Offering A Safe and Creative Container for Internalised Trauma Associated with Coronavirus, Using Dramatherapeutic Underpinnings

Abstract

This paper discusses the applied use of dramatherapeutic underpinnings in creating and utilising a safe and creative container for internalised trauma associated with coronavirus. The case study explores 'Creative Calm throughout Coronavirus' (CCC); a ten-page document designed using methods from dramatherapy. The defining features of this resource are identified as the accessibility of the resource, the invite to be creative, and the safe container to project internalised feelings into creativity- all of which come together with opportunity for creative resilience throughout the traumatic period of the coronavirus pandemic. Contribution is made to the evidence base for advantages of embedding dramatherapists within organisations.

Keywords

Dramatherapy, Covid-19, Internalised trauma, Creative arts psychotherapies, Mental health, Psychiatry

Introduction

The presenting problem requiring this initiative was due to my workplace's regulations surrounding the coronavirus pandemic; I was unable to see newly referred dramatherapy patients face to face. Careful consideration of my client group (14-65 year-olds with experience of psychosis) concluded that beginning a therapeutic relationship via voice or video call would not be appropriate. Further reflection included considering the current potential needs of patients and staff in the settings I have worked in as a dramatherapist; inpatient private and NHS hospitals, mental health charities, and NHS community mental health services. The aim of this initiative was to design a resource offering a safe and creative container for aforementioned staff and patients. Specifically, the aim was for the resource becomes a container for internalised trauma throughout coronavirus, using dramatherapeutic underpinnings in order to foster calm. This initiative seeks to provide evidence for embedding dramatherapists within the NHS 10-year plan; this case study will exemplify an inexpensive resource developed by a dramatherapist, providing support for both staff and patients.

Initiative objectives;

1. Offer a safe container for internalised trauma associated with coronavirus

2. Offer a creative container for internalised trauma associated with coronavirus

3. Foster a sense of calm throughout coronavirus

4. Exemplify dramatherapeutic application outside of the therapy space.

The solution was to create a resource; I imagined a dramatherapy session- the check in, the releasing of the outside world and the focus on an individual's inner world, and the check out. I wanted to capture a dramatherapy session in a dramatherapy resource; offering grounding, reassurance and connection-to-self.

I produced 'Creative Calm throughout Coronavirus' (CCC). This free resource is a ten-page document, inviting those who access it to allow themselves time with a creative outlet for some of the uncomfortable feelings they are experiencing; internalised trauma in response to coronavirus or otherwise. The most defining features of this resource are the accessibility of the resource, the invite to be creative, and the safe container to project internalised feelings into creativity- all of which come together with opportunity for creative resilience throughout this traumatic period.

Accessibility of the resource

To meet initiative objectives 1, 3 and 4.

At a time in which accessing therapy or sharing therapeutic time with others is unlikely, and in some instances impossible, CCC gently invites individuals to project and process their internal world. Using dramatherapeutic underpinning, the resource holds a variety of tools an individual is safe to explore independently; at their own pace and at whatever times feel appropriate.

The resource comprises of separate pages of activity invitations, which can be completed separately or together. An individual with the resource is able to decide which elements of the resource may be helpful or approachable for them; one individual may decide to focus on artwork elements, others on grounding breathing features, and some a combination of all components.

Throughout the coronavirus pandemic individuals' schedules are changeable, meaning likelihood of achieving scheduled appointments with health professionals diminishes further. CCC is a paper resource, which can be approached at any time. This flexibility offers individuals a sense of empowerment; spending time with the resource is on an individual's terms and they are responsible for taking time for themselves. Therefore, by making use of the resource an individual is demonstrating self-care, whilst establishing autonomy.

The accessibility of the resource is further exemplified by the lack of noise the resource requires. Whilst CCC holds invitations to make sounds or listen to music, an individual is able to practise discretion. An uncomfortable truth of social distancing measures in response to coronavirus is that many individuals across the globe are trapped in accommodation in which they do not feel safe. Through CCC offering the opportunity to be a silent resource, the likelihood of individuals identifying a safe time and place to access the resource is increased.

Invite to be creative

To meet initiative objectives 3 and 4

The resource was initially created for 14-65 year-olds with experience of psychosis; the vast majority of whom are adults and left education, in which creativity is explored, many years previously. Subsequent wider distribution of CCC continued to reach both adult and child populations. The use of creativity is known to decline with age [1,2], whilst research shows 'creative thinking is a universal ability that can help adults manage satisfying lives and that is increasingly in demand in the workplace' [3]. CCC offers adults, and children alike, the opportunity to enhance their creative potential; whilst adults may not seek creative or playful material, dramatherapy provides evidence [4,5] that fostering creative thinking in adults can produce positive outcomes. Dramatherapists consistently work to promote creative expression of adults, thus empowering individuals and leading them to self-transformation.

A safe container to project internalised feelings into creativity

To meet initiative objectives 1, 2, 3 and 4.

Coronavirus is a pandemic instigating trauma for a vast majority of our world's population. Many will be impacted by illness and subsequent bereavement, and immense numbers traumatised by the disorder caused; loss of jobs, accommodation, and disruption of routines to name a few. Whilst social distancing measures are in place, it is not possible for many individuals to connect with arts therapists, mental health practitioners or creatives. Implications of the pandemic have led to an increase in isolation, consequently safely processing trauma experienced is incredibly difficult at this time.

CCC offers individuals the opportunity to externalise their internalised trauma. Rather than a direct and literal form of externalisation, CCC encourages cathartic release through creativity. Through, often subconscious, projections of internalised feelings, individuals are able to experience a liberating sense of relief [6-8]. Using creativity rather than discussing trauma is more tolerable for individuals, therefore safer for an individual to manage at a time they do not have access to professionals. CCC consequently uses dramatherapeutic tools to offer individuals opportunity for creative resilience.

Upon beginning this initiative, I hoped to compile available resources for a 'resource pack' for my patients. I was unable to find resources to contribute to the creative container. Therefore, I utilised creative and therapeutic skills specific to being a dramatherapist, and adapted techniques used throughout dramatherapy in order to create a resource to encourage a container for internalised trauma, to encourage a foundation of calm. I was able to draw inspiration from many creative methods used within traditional dramatherapy sessions. Dramatherapeutic inspiration included the six-part story method [9,10], projective methods [7,8] and Kramer's sublimation [11]. A limitation to the initiative's design was the lack of dramatherapy materials individuals have access to without compromising objects within an individual's accommodation which have associated feelings and memories attached, consciously or otherwise. Subsequently, CCC requires only the paper resource and pens/pencils. Distribution of CCC is via online PDF and paper copies. It is important to acknowledge access to paper and pens is not available to everyone, therefore limitations of those able to access CCC remain.

The initial obstacle for this initiative was the short timescale available for creation; coronavirus effected the world unexpectedly and with immediate effect, and resources to offer relief were needed instantaneously. Effective and fast working was required in order to promptly provide a safe and creative container for evoked emotions. A challenge for this initiative was to maintain careful balance to meet this pressure whilst also ensuring maximum protection of individuals accessing CCC.

An important foundation of CCC was to safeguard those using CCC to avoid feelings of traumatisation or re-traumatisation without an arts therapist present to witness and go on to ensure individuals are safe to be alone. Despite precautions, it is important to acknowledge it is plausible that traumatisation is not impossible whilst using CCC. Initially the resource was shared exclusively within my NHS trust to patients I was available on the phone for, to ensure we were able to process any negative responses. However, following careful dissemination through arts therapy colleagues and receiving positive feedback rather than reports of traumatisation, it was agreed the resource should be made more readily available to external organisations and individuals.

Results

The CCC initiative spread over the world, with the resource being distributed via email to 524 organisations and individuals, in twelve countries (known at time of writing). 176 of those requesting CCC via email responded with qualitative feedback, respondents are identified in this case study as 'participants'. Data thus far has been measured using thematic analysis. There is opportunity for subsequent evaluation of effectiveness of CCC to meet the initiative objectives and additional research questions, to be conducted incorporating use of quantitative data, compiled through inviting those CCC has been emailed to, to complete an online questionnaire.

The aim of the initiative was primarily focused towards individuals referred for an NHS Early Intervention in Psychosis Service (EIS), however following wider dissemination of CCC, data included to evidence effectiveness of CCC to meet initiative objectives is wider spread to include a vast population. The initiative objective remained primarily to offer a safe and creative container for internalised trauma, fostering calm throughout coronavirus, using dramatherapeutic underpinnings.

An inductive and semantic approach to thematic analysis was followed in order to minimise bias, allowing themes to be determined following data collection [12,13]. Ensuing analysis provided evidence of the breadth of reach of the initiative; demographics of those CCC have been disseminated to are identified as;

Settings (using participants' terminology);

- School

- NHS

- Parliament

- Government

- Forensic

- Hospice

- Outpatient

- Inpatient

- Prison

- Care home

- Low secure and locked ward

- Voluntary

- Charity

Client groups (using participants' terminology);

- Children

- Look after children

- Special Education Needs

- Adult mental health

- Cognitive Impairment

- Enduring Mental Health Difficulties

- Offenders

- Clinicians

- BME Groups

- Victims of domestic abuse

- Child and Adolescent Mental Health

- Young People

- Family

Table 1 demonstrates the themes identified using thematic analysis, whilst also indicating codes determined by terms taken from participant feedback. In order to increase validity of themes, a minimum of 20 participants have referenced each theme.

The themes identified demonstrate the initiative's objectives being met. The objectives and the efficiency of achieving these are outlined below.

1. Offer a safe container for internalised trauma

Significant themes: Containment.

Rich quote to support initiative objective being met:

It has been a huge relief to offer your resource to my clients with enduring mental health difficulties, they have reported feeling held which is just a revolutionary relief that I didn't know was possible in lockdown

Participant 132

2. Offer a creative container for internalised trauma

Significant themes: Containment, creativity

Rich quotes to support initiative objective being met:

Our workforce can't express our gratitude enough for this creative blessing, we thank you for sharing a creative resource we can pour our strange energies into safely.

Participant 47

I work with young offenders on a OPD pathway wing and we are getting packs together. It will be a valuable part of their creative container.

Participant 83

3. Foster a sense of calm throughout coronavirus

Significant themes: Calming, process of transformation

Rich quote to support initiative objective being met:

Using your creative calm pack is the only time I feel calm at the moment and has helped me start to accept the way things are

Participant 129

4. Exemplify dramatherapeutic application outside of the therapy space

Significant themes: Request for further information regarding dramatherapy

Rich quotes to support initiative objective being met:

I have made sure each organisation knows that this was created by you and that you are really helping people. The feedback is so positive for both younger and older people. *organisation* would like to share your story and who you are in our news letter.

Participant 83

I am a clinical psychologist in Poland and I apologise my drama therapy knowledge is not great, I would like to please arrange a slot to speak about ways we could include drama therapy into remote treatment.

Participant 164

5. Additional outcome. Process of transformation

Significant themes: Process of transformation, self-empowerment

Rich quote to support initiative objective being met:

I've shared your resource with other clinicians working in forensics, it is very strange for us being out in the covid19 whilst offenders are away from it. I shared because it made me surprise myself that I could use an arty resource and afterwards feel a change in my thinking about the strange times.

Participant 12

Discussion

This initiative has successfully demonstrated publishable data regarding the value of embedding arts therapists within organisations, supported through evidencing effective use of dramatherapeutic underpinnings of resources external to the dramatherapy room. All objectives of this initiative have been met. Creative Calm throughout Coronavirus;

1. Offers a safe container for internalised trauma associated with coronavirus

2. Offers a creative container for internalised trauma associated with coronavirus

3. Fosters a sense of calm throughout coronavirus

4. Exemplifies dramatherapeutic application outside of the therapy space.

A further finding of this initiative was evidenced;

5. Dramatherapists' ability to offer creative and metaphorical tools in order for individuals to undergo a process of transformation.

This process of transformation is further evidenced through participants identifying a change within themselves. This progression was achieved using a simple pathway created by a dramatherapist, to share with individuals to utilise independently.

The process of change CCC enables, offers potential for organisation to better place their funds through employment of arts therapists. Arts therapists are able to use unspoken, creative tools in order to engage clients with services; participants reference processes such as 'fear into acceptance' and 'becoming unstuck'. This offers opportunity for individuals to release resistance to a service, encouraging engagement and therefore signifying potential for a reduction of missed appointments, and ultimately fewer wasted resources.

Furthermore, dramatherapeutic resources such as CCC require minimal funding, whilst providing an approachable resource for individuals. Organisations have prospect to embed dramatherapists within their services, to create unique engagement pathways. This initiative provides evidence for inexpensive resources devised by dramatherapists to meet individuals at point of referral, or entrance to a service. This framework allows dramatherapists to ascertain individuals' needs in a creative and indirect manner before referring on to further appropriate assessments once an individual is ready to engage.

The process of transformation arts therapists enable may also be taken as a preventative measure moving forward with the 10-year plan from the NHS. Participants reference 'release of anxiety', 'growth, and 'change in thinking'; dramatherapists have the ability to undertake a small amount of work with an individual to enable a process of change. Arts therapists possess a unique creative skillset to engage clients, and go on to access and consider individuals' needs which will be vital to underpin the redesign of health services. Embedding dramatherapists within organisations will promote delivery of the 10-year plan from the NHS; using dramatherapeutic underpinning, measures can be designed to reduce numbers of individuals needing to access NHS resources, to increase engagement with social care and voluntary sectors, with potential to reduce inpatient admissions-holding individuals' wellbeing in the community.

It is important to note, a number of participants of this initiative are health professionals who accessed CCC for themselves and to disseminate to colleagues. Throughout coronavirus, dramatherapists have demonstrated use of their skillset to assist with creating containers for staff's traumatisation as well as patients'. Through embedding dramatherapists within organisations, staff wellbeing is fostered and encouraged. Arts therapists providing resources such as CCC for colleagues, result in staff retention and reduction in staff sickness. This context will be particularly relevant whilst moving forward with organisational restructuring following this pandemic; NHS and front line staff are at high risk of traumatisation due to the disorder, illness and death the pandemic has exposed them to.

This initiative has an evidence base of 176 participants, with data gathered including resources external to dramatherapy; participants range from arts therapists, to individuals from psychological services and social services. This differentiates this initiative from available dramatherapy resources focusing on dramatherapist and service-user feedback. However, were further evidence compiled, it would be possible to collect service-user engagement data. Furthermore, the evidence of this initiative is compiled from 12 countries; findings are able to inform the NHS ten-year plan through gathering data from a multitude of professional, and socioeconomic backgrounds. Further research into the initiative has potential reach of 524 participants, and were quantitative data to be collected, it would be possible to demonstrate demographics in order to inform redressing of socioeconomic populations that have previously experienced health inequalities.

The pandemic of coronavirus has caused unexpected disruption to the world, and this initiative provides evidence of dramatherapists' ability to offer relief under immense time pressure, with lack of traditional dramatherapy materials. In extraordinary circumstances, dramatherapists are able to provide safe and creative containers, promoting individuals within an organisation. Dramatherapists enable those with potential to strain organisations such as the NHS, to become unstuck and externalise previously internalised trauma.

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