benefits for older adults: aerobic power, muscle endurance, strength, and flexibility of
the lower body; static and dynamic balance/agility; and gait speed. For people with neurological
disorders, dance can bridge the gap between an enjoyable social activity and a therapeutic
exercise dispensed at the proper intensity to target strengthening, mobility and balance. It may be
a particularly valuable intervention to help older adults stay healthy and connected with others.
In a recent study by Hackney et al., 30 hrs. of adapted tango lessons were offered to an
individual in the chronic phase of stroke recovery. After the intervention, improvements were
noted. In a meta-analysis on the effectiveness of dance therapy, Ritter and Low suggested that
socialization, emotional expression, body-awareness, movement quality and coordination can be
attributed to dance. Similar to numerous complex sensorimotor activities (e.g., sport, fitness and
physical performance), dance requires the integration of spatial patterns, rhythm, synchronization
to external stimuli and whole-body coordination. While dancing, the focus of participants is on
postural control, voluntary stepping strategies, whole-body coordination, and somatosensory
awareness. Performing dance also demands a type of interpersonal coordination in space and
time that is almost nonexistent in other social contexts.

The use of dance in post-stroke rehabilitation is consistent with the recommendations for Stroke
Care stating that patients should regularly participate in an aerobic exercise program that takes

52
into consideration the functional limitations and impairments. While there is evidence supporting
the use of dance for older adults and individuals with disabilities, most of the dance interventions
are delivered in the community or in laboratory-controlled settings, rather than in a hospital
setting. There is a need to determine the extent to which a four-week dance intervention
delivered for individuals post-stroke is feasible, in addition to the usual care, in the context of
functional intensive hospital-based rehabilitation. More specifically, the feasibility of
incorporating a dance intervention in a hospital-based rehabilitation setting was defined as:
(1) participants’ tolerance to the type of exercise;
(2) the intensity and the frequency of the dance intervention;
(3) level of risks (occurrence of adverse events);
(4) participation;
(5) participants’ satisfaction with the intervention;
(6) availability of equipment and space, and support from the organization and the staff.
A secondary objective was to identify the obstacles to implementing this intervention and
ensuring its sustainability.

Experimental section
A biweekly dance intervention was conducted between February and July. A modified 45-
minutes dance class was delivered in a group format twice a week over 4 weeks to individuals in
the sub-acute phase of post-stroke recovery. It was given in supplement to the usual care. The
participants could join the group at any time. The care was organized by program (stroke,
traumatic brain injuries, work injuries, etc.) and was client-centered. The interdisciplinary team
consisted of nurses, physical and occupational therapists, social workers, speech-language
pathologists, dieticians, and neuropsychologists (the team’s composition varied based on the
patient’s needs). The usual care consisted of daily 45-min sessions of occupational and physical
therapy. Based on the client’s need, speech-language pathology or psychology consultations
were also offered (frequency determined by the rehabilitation goals). In addition, clients had the
opportunity to participate in recreational activities and educational sessions about stroke and fall
prevention. No formal aerobic exercise group was offered. In the stroke program, all
interventions were delivered in an individual format, except for educational sessions. The overall
goal of the dance intervention was to increase the intensity of treatment offered to the clientele
post-stroke and to implement an aerobic exercise program, delivered in a group format, focusing
on physical and cognitive impairments.

Participants
Participants were included in the therapy regardless of their co-morbidities or the medication
taken, as long as they were in a stable medical condition. All clients with severe motor apraxia,
severe mixed aphasia, tetraplegia or who presented with a poor tolerance to a group setting or
significant behavioral problems were excluded from the therapy. Clients who did not have the
endurance to tolerate a minimum of two 45-min of treatment per day were also excluded as the
participants still had to undergo their usual care in addition to this therapy. To ensure a sufficient
number of participants in each dance session, the group was open to individuals with other
medical conditions with similar impairments, such as musculo-skeletal disorders, multiple
sclerosis or traumatic brain injury. No data were collected on those participants because they did
not consistently participate in each dance session and no formal objective was defined.

53
Recruitment of participants
The physical and occupational therapists suggest participating in this therapy, as an adjunct
therapy, to the clients who meet the inclusion criteria. The potential participants have the
opportunity to observe a dance class prior to consenting to participate in the dance therapy.

Dance intervention
The dance styles used for this group was a combination of jazz dance and merengue. Jazz dance
was selected, because this style combines whole-body movements requiring flexibility, balance
and endurance, with perceptive-cognitive skills. By using choreography or short routine, it
allowed the repetition of the dance steps learned to foster memorization and added the additional
challenge of remembering a sequence of steps. Jazz dance encompasses various other dance
styles, such as swing and rock-and-roll, and it is commonly performed in ballrooms, making it
easier for participants to relate to a previous dance experience. The basic steps of the merengue
were also incorporated into the dance intervention, because the steps are simple, easy to learn
and promote the transfer of weight from one side to the other. Dance exercises were targeting
flexibility, balance, endurance, upper extremity function, perception (visual imagery and
incorporation of the affected side for individuals with hemi neglect) and memory. The dance
steps demonstrated by the dance instructor were the same for all participants. However, given the
great variability of each participant’s functional ability, the complexity and the intensity of the
dance exercises were progressed according to each participant to achieve an appropriate
challenge at moderate treatment intensity (measured with the Borg Rating of Perceived Exertion
Scale). All the dance steps could be performed in sitting or standing position. The sessions were
led by an occupational therapist (OT) that had previous dance experience in various dance styles.
Depending on the number of participants, assistance to the dance instructor was provided by one
or two OT students, typically using a ratio of three participants for one therapist. The OT
students were already trained to analyze an activity to ensure patient safety, minimize the risk of
fall and modify the exercises for each participant, when needed. The equipment required to run
the dance class included chairs and a portable media player with music. A therapeutic plinth
adjustable in height was also used for all participants who did not have enough balance to
perform the activity in standing position, but could sit down without back support. The dance
class was conducted in a small portion of the occupational therapy department (5 m2). To avoid
interference with the usual care, the dance class was given at the end of the working day (from
3:15 to 4:00 p.m.). This time slot was the least busy of the day, which allowed minimized
disturbance for other therapists and their patients in terms of space and noise from the music.
The structure of the modified dance consisted of five components:
- warm up,
- technical exercises,
- improvisation,
- a short routine and
- a cool down.

Modification to the dance class specifically for individuals post-stroke

To target the dance intervention for individual’s post-stroke, weight bearing on the most affected
side and integration of the impaired limbs were strongly encouraged. Participants were
encouraged to find solutions to allow them to perform a movement they found difficult due to
physical limitations secondary to stroke. During the improvisation, participants were instructed

54
to be creative in the movements performed to generate a larger repertoire of dance steps.
Suggestions of alternative dance steps were also proposed to the participants, either to encourage
them to use a larger range of movements or to adjust the level of challenge. For the participants
with severe decreased balance, the dance steps were performed in sitting position. These
participants were encouraged to move their arms and legs, move the wheelchair forward and
backwards and perform flexion/extension or lateral flexion of the trunk. Participants with poor
standing balance were paired with a dance instructor (or a family member) who held their hands
to increase their support and provide tactile input for increasing stability. External support was
also offered and participants were encouraged to increase their base of support. Bilateral
movements, passive mobilization of the affected extremity and weight bearing were encouraged
for participants with severe hemiparesis. To facilitate the memorization of the dance steps for
individuals with cognitive deficits, the routine was taught step-by step and each dance step was
given a name or an image. When performing the routine, a dance instructor demonstrated the
routine in front of the group and provided cues for the following movements.

Outcome measures
The dance instructor kept a journal containing the feedback of the participants on the dance
intervention. She also completed an unstandardized observation grid for each participant,
containing the following elements:
- participation and social interaction (interaction with the other participants, ability to follow
instructions),
- balance (use of external support, loss of balance),
- endurance (portion of the dance class performed in sitting/standing position, rest period
needed), rhythm (ability to follow the music rhythm),
- quality of movements (use of the impaired limbs, fluidity and smoothness of movement, ability
to reproduce the dance steps), and
- memorization of the routine (with or without model).
Because participants continued their rehabilitation, which aimed, among others, at improving
balance, it was expected that participants’ balance would improve over time. To document
changes in balance over time, the treating physical therapist administered the Berg Balance Scale
(BBS) in the week prior to and following the dance intervention, since it was routinely used. The
socio-demographic characteristics of the participants and performance in standardized
evaluations were taken from their medical chart. Thus, different assessments were used to
determine the presence of cognitive deficits from one participant to another.

Results/participation
Over a period of 20 weeks, 16 participants were recruited for the class and nine participants
completed eight dance sessions. None of the participants had any formal training in dance prior
to their stroke, defined as having taken more than one year of dance lessons in adulthood. Of the
participants who dropped out from the dance classes, four participants were discharged from
rehabilitation before the completion of eight dance sessions. Three other participants dropped out
of the dance class after trying one or two sessions, because they did not like this intervention and
were not engaged in the dance classes. The mean age of those participants was 63.7 years (range
47-78) and the majority of the participants were female. Participants were taking 5.9 medications
daily, excluding medication taken when required.

55
The number of individuals who participated in the dance intervention varied from three to eight
at one time. This number included the study participants, individuals with other medical
conditions and former participants who continued to participate in the dance intervention after
the completion of the program, as out-patients. For all participants with low BBS initial score,
the BBS improved over time, as they continued to receive their usual care in addition to
receiving the dance intervention.

Frequency, duration and intensity

For this study, nine participants were able to complete a 45-min dance class in addition to their
usual care. A 45-min session was long enough to respect the structure of a usual dance class and
allowed participants to learn a short routine with a few dance steps. Participants often
experienced mild to moderate fatigue after 45 min of moderate intensity dance exercises.
However, beyond this time, a significant increase in fatigue was reported, even if the exercises
were modified to allow more resting time. In the context of functional intensive rehabilitation,
the frequency of two sessions per week in addition to the usual treatment was feasible and
realistic in terms of the availability of therapists and turnout to the dance class. The intensity of
the treatment was not standardized but graded for each participant according to endurance levels
to provide moderate treatment intensity.

Space
The dance class can be performed in an open or closed room. The selection of an open room
rather than a separate private area had advantages for the dance program, but also some
inconvenience or the other OTs. One of the advantages for the participants was that they enjoyed
performing the learned choreography for an audience composed of therapists, family members or
other clients in the treatment room. Another advantage was the ability to stimulate the interest of
other clients and possibly recruit new participants. Because of the proximity of the class to the
other therapists, additional assistance was available if required. The inconvenience for the other
therapists using the room included a temporary loss of space in the treatment room and the
possible disturbance to their clients due to the music. Since the dance class was performed in a
corner of the therapy department, this prevented from having anyone walk through the dance
class while it was taking place and minimized disruption. No formal complaints were received
from either the therapists or the patients for losing space or being disturbed by the music.

Music selection
The songs that solicited the most participation were the popular hits of the 50s’ to 80s’.
Participants reported that they preferred songs with a fast pace and a strong beat, whatever the
music style. Most of the time, the music was selected based on the participant’s preference in a
predetermined playlist.

Occurrence of adverse events

The main risks for participating were the risk of fall and an increase in fatigue. No negative
consequences to participation were experienced during or after the dance classes, except
increased fatigue: ‘I worked hard, I’m tired’. However, when surveyed, the participants did not
feel more tired than after their usual therapies: ‘I feel as tired as after a good session of physio’.
During the dance class, the participants did not want to stop even if they were becoming
fatigued.

56
Participants’ perception
Participants reported that dance was a challenging, but enjoyable activity, and it was a great
complement to their usual therapies. They also mentioned that they enjoyed interacting with the
other participants. Two participants expressed that the dance intervention gave them confidence
to move in their own body and dance in an informal social context. One participant said ‘The
dance intervention allowed me to meet other people with the same kind of problems as me’.
Another one expressed that ‘The exercises are not easy, but I have a lot of fun to attend those
classes’. Participants also spontaneously reported an improvement in their standing balance and
a decreased fear of falling: ‘I feel safer to move when I'm standing’, ‘I can see that my balance is
better, because of the dance group’. All participants reported that they liked to perform in front
of a small audience because they feel ‘proud of their accomplishment’. They stated that it was
their favorite part of the dance class. Eight participants mentioned being satisfied with the dance
intervention and one expressed being ‘neutral’. Of the seven participants who dropped from the
study, three did not enjoy the intervention and consequently dropped the classes. The remaining
four participants expressed being satisfied with the intervention, but received their discharge
before the completion of eight dance classes.

Discussion
The aim of this programme was to determine the feasibility and application of dance intervention
to address physical and cognitive impairments in individuals post-stroke. Based on the results, an
adjunct modified dance class was feasible in the context of functional intensive in-hospital
rehabilitation for individuals in the sub-acute phase of post-stroke recovery. The frequency,
duration and intensity of the dance classes were well tolerated by the participants, which is
consistent with other studies using dance for individuals with neurological disorders or exercise-
based intervention in the sub-acute phase of stroke recovery. The results suggested that dance
could be performed in a limited space, contributing to its use in rehabilitation. Throughout the
implementation of the dance classes and the duration of this therapy, the program coordinators
and the staff were open and supportive. However, all clinicians and program coordinators might
not perceive the benefits of using dance in rehabilitation or adopt an open attitude, which can
represent an important obstacle to the recruitment of participants and its sustainability. The level
of risks associated with the dance intervention was low, as no adverse events occurred during or
after the intervention. The potential risks of dance-based exercises should be anticipated and
addressed to ensure participants safety. Because dance is an enjoyable activity that is not always
perceived by the participants as typical physical exercise, they can become fatigued. Therefore,
the monitoring of the level of fatigue and exertion with a visual-analogue scale at different times
during the class can prevent excessive fatigue.

Concerning participation, a high attrition rate (43.8%) was noted. This attrition rate can be
partially explained by the short length of stay in in-patient rehabilitation, as 4 out 7 participants
were discharged before the completion of the program and were not able to pursue their
participation as outpatients, despite the enjoyment of the dance classes. Thus it is suggested that
patients should be enrolled in the dance class early in the rehabilitation process. Since the
majority of the participants who completed the program continued to attend the dance classes
after the completion of the therapy, the duration of the program could be different for each
participant and determined based on the individualized treatment plan.

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Dance can be intimidating for people who have not participated in dance classes in the past. This
could have contributed to the lack of engagement of the three participants who dropped the class
and could have influenced enrolment. The incorporation of this modality into the individualized
treatment plan could help to strengthen the sense of engagement and could help in the gradation
of the dance steps for each participant. One of the factors influencing participation was the time
at which the class was scheduled. To avoid interference with the usual care and scheduled
therapy, the dance class was offered at the end of day. However, this time slot was also a period
when patients were more tired or were receiving visitors. Another time slot could, potentially,
have resulted in a better participation.

Overall, 75 % of the participants enjoyed the dance intervention. The dance intervention
promoted social interaction, as it was performed in a group format. The collaboration and
camaraderie between participants, the sense of accomplishment and the perceived improvements
contributed to the satisfaction towards the intervention. Due to the important diversity in the
participants’ impairments, the results suggest that the class can be taught to people across a
spectrum of impairments. Individuals in the sub-acute phase of stroke recovery could improve
quickly, which illustrates the importance to progress the level of difficulty based on the
participants’ improvements.

Conclusions
Dance is a promising treatment intervention that can be used as an innovative adjunct therapy to
target multiple impairments in individuals in the sub-acute stage of post-stroke recovery, in a
hospital setting. Dance is feasible to integrate to the usual care in a context of functional
intensive rehabilitation, as little equipment and space is needed. The results suggest that a dance
intervention can be sustained over time, due to the support from the organization and the staff.
The dance exercises and the choreography can be adapted to the capacities of each participant
with various impairments to provide an appropriate challenge. Moreover, the participants
perceived dance as an enjoyable social and physical activity, which contributes to treatment
adherence.

References
1. World Heart Federation Stroke. (accessed on 25 November 2014). Available online:
http://www.world-heart-federation.org/cardiovascular-health/stroke/
2. Hakim A.M., Silver F., Hodgson C. Organized stroke care: A new era in stroke prevention and
treatment. Can. Med. Assn. J. 1998;159:S1.
3. Mayo N., Wood-Dauphinee S., Ahmed S., Gordon C., Higgins J., Mcewen S., Salbach N.
Disablement following stroke. Disabil. Rehabil. 1999;21:258-268. doi:
10.1080/096382899297684. (PubMed) (Cross Ref).
4. Dogğan A., MengüllüoGĞlu M., Özgirgin N. Evaluation of the effect of ankle-foot orthosis
use on balance and mobility in hemiparetic stroke patients. Disabil. Rehabil. 2011;33:1433-1439.
doi: 10.3109/09638288.2010.533243. (PubMed) (Cross Ref).
5. Berrol C. Dance/movement therapy in head injury rehabilitation. Brain Injury. 1990;4:257-
265. doi: 10.3109/02699059009026175. (PubMed) (Cross Ref).

58
The use of poetry therapy with domestic violence counselors experiencing secondary
post-traumatic stress disorder symptoms
Domestic violence counselors who are exposed to the traumatic material of clients may be at risk
of secondary posttraumatic stress disorder (SPTSD) and are in need of effective interventions
that combat symptoms of SPTSD. The focus of this therapy is on the examination of the
effectiveness of poetry therapy for domestic violence counselors experiencing SPTSD
symptoms; and on an investigation of the predictors of SPTSD symptoms. The results showed
that poetry therapy reduced SPTSD symptoms in domestic violence counselors. Gender,
openness to experiences, and agreeableness were significant predictors of SPTSD symptoms.

Poetry therapy, as a form of expressive arts therapy, is being used increasingly by mental health
professionals, perhaps because of the healing value of its emotional expressiveness. The word
psychology itself suggests the connection between poetry and emotional healing, with psyche
meaning soul, and logos meaning speech or word (Longo, 1996). While folk healers have
understood the healing power of the story since ancient times (Feder, 1981), therapists are
rediscovering the validity of narrative and poetic techniques used to promote emotional healing.
Poetry therapy is defined as the integration of language arts and psychotherapeutic theory. Poetry
therapy includes poetic and narrative techniques. Poetry therapy is increasingly being used in
hospitals, schools, and community settings (Mazza, 1993, 2003). As poems and stories can be
interpreted as being about someone other than the client, poetry therapists propose that literature
can be used as a safer way to express issues, identify problems, or confront inconsistencies in a
defended participant who may feel safer discussing personal issues when the focus is not on his
or her own life. Proponents of poetry therapy contend that writing and responding to the writings
of others allows individuals to express emotions, validate feelings, define ideas, put experiences
in context, scrutinize assumptions, learn vicariously, connect with others, and become more
aware of personal choices (Hynes & Hynes-Berry, 1994). Although traditional quantitative
research on poetry therapy is limited, there have been numerous qualitative studies, narrative
reports, dissertations, and case studies indicating that poetry can be a powerful tool for
promoting emotional expression, reducing tension, and facilitating healing (Fuchel, 1985;
Mazza, 2003).

Reports and writings of domestic violence victims/survivors suggest that the use of poetry
therapy with trauma survivors is common and useful (Campbell, 1998). For instance, Booker
(1999) documents the use of poetry to empower and raise the consciousness of Latina victim!
survivors of spousal abuse. It stands to reason, if poetry therapy is useful in healing victim!
survivors of domestic violence, poetry therapy may also be useful in helping domestic violence
counselors who hear stories of interpersonal violence and are thereby at risk for symptoms of
secondary posttraumatic stress disorder (SPTSD).

SPTSD is a subsidiary form of posttraumatic stress disorder (PTSD) that occurs following
vicarious exposure to a sudden, life-endangering or traumatic event, which includes childhood
sexual abuse and severe threats to psychological integrity. Symptoms of SPTSD, similar to
PTSD, are characterized by intrusive thoughts about the event, hyper arousal in response to
reminders of the event, and avoidance of situations that remind the affected individual of the
event (APA, 1994).

59
SPTSD occurs in individuals traumatized through their close interactions with primary victim!
survivors who may tell vivid stories about a dangerous event or demonstrate its effects.
Researchers have noted variations of symptoms in professional helpers that often signal SPTSD
(Dutton & Rubinstein, 1995). For mental health providers, studies have shown specific SPTSD
symptoms such as intrusive imagery related to a client’s trauma (Herman, 1997); numbing or
avoidance, which may include avoiding certain clinical topics or clients (Courtois, 1988); and
impairment in work functioning (Boylin & Briggie, 1987).

Possibly the most wide-ranging and potentially destructive symptom of SPTSD in counselors is
that the provision of competent care to clients can be compromised. The occupational effects of
SPTSD may include withdrawal from friends and colleagues, feelings of isolation and lack of
appreciation, a loss of professional commitment and judgment, and decreased self-care (Boylin
& Briggie, 1987; Figley, 1995). Unacknowledged or untreated, SPTSD in clinicians may
ultimately result in professional burnout (Foa, Jonathan, Davidson, Frances & Ross, 1999).

Although there have been few studies on the factors related to SPTSD in domestic violence
counselors, research on SPTSD symptoms in health care workers, law enforcement providers,
and other professionals exposed to the effects of trauma through their work shows that
demographic variables such as gender (Breslau et al., 1998) and age (Beaton & Murphy, 1995;
Figley, 1995) are risk factors for PTSD. Work-related variables such as the number of years
working with trauma victims have also been associated with SPTSD in professional helpers
(Creamer & Liddle, 2005; Salston & Figley, 2003). However, results have been mixed. Some
studies show that less experienced trauma workers may be more likely to suffer from symptoms
of SPTSD (Creamer & Liddle, 2005; Ghahramanlou & Brodbeck, 2000; Linley, Joseph &
Loumidis, 2005), whereas other studies show that more time in the field working with trauma
may be related to increased vulnerability (Baird & Jenkins, 2003; Price, 1998). Differing
personality characteristics are also associated with adaptive (or maladaptive) responses to
traumatic stressors (Heyer, McCranie, Boudewyns & Sperr, 1996; Penley & Tomaka, 2002).
That is, the research suggests that individuals with more flexible and adaptive personality
characteristics are better able to handle traumatic stressors (Heyer et al., 1996). The research
suggests that there are a number of factors that are associated with increased risk of SPTSD for
domestic violence counselors. Therefore, it is especially important that domestic violence
counselors have effective ways to deal with SPTSD (Pearlman & MacIan, 1995; Walker, 2005).

Since writing is an activity that is easy to engage, low cost, and affords the opportunity for
details related to secondary victims’ clients to remain confidential, it may be a useful strategy for
coping with SPTSD. The research suggests that emotionally expressive writing is a therapeutic
intervention proven to be beneficial to the writer in terms of both physical health and mental
health in a variety of circumstances (Pennebaker, 1998, 1999). These include reductions in
physician visits (Pennebaker & Francis, 1996), improved immune functioning (Pennebaker,
Kiecolt-Glaser & Glaser, 1988), and increased psychological well-being (Lepore, 1997).
Although the research suggests that emotionally expressive writing is beneficial, there are a few
published empirical studies examining the effects of reactions, interventions, risk factors, and
preventative measures for trauma counselors. As such, scholars have called for more empirical
studies in this area for this population (Stamm, 1997). Since physical and mental health benefits
for counselors writing about trauma are possible, given the Pennebaker and colleagues’ research

60
findings, studies on the effects of work-related trauma in domestic violence counselors should be
useful. In addition, empirical studies on the efficacy of poetry therapy as an intervention have
been called for by researchers promoting this growing therapeutic modality (Mazza, 1993, 2003).
Furthermore, anecdotal evidence indicates that poetry therapy may be successful with domestic
violence counselors in alleviating symptoms of traumatic stress (Mazza, 1991).

If, as Pennebaker (1998) asserts, writing about traumatic events at deeper emotional levels is
more beneficial to those experiencing distress, it stands to reason that, for some individuals,
writing in response to poetry, or writing poems in which deep emotions about traumatic events
are expressed, may increase benefits inherent in the writing experience. Since engagement with
the process of expressing emotions has been shown to be a positive prognostic factor in studies
involving PTSD victim! survivors (Jaycox, Foa & Morral, 1998), poetry therapy is a process that
engages the participant in processing personal emotions (Hynes & Hynes-Berry, 1994) and
therefore poetry therapy may be a benefit for domestic violence counselors. Thus, the purpose of
this study was to expand previous research documenting the benefits of writing about traumatic
events by examining the impact of poetry therapy on SPTSD symptoms in domestic violence
counselors. Another purpose of this study was to determine which characteristics might predict
the development of SPTSD symptoms. The research questions for this study are:
1. Does poetry therapy have an impact on SPTSD symptoms in domestic violence counselors?
2. What demographic, workplace, and personality variables predict SPTSD in domestic violence
counselors?

Participants
A sample of 55 domestic violence counselors (six men and 49 women) volunteered to participate
in the study. Age of the participants ranged from 23 to 53. Over 80% of the participants had a
master’s degree in counseling or social work. A majority of the participants worked in a
nonprofit agency (n"43) and had less than 7 years working with trauma victims.

Procedures
Participants were recruited via emails and in-person visits to domestic violence centers in four
states: An email or letter was provided to domestic violence counselors which provided
information about the study.

Participants were informed on the website that their responses were anonymous. Participants
were instructed to use their login id on subsequent visits to the website. Participants randomly
assigned to the poetry therapy groups could access their assignments using their login id and
password. Their login id appeared on all submissions to allow survey and writing activities to be
matched for each individual participant. In addition, a researcher contact page allowed
participants having questions about the website or the research project to email the researcher.

The design of this study utilized structured poetry therapy activities, with the time and spacing of
activities similar to that used in Pennebaker’s basic expressive writing paradigm (Pennebaker,
1997). In Pennebaker’s model, participants in the writing groups are typically asked to write on
three occasions, for a period of 15! 20 minutes where they wrote about their deepest thoughts
and feelings (Pennebaker, 1997).

61
This study was intended to promote emotional disclosure through the use of poetry. Poetry
therapy as used in this study was designed to promote writing about work-related stress that is
personal and emotionally focused. Participants were instructed to respond to a poem reflecting an
emotional theme typical of PTSD reactions documented in research literature. All poems used in
this project were selected in conjunction with a registered poetry therapist and had been used
previously in support groups for domestic violence counselors. Selected poems reflected a
variety of emotions, including guilt, anger, sadness, and a sense of helplessness in response to
events out of control. The chosen poems were also the top three most frequently used poems in
poetry therapy used by therapists (Reiter, 1997). Participants were provided with a different
poem for each of the three occasions, in the following order: The Armful by Robert Frost (1928);
Autobiography in Five Short Chapters by Portia Nelson (1993); and The Journey by Mary Oliver
(2004). For the ‘No Writing control group’ participants in this group were told to go about their
daily routine as usual. Instructions given to the group were as follows, ‘Please go about your
daily activities as usual, without writing about them, unless writing is part of your normal
routine. After ten days to two weeks, please log back in and complete the post-treatment
assessments.’

Results
A total of 27 participants were randomly assigned to the poetry therapy group. However, two
participants did not complete the posttest instruments, leaving only 25 individuals in this group.
For the No Writing control group, there were 28 participants. The mean scores for the Poetry
Therapy and No Writing control participants on the pretest were 24.44 and 24.29, respectively.
The mean scores for the Poetry Therapy and No Writing control participants on the posttest were
20.24 and 20.71 respectively.

The mean pretest score was significantly greater than the posttest score indicating that poetry
therapy had an impact on decreasing SPTSD symptoms. The results of this analysis found that
gender and openness to experience were significantly related to SPTSD symptoms. Furthermore,
participants who were more open to new experiences were less likely to experience SPTSD
symptoms. Participants who were classified as male and those who had an agreeable personality
were more likely to experience SPTSD symptoms.

Discussion
The results of this study indicated that domestic violence counselors assigned to the poetry
therapy group showed a decrease in SPTSD. This finding is consistent with prior studies on
emotionally expressive writing that show a decrease in symptoms following writing treatments
(Pennebaker, 1998, 1999). The finding that poetry therapy is effective in reducing stress
symptoms supports anecdotal reports about the benefits of poetry therapy for clients
experiencing SPTSD symptoms. Regression analyses results showed that gender and
agreeableness were related to increased SPTSD symptoms for this sample. Individuals with an
agreeable personality, according to the IPIP measure, encompass cooperation, trust, and
sympathy (McCrae & John, 1992). It may be that people who are more sympathetic are more
emotionally vulnerable than those who are empathic (McCrae & Costa, 1997). Empathy differs
from sympathy in that empathy is used by clinicians to enhance communication and delivery of
care, whereas sympathy implies shared feelings with the sufferer as if the pain belonged to both
persons.

62
It is interesting to note that gender, particularly participants who were male, was related to higher
SPTSD scores. However, since there were only six male participants in the study, future studies
are needed to examine the impact of SPTSD on male domestic violence counselors. There are a
number of limitations restricting generalizability of this study. First, the study was open only to
participants who self-identified as domestic violence counselors and had adequate access to the
Internet to allow them to participate via the research website.

Counselors who did not have email accounts may not have been made aware of the project, and
only those with regular access to the Internet would have been likely to participate. Solicitation
of volunteers through emails, at writing workshops for counselors, and through personal
networking may also have biased the sample in favor of individuals more likely to write or view
writing favorably as a form of self-care. As this was an anonymous study with only intrinsic
rewards for participation, those who did not view writing as a favorable activity may have been
more likely to decline participation or drop out of the study. In addition, because participation
was anonymous and online, it may have been easier for participants who did not like the writing
activities to drop out. Therefore, individuals who were not inclined to write may have been
under-represented. Another possible problem influencing participation was the time and
involvement required of participants. This was a long study requiring that participants go back to
the site on more than one occasion. Participants who were busier, under more stress, had less
access to a computer, or were less motivated by intrinsic factors related to participation in the
study may have found it more difficult to complete the activities.

Implications
The findings from this study have implications for counselors and administrators in agencies
providing services to domestic violence victim! survivors. The findings suggest that practitioners
can benefit from poetry therapy to relieve stress associated with symptoms of SPTSD. As
researchers have suggested (Stamm, 1997), administrators should provide education on SPTSD
to staff who work with domestic violence victims. Part of the education on SPTSD should
include information on writing as a technique for self-care. Support groups that utilize writing
and poetry therapy may be an especially effective means of helping staff cope with stress. For
counselors working in isolation at satellite sites or smaller sites, poetry therapy via email or
Internet discussion forums may provide a way for these counselors to engage in self-care or
connect with others. As domestic violence counselors learn to care for Poetry therapy and
posttraumatic stress, they will be able to better deliver effective counseling to clients seeking to
escape the dangerous and debilitating effects of domestic violence.

References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders
(4Th ed.).Washington, DC: American Psychiatric Association.
Baird, S., & Jenkins, S. (2003). Vicarious traumatization, secondary traumatic stress, and
burnout in sexual assault and domestic violence agency staff. Violence and Victims 18, 71!86.
Beaton, R., & Murphy, S. (1995). Working with people in crisis: Research implications. In C. R.
Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder (pp. 51!81).
New York: Bruner/Mazel.

63
Booker, M. (1999). Poetry, healing, and the Latin American battered women. Journal of Poetry
Therapy 13, 73!79.
Boylin, W. M., & Briggie, C. R. (1987). The healthy therapist: The contribution of symbolic-
experiential family therapy. Family Therapy 14, 247!256.
Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis, G. C., & Andreski, P. (1998).
Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area survey of
trauma.Archives of General Psychiatry 55, 626!632.
Campbell, U. (Ed.) (1998). Empowering survivors of abuse: Healthcare for battered women and
their children.Thousand Oaks, CA: Sage.
Corcoran, K., & Fischer, J. (1994). Measures for clinical practice: A sourcebook (3Rd Ed.).
Adults, Vol. 2. New York: The Free Press.
Costa, P. T., & McCrae, R. R. (1985). The NEO personality inventory manual. Odessa, FL:
Psychological Assessment Resources.
Courtois, C. A. (1988). Healing the incest wound: Adult survivors in therapy. New York: W.W.
Norton &Company.

THERAPY IN COMMUNITY SETTINGS

THERAPY IN EDUCATIONAL SETTINGS

64
EMERGING TRENDS
EMERGING TRENDS IN MUSIC THERAPY
Conventional Music Therapy
Scientific studies have shown the value of Music Therapy on the body, mind and spirit of adults,
children and even foetuses. The intention of Music Therapy is to assess physical or mental
capabilities and promote pain relief, muscle relaxation, mood management, coping skills,
emotional expression and stress reduction.

Music Therapy is clinically proven to enhance the treatment of depression, anxiety, brain injury,
stroke, Alzheimer’s disease, Parkinson’s disease and cancer. Research has found that Music
Therapy, when used with patients receiving high-dose chemotherapy, can help ease nausea and
vomiting. Some studies have shown that music helps decrease the overall intensity of a patient’s
experience with pain and may result in a reduced need for pain-relief medication.

Music Therapy is a rich resource for improving quality of life for patients. Many forms of Music
Therapy are based on traditional and scientific theories.

 All forms of music may have a therapeutic effect, although music from one’s own culture
may be most effective.
 In Chinese medical theory, the five internal organ and meridian systems are believed to
have corresponding musical tones used to encourage healing.
 Types of music differ in the neurological stimulation they provide. Western Classical
music has been found to inspire comfort and relaxation whilst Rock may lead to high-
energy and animation in some but unease and discomfort in others.
 Music has been clinically proven to affect bodily functions, influencing respiratory and
heart rate, cardiac output, blood pressure, muscle tone, papillary responses and skin
reaction. In line with a desired outcome, music can be used to calm or accelerate these
functions. A sedative yet up-lifting composition (like Pachelbel’s Canon in D Major) can
relieve pain, reduce stress and anxiety resulting in a quicker recovery with less pain
medication. Similarly, stimulating music (such as The Black-Eyed Peas ‘I Gotta Feeling’)
can be a mood-lifter and motivating factor in physical and psychological rehabilitation.
 Listening to music live OR recorded can also effect responses. Live music in a social
atmosphere is believed to encourage socially accepted ways of expression and behaviour
in a group, whereas listening to recorded music in private may inspire a mature internal
examination of personal issues.
 Improvisational Music Therapy involves spontaneous creation of music with voice,
instruments or body. This allows creative expression, energy release, development in
personal insight and redirection of negative emotions.
 Recreative music implements singing and playing instruments to pre-composed music.
This can help develop a sense of mastery and increased self-confidence.
 Composition methods involve creating one’s own vocal or instrumental pieces as a means
of self-expression.
 In a hospital setting, Music Therapy bestows upon patients a safe and familiar way to
cope with their hospitalization. When experiencing the physical stress of invasive
procedures, the emotional stress of unexpected news and the inability to conduct normal

65
 activities, Music Therapy provides an avenue for the patient to express feelings and
regain a sense of control.
 Music may also be used in the classroom to aid children in the development of reading
and language and enhance their communication and cognitive skills.

A music therapist designs individual or group sessions based on the patients’ needs, using
improvisation through singing, rhythm and instrumental work. Additional techniques include
lyric analysis, songwriting, music with imagery, music relaxation and active music listening. The
therapist begins with an initial assessment and follows-up with an interdisciplinary treatment
plan using the appropriate techniques.

Music Therapy in Practice

Music Therapy has now become a valuable resource recognized by enlightened healthcare
professionals across the world. Long may it continue to be used in addressing the physical,
emotional, cognitive and social needs of individuals in need.

CanSupport is a free Delhi-based palliative-care support group and NGO for patients of all ages,
all socio-economic groups, in all stages of cancer. The children who come to their Monday
Daycare range from 2-18 years, although it is the children of 5years and up that really engage
with Music Therapy. They keep a variety of instruments on hand; guitars, flutes, drums,
xylophones, energy chimes, whistles, rattles and shakers etc. Every child gravitates towards a
particular instrument playing as and how they like, each contributing to the magnificent
cacophony of sound as a whole. It might not make melodic sense, but the joy and release of
‘making LOUD sounds’ is all too evident and a joy to see!

Although a number of children are part of a ‘floating population’, in and out of Delhi for
treatment, their work with the more permanent members has yielded encouraging results.

One clear improvement has been in communication. Some children, previously reserved,
hesitant, withdrawn or dejected, started to open up. They slowly began engaging with one
instrument or another, enjoying the new found freedom of experimenting with sound. After a
session of 30-60 minutes, one noticed a marked difference in their mannerism and body
language, eye-contact and interaction. No longer so shy and introverted, they became a little
more aware of the group and contributed to the energy within it.

Experimenting with music boosts the children’s self-confidence and creativity, helping them feel
relaxed and comfortable in the Daycare environment. For example, using drums enables them to
vent and release anxiety, fear and anger about their illness. In turn, this improves communication
with peers, siblings, parents and outsiders. An hour of Music Therapy is a complete distraction
from the pain and symptoms they experience during their treatment.

What these children experience through Music Therapy is a shift from isolation to acceptance,
from pain to joy and fun. Since an inspiring trip to Seoul, Korea, for a Music Therapy conference
in June 2011, they now incorporate music with imagery into their therapy, innovating new
activities around music to ensure that the children enjoy each session.

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Further Advancements in Music Therapy

Music Therapy and Imagery Techniques

Music therapy with Imagery is a process by which music and visualization bring about
therapeutic change. During this process, the client may experience visual imagery, trance-like
states or body responses inspired by the music. This in turn promotes relaxation, self-exploration
and an increased ability to cope with major life issues in a healthy manner.

Music and imagery also encourages a deeper understanding of the self on its spiritual journey.
Music with guided imagery, based on the Bonny Method of Guided Imagery with Music
(BM), may help produce altered states of consciousness, uncovering hidden emotional responses
and creative insights, self-knowledge and healing.

The application of Bio-feedback rapidly expanded in the 1990s with the advent of the
microcomputer and computerized psycho physiological data acquisition systems. With these
developments, Bio-feedback is gaining an ever-widening acceptance in the medical arena.

Within the parameters of alternative medicine, Bio-feedback is called Mind-Body Therapy.

Designed to enable control of the body through thought and will, it is based on the ancient
principle (and scientific study) of ‘Mind over Matter’; that humans have the innate ability to
influence automatic and involuntary functions of the body through the mind alone.

Bio-guided Music Therapy distinguishes itself from other music therapy models by virtue of the
client’s physiological data being actively recorded during the session. This real-time data may be
presented in key, scale and tempo for flexibility in musical interaction with the music therapist or
group.

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EMERGING TRENDS IN DANCE MOVEMENT THERAPY

Dance/Movement Therapy (DMT) is a field that holds incredible potential and capability to
develop. In the past few years, the world of Dance Therapy has grown and extended,
accomplishing new heights every day. DMT is practiced in various clinical settings and is used
for psychotherapeutic as well as physiotherapeutic purposes.

Dance has been used therapeutically for thousands of years. Though dance has been a mode of
expression for ages, it wasn’t until the past half century, that it was considered as a form of
therapy. The concrete establishment of dance as therapy occurred in the 1950s, with Marian
Chance, who later founded the American Dance Therapy Association.

Research holds an important place within DMT and occurs at different levels within this
practice. It allows the DMT practitioner to evaluate the outcomes of their work. Research can
also be carried out to advance in the profession, by looking at new avenues and through findings
from conference presentations and publications. A variety of methodologies, including
qualitative, quantitative, arts-based approaches are used to study DMT. Many studies have
recently been conducted, which are helping Dance Therapy in receiving more recognition and
popularity.

A review titled ‘Dance/movement therapy for cancer patients’, was conducted in January 2015.
The three studies in the review included a total of 207 participants, who were women with breast
cancer. The findings of individual studies suggested that dance/movement therapy had a
beneficial effect on the quality of life and strength of women with breast cancer. Besides, there
were no adverse effects of dance/movement therapy interventions.

The most recent review for DMT was in February 2015, titled ‘Is dance movement therapy an
effective treatment for depression? A review of the evidence’. The findings of the research stated
that overall there was no evidence for or against DMT, as a treatment for depression, although
some evidence suggested, that DMT is more effective than standard care for adults. There was a
large positive effect observed for social functioning.

Another review of the effect of DMT on Parkinson’s disease noted that DMT appears to meet
most requirements for exercise programs for patients with Parkinson’s. Benefits in gait function,
balance, and quality of life were found in short-term studies, though further studies need to be
done to see if any of these benefits are seen long-term.

Many international organizations are working towards taking Dance and Movement Therapy
Forward. These organizations were established in order to uphold high standards in the field of
DMT. Such associations help connect individuals to therapists and DMT.

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The American Dance Therapy Association

The American Dance Therapy Association (ADTA) was founded in 1966 by Marian Chace, the
first president of the ADTA, and other forerunners of creative movement. Along with setting
standards, that therapists must attain to become licensed therapists, ADTA keeps an updated
registry of all movement/dance therapists who have met ADTA’s standards. In
addition, ADTA also publishes the American Journal of Dance Therapy and sponsors annual
professional conferences.

There are only 6 ADTA approved master’s programs from which to earn Registered
Dance/Movement Therapist (R-DMT) credentials: Antioch University New England in New
Hampshire, Columbia College Chicago in Illinois, Drexel University in Pennsylvania, Lesley
University in Massachusetts, Naropa University in Colorado, and Pratt Institute in New York.

The Association for Dance Movement Psychotherapy, United Kingdom

The Association for Dance Movement Psychotherapy, United Kingdom (ADMP, UK) was one
of the first organizations established to regulate the field of Dance Therapy. ADMP, UK,
accredits therapists and oversees that all regulations are followed.

There are five universities in the United Kingdom that offer graduate programs in Dance
Movement Psychotherapy and have been approved by the ADMP, UK: Dance Voice Therapy
and Education Centre, Bristol, Edge Hill University, Goldsmiths University of London,
University of Derby and University of Roehampton.

The International Dance Council CID, Paris

CID is the official umbrella organization for all forms of dance in all countries of the world. It is
a non-governmental organization founded in 1973, within the UNESCO headquarters in Paris,
where it is based. It brings together the most important international, national and local
organizations, as well as select individuals, active in dance. It includes every form of dance from
classical, ballet, modern, folk, ballroom, Oriental, Tango to therapeutic, recreational, revivalist
etc.

The members of CID are specialists in cultural studies, art historians, psychologists, sociologists,
anthropologists, philosophers, theologists, medics, choreographers, dance teachers, dance
therapists, dance film directors and other professionals.

CID’S 49Th World Congress on Dance Research – LINKING WORLDS THROUGH DANCE
was be held at Dadar-Mumbai, India, from the 7-11 December 2016.

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Dance Heals: Newly Popular Therapy makes big strides with Movement

Dance as therapy: Newly popular DMT treatment makes big strides via teaching patients
movement.

The fact is that anyone at any time can be betrayed by body, mind or both, whether the cause is
illness, accident or simple old age. In that event, the little-known treatment of dance-movement
therapy holds out hope to people, from cradle to grave, to live as fully as possible.

Fame and money are no defense against poor health, as ‘Dancing with the Stars’ judge Carrie
Ann Inaba learned. After seeing the effects of cancer on her mother six years ago, she became
the national spokesperson for L.A.-based Drea's Dream, a dance-movement therapy (DMT)
program for children with cancer and special needs.

The field of dance-movement therapy in fact seems to be undergoing something of a boom, at

least in Chicago. Columbia College's master's program, one of only six approved by the 50-year-
old American Dance Therapy Association, drove a 33 percent jump in enrollment in the creative-
arts therapies department last year - the largest growth of any college department, according its
chair, Susan Imus.

With the observation that ‘war changes medicine,’ Imus notes that DMT got its start in the
1940s, when St. Elizabeth’s Hospital in Washington, D.C., invited dancer Marian Chace to work
with traumatized World War II veterans there. That was before the advent of antipsychotic drugs,
so the benefits of DMT alone were obvious, Imus says. Claiming the therapy's scientific basis,
she says clinical studies have measured ‘how dance changes your biochemistry.’

But it's a big jump from the science lab to a DMT session for brain-injured clients at Chicago's
Anixter Center: Students of all ages, abandoning wheelchair, walker, or cane, each dance in their
own way and - remarkably - in time with the music, which ranges from perky electronica to
down-home fiddle tunes. A man with a big scar across his head worms his way, hips waggling,
between another man and a woman, who are dancing face-to-face, if not cheek-to-cheek.

Still, this isn't a nightclub, or a dance class. Though dance-movement therapist Lisa Goldman
does give verbal instructions, the aim isn't aesthetic but therapeutic. Trying to get participants out
of their vertical planes, for instance, or create more diagonals with their bodies is intended to
‘heal the brain,’ she says.

Some comply with her directions, some don't. And in the talkback after the session, Goldman
focuses on the difference between being on-task and off-task.

That kind of verbalization, Imus says, is part of what defines DMT, which aims for ‘coherency
between nonverbal and verbal communication.’ Significantly, M.A. candidates at Columbia take
numerous psychology courses, and their degrees are in DMT and counseling.

DMT can be hard to define, especially since its wide-ranging methods and goals overlap with
those of other movement practices aimed at improving quality of life: physical therapy, yoga, the

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body-language training sometimes given to executives and job seekers. Plain old recreational
dance can enhance mood and physical functioning, and classes can be tailored to special-needs
populations: Hubbard Street has held adaptive-dance classes for Parkinson's patients since 2008,
and started its Autism Project, for kids 5-14, last year.

But those are not DMT. While it may share some methods or aims with other movement
practices, with DMT the goal is nothing less than reconfiguring the brain through neural re-
patterning.

Goldman offers two such sessions weekly at Anixter, which provides a huge number of services
to people with various disabilities. A 1994 graduate of the M.A. program at Columbia, Goldman
has directed Anixter's New Focus brain-injury program since 2003. And she believes DMT is
perfect for such clients.

Assuming a body-mind connection, DMT posits that a larger movement vocabulary makes the
client more capable and flexible not only physically but mentally and emotionally. So, using
Rudolf Laban's system of movement analysis, DMT explicitly aims to grow clients' movement
vocabularies, enabling them to take the body in all three dimensions at once, for example, and to
increase movement's ‘flow,’ or ‘going-ness.’

DMT is beneficial to brain-injured clients in other, less tangible ways as well. Aphasia is
common, Goldman says, and ‘when you don't have words, being able to express yourself and
communicate with others through movement is a relief.’

DMT can also provide ‘a spiritual experience,’ she says. ‘These people have survived - some
have died and were resuscitated. Then the question is, 'OK, I survived, but I have all these
challenges. What is the meaning and purpose of my life?' DMT provides an outlet for that, and
it's a way to connect with other people who survived. That interpersonal connection is in and of
itself brain candy: It affects the brain chemically and can create neurological re-patterning.’

One of New Focus' biggest success stories belongs to a man who suffered a stroke at 41.
Afterward, despite having ‘used the computer up, down, all the way around for his work,’
Goldman says, he no longer even knew how to turn one on. After months of struggle (‘he
worked so hard!’ she adds), he broke out of his movement prison dramatically one day by
launching into a chair-bound jazz layout. (Goldman demonstrates, leaning back in a complex,
flowing motion in three directions, arms and legs thrown out.)

Eventually Anixter hired the man to teach computer classes. And though right after the stroke his
marriage ‘struggled,’ Goldman says, the family got back on track and survived.

Nancy Toncy, who has a 2003 Columbia College master's, is the clinical supervisor of a Rogers
Park program for victims of domestic violence. When hired five and a half years ago, she
introduced DMT to the agency, where she counsels English, French and Arabic speakers (she's
originally from Egypt).

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Body language and self-image are hugely important in this field. ‘I let the client know that we're
going to pay attention to how their bodies experienced the abuse - a first step in recognizing that
your body actually matters,’ Toncy says.

When she first meets clients, Toncy looks for the physical effects of habitual violence. ‘Someone
constantly worried for their safety will be adjusting in their chair, trying to find a stable base,’
she explains. ‘If someone is predominantly depressed, I might see a collapsed posture, slouched
shoulders, and shallow breath.’ Using a ‘body-up’ approach, she empowers the person partly by
adjusting posture.

Physically mirroring clients is also crucial. Poor self-images result from the fact that with ‘their
partner - their mirror - the constant reflection was negative, critical,’ says Toncy. Mirroring
clients' movement and breathing enables her to both understand their experiences from the inside
out and to model with them a healthy ‘mutual’ relationship.

For survivors of domestic abuse, Toncy says, an expanded movement vocabulary can translate
into ‘life feeling more ordinary, experiencing life more fully.’ Clients have told her that ‘just to
have the space to move and breathe, to get bigger and smaller, stronger or softer, to be and do
what they want and for that to be witnessed: That is healing.’

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EMERGING TRENDS IN DRAMA THERAPY

Drama therapy improves mood, reduces pain during hemodialysis

Researchers are exploring the effects of drama therapy on patients undergoing chronic
hemodialysis and are the first in the world to study the topic.

Ansley, a former professional hospital clown, has a family member who will soon be receiving
dialysis treatments. The treatment for kidney failure uses a machine that removes wastes and
fluid from blood, and then returns clean blood to the body.

Preliminary results of the study show trends in improving mood and reducing pain after using
drama therapy, which is the use of drama and theater to achieve healing outcomes. Hemodialysis
patients must follow a strict treatment schedule and typically visit a clinic two or three times a
week for up to four hours per visit.

Ansley worked with patients at a Manhattan dialysis clinic during treatment sessions.‘Patients
are sitting there with a lot of time on their hands,’ she said. ‘Some choose to watch TV, read or
fall asleep. Others inevitably start to think about their worries in life.’

Patients could not move during treatment, so Ansley brought prompts like pictures, games,
guided imagery and music. She asked questions to help patients verbally improvise a scene, story
or character. Some patients created a detective character, and story themes included death,
loneliness and friendship.

Drama therapy creates a wonderful metaphor and distancing effect for people so that they can
talk about their problems. They can create characters who are dealing with similar issues and
succeed, which gives them hope for themselves. It’s empowering and helps them feel more in
control of their lives.

Patients completed surveys before and after each session, and a 65-item Profile of Mood States
assessment before and after the study. They reported that drama therapy was an enjoyable way to
pass the time during treatment and took their mind off of their worries. They also perceived that
the therapy reduced their pain and improved their mood.

Ansley gave patients a personalized book of their stories, along with recordings of some of their
creative work.

‘Having something to look forward to, discovering a new talent and finding a passion for
creativity can change a person’s perception of his or her life,’ Ansley said. ‘Drama therapy is an
invitation to have some fun and discover new possibilities.’

Drama Therapy experienced in 1 to 1 or within a group context

Drama & Movement Therapy is an emerging powerful and effective creative therapy and can be
experienced in a 1 to 1 setting or within a group context. It is a non-confrontational therapy
focusing on the individual and their journey through the use of movement, myth, storytelling,

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drama, improvisation, sound and play. Talking does form an important part of a session but the
therapist will offer creative material that relates to the themes that emerge from the spoken word.
This encourages the individual or group to use the space to explore the different roles and aspects
of their own stories from a safe distance.

Throughout the ages people have always engaged with the healing power of theatre, drama and
storytelling. Drama therapy embraces the familiar relationship we have with creative expression
and builds on that, giving the participant the chance to explore feelings, fears, dreams, patterns,
behaviours and unrealised parts of the self. Private 1 to 1 sessions are also available.

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