Phase III. The results from the two strands were compared and integrated. Grounded on the results from the second phase, the substantive model from the first phase was reviewed and
CHAPTER 4: PHASE I - EXPLORATORY PHASE: MODEL GENERATION
4.2.3 Data Collection and Analysis
A formative model was developed using an iterative approach of reviewing the literature, constructing a model, going back to literature, making changes, and determining on model fit, thus data collection and analysis took place simultaneously (Johnson, 1998). The search of the literature was limited to published DMT research studies on chronic pain management. I searched electronic databases and trials registers including MEDLINE, CINAHL, PSYCINFO, Proquest Digital
Dissertations, and ClinicalTrials.gov. Selected studies were reviewed to identify key characteristics or concepts in DMT for people with chronic pain. Based on the variables identified from each study, visual models that depict the central concepts were drawn. The visual representations were solely based on my interpretation of the concepts. I did not seek feedback from the researchers. Therefore the presented implicit models may not represent the comprehensive ideas of the original researchers.
Key themes were identified from the implicit models. Through a process of comparison of the identified variables and conceptualization of the relationships between the variables, visual models that depict the variables and their causal relationships were drawn in order to construct a conceptual model, that is the formative model. During this process, my previous knowledge on the topic based on clinical experience was used to constantly compare to the emerging findings from the literature, and integrated into the model building process. The overall course of formative model development was a creative process of combining the implicit process models and turning them into an explicit model.
4.2.4 Findings
4.2.4.1 DMT implicit models. Four implicit models of DMT for chronic pain were identified from the literature. They varied in terms of the types of research methodology and interventions. Table 2 demonstrates the characteristics of the selected studies. Brief descriptions of the model and visual display for each implicit model will be presented.
Table 2. Background of the DMT implicit models
Authors Year Type of study Population Treatmen
t duration Type of interventio
n Bojner-Horwitz, E.,
Theorell, T., &
Anderberg, U. M 2003 Randomized Controlled Trial
4.2.4.1.1 Bullington et al. model A. The first implicit model was identified based on the findings from a qualitative study by Bullington, Sjöström –Flanagan,Nordemar, and Nordemar (2003). Bullington and colleagues contended that the key concept that represents the therapeutic process of DMT for people with chronic pain is achieving a sense of ‘order out of chaos’. Living with chronic pain is described as being in a chaotic and disintegrated state; the successful process of healing is recognized as achieving a sense of control, sense of wholeness and identity renewal by developing a new personal meaning (‘meaning evolution’). There are two main mechanisms that support this process, namely, ‘integration’ and ‘loosening’. Integration has to do with linking one’s mind, body, and emotion as well as one’s self in the past and future. Loosening on the other hand, has to do with loosening the mental and physical rigidity and moving toward to achieve flexibility and creativity. The model diagram is presented in figure 4.
4.1.4.1.2 Bullington et al. model B. In their publication in 2005, Bullington and colleagues presented two case studies, one of which described a therapeutic process of DMT with a patient with
chronic pain. In this publication they identified some additional factors and aspects in the therapeutic process. The overall therapeutic process was still viewed as a ‘ordering chaos’ in which the clients find structure through gaining awareness of the fragmented pieces of their experience (i.e.,
thought/feelings/memories), achieve integration by making meaningful connections, and move toward discovering a new meaning and sense of coherence. They underlined ‘meta-perspective’ as an important aspect of this process. Meta-perspective refers to the ability for an individual to separate oneself from the pain and see self, pain, and current circumstances from an objective point of view.
This process was identified as a process of articulation. They identified that there are two types of chaos – one referring to the pathological state of disintegration, and one referring to the
overwhelming sense of disturbance a client may experience as a part of the therapeutic process at the beginning stage of the therapy. The therapeutic relationship was suggested to be an important element that can provide structure and support throughout the therapy process. The implicit model is
illustrated in figure 5.
4.2.4.1.3 Bojner-Horwitz’s model. A simple implicit model was depicted based on the findings from a randomized controlled trial study on fibromyalgia patients by Bojner-Horwitz, Theorell, & Anderberg (2003). This study was aimed at examining DMT’s effect on change in stress related hormones -prolactin, dehydroepiandrosteronsulphate, cortisol, and neuropeptide Y. The results on the stress hormones were not statistically significant. However another component of the study (i.e. patients’ self-interpretation of the video) provided some meaningful findings. The results showed that DMT helped improving the level of self-perception on mobility, life energy and movement pain and body image in women with fibromyalgia. They contended that this changes which might be related to the pain reduction and increased sense of well-being. Two DMT factors that contributed to this process were identified, namely body awareness and expressive movement.
Figure 6 demonstrates the model.
4.2.4.1.4 Sjöström-Flanagan model. Sjöström-Flanagan’s work (2004) suggests the
importance of using different forms of metaphors in the DMT process with people with chronic pain.
The healing process of individuals can be shown in the pattern of meaning evolution and the characteristics of movement metaphors emerging throughout the course of therapy. Sjöström-Flanagan’s implicit model shows that specific metaphors might support individuals to get in touch with their body which, in turn, brings heightened awareness on their body, feelings and behavior; this then allows them to be open to new ways of coping and relating in life. As individuals increase access to ego functions (i.e., thinking, feeling, sensing and intuiting about the situations) they feel more in charge of their lives. Figure 7 displays the implicit model.
Figure 4. Bullington et al. Implicit model A Figure 5. Bullington et al. Implicit model B
Figure 6. Bojner Horwitz’s implicit model Figure 7. Sjöström-Flanagan’s implicit model
4.2.4.2 Thematic analysis of the implicit models. From the four implicit models of DMT for chronic pain management, several key themes were identified as factors and
mechanisms for the therapeutic process of DMT. They included ‘integration/connection’, ‘self-awareness’, ‘differentiation/objectification’, ‘expressive movement’, ‘loosening/releasing’,
‘meaning-making’, ‘therapeutic relationships’, and ‘feeling in charge’. Brief description of each theme is provided below.
Integration/Connection. This theme refers to DMT’s mechanism of integrating different domains of individuals’ perception and experiences (ADTA, 2009). Three of the implicit models described experience of chronic pain as a state of disintegration, dissociation or ‘a problem of linkage’ (Bullington et al., 2003; Good, 1992; Jackson, 1994). Thus they suggest that one of the important mechanisms of DMT is the reintegration of the isolated pieces and restoration of a sense of coherence for these individuals. Integration starts with connecting to one’s body and reclaiming one’s dissociated body as ‘one’s own body’. Then peoples’ thoughts, feelings and memories that had been disconnected from their awareness are integrated as well. Integration also includes reconstruction of one’s identity, which requires the ability to integrate the self of the past and present as well as to project oneself into the future.
Loosening. This theme refers to DMT’s capacity of loosening up rigidity in all levels (i.e., physical, emotional, cognitive and social), enabling individuals to become more open and flexible for a new experience. This may be achieved by first releasing physical and emotional tensions through movement, increasing awareness and expanding the movement repertoires, and promoting creativity. This, in turn, may lead to widening attention, increased social interactions and opening up to new and various ways of coping.
Self-awareness. This theme refers to both sensitivity toward one’s physical condition and having a perspective on the psychosocial situations related to the pain experience. Increasing self-awareness was included in all implicit models in some degree. They recognized that DMT allows people to ‘listen to their body’ and become more aware of their physical capacity, characteristics
of pain, pain intensity and attitude towards one’s body. Through the authentic movement process, individuals may also become aware of underlying psychological issues connected to their pain experience.
Articulation. Differentiating various aspects of the pain experience toward articulation of perception was identified as a mechanism of DMT. Here the term articulation is used to describe the ability to or a process of developing clarity about thoughts or feelings, and specifying or differentiating characteristics of an experience. Exploring one’s pain experience and expressing the pain, as well as thoughts and feeling associated with pain, through symbols and metaphors may allow one to 1) differentiate different aspects of the pain experience (e.g. parts that are affected by pain and those that are not; times when one is in pain and times when one is not) and 2) separate self from pain and see one’s pain in a more objective perspective. This process might help people to perceive pain as more manageable.
Expressive movement. Engaging in a spontaneous movement exploration may evoke certain emotions allowing people to experience various emotions and become aware of them.
While acting out one’s thoughts or feelings, individuals may be able to discharge repressed emotional tensions, which may lead to physical relaxation and pain reduction. Often metaphors and symbols were accompanied in expressing specific thoughts or feelings related to pain experience. Having a means of self-expression in movement itself was identified to have a healing effect.
Meaning-making and transformation. Meaning-making was recognized as an essential part of the healing process in DMT for chronic pain management. Movement exploration and symbolic expression may facilitate individuals to find some kind of meaning of their pain experience. The initial meaning which can be body/emotional-meaning could be developed and articulated to a consciously recognizable, a higher- order meaning (Bullington et al., 2003). As people develop awareness and integrate their experiences and perceptions, these meaning may evolve toward a more holistic and healthy one.
Therapeutic relationship. The relationship between the client and therapist was identified as a central factor. Dance/movement therapists provide an open and safe therapeutic structure in which clients can feel accepted as they are, feel safe enough to engage in the self-exploration process and sustain through the vulnerable and overwhelming stage of therapeutic process.
Taking charge. The implicit models recognized that one of the main therapeutic outcomes of DMT is individuals’ achievement of taking/feeling in charge of their life. DMT supports individuals to strengthen and restore a sense of self and have a sense of order and control over their experience, thus enable them to give up the victim mentality and reclaim self as the agent one’s life.
4.2.4.3 A meta theoretical-model (Formative model). The theoretical model shown in figure 8 was developed based on the general factors and mechanisms that were identified as most important in the implicit models.
Figure 8. The meta theoretical- model (formative model) diagram
The therapeutic process of DMT for people with chronic pain is a gradual process of moving from a state of chaotic disintegration and rigidity toward achieving a sense of coherence, flexibility, and sense of control. Throughout the therapy process the meaning individuals ascribe to the pain experience may evolve and be transformed so that it can be accepted and integrated into the context of one’s identity and life trajectory. Two mechanisms are identified as central to this process, namely ‘integration’ and ‘loosening’. Integration refers to the process of restoring broken connection between mind and body and sense of conference and continuity of one’s identity that was interrupted due to the pain experience. Loosening up denotes the process of releasing tension and rigidity not only in a physical dimension but also cognitive, emotional, socio-behavioral level. These two divergent types of mechanisms (one binding/connecting and one releasing/liberating) dynamically work together with several other factors – self-awareness, emotional expression, articulation, meaning making, and creativity - supporting this process. The movement-based exploration of self, pain and relationship with others allow individuals to develop awareness and insight, to express repressed feelings thereby help them to
decompress/discharge emotional tensions. In this context, DMT also addresses cognitive functioning by helping people to develop a more articulated understanding of one’s body, movement and pain and explore the meaning of the pain experience. Awakening individuals’
creativity plays a role in supporting the therapeutic process and opening up possibilities towards new ways of coping. The clinical encounter and therapeutic relationship that is non-directive, open and accepting is a critical therapeutic component in DMT. As results of the process,
individuals gain a sense of coherence and wholeness, become more open to alternative/new ways of coping, and take charge of their life, reclaiming self as the agent of one’s life.