Structure and Contents of DMT Sessions

Although the theme and types of activity for each session varied, the overall structure of each group DMT session was as follows: 1) verbal check-in and movement warm-up; 2) main activities; 3) cool-down; 4) journaling; 5) group discussion; and 6) closing.

5.4.1.1 Check-in and warm-up. I began each session by inviting the participants to sit in a circle to briefly ask about how their week had been, and how they were feeling mentally and physically on the particular day. Then I led a semi-structured body movement warm-up consisting of gentle movements such as deep breathing, stretching and mobilizing different body parts. The purpose of the warm-up exercise was to a) increase the participants’ in-the-moment awareness of their physical and emotional state; b) release physical tension or emotional stress; c) mobilize each body part to prevent injury; and d) prepare the participants’ mind and body for the main DMT activities. The findings from phase I indicated that ‘loosening up’ one’s mind, body and emotion is an important mechanism of DMT for chronic pain; thus I focused on utilizing warm-up process to help people to experience a dynamic sense of relaxation to release tension in all levels and ready for the main activity.

In addition, “Connection dance” was used as a part of the warm-up throughout the study period. “Connection dance” is a series of movements that were choreographed for this study; it is aimed at facilitating body coordination and integrative movements. It is a modified form of Brain dance™ which is based on the concepts of the six connectivities in the human body as suggested by movement specialist Irmgard Bartenieff. The “Connection dance” was introduced to the participants during the second treatment session and used in the subsequent sessions. I made a video recording of myself performing the “connection dance” and created a private link on the YouTube, which was only shared with the research participants so that they could watch and practice it at home.

5.4.1.2 Main activity. After the warm-up, I introduced the main movement-based activities that were pre-designed to address various topics related to the participants’ experience of chronic pain and resilience based on the findings from phase I. I utilized several key DMT techniques that might support the therapeutic processes identified in the model. These included:

an applied form of authentic movement, in which the mover engages in a improvisational free-style dance/movement while the therapist and/or other group members witnessed the mover

(Adler, 2007); mirroring, a technique in which typically two individuals engage in a synchronous movement interactions in which they reflect not only each other’s body attitude, form or quality of movement but also the perceived internal state of the partner (Sandel, Chaiklin, & Lohn, 1993); enactment or role-playing, in which individuals act out their thoughts or emotions in movement, or act as if he or she is another person; kinesthetic imagery, which involves active visualization of thoughts or feelings and moving to or with the specific imagery; and creating and performing movement-based narratives, which will be explained in detail in the following

section.

The above techniques were utilized during the sessions for the following reasons.

According to the findings from phase I, Authentic movement may promote a person’s sense of connection between their mind and body. It has been reported that individuals suffering from pain for a long time often develop a tendency to dissociate their thoughts and feelings from their body as a defense mechanism (Leder, 1990; Osborn & Smith, 2006). This may cause not only a sense of disintegration in self, but also difficulty in interpersonal relationships. By engaging in

spontaneous movements that are led by one’s inner impulse, and having an experience of “being moved” rather than “moving”, individuals may be able to focus on the relationship between mind and body and may feel an enhanced sense of connectivity between their mind and body. The substantive model suggested that interpersonal connection is a significant mechanism in the therapy process. The mirroring technique was used to increase awareness of and insight into self and others through means of kinesthetic empathy. When two people move together as they embody and reflect not only the physical characteristics or quality of movement but also the affect and inner state of one another, they may become more sensitive to other people’s non-verbal language and become a better communicator. Moreover, mirroring exercises may improve an individual’s level of awareness towards his or her own movement patterns, habits or emotional state by seeing, recognizing, and re-experiencing the characteristics of oneself being reflected in others. This may also help people with chronic pain to feel accepted and understood by others,

while they increase understanding of other people’s (e.g., family and caregivers or colleagues) views or needs at the same time, thereby improving the overall quality of their interpersonal relationships.

The findings from phase I indicated that symbolic expressions and acting out images could help people to objectify pain and reinforce therapeutic goals. Therefore I encouraged participants to actively utilize imagery and enact symbols or metaphors related to their thoughts or feelings related to the pain experience, thereby facilitating them to concretize their

experiences, externalize pain, find meaning, and gain an objective perspective on their experience of pain.

These movement activities were designed to increase the participants’ awareness of their body and movement; to explore, identify and express their emotions; to recognize existing thought patterns and coping skills; to practice new ways of thinking and coping; and to facilitate interactive communication and group cohesion. It is important to note that the implementation of the techniques outlined above and all movement activities were designed to target specific resilience-promoting factors that had been identified in phase I. In addition, my clinical

knowledge and understanding of the literature related to DMT were incorporated in the process of designing the intervention. A summary of the themes and activities for each week’s session is provided in the table below.

Table 8. DMT session contents

Wk Themes Objectives Activities

1

• Going over group rules and safe space statement

• Introducing self with movement

• Warm-up while moving body parts in isolation and as a whole

• Creating a visual self-portrait and then expressing it through movement

2

• Learning and exploring 6 connectivities within one’s body; i.e., breath, core-distal, head-tail, upper-lower, body-half, cross-lateral (Bartenieff, 1980) and the psychological concepts related to each connectivities

• Learning the “connection dance” sequence

3

• Various improvisational movement focused on the exploration of six senses– visual, auditory, olfactory, touch, taste, and proprioception (I see, I feel, I hear..)

• Creating & performing a movement narrative 1 - “My story of self in pain”

• “My Bubble” - Exploring one’s movement repertoire in relation to a various space elements and broaden the scope of attention and movement

• Exploring the interactive space: moving in space with others, becoming aware of one’s proximal preference and experience dynamic use of interpersonal space

• Focus training (internal and external, being present)

• Creating a visual symbol of pain and expressing it into a movement representation

• Partner work: 1) Acting out how one’s pain looks/feels like 2) having a partner to imitate and embody one’s pain and observe it; and 3) create a movement response toward one’s own pain re-enacted by the partner

• “Today I feel…..”: expressing one’s emotional state through physical movement

• “Masks”- exploring different emotions and expressing them in dance & movement

• “Ocean of emotion” – projecting feelings to the weather in the ocean and moving with a prop (a large blue stretch cloth) according to the particular emotion with different intensity

7 • Making Connections II

1. Increasing sensitivity to nonverbal

• Shaping exercises and contact improvisation

Interpersonal

• A various mirroring exercises

8

• Learning and experiencing Laban’s 8 movement elements (i.e., Efforts- Flow, space, weight, and time) and its

psychological implication

• Imagery based exercise: imagining one’s body as being made of different materials (rubber band, marshmallow, wire, feather, water, wood, fabric etc.) and moving to the imagery

• Dancing with 4 elements (air, fire, water and earth)

• Learning and performing a group circle dance – “Peace dance”

An essential component of the DMT intervention was the participants’ partaking in creating and performing movement-based narratives. Narrativization is considered a critical way through which individuals with chronic pain can create reflection, find meaning and understand their pain experience, thereby serving as an important part of finding a sense of wellness within illness (Ressler, Bradshaw, Gualtieri, & Chui, 2012). Using a narrative feature in conjunction with movement expression was also mentioned in the phase I findings. In this study, two forms of movement-based narrativization were employed as a part of the main activity.

Two movement-based narratives were created at two different time points (3^rd and 9^th week). It was expected that by week 3, participants’ potential anxiety about expressing oneself through movement in the presence of other people would be lessened. In these two narrative-making sessions, participants were asked to choreograph a short movement-based narrative in which they narrated a story of self in relation to their pain trajectory. I provided an underlying structure for the narratives and had the participants choreograph creative movement expressions based on the given framework.

Narrative #1. The first movement-based narrativization was about creating and performing a story of self in relation to their pain experience with respect to time. Since one of the essential characteristics of narratives is to have a temporal component within, the structure of the movement-based narrativization was designed in a chronological order –past, present and future. This format was adapted from an existing dance-based exercise that was designed and applied by a dancer/choreographer Bill T. Jones who had led dance-based workshops for patients with terminal illness (Moyers, 1997). The instruction for this narrativization was, “Please choreograph a story about yourself in relation to your pain experience through dance and/or movement expression focusing on the following four time points – 1) the time before you had the pain condition; 2) the time you first started to develop the pain condition; 3) the present; and 4) the imagined future. At the end your story, finish it with a still pose like a statue in a museum that shows how you would like to be remembered by others. ”. The participants were informed that the narrative would be performed in front of the other participants in the group.

Figure 14. The structure of the movement narrative I

A legacy statue Self in the

future Self in the

present Self when the

pain condition first started Self before the

pain condition

The participants were asked to find a space in the room where they could concentrate on the individual process and create the narrative in 15 minutes. When completed, they were asked to first practice the choreographed piece on their own, and then to perform it in front of the other group members, while the rest of the group members witnessed the individual’s performance.

After performing and watching everyone’s narrative performance, the participants were asked to write a journal about their experience of creating and performing a movement narrative as well as witnessing others’. Participants were then asked to gather together to share their thoughts and feelings about the experience. All the performances were video-recorded for use in post-intervention interviews with each participant.

Narrative #2. The second movement-based narrativization exercise was done in the 9^th week. This time, the narrativization was structured around a format of an autobiographical poem.

Participants were asked first to complete a fill-in-the-blank type poem titled “I am”. The script was a modified from a well-known self-filling type poem “I am” (author unknown). In addition, I incorporated four concepts from Sanctuary Model® (Bloom, 2009) within the scripts of the poem, namely safety, emotions, loss, and future (S.E.L.F). S.E.L.F are suggested to be fundamental domains that have to be addressed in all healing process according to the Sanctuary model. I believed that each domain from S.E.L.F is relevant to pain rehabilitation principles and psychological resilience; thus each domain was integrated into the verses of the poem (e.g.

“Because of the experience of living with pain I’ve lost __________”). When finished with writing, the participants were asked to choreograph dance/movements for each verse they had written. Each person presented the choreographed poem in front of the rest of the group members and all narrative performances were video recorded for review during the exit interview (See Appendix D for the poem).

5.4.1.3 Cool-down. I brought the main activity process to an end by gathering the participants in a circle and leading a series of movements consisting of gentle stretching and deep breathing exercises.

5.4.1.4 Journaling. At the conclusion of the main activity, participants were given about 5-10 minute to journal about their experience. The instruction was to “write about your

experience from today’s session. What did you learn about your self and/or others through today’s session? Please write about any thoughts, feelings, physical sensations and new discoveries you had during the session.”

5.4.1.5 Group discussion and debriefing. After journaling, the participants gathered to discuss any significant thoughts or reflections they wanted to share with the group members. The purpose of the journaling and group discussion was to enable participants by verbally processing their movement experiences and internal reflections, to process the physical and emotional experiences cognitively and gain new insight and understanding about themselves and others;

this, in turn, may have lead to changes in their thoughts, feelings or behaviors.

5.4.1.6 Closure. I led a movement-based closing ritual to bring the session to an end.

This was done in a circle while the participants were guided to follow a sequence of movements and deep breathing designed to help them feel centered and grounded and to prepare them to transition to their daily routine.

Each DMT session was video recorded. The video-recordings of the DMT sessions were transferred from the camcorder to an encrypted external hard drive immediately after each session. Once the data were backed up, the files were deleted from the camcorder. The hard drive was stored in a locked secure cabinet at each research site during the treatment period, and then transferred to a locked cabinet in the department of Creative Arts Therapies at the end of the treatment period. Explicit consent for video-taping the sessions was obtained from all participants.

5.5 Qualitative Strand