Dramatherapy: History, Applications and Outcome Measures

What is Dramatherapy?

I first discovered Dramatherapy when I was picking my options for A-levels. We were all given a sheet with a list of careers on them and my interest was piqued when I came across this term. I had been involved in Drama since a young child and had specifically picked Theatre studies and Psychology for A-level because of my interests in both. However, I wasn’t made aware that I could join both of my passions together up until this point.  I hadn’t thought that far into my future yet, but that piece of paper set up my academic journey for the next five years.

I remember going onto the NHS choices website after seeing this term, searching ‘Dramatherapy’ and coming back with very limited information. Part of me felt that this was a very big risk. I was essentially choosing a career path I knew very little about. But something about it called to me.

Viewing the Health Careers website now in July 2018, the headline states

“Dramatherapy uses role play, voice work, movement and storytelling to help clients explore and solve personal and social problems”.

The description on The British Association of Dramatherapists website is:

“It is a form of psychological therapy, that focuses on the healing aspects of drama and theatre, using all elements of the performance arts. Dramatherapy uses drama as its main mode of communication to create distance from possible issues the individual may have difficulty addressing” (BADth, 2018).

History

To understand how Dramatherapy in the UK was born, we must go back to its roots. The development of using drama as therapy can be dated back to the 18^th century around Europe. Although we are aware that dance, rhythm, storytelling, and rituals were used way before this.

It was not until the 18^th century that drama began making an impact on those in mental health hospitals. Drama became a form of appropriate recreation and patients were allowed to create their own plays to explore their own psychoses. Throughout the years, it evolved and a focus on theatre as therapy became more defined in the 20^th Century.

‘Therapeutic Theatre’ really began to bloom during this era, some directors and playwrights who also had an influence on this shift were Constantin Stanislavski’s emphasis on spontaneous performance and improvisation, Bertolt Brecht’s alienation method and ‘breaking the fourth wall’, and Atonin Artaud’s Theatre of Cruelty.

The development of theatre as therapy continued after the Second World War. Jerzy Growtowski’s 1960 view that the performer’s body was just as important as the script as a means of communication is still central to Dramatherapy today. We acknowledge and work with the non-verbal just as much as we would with what the clients verbally say.

The first use of Dramatherapy as a term in the UK was in the 1930’s was by Peter Slade, an actor. He had been interested in children’s play and had used it in a paper which was submitted to the British Medical Association. Following this, he worked with children in education and developed his method of working with adult mental health patients. Slade “dedicated 60 years of his professional life proving the importance of drama to the process of healing and growth” (Langley, 2006, p.12).

Following Peter Slade’s input, dramatherapy was further developed in the UK by Billy Lindkvist and Sue Jennings. Lindkvisit created the Sesame Approach, a method of Dramatherapy that encompasses drama and movement and is currently taught at the Central School of Speech and Drama. Jennings was also an actress and social educator around the same time as Slade. She created the Neuro-Dramatic-Play model and the Embodiment-Projection-Role model. EPR and NDP have both heavily influenced my practice from training to post-qualifying. Sue Jennings has written many books on dramatherapy. According to Langley (2006), “the early work Sue Jennings did with children coincided with the time Billy Lindkvist although they were not known to each other at the time”.

How is Dramatherapy used:

As stated earlier, my practice has been influenced by the Jennings NDP and EPR models, but also Mooli Lahad’s Six Part Story (6SPM), which I have found to be a great assessment tool. Depending on the needs and abilities of the client, I am able to adapt my sessions to cater for every individual. In my own practice, I particularly use storytelling, role play, small objects, and arts materials. However, you can also use movement, music, fabrics, mask work and puppetry. It is also important to note here that although these materials can aid the session. Dramatherapy does not solely rely on these, and no artistic skill is needed. I have facilitated a few sessions with a small piece of fabric and a collective imagination!

Dramatherapy can evoke positive qualities such as:

• Playfulness
• Imagination
• Humour
• Expressiveness
• Improve listening skills
• Emotional awareness

As Dramatherapy does not rely on verbal communication, it can provide a safe space for the individual to express, explore, and understand their difficult thoughts, feelings or situation. The ‘safe space’ I am referring to is the most important element of a Dramatherapy session, be it the visible, physical container of the room or therapist, or the invisible container of the dramatic metaphor. Rogers (1993, p.11) states that as the individual explores their “secret garden: a place where their true self exists”, they will be able to discover and/or understand their Self.

This is probably my favourite quote describing how we as therapists must be open to enter the client’s world in order to guide them. The Dramatherapist’s role is to support the client to explore their personal reality from within the safety of the imaginative realm (Swanepoel, 2011, p.103). By using the dramatic imagination and embodied metaphor, this enables the individual to access and work through repressed and unexpressed material (Milioni, 2007; Warren, 1996). Dramatherapy has so many different elements to it but, ultimately, it is a humanistic approach that gives clients the ability to freely explore the therapy room and therapist’s materials, enabling them to build a therapeutic relationship on their own terms.

It is also important to note that due to Dramatherapy’s many elements; it can be used in a variety of settings with a range of clients and issues. I have friends and colleagues in schools, hospitals, rehab, and prison settings working with both children and adults, exploring problems such as ASD to anxiety and anorexia nervosa, bereavement to bipolar. As well as my current job role, I have practiced as a Dramatherapist in adult mental health inpatient hospitals, children’s disability units and have facilitated a Dramatherapy social skills group for children with ASD.

The Dramatherapy Journal, the official journal of the British Association of Dramatherapists, has so many articles detailing the work Dramatherapists are doing with their clients. In 2013, a special Dramatherapy and Autism edition was published focusing on how Dramatherapy can be used to support individuals on the Autism Spectrum.

There is also a lot of work around Dramatherapy and trauma, which I find particularly fascinating as the body has the ability to hold trauma and subconsciously relocate it. “Something that has been held in by the client, namely the trauma, moves into the domain of the shared and the dramatherapeutic space” (Jennings, 1990).

Outcome measures: Can you measure dramatic engagement?

I have found many Dramatherapy assessment tools to be more giving in capturing the dramatic engagement of a client.  As mentioned earlier, Lahad’s Six Part Story Method (6SPM) is usually my go to assessment tool, alongside routine outcome measures (ROMS). It was originally created as a tool for stress and anxiety. It provides a blank canvas for the client to enter into their own world, they are asked to create a story in the form of a storyboard strip with six parts,

“it addresses roles, characters, heroes, villains, damsels in distress and characters to be rescued.  It looks at where the action takes place geographically, when it takes place, e.g. day, night and considers the tone of the story, happy, sad, funny, tragedy or comedy.  The story addresses relationships, obstacles and how to overcome them” (Integrated Treatment Services, 2018)

Not only is this a useful gauge of the client’s imagination capacity, within each of these sections, I can get a sense of what the client is struggling with by seeing if they have centred themselves in this story, what their support network looks like and if they see a resolution. Even if the client does not put themselves in this story, it is a starting point to unpick what they are struggling with, within the safety and container of a dramatic medium. Forthcoming sessions may focus on bringing characters or the story to life through small objects, puppetry, and even role play if the client is ready. Other forms of assessment tools are story cubes, OH cards and spectrograms.

As a Dramatherapist, I am aware that standardised outcome measures do not directly fit well into the Arts Therapies due to their quantitative background. However, working in an NHS setting, I have found that routine outcome measures (ROMs) such as Revised Children’s Anxiety and Depression Scale (RCADS) https://www.corc.uk.net/outcome-experience-measures/revised-childrens-anxiety-and-depression-scale-and-subscales/ and Strength and Difficulties Questionnaire (SDQ) https://www.corc.uk.net/outcome-experience-measures/strengths-and-difficulties-questionnaire/ are a necessity. During my training, I struggled to understand how a quantitative measuring tool could track the progress of the qualitative nature of Dramatherapy. Within the Arts Therapies, I have found this to be a constant topic of conversation as our healthcare system is readily promoting talking therapies such as CBT that can be limited to a certain amount of sessions and tracked as the clients follow a fixed piece of work with their therapist.

The issue I found myself having was with the erasure of other therapies because of this. Dramatherapy can be just as effective, but may not be recognised as such, due to the lack of appropriate measures that can effectively capture the sessions. This in turn also affects the number of titled Dramatherapy jobs being advertised as opposed to a blanket child/adult mental health practitioner role. During my search I found PSYCHLOPS Kids, a routine outcome measure specifically created at the Institute of Psychiatry with the help of Roundabout Dramatherapy http://www.roundaboutdramatherapy.org.uk/, a London based Dramatherapy charity.

There are three versions of this outcome measure: Pychlops, Pyschlops Teens and Psychlops Kids: http://www.psychlops.org.uk/versions. With the input of Dramatherapists in creating this, it has the ability to capture both qualitative and quantitative data. I found the PSYCHLOPS Kids to be really helpful during my training. I was working with children with varying disabilities and knew other standardised forms would not be able to fully capture the client due to this. Working with children especially, the use of parental and teacher evaluations is extremely beneficial in capturing the whole picture. I have spoken to some Dramatherapists who do use Psychlops alongside other standardised outcome measures. However, I still feel this is something that we can look at, we as Dramatherapists must not shy away from using ROMS. I have also found goal-based outcome measures (GBOM) https://goalsintherapycom.files.wordpress.com/2018/03/gbo-version-2-march-2018-final.pdf to be a useful indicator of keeping the therapeutic goals in mind.

I am aware that this topic is still in conversation within the Arts Therapies community when it comes to registration standards and clinical commissioning for treatment. As Jones in 2005 states “if health services are not satisfied change is occurring in a way they understand, or at a pace they find satisfactory, then the Arts Therapies will dwindle into abandonment as viable options of client care” (p.211).

Further Resources:

I am currently in an Emotional Wellbeing and Mental Health Service (EWMHS) for children and young people. The NHS service is based in Southend, Essex and Thurrock and has seven teams over Essex. It is split into four pathways depending on the needs of the individuals; Neurodevelopmental, Complex, Behaviour & Conduct and Mood & Anxiety. We offer group interventions, 1:1 therapy, family work and parenting courses. The service was designed to replace CAMHS tier 2 and 3, and allows for self-referrals alongside professional referrals. EWMHS also has digital partners for those in need of more immediate or additional support; Big White Wall and Kooth are online counselling services we often signpost our young people to https://www.nelft.nhs.uk/ewmhs-support.

Dramatherapy is currently taught in the UK as a postgraduate Masters at the University of Derby (where I studied), the University of Roehampton, Anglia Ruskin University, and Central School of Speech and Drama.

https://www.derby.ac.uk/postgraduate/therapeutic-practice-courses/dramatherapy-ma/

https://www.roehampton.ac.uk/postgraduate-courses/dramatherapy/

https://www.anglia.ac.uk/study/postgraduate/dramatherapy

https://www.cssd.ac.uk/course/drama-and-movement-therapy-ma

Dramatherapists can be members of The British Association of Dramatherapists (BADth), and are registered with the Health and Care Professions Council (HCPC)

www.badth.org.uk

http://hpc-uk.org/

References:

Haythorne et al (2012) Roundabout and the development of PSYCHLOPS Kids Evaluation in Dramatherapy with Children, Young People and Schools, Enabling Creativity, Sociability, Communication and Learning (pp. 185-194)

Integrated Treament Services, 2018,

Jennings, S., (1990) Dramatherapy with individuals and groups. London: Jessica Kingsley Publishers.

Jones, P. (2005) The Arts Therapies: A Revolution in Healthcare, Hove and New York: Brunner-Routledge

Langley, D. (2006) An introduction to Dramatherapy, SAGE Publications, London

Rogers, N. (1993) Facilitating Creativity in The Creative Connection: Expressive Arts and Healing, (pp.11-25)

This is an independent article and the views are not necessarily those of ACAMH.