Clinical Eectiveness of dramatherapy in the recovery from neuro-trauma

7/30/2019 Clinical Eectiveness of dramatherapy in the recovery from neuro-trauma

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disability and rehabilitation , 1999; vol. 21, no. 4, 162174

Clinical eectiveness of dramatherapy in therecovery from neuro-trauma

PAT MCKENNA* and EILEEN HASTE

Rookwood Hospital, Llanda, Cardi CF5 2YN, Wales, UK

Accepted for publication : July 1998

Abstract

Purpose : To investigate the clinical eectiveness of a shortcourse of dramatherapy (an eclectic term encompassing all thearts therapies), delivered in a one-to-one interaction, in asample of 10 patients in a neuro-rehabilitation unit.Method: Each participant received ve individual one-to-onesessions of therapy over a 5 week period. A semi-structuredinterview was carried out with each participant following the

course.Results : Qualitative analysis of the taped interviews elicitedhow the therapy co ntrasted and complemented the rest of therehabilitation setting and therapies and how it helped psycho-logical adjustment to severe disabilities resulting from neuro-trauma. There were four ways in which it appeared to empowerthe participants and nurture their self esteem. It provided themwith a sense of personal space in an otherwise institut ionalsetting; it allowed escapism and enjoyment; it awakenedcreativity and a sense of po tency; and it provided a metaphorto explore personal issues.Conclusion : Dramatherapy made an important contributionto the healthy adjustment of some patients both to hospital lifeand to acquired disability. The reports from the patients

indicated that this approach to rehabilitation should be fu rtherincorporated and developed in neuro-rehabilitation.

Introduction

The majority of people in a neuro-rehabilitation unit

have shared the same trauma of a sudden, life threatening

event which leaves devastating sequelae aecting physical

and}or cognitive status. The psychological eects of such

trauma are aptly described by Duggan and Grainger " as

`capable of shattering our equanimity to such a

degree that we are cut completely adrift from our

existential moorings and thrust into an ocean offears and inadequacies, a turmoil of existential

chaos. (p. 64)

At the same time, the individual has to negotiate his}her

new role as a patient and meet the expectations of family

and sta (as well as their own) in adjusting to disability

and in learning new skills. This process is an intensi-

* Author for correspondence.

cation of social relations, described by Duggan

Grainger as keeping

` our balance among the conicting demands

pressure of the social networks that sustain us

also distort our judgement, circumscribe

awareness and most important of all res

our freedom to be ourselves. We are pulled this

and that in the present by others present . (p.

This study explored the use of dramatherapy in mating adjustment to neuro-trauma within the hos

setting. The rationale for this lies in the power

subjective perception has to change the individ

relationship to actual or external reality, a relation

currently emphasized in clinical health resea

Johnston# in her model of disability described the fa

within the health setting of current practice and meas

of outcome to allow for this crucial stage in adjustin

physical disability. The medical model of care which

characterized the health service for most of its exist

has viewed health mechanistically as a lack of phyinrmity. In rehabilitation terms, this criterion look

objective physical measures such as mobility, phy

strength and lack of physical disability to gauge recov

The traditional model of disability, current in the he

service and embodied in the World Health Organisa

model 1980$ similarly assumes a simple causal link f

physical impairment to handicap outlined as sh

here:

Disease or disorder! impairment ! disability! handic

This simple linear relationship does not hold u

clinical experience. A `good outcome following

habilitation often exists alongside social or emoti

misery and distress. In examining and integra

psychological models of adjustment (emotional,

havioural and coping models) Johnston proposed

impairment also gives rise to mental representat

which can aect coping behaviours and moderate

09638288}99 $12.00 # 1999 Taylor & Francis Ltd


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Dramatherapy and recovery from neuro-trauma

relationship between impairment and disability. John-

ston further found that mental representations could

predict level of disability when coping behaviours (as

taught by therapists) did not. To maximize the chances

of a positive adjustment to disability, rehabilitation

programmes need to address mental representations and

subjective perception in patients.

The health service is presently revisiting a psychosocial

concept of health which addresses quality of life andwhich includes a state of subjective well-being. This

move is reected in the World Health Organisation,

WHOQOF Group 1994$ which now denes quality of

life as

`An individuals perception of their position in life

in the context of culture and value systems in which

they live, and in relation to their goals, expecta-

tions, standards and concerns. It is a broad ranging

concept incorporating and aected in a complex

way by the persons health, psychological state,

level of independence, social relationships and theirrelationship to salient features of the environment .

In practice, there still remains the problem of how to

redress the balance and nurture psychosocial well-being

within the healthcare setting. The following project

reects one attempt to supplement the traditional

medical model of care with the newly evolving psycho-

social model of care within the health service, and within

rehabilitation in particular.

Dramatherapy refers to the application of all creative,

artistic and imaginative activities to produce positive

change in people within a focused therapeutic context.Its therapeutic eect is attributed to the belief that the

reality experienced through imagination is capable of

providing as much an eect on ones being as actuality

and can provide as potent a vehicle for coming to terms

with reality as objective experience.% , &

All of these benets apply to dramatherapy work,

whatever the setting. More specically, in the context of

working with clients who are having to adjust to physical

and}or neuro-disability, traditional therapies (physio-

therapy, occupational therapy, speech therapy and

neuropsychology) necessarily address the objective world

and the fact of disability, continually reinforcing the loss

and change. Dramatherapy can release the individual

from the immediate present and give time to explore

those parts of the subjective world untouched by the

present loss. Some anecdotal evidence for benets of this

in the rehabilitation setting arose when the drama-

therapist piloted some experimental sessions within

Rookwood on a one to one basis with a heterogeneous

group of patients from January to March 1995. This

method of ` open sampling produced positive feedb

from patients and sta and warranted f urther ex

ration of potential benets.

This study represents an attempt to evaluate form

the eects of dramatherapy intervention on the reco

process following severe neuro-trauma. The appro

best suited to the aims of the study was that of groun

theory, , ( which allows for theoretical formulation

emerge from the process of investigation as an product. Thus, no a priori hypotheses were for

beyond a general understanding that the therapy w

essentially engage the client in a creative process whi

understood on some level to be personal and symbol

them, and that this would be of heuristic value in t

adjustment to the hospital setting and their acqu

disabilities.

Method

choice of participants

Originally, patients recovering from head injury wto be targeted but this proved too narrow a select

given the constraints of the research timetable and

availability of patients. In particular, care needed t

exercised in predicting the likely length of hospitaliza

for each patient. Consequently, the selection cri

were expanded to include any patient with a traum

event to the central nervous system producing severe

sudden disability. Ten completed the course, six pati

were recovering from head injury, one from a cere

vascular accident, two from removal of a cerebral tum

and one recovering from Guillain Barrie syndrome

structure of the therapeutic intervention

The introductory session included an interview

the dramatherapist in order for her to prepare

individual programme of activities based on t he inte

of the participant. The following week therapy

commenced on a one to one basis with the particip

and dramatherapist and this occurred for 1 hour e

week for 5 consecutive weeks. In the fourth sessio

Video camera was positioned in a corner of the room

allow later observation by the neuropsychologist.

content of the therapeutic intervention

The therapy used various artistic forms of crea

expression, within an aesthetically pleasing environm

in order to stimulate and release the imaginative

creative ability of the participant. The activities c

either be used in self reference to address present conc

and diculties, or could be externally focused


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P. McKenna and E. Haste

distanced from self, as each participant wished. Using

visual images, objects, music, making materials, maps,

myths and legends, poems, relaxation t echniques and

visualization, clients engaged in creating sound re-

cordings, stories, pictures, landscapes and sculptures.

Sometimes these involved movement on a small scale,

and at others, a combination of the above means were

employed. These accomplishments were either purely

narrative or were symbolic of personal journeys or werespecically related to personal issues. Although it was

emphasized that the treatment was not performance

related, some clients chose to record parts of the process

through photos, pictures or the written word (for an

example, see Appendix I for Rebeccas poem).

measurements of effectiveness of the therapy

To monitor the responsiveness of each person within

the dramatherapy session, the dramatherapist lled in

two checklists immediately after each session. One,

devised by the neuropsychologist, helped to gauge theresponsiveness of the participant. The other, devised by

the dramatherapist, aimed to judge the appropriateness

of the material for the particular individual (see

Appendix II, (a) and (b)). Following the fourth session,

the neuropsychologist also lled in these checklists, after

observing the session on video.

Within a few days following the last session, the

neuropsychologist carried out a semi-structured inter-

view, which was tape recorded in most cases (the facility

was not available for the rst two). The central questions

were how enjoyable or worthwhile the course had been

to them and what relationship this had, if any, to the rest

of their experience in the hospital. They were also asked

to rate the importance of the two main therapies,

Physiotherapy and Occupational Therapy as well as

Dramatherapy in their rehabilitation programme on a 4

point scale from `not important to `very important.

Results

Of the 10 patients who entered the course, One patient

(John) died just before the nal session and another

(Greta) was transferred to another hospital just before

the nal session. The patient who was transferred was

visited for follow up interview in the other hospital so the

database was complete but the course shortened by one

session. These two patients were kept in the database as

they had completed the bulk of the course. However,

interviews were collected for only nine of the group.

Table 1 displays the sex, mean ages and medical

condition of the group and the mean time for par-

ticipation in the dramatherapy course.

Following session four of the dramatherapy cou

both the dramatherapist and the neuropsychologist

lled in the checklist measuring engagement of

participant in the session. The correlation for this

very strong (r 5 0.87) and signicant at the 0.001 l

This is hardly surprising as most participants w

scoring close to, or at, ceiling, indicating that they w

able to both carry out the activities and inte

appropriately with the dramatherapist.At the end of the entire series of interventions

dramatherapist was asked to dene the ways in w

she felt the therapy had been of benet to

patients. She dened four distinct processes that she

ceived during the sessions, which were not mutu

exclusive but which did represent increasing level

involvement:

(1) Take control of details in the environment

eect or can enhance their ability to be themse

i.e. create a personalized space;

(2) Enjoy or rediscover the nature of p lay, creatand spontaneity;

(3) Develop existing skills and discover new abi

and therefore experience the role of creator;

(4) Gain insights into the nature of their psy

emotional processes. This is achieved by tr

lating their inner world into a concrete m

festation which can then be observed from a

perspective.

The ratings of importance from all therapies from e

participant were as seen in table 2.

individual profiles of participants

The following descriptions provide background

formation on each participant and give a brief overv

of their experience and attitude to the dramathe

course.

Greta

Aged 35, was a young artist who had severely impa

visuo perceptual skills following a brain haemorrh

For much of the time, Gretas rehabilitation program

reinforced the loss of basic levels of skills in which

Table 1 Age and sex of group participants and time monitored

Age Sex Time monitored (d

Mean Range Male Female Mean Range

34.5 1669 5 5 38.2 2742

(n 5 10).

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Table 2 Frequency ratings of importance of therapy to treatment (4

5 very important, 3 5 important, 2 5 slightly important, 1 5 not

important (n 5 9)

Categories: 1 2 3 4 Total

Physiotherapy 0 0 1 8 9

Occupational therapy 1 2 4 2 9

Dramatherapy 0 2 4 3 9

had excelled before her illness. For her, dramatherapysessions were comforting and comfortable and allowed

her to experience the sheer enjoyment of her creative

skills freely, the impairment being irrelevant. In this way,

she could again experience continuity of self. She often

expressed this during sessions. Of equal importance to

her was the space and medium it provided for her to

work through problems she needed to solve by using the

materials as metaphor.

Mike

Aged 41, was recovering from the removal of a brain

tumour which aected mobility and coordination. Newly

wheelchair dependent, he had also to contend with visual

and auditory impairment as well as continuous pain and

facial disgurement. For him, the main benets of

dramatherapy consisted of restoring self condence and

demonstrating his creative abilities, as well as showing

him that he could adapt this facility in other ways than

he had in the past, allowing him to express some hope in

the future. Mike was naturally ecient and organized

and found the inconsistencies in communication and

changes in timetables which occurred in the hospitalroutine very dicult to tolerate and increased his sense

of helplessness. He found dramatherapy increased his

self esteem and redressed the balance.

Mike was also interviewed 7 months later when he was

readmitted for routine review. Mike was still very positive

in his appraisal of the course and gave his permission for

this to be reproduced in its entirety (see Appendix III).

Ned

Aged 30, was a young man in his early thirties who had

suered a third head injury which left no obvious

physical decit nor primary problems with language,

perception or memory and he was above average in

intelligence. His personality had become increasingly

odd and his awareness of social rules was poor. Neds

overriding cognitive decit was of the ` executive syn-

drome which had never been recognised before, even

though it was suspected that it had rst been acquired in

his earlier head injuries. For most of the time, Ned was

dogged by a sense of being disjointed in life and bein

by others and he described a part of him that

helpless, worthless and confused, a feeling that he ha

`quite got the grip of whats happening all the time

dramatherapy, he was able to experience a continuit

self that predated his head injuries, when he was ha

playing alone for hours in the countryside and on

beach. The contribution that dramatherapy prov

was to allow him to clarify what way of life suitedneeds and personality. This also allowed him to pl

blueprint for work and living which also became pa

his community programme. Some 5 months a

discharge, his social worker rang to request a lis

dramatherapists in their local area.

Sharon

Aged 25, was recovering from a head injury resul

in physical disabilities which required wheelchair

bility. Her cognitive diculties were subtle but se

and she was extremely passive, mostly unable to iniconversation and giving answers which were usu

semi-automatic and appeared to be based on what

expected. Sharons premorbid background inclu

involvement with various social services and o

agencies; and wariness of institutional or professi

personnel was a long-standing trait. For Sharon,

dramatherapy sessions seemed another element of

rehabilitation which she tolerated b ut with which

never seemed to engage fully. At initial interview with

dramatherapist Sharon `showed neither resistance

enthusiasm towards dramatherapy. She seemed wi

to take part . At interview, her responses were nearl

mono-syllabic and her strongest reports of its eec

ness were as a way to get o the ward (the rare respo

she volunteered, apart from `yes and `no) and that

enjoyed it. Though part of her inability to elaborate

due to diculties in producing creative thought, she

appeared to remain guarded in all her relationships

activities in the hospital.

Graham

Aged 17, was still of school age when he had a h

injury which left him with a very mild hemiplegia w

required a wheelchair for a short time, memory

pairment and some generalized intellectual blun

which were resolving quickly. He was also very kee

leave hospital and return to his peer group. Not atyp

of his adolescent group, Graham was almost to

invested in his friends and music and it seemed impor

for him to maintain a stance of indierence to anyt

outside this remit. Graham tended to be ov


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dismissive of dramatherapy, in keeping with his general

attitude to everything in the hospital, apart from

physiotherapy which he considered was important in

helping him achieve a normal gait. In spite of this,

Graham worked in a very focused and engaged way

during sessions, discovering a real talent for creative

artwork and often showed spontaneous pride in what he

had produced. However, positive responses were often

followed by dismissive ones to keep in line with hisgeneral life script at present. Grahams appraisal of

the course consisted mostly of its benet in allowing him

to listen to his music without wasting his own batteries,

producing a good picture and passing time instead of

`hanging round the ward.

Mel (Melissa)

Aged 30, was a health professional recovering from a

debilitating neurological disease which caused severe

paralysis. She still needed wheelchair assistance for

attending departments and physical mobility was stillgreatly reduced. Mel particularly appreciated the op-

portunity to be in a more individual atmosphere in which

she could be free to indulge in whatever form of

imaginative play she wished and which did not need to

lead to a nished product, conform to a goal or

specication but to be enjoyed purely in the present. Mel

found this very easy and used the session in the fullest

possible way. It seemed that she created a space that in

the context of her situation, was a healing place. Mel

was extremely appreciative of the sessions as both time

out from being a patient and for the sheer pleasure of

engaging in imaginative experiences. She also valued the

contrast in the environmental atmosphere.

Maurice

Aged 69, was a retired consultant who sustained a

head and spinal injury after falling. He preferred to rest

most of the time, preferably on his bed. He found it

dicult to concentrate on anything for long and was

plagued by discomfort, always needing to return to his

bed. Consequently, he shortened his dramatherapy

sessions and interview to a point where he could interact

at a purely socially scripted level, relying on semi-

automatic social niceties. Maurice had been very able

intellectually and was socially polished. His cognitive

decits prevented him from more complex processing.

Consequently, much of his behaviour circumvented any,

or real, engagement with the material. Though Maurice

was very positive in his appraisal of the course, his

account bore little relation to what had actually occurred

in sessions.

Joanne

Aged 36, had sustained a head and spinal in

following a road trac accident. Her cognitive de

included an inability to grade her emotional respons

the magnitude of the problem and she was preoccu

and overfocused on many diculties, being both agit

and highly anxious. Joanne needed intensive psy

logical support from the team which was of limited

transient benet as her cognitive decits preventedfrom fully incorporating these insights in the long t

The dramatherapy course complemented these

proaches by providing her with time out from

preoccupation and the opportunity for physical re

ation which she valued above all other benets. Tho

this aim was simple and very focused, it fullled Joan

psychological need to experience some measure of p

and tranquillity.

John

Aged 49, had sustained severe cerebral dam

following removal of a brain tumour and had bee

Rookwood for nearly 2 years. For almost a year, he

produced very little response to his environment

suered uncontrolled epilepsy. After 1 year, when

epilepsy had been controlled with medication, J

slowly but surely began to recover, rst moving his li

a little and eventually being able to use a litewriter a

nally, to talk. After another year, John took part in

dramatherapy project. John was very able intellectu

before his operation and, though he had a signi

degree of generalized intellectual impairment, wasable to function at an abstract level and wanted to

the sessions to develop a tape of Bob Dylans music

a commentary. John died before the last session, an e

which was unexpected and traumatic for his family

the rehabilitation sta. During the fourth, vide

session, John reiterated his intention that the tape wa

be made for others to hear. Thus, John left a valu

asset for others to use and the video of the fourth ses

was given to his family. The dramatherapy course

been uniquely, if idiosyncratically, valuable in Jo

case.

Rebecca

Aged 21, was a young woman who had been invo

in a road t rac accident 2 years previously which lef

with a severe head injury and long term physical

cognitive decits. Rebecca had been living in a reside

home which was geared to meet the needs of people

were physically disabled where she found the climat

166


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be institutional and unresponsive to her needs as an

individual. She took part in the dramatherapy course

when she returned to Rookwood for review to help

assess her suitability for a place in a transitional

rehabilitation unit. Rebecca was still reliant on wheel-

chair mobility and was very aware of what she had lost

in terms of physical and social independence. She

described the dramatherapy as ` brilliant on several

occasions and used it both to rediscover her creativity viawriting poems, which she had not done since a teenager,

and to work through personal issues. She also empha-

sized the dierence between it and other therapies as

being the rst time that she felt herself to be an equal

partner in the exchange.

Summary

Thus, ve of the nine participants (Greta, Mike, Ned,

Mel and Rebecca) were very positive in their appraisals

and could provide rich, multi-faceted descriptions of the

benets of the experience for them. Their self reports alsomatched the subjective observations of the therapists. A

further participant, Joanne, felt positive about the

sessions as a form of relaxation therapy, which was

observed to be the case by therapists but this seemed to

be the extent of its use for her. Although this was only

one element of the many potentially available in the

treatment, extreme anxiety was the most disabling

symptom of her illness and she could easily be brought to

the point of sleep in the sessions. Of the remaining three

people who were interviewed, Maurice gave very positive

feedback about the experience but this did not tally with

his observed behaviour during the sessions and it was

doubtful that he had really engaged with the activities.

The nal two interviewees, Graham and Sharon, were

politely positive but unconvincing in their appraisals. In

spite of this, Graham had seemed able to engage more

than he had expected or intended to but needed to retract

whenever he showed enthusiasm. Though John died

before he could feed back his feelings about the course,

he had, in the fourth session, emphatically reiterated his

intention that he was making the tape specically for the

benet of other people to use and his creative endeavour

speaks for itself to some extent.The overall summary of these self reports are sum-

marized in table 3.

Qualitative analysis: the ways in which the therapy was

eective

The transcripts of the interviews with the participants

were studied at length individually and comparisons

across transcripts made. Individual concepts elicited by

Table 3

Self report Therapists reports

Greta 111 111

Mike 111 111

Ned 111 111

Mel 111 111

Rebecca 111 111

Maurice 11

John ?? 11

Graham 1 11

Joanne 1 11

Sharon 1 1

111 Highly benecial, 11 benecial, 1 a positive experien

no data no real benet.

each participant were grouped into core concepts w

they overlapped with concepts from others. From

the following four categories emerged which sho

remarkable congruence with those which the dra

therapist had produced independently (see page 1

Thus these categories emerged through a procesinitially noting common themes, successively rene

re-reading each transcript, and considering the stren

commonality and variations across them. The numb

patients who reported nding benets in each of t

four ways are also indicated.

creating a personalized space : contrast to

traditional therapeutic interventions

All the ways in which the participants described

therapy as being eective lay in its contrast to traditi

therapeutic interventions. This reects the rst prodescribed by the dramatherapist as the ability to

control of details in the environment that eect or

enhance ones ability to be oneself, i.e. creat

personalized space. Six of t he nine participants who w

able to feedback at interview gave clear accounts of

process, part of which reected a balance betw

freedom and structure woven into activities, tailore

suit the individuals creative needs and personal s

which also empowered the individual and made them

in control of the procedure. Greta described thi

follows:

`Eileen had the sensitivity to nd my crea

way came from my inner space, which

painting That approach, that Eileen develo

concentrated on what you enjoyed.

Mike and Graham expressed this as being able to li

to their music as and when they wanted and

described this most directly in the following way:

`She was quite easy to go along without


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structure, but shed also have content to keep it in

control and not go wandering o She didnt

demand of you. She just let you go, but kept it

within thered be times when shed b ring it back

inyou know lead where she wanted to go really.

Rebecca described the sensation of empowerment thus:

` it was really peculiarnormally with the

therapist, you think ` theyre the therapist, Im the

patient. When I was with Eileen it was like she was

my friend. The only dierence was that I was in a

wheelchair. So that helped me see really ``what

dierence does it make?.

The feeling of being in control and empowered also

engenders a sense of timeless and personal space. This

was brought up by Mel:

`There was not really any demands on you. It was

pure easy goingThe hour just ew by really we

were just here doing what we wanted to do.

and Ned

Òh crikey, has the time gone that quickly? I was a

little bit sorry that it was nishedÌt is more

enjoyable than the other therapies

Part of the contrasting experience of having both

freedom and control over the proceedings was due to the

non-clinical environment. Mel, who was a health worker

and used to the clinical setting, particularly remarked on

this:

`The atmosphere was really calm and placid and

quiet. Also its nice in there because its just one

person in an environment that you want it to be.

Eileen says ``do you want the lights on and which

music do you like on?.

All of the participants had been in hospital at least

several weeks and many for months and some were

acutely aware of the ways in which they were vulnerable

to becoming institutionalized. Participants listed the

opportunity to leave the ward as a benet in itself. As an

antidote to institutionalization, the therapy was much

valued:

`you get pushed and pulled around a lot in an

institution. Clothes, untidy, little things, being

woken up too early. Riled me a lot insensitivity.

Got me away from the ward. (Greta)

ìts time out from being a patientyou just felt

it was a change from sitting on the ward, the

horrible magnolia walls.It gets you out of that

rut of routine The nurses control the environ-

ment, they control when the lights go on and

when the TV goes on and othe routine

hospital decrees when you eatyou can bec

overwhelmed in a sense of the routine. (Mel)

Beyond the pleasures of the process of empowerm

further benets experienced reected deeper engagem

with the process to provide the experience of escap

and enjoyment, the awakening of creative potential

improvement in self condence as well as a meangaining insight into ones inner world. These reected

same processes described by the dramatherapist spec

on page 164 in terms of rediscovering the nature of p

creativity and spontaneity, experiencing the role

creator and gaining insight.

escapism and enjoyment : rediscovering the natu

of play , creativity and spontaneity

This was the most commonly reported benet, cle

described by eight of the participants. Their awarenesheer pleasure during the sessions demonstrated for t

that subjective experience need not be dependent on

reect, actuality and that pleasure could be accessed

a regular basis even in stressful or distressing

circumstances.

Sharons consistent and positive response to whe

she enjoyed dramatherapy was always to say `

Given that she was not able to give any more elabo

responses beyond the mono-syllabic, this sparse

persistent response could reasonably be taken at

value. Graham was also unable to expand bey

conrming he ènjoyed the experience.

Others were more clearly enriched by the process

for some the promotion of a positive state of m

increased their ability to look positively on di

circumstances. Greta described this as making her

quite happy and joyful and thus feeling better a

herself and more uplifted, Tony was especially surpr

at his facility:

Ìt was an hour I could almost forget about

condition I was using my imagination, I

forgetting. When I was taking the photograph

making up my vision in 3D using what she ha

the bag string, pebbles, shells, I found it ra

silly but a good laugh and that made me feel g

The ve sessions went very quick I had tho

that it was a long time but in no time the ve

gone already In contrast, I cant concentrat

the ward, I cant read a book or do anything on

ward because the pain distracts me. But the

could.

168


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Ned, in comparing it to the work he was doing for the

rest of the time in the hospital, described his experience

as follows:

Ìts more enjoyable in a lot of ways. Its lovely

music, its nice and relaxing. Got to sort of poodle

around and paint. I love looking through bagfuls

of dierent artefacts. I nd that quite fascinating,

beautiful shells and things. I could sit there and

make pictures and use my imagination.

Mel experienced escapism most acutely:

Ì actually forgot I was sat in the [wheel] chair and

almost at one point went to stand up and go Its

more than an hour away from the ward. Its an hour

in a dierentdoing something that you want to

do its something that you could totally enjoy and

not really know at the time how much eect its

having on you until you, like I said, until you get

back. And then you realise ``here we are again.

A more passive form of enjoyment might be thought ofas relaxation and this was most valued by Joanne for

whom the sessions could provide physical as well as

psychological release from the agitation and anxiety of

obsessional preoccupation with minor problems centring

on her health and interactions with sta. In relaxing, she

could escape her present situation and, with the help of

pictures, immerse herself in imaginary scenes of her

choice (at the seaside with her children). Ned also

beneted from the relaxing eect which lasted beyond

the sessions and helped in his general interactions with

sta:`Because it was nice relaxing music. I was sort of

just relaxed. Ive found actually since then, Ive

kind of learnt how to relax a bit better.

awakening creative potential and improving self

worth and confidence

Seven of the group actually produced creative works,

ve of whom described a consequent process of feeling

empowered which contrasted with their previous feelings

of dependency, worthlessness and sometimes hopeless-

ness. While the previous level of engagement led to a

positive state of mind this level of engagement provided

concrete evidence of an ability to make a positive

contribution and be of use and worth in sometimes novel

and experimental ways. Thus, it became apparent that a

negative and unproductive future does not inevitably

follow the fact of disability. Mike particularly beneted

from discovering his creative talent and described how

this cascaded to enrich his self image:

ànd it was nice to express what I though

never done that not since I was in schoo

`Though I cant do those things again [referrin

impaired coordination preventing playing o

keyboard] this reminded me that I was still n

my head, I can still be creative.The chanc

being even a little bit creative because I c

play music any more, make anything, basi

cant do anything, and therefore cant expmyself, it is reassuring that havent really lost i

there. Ì dont know why but like exercise

when I leave the premises Im still exercising,

more condent. Therapy apart from body

mechanics is important. Brain still needs so

thing.

Ned:

Ì got to sort of poodle around, do some pain

get some sticks and things and make things

generally it was good. It encouraged me to use

imagination.Greta and Mel were also very much at home in the

of creation and for Greta the experience was an exten

of her everyday life as an artist. Though she used

process to gain insight into her present coping m

anisms, it was clear that she also relished the creative

in its own right enjoying the aesthetic sensuality o

medium. Greta had marked visuo-perceptual impairm

and was often devastated by her consequent reduced

in visual artistic ability when engaged in her o

treatment sessions. Dramatherapy provided her

new ways to experience her creativity:`by working with other modalities, touch

textureI had to pick up objects and underst

them through touch.

Mel, who described becoming estranged from crea

activities in the normal course of her very busy life

working mother, was delighted with the opportunit

re-explore the experience and consequent empowerm

Ànd it was nice to be able to do something

looked lovely and was nice to do and was v

textural, which helped a lack of sensation in

hands. Às we get older we just get so invo

with going out to work, earning money, d

housework. [On creativity] I can still do it, its o

to do it. You always think `Òh art, Im not g

to be very good at that. But the positive thin

theres always something creative in everyb

Whether its, not exactly draw or paint, but jus

objects to make a picture, or make a story or po

or something like that. I really enjoyed doing


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pictures. It wasnt something that you had to do. I

liked using the fabric. It was nice to be able to do

that. To take that awaythat you are still able to

do something worthwhile in the community.

Rebecca was delighted to discover she could still write

poetry and had been sceptical at rst. By examining

poems she had written as a teenager (5 years ago and 3

years before her accident) she rst identied similar

feelings between now and then. She was surprized at theability she had demonstrated and did not feel that she

still had the creative ability and had no conscious

intention to attempt a poem. After using word maps in

earlier sessions, Rebecca produced a poem spon-

taneously and eortlessly in the fourth, videoed session.

(see Appendix 1). Rebeccas head injury had aected the

motor control of her vocal apparatus and she was very

dicult to understand, so that conversation was slow

and Rebecca often had to repeat herself and even spell

out words before they could be understood. Through

poetry, Rebecca could have a potent voice. Johns case,perhaps most clearly, embodies the act of creation,

empowerment and usefulness for the community in

producing a piece of work clearly specied to be made

available and used by others, as a gift outlasting his

mortality.

psychotherapeut ic process

Three of the group, Greta, Ned and Rebecca, were

able to both engage in the creative aspect of the therapy

and direct it towards examining personal i ssues. Mel saw

this potential but did not wish to use it in this way. Shealso pointed out that the limited number of sessions

could curtail this aspect of the therapy. For Mel, the

other three aspects were what she needed at that time and

she was able to clearly articulate this:

`Its too short a time to have a counselling

relationship as such, but like I said shes very easy

to talk to and very understanding. You could use it

in that sense i f you wanted to, but I didnt use it in

that sense.

Greta, whose artistic nature needed no time for

reacquaintance with the creative process, almost im-mediately focussed the sessions on salient issues in her

life:

`Helped me work out things from being here after

my illness things from the past. Quite thera-

peutic. It helped me to see the pressure I was

putting on myself before the illness by shifting

what objects stood for in the session it showed

me how I could shift things in life. Whole way of

working was very interesting, very clear. It he

me to gain insight into the past and has

reaching consequences for the future.

Ned took a little longer to discover this potential of

therapy but was able to clarify certain areas of confu

in his life:

`It made me sort my thoughts out a little bi

made me realise that theres two denite side

my character There was a small stone in

shape of a heart which I ended up putting in

countryside which made me realise thats wh

really wanted to be. It made me kind of re

things about myself which I suppose Id alw

known, but I hadnt really though about. I thi

helped me realize aspects of my character. I th

it actually helped me know what I wanted whi

half the battle. Because to be honest with you

had no idea for a long time what I wanted to

Basically Ive just gone from the one job to the

job and then Ive got frustrated because it hareally been what I really wanted to do, but it

just because it was paying the bills and so I

doing it.

Rebecca was caught up in the struggle to acknowled

degree of permanent disability and was still ndin

dicult to fully invest herself in the present, loo

always to the future when she would walk again.

poem expresses the frustrations brought about by

promise of normality ` in time, the scale of which is n

specied. Her poetry writing is a potent vehicle for h

both express her feelings in a positive and creative and as an excellent focus for therapy to help Reb

nd a way to adapt to her present level of disability.

uncommonly after the devastating eects of head inj

Rebeccas frustration had begun to be expresse

destructive ways which threatened her well-being and

image.

status as a therapy

Finally, with the exception of John, each partici

was asked whether they thought dramatherapy w

luxury or an essential element in their treatment. O

three people (Joanne, Graham and Sharon) describ

as a luxury or irrelevant to their treatment and progr

Joanne described it as `nice but not essential, Grah

thought of physiotherapy as the only relevant treatm

for his needs, Sharon tended to give mono-syll

answers or to say `dont know but rated all therapie

equally important and gave no real indication of ha

valued dramatherapy. Maurice described it as being

170


10/13


a luxury, could be an essential part of treatment but this

appeared not so much a conclusion from his personal

experience (given he had not really engaged in the

process) as the semi-automatic stance of the cultured

professional. The remaining ve participants thought it

was an essential element in treatment. Their responses

were as follows:

`not only a good complement but stands alone,

more benecial than OT at Rookwood. (Greta)

Ì think its not [only] a complementary element

but a necessary element. (Mike)

`For me, yeah. For people certainly with my

character, it gave me the space and the time.

(Ned)

Ì think people will really benet from it. Because

it is time out in more senses than just time away

from the ward, its time out from being a patient.

Its time out doing something creative. Doing

something that you want to do. Listening, justquiet. I think it will get people, especially people

whove been here for a long time, it gets you out of

that rut of routine. It makes you think a bit more.

(Mel)

Ìt should [be an essential part of treatment]

because it makes you feel better about yourself.

(Rebecca)

Discussion

Qualitative data from a small group of participantsprovides some promising evidence that dramatherapy

can be an eective method of intervention for some

individuals in their rehabilitation following neuro-

trauma. In describing, in depth, the eects of drama-

therapy on a few carefully studied participants it has

been possible to gain some insight into the psychological

mechanisms of adjusting to neuro-trauma. The semi-

structured interview was drafted in a loose format to

allow each participant to say whether or not the course

had been useful and if so, to describe how it had been

useful. In the analysis of the responses, a clear symmetry

between the ways in which the participants beneted and

those dened by the dramatherapist emerged, increasing

the validity of these conclusions. These were to redress

the balance of power within the hospital setting so that

patients were allowed to experience control over their

environment, to experience fun as an antidote to the

negative circumstances of their illness, to be empowered

by their own creativity and to examine their own

psychological processes by using the materials as props.

These are equivalent to core categories in term

grounded theory( but their validity would also req

further instances beyond the handful of cases prese

in this series to achieve saturation point.

The results also support Johnstons claim that me

representation of impairment inuences level of disab

and mediates coping behaviours. For instance, Mike

Rebecca both fed back that the course acted as a spu

aid them alter their perceptions of the nature of timpairment. Mike recognized he still had power t

creative and eective in his life and felt more detac

and less of a victim to the vagaries of bureauc

timetabling and organization, a view he was

expressing 7 months later. Rebecca gained a percep

of herself as no dierent from others, apart from b

wheelchair dependent.

Notwithstanding these positive reports on the ther

not all the participants beneted to the same extent

in a homogeneous manner. It was not possible to pre

in advance who would benet maximally and who w

benet least nor in what way each would use the therWithin the research framework of this project,

amount of dramatherapy these patients received ha

be uniform and delineated by the constraints of

research protocol. The dramatherapist had origin

envisaged 10 treatments as being a reasonable expo

to the medium, particularly as most adults express a

of condence and some wariness of involvement in

creative arts. This wariness was increased by the t

`dramatherapy which was in fact a misnomer

misleading for both the participants and sta who c

often not override the belief that it was to do with acThis occurred even with the full written descriptio

therapy at the introductory stage and a direct

nouncement at every chance that it was a misnomer

this series, Greta, the artist, initially `thought of dr

as not pleasing to her. Ned described `having r

vations and `not being really sure what it involved.

fear of having to perform also occurred for art

endeavour as expressed by Mel:

`First of all, I thought `Ìm not going to be

good at this art stu and whatever initially

always felt that Im not very good at arty thinthought ``will I be able to do this?

Most of the patients were thus taken on `cold and

very vulnerable and disrupted time in their lives. It

note that with such little exposure and in so short a

the participants were able to respond so well.

However, as the number of participants was small

the form of therapy challenging, further studies

needed to explore how well these ndings can


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replicated in the larger population of patients in post

acute rehabilitation for neuro-trauma. The constraints

posed by certain cognitive decits and by pre-morbid

personality traits also needs consideration in appraising

the therapy at an individual level. These interactions

were not systematically explored in this small sample nor

were they the focus of this study which sought to assess

the benets of the therapy. The question of boundaries of

application is an important one in targeting the subset ofpatients who will maximally benet. Setting these

boundaries is not easy. Though it would appear

reasonable to assume that compromised insight might

impair ability to benet from the therapy this was not

necessarily the case. Some participants who had impair-

ments of the executive system which did compromise

their ability to integrate and monitor their intellectual

and psychosocial behaviour at the higher and subtler

levels of functioning, beneted particularly well. Others

with more pronounced diculties in ability to monitor

their thinking processes had greatly restricted or dubious

benet. Pre-morbid personality factors also appeared toinuence motivation within the therapy but how far

previous experience, or lack of it, in creative activities

can inuence outcome needs to be determined.

Similarly, the amount of exposure to the therapy needs

to be explored in terms of how well the four posited ways

of benet can be developed. Overall, the participants

rated the importance of dramatherapy as equivalent to

occupational therapy but not so important as physio-

therapy. Yet their exposure to these therapies were not

equal. In contrast, each participant would have received

almost daily physiotherap y and occupational therapyoften for some weeks before the dramatherapy com-

menced and for very many weeks after. They received

only ve single sessions of dramatherapy spread over

some weeks (usually ve, sometimes four). The par-

ameters of exposure needed to achieve maximum

creative, psychotherapeutic and long term benet, also

need to be mapped so the timescale of sessions can be

tailored to suit the needs of individuals.

This project demonstrated how addressing the inner,

subjective world of a small group of patients and

allowing them to experience their own creativity could

give them access and insight into their own strengths and

intrinsic worth. This process appeared to boost successful

coping within the hospital setting but how well this

extends to the community which is arguably more

important is a further avenue needing exploration. It is

within the setting of the community that coping

mechanisms are really tested for long term adjustment to

disability. Psychological coping is so intimate a part of

physical coping that any physiotherapy gains made in

hospital can easily be lost if psychological copin

inadequate. Hospital life does not prepare patients

the attitudes of society to disability and the eect t

attitudes have on disabled people. Fitzgerald) descr

how science, bureaucracy and organized religion h

played an important role

`in shaping the construction of disability as

broken, incomplete and imperfect self, as the

requiring management, and as the object of pitcharity,

and how, in the face of disability, the individuals

image, which is determined by the interaction of inte

resources and the external inuences, shapes who he

becomes. De Rozario* highlights the increasing evid

to show how

`it is the individuals volitional system, that is,

persons inner and interactionist world of val

beliefs, attitudes and inspiration, that help

mediate, buer and determine the proces

successful coping.

Conclusions

This study demonstrated how dramatherapy can

some patients cope with both the hospital environm

and acquired disability following severe illness

accident. In particular, it highlights the role of

subjective world of the individual in successful co

and adaptation to disability. However, the machi

within the NHS and within the rehabilitation specia

has evolved to service physical well being under

medical model of care. These results support the case

further incorporation and development of this therap

the acute rehabilitation setting and to explore ho

might impact on longer-term coping and adaptation

particular, it provides a starting point for fur

investigation of the emerging themes that a personal

space within the rehabilitation setting, play as a form

therapy, creativity, and the use of dramatherapy

examine intra-personal psychological processes, ca

important for patients well-being, empowerment

self esteem.

Acknowledgements

This research was funded by a Clinical Eectiveness grant awaby Bro Taf Health Authority, without which no therapy could occurred. We are especially grateful to all the patients who agretake part in this project. We would also like to thank the nursingand the multidisciplinary team at Rookwood Hospital for enthusiasm, support and cooperation in the smooth running oproject. We would also like to express our gratitude to Torgeir BWyller and Mark Edwards for their very helpful and co nstrucomments in reviewing this manuscript.

172


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References

1 Duggan, M, Grainer R. Imagination, Identication and Catharsis inTheatre and Therapy. London: Jessica Kingsley, 1997.

2 Johnston M. Modes of disability. The Psychologist 1996; May:205210.

3 Patrick DL, Erickson P. Health Status & Health Policy: AllocatingResources to Health Care. New York: Oxford University Press,1993.

4 Jennings S. Dramatherapy. Theory and practice for teachers andClinicians. London: Routledge, 1987.

5 Cattanach A, Mitchell S, Chesner A, Meldrum B. The handbook ofdramatherapy. Routledge. England.6 Glaser, BG, Strauss, AL. The Discovery of Grounded Theory:

Strategies for Qualitative Research. Chicago: Aldine, 1967.7 Strauss AL, Corbin J. Basics of Qualitative Research : Grounded

theory Procedures and Techniques. Newbury Park: Sage, 1990.8 Fitzgerald J. Reclaiming the whole: self, spirit and society.

Disability and Rehabilitation 1997 ; 19 : 407413.9 De Rosario L. Spirituality in the lives of people with disability and

chronicillne ss: a creative paradigm of wholenessand reconstitution.Disability and Rehabilitation 1997 ; 19 : 427234.

Appendix I: example of an activity during therapy

session : Rebeccas poem

Appendix II (a): behavioural response to dramathera

session

(1) He}she uses hands, arms and upper body to gesture

appropriately

almost never 1

sometimes 2

often 3

(2) He}she initiates the use of hands and arms to manipulate th

environment appropriately

almost never 1 sometimes 2

often 3

(3) He}she uses head, eyes, facial expressions appropriately

almost never 1

sometimes 2

often 3

(4) He}she shows some attending when engaging with therapist

1 orientating

2 continuous focussing

3 passive responding

4 initiation

(5) He}she shows some non-verbal emotional responsiveness wh

engaging with therapist.

1 non e

2 smile}frown

3 laugh}tears

(6) He}she shows some verbal emotional expressiveness when

engaging with therapist.

1 non e

2 cadence}some}prosody positive}negative

3 expresses pleasure}anger

(7) He}she shows recognition}familiarity of therapist

1 non e

2 something (positively}negatively)

3 often (positively}negatively)

(8) He}she is responsive to environment

1 hardly ever2 sometimes

3 often

Appendix II (b): engagement in dramatherapy sessio

Is the client able to engage in the material

mostly

at times

not at all

At what level is the client engaging

his}her mind seems focused

is physically involved

is vocally involved

is engaging with the dramatherapist

Does the client seem

inhibited

frustrated

confused

willing to engage

relaxed

resistant

apathetic

anticipating}curious


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Appendix II (b) (cont.)

Is the material therefore

too abstract

too complex

not relevant enough

not appropriate for this client

Outline of patients potential opportunities within dramatherapy.

Outline of patients needs within dramatherapy.

Appendix III: Mike: Excerpts from Interview 2:

7 months post dramatherapy course (September 1997)

Pat ` So its actually seven months on. Have you thought much

about that dramatherapy you did since?

Mike `When I looked through my drawers at home which I keep

for my cassette tapes and my photographs from drama

groupI remember then of the times I used to come up for

those sessions. I sometimes think about the things Ive done

and what was involved and look at those lessons. When I had

to make a layout of what was supposed to have been the

landing space on the Planet Jupiter with all rocks and bits of

string and everything. I must admit it looked good. On the

photograph it looked as if it was okay fair enough itlooked a bit toyish, manufactured, but it looked quite good,

really. It was surprising. Yes I do remember. What it did for

me was me personally it gave me I remember it did

give me at the time, during the day when I really didnt think

so much about my condition I mean when I went to

Occupational Therapy I was working to improve my

condition because of my condition. And when I went to

Physiotherapy I was doing the same there, but when I went to

Dramatherapy it was nothing to do physically with my

treatment. And well being in this place I found it was much a

social thing as well. I didnt consider it as a treatment. It was

nice to know that after having gone through all this and

feeling the way I did it was nice for me to think that I could

get out of my system. I knew I could come up here and I

wasnt depressed. I wasnt angry. In fact I used to get lost in

my subject.

Pat ` So you know when you said that when you were home youd

open your drawer and youd see what youd done and it

reminded you of it, what was the feeling that accompanied it

whenever you thought of those sessions within the context of

your hospital stay ? What was the feeling?

Mike `Happiness I think. Well say Im in my drawer and I pull out

an appointment card or a letter and I go through these things

with a serious mind, but when I pull out anything from the

Drama I see the photographs and my book as such. My book

of one page. I smile!

Pat `So ``are you glad you did the dramatherapy?

obvious isnt it? Then the other question was ``did you e

the thing itself apart from getting away from the wa

Youve answered that.Do you think it provides a po

sense of your ability to adjust disability? Does it give

something to help you?

Mike `Yes. Well it after the Dramatherapy I realised that I c

do something as an activity at home. And keep my mind

And to escape. Ive never done it before. Since Ive been

really havent had the patience to do anything. Eve

Physiotherapy I couldnt keep my concentration very Ive been told that. I was miles away. I used to get inv

for so long, but I wouldnt be interested then.

Pat `When you were doing Physio in Rookwood?

Mike ` Yes. R ight from the beginning. Mind you Ive only been

since last December. I did have a lot of hurt, as far a

concerned is grief. Because I think I lost my life

Basically I did at the end of the day, thats my liveli

gone. Dramatherapy helped me, made me believe that I

do things which dont actually connect me with being dis

or my disability. I can escape out of it.

Pat ` Youre not just your disabilities?

Mike `No.`Well when I used to come to dramatherapy I us

escape being misunderstood and come in and doing my

listening to music and talking in general I realised thennot just a patient. Im a human being as well. Im

understood on that level. Because it may have been a the

but I wasnt being a patient here I wasnt being treat

such. So I behaved as such. So I didnt feel so helples

more really or misunderstood. So when I went back t

ward I wasnt a patient. I was a normal human being

wasnt very well.

Pat ` Did it change your ability to assert your needs whil

were in hospital or to negotiate decision making process

your treatment? Did it give you condence, I suppose?

Mike ` Yes it did. Yes in the same way as being misunder

before. Its hard to explain it, but knowing that Id been

ill and very restricted. I couldnt move, I couldnt mov

wheelchair at all. I was very dependent. But like I said b

knowing that when I came here afterwards I realised I w

just patient after patient. I was a comparatively normal p

who has just maybe begin to rationalise things that

gone wrong as far as my treatment. My appointments, m

downs had been concerned and if I hadnt com

dramatherapy I think I would have still been the sam

would have still felt put upon. I would have still bee

patient. The underdog. But now as far as treatme

concerned. Im not saying now, but after the dramather

didnt actually call the shots, but I had a voice in m

those decisions. And because I had more condence in m

I was able to do that. I was able to do that more conden

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Clinical Eectiveness of dramatherapy in the recovery from neuro-trauma

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