Dancing with Loss
A Final Clinical Report submitted in partial fulfilment of the requirements for the degree of M.A. Dance Movement Psychotherapy
Professional and Community Education (PACE), Goldsmiths College, University of London
Do not go gentle into that good night,
-D. Thomas (1974)
*All names have been changed for confidentiality purposes.
This Clinical Report focuses on the exploration of loss that occurred
in a therapeutic relationship with a group of older persons diagnosed
with dementia. It describes a mode of practice in Dance Movement Psychotherapy
(DMP) through a review of literature in psychodynamic psychotherapy, DMP,
and dementia care; a movement exploration; and in-depth discussion of
This FCR is dedicated to M.D. Javier, Ralt, Daniela, Jimena, Javier and
This Final Clinical Report discusses a mode of practice constructed during my training at Goldsmiths University as a student of the M.A. Dance Movement Psychotherapy (DMP) programme. I facilitated DMP sessions with a closed group over a period of six months during my placement at an Older Persons Day Hospital in a London Primary Care Trust. As a trainee, I began process of becoming aware of the position I hold within a clinical placement in the wider socio-political and multicultural context of mental health care. My work was focused on DMP treatment for older persons with dementia.
Contextualizing, the post-graduate therapy-training programme I am currently completing is one of five programmes recognized by the Association for DMP in the United Kingdom (ADMPUK). The Association sets criteria for training including experiential learning, personal therapy and supervised placements aimed towards developing a safe and effective clinical practice. ADMPUK works with other Creative Arts therapy professions, and is ‘active in the continuing development of a European Dance Movement Therapy network, supporting international sharing’ (ADMPUK, 2010). DMP is continuously informed by international research, its use throughout the UK is promoted by the Association, and regulated by it through the Principles of Professional Practice. In 2004, ADMPUK began a registration process with the Health Professions Council (HPC), the body that regulates allied health professionals and healthcare scientists in the UK setting standards of professional training, performance, conduct and hold a register of health professionals who meet them. They also set standards of proficiency, education and training, and for continuing professional development. (HPCUK, 2010) Once completed, DMP will be regulated through standards of proficiency similar to the already existing ones for music, drama or art therapy.
My clinical placement offered older persons with dementia an opportunity to experience group DMP. I work at an Older Persons Day Hospital that provides them an alternative to being admitted to hospital, support and treatment mostly through therapeutic group work over a period of weeks. The length of stay for clients is not permanent and depends upon their individual needs. Support and advice may also be provided to families and carers. A mental health team of which I am part of as a trainee DMP runs the setting, often working in conjunction with the Home Treatment Team and local Community Mental Health Teams (CMHT). The staff team is formed of Mental Health Nurses, a Consultant Psychiatrist, a Day Hospital Doctor and administrative staff. In addition within the CMHT, clients may have access to Psychologists and Occupational Therapists. Fortnightly on-site supervision for two trainee DMPs is provided by the Head of Psychological Therapies within the Trust, a trained Drama Therapist. It complemented off-site weekly group supervision at University that fulfills both HPC and ADMPUK criteria, critically observing and unpacking the development of my work as a trainee DMP, throughout the therapeutic group process. General aspects of my clinical work would be discussed with my line-manager, a Mental Health Nurse. I provided DMP sessions at the Day Hospital alongside a co-worker; in addition, a placement manager from the Psychology Team as part of CMHT would also be aware of my work and keep ongoing communication with the University. Clients are referred to this service and confidentiality is observed at all times. Only staff directly concerned with a client’s care would have access to his or her personal details.
The service I offer fulfills ADMPUK criteria, in order to register as a DMP and practice professionally in the UK. DMP vacancies may be found as a paid job within the Trust; this is a post a trainee would aspire to fill once training and registration to practice are complete. The first DMP service for clients with dementia is listed on the Department of Health’s website, demonstrating the trust’s commitment to innovative care practices. At the same time, UK requirements in dementia care are met in relation to the National Dementia Strategy (NDS), a document designed to transform the quality of dementia care through initiatives to ‘make the lives with people with dementia, their carers and families better and more fulfilled’ (Department of Health, 2009). On Tuesdays, the Day Hospital’s activities are dedicated to clients in treatment for dementia, when our DMP group met weekly.
I.1 The Greatest Medical Challenge of the XXI Century
In the United Kingdom, a mainstream newspaper article calls dementia
the ‘greatest medical challenge of the 21st century’, as claimed
by the Alzheimer’s Research Trust in February 2010 (Erwin 2010,
p. 27). The Trust declared this incurable medical condition costs Britain
£23 billion every year: this is more than cancer and heart disease
combined, while receiving a fraction of the funding. In addition, about
822,000 people in Britain suffer dementia, being ‘17 percent more
than previously thought – and the figure is likely to pass the million
mark before 2025’. (Erwin 2010, p. 27) Oxford University health
economics professor, Alastair Grey, commented that these figures make
research in the subject essential, as there is a ‘lack of effective
treatments for dementia’ (Erwin 2010, p. 27). Currently, there is
no known cure, cause or definitive treatment for Alzheimer’s disease
(AD). Nevertheless, action has been taken to counteract this concern.
The recent publication of the NDS in February 2009 is backed by £150
million over the first two years. It is estimated that it will increase
awareness of dementia, ensure early diagnosis and intervention and improve
the quality of care provided. Proposals include the introduction of a
dementia specialist into every general hospital and care home and for
mental health teams to assess people with dementia. (Department of Health,
Dementia is the decline in memory and other cognitive functions in comparison with the patient’s previous level of function as determined by a history of decline in performance and by abnormalities noted from clinical examination and neuropsychological tests. A diagnosis of dementia cannot be made when consciousness is impaired or when other clinical abnormalities prevent adequate evaluation of mental state. Dementia is a diagnosis based on behaviour and cannot be determined by brain scan, EEG or other laboratory instruments, although specific causes of dementia may be identified by these means. (McKhann et. al. 1984 in Kitwood, p. 21)
Dementia, also called Organic Brain Syndrome (OBS), is an umbrella term that encompasses many different diseases. There are over 70 known causes for dementia, and many cases are a mixture of two or more different types of dementias. AD is the most common form, accounting for 50% of the dementias (Buettner, 1997). AD is referred to as OBS because it is the temporal and parietal lobes of the brain that it attacks fiercely. These are the regions of the brain that govern many higher-level intellectual activities such as language. The frontal lobes, which govern motor and speech functions and where personality and emotional control reside, are often relatively intact until the end stages of the disease (Gardner, 1974). According to the American Psychiatric Association’s Diagnostic and Statistical manual for mental disorders (DSM-IV-TR) the second most frequently diagnosed form of dementia is vascular dementia (formerly known as “multi-infarct dementia”) in which series of small strokes, sometimes called TIA’s block small arteries in the brain. The common symptoms associated with vascular dementia include short-term memory impairments, confusion, and other symptoms. Characteristically, the onset of vascular dementia occurs in abrupt steps, rather than the slow onset and steady decline common in AD clients (Greene, 2004, pp. 148).
According to DSM-IV-TR (2000) AD is made up of four stages, and clients may show signs of various stages simultaneously. Stage 1 includes confusion and awareness of a memory problem. There is a decreased ability for learning and difficulty concentrating. During Stage 2 a client shows poor judgement, disorientation, increased withdrawal, and apparent attempts to shut down a confusing external environment, showing the first signs of agitation and aggression. Stage 3 is an advanced stage of AD, when both expressive and receptive communication becomes difficult for a client. There is a significant loss for performing daily living tasks. A client shows anger and confusion, sometimes towards caregivers. Boredom and inability to focus are major issues that lead to behavioural disturbances. Finally, at Stage 4 or terminal stage of AD is characterized by substantial physiological decline. The client needs to be fed, is incontinent, and unable to recognize family members. Some are even unable to walk or talk. The actual cause of death for most persons with dementia is failing of the organs, infection, or a general physical decline. (Greene, 2004, pp. 149)
As McKhann (Kitwood, 1997) defines, AD is a diagnosis based on behaviour although specific causes for it may be found by medical tests. American pioneer psychiatrist David Rothschild states that neuropathology alone cannot account for the manifestation of primary dementia, and (as in the parallel case of stroke) psychological aspects were always involved (Rothschild 1937; Rothschild and Sharpe, 1944 in Kitwood, 55). DMP, as a form of psychodynamic psychotherapy, approaches these.
I.2 Loss in Psychotherapy for Older Persons
Melanie Klein understands the feeling of loss as mourning. (Klein, 1988, pp.347) I will use loss and mourning as synonyms. Freud linked anxiety to a fear of the loss of the object: originally a mother who protects her baby from ‘being hopelessly exposed to an unpleasurable tension due to instinctual need’ and later mentions a ‘fear of loss of the penis’, an organ which would allow the child to ‘be once more united to his mother – i.e. to a substitute for her – in the act of copulation’ (Freud, 1975 in Segal, 2003). In my understanding, when the baby is faced with the fear of loss of his mother he experiences anxiety; and anxiety, the ‘unpleasurable tension’ Freud describes, in an embodied sense could be experienced as an initial shock, stillness, lack of air or restricted breathing, muscle tension, impulse to cry, need to evacuate, shivering, or other somatic responses related to fear. Once this initial encounter with loss has been recognized, the individual may continue the work of mourning.
Freud points out in ‘Mourning and Melancholia’ that an essential part of the work of mourning is detailed reality testing. He goes on to say that ‘when this work has been accomplished the ego will have succeeded in freeing its libido from the lost object’ (ibid.) This means that when the work of mourning is accomplished a release of energy resulting from the process of letting go of the lost object is experienced. Abraham found that in the work of normal mourning, ‘the individual succeeds in establishing the lost loved person’ – Freud’s lost object – ‘in his ego, while the melancholic has failed to do so.’ (Klein, 1988, pp. 362) Pearl King’s influential works on psychoanalysis in Britain in the 1970s noted common anxieties of ageing persons listed as losses and threats of loss (King 1974, pp. 22-37).
Bowlby (1969, pp. 209), describing attachment behaviour, writes that a threat of loss to a principal attachment-figure creates anxiety, and actual loss sorrow; and both are likely to arouse anger. Bowlby seems to echo the relation Freud found between anxiety and the fear of loss of the object. Robertson (Robertson & Bowlby, 1952 pp. 131) identified three phases of separation response: protest, related to separation anxiety; despair, related to grief and mourning; and denial or detachment, related to defense mechanisms, especially repression.
Klein’s view is that while it is true that ‘the characteristic feature of normal mourning is the individual’s setting up the lost loved object inside himself, he is not doing so for the first time but, through the work of mourning, is reinstating that object as well as all his loved internal objects which he feels he has lost. He is therefore recovering what he had already attained in childhood’ (Klein, 1988, pp. 362). I relate more easily to a Freudian point of view on the work of mourning, however Klein’s views complement and inform my thinking.
Ardern, in his chapter in ‘Psychological therapies for Older People’ writes that many clients entering psychodynamic therapy will have experienced problems in their own early life attachments, and probably will be facing losses, ‘a crucial one being the anticipated loss of independence.’ (Ardern in Hepple et.al., 2004, pp. 35).
Kitwood (1999, pp. 80) cites Bell and McGregor when they explain that a person with dementia may not experience an ordinary sense of the linear course of time, implying that an ‘old grief or fear might erupt into the present, with all of its original freshness’. Interpersonal psychotherapy offers a technique that, when focused on grief and loss, observes that ‘reactions to the therapist may show how the patient has cut off from others or developed relationships that mirror the one with the lost person. (Miller and Reynolds, in Hepple et. al., 2004, pp. 117).
Also, in working with dementia care, strong reactions may be evoked, for example, by a person’s death. A member of the care team may find that ‘over and above the grief that actually belongs to this event, he or she is caught up in overwhelming feelings of sorrow and loss’. (Kitwood, 1999, pp.126)
I. 3 Two definitions for DMP
Leading DMPs in the field of dementia care in the UK currently use Goodill’s (2005) definition for DMP as an ‘interdisciplinary treatment medium: a hybrid of the art of dance and the science of psychology adapted to human service’. This implies an integration of disciplines, an art and a science merging their strengths towards providing a treatment service in favor of a person. The definition instantly associates DMP with the Creative Arts, but also places the practitioner in the stable ground of a science, and directs them towards a specific outcome: human service. In my opinion it is concise and the description provided is accessible for staff team members who are not familiar with DMP specific language.
In contrast, ADMPUK (2010) defines the profession as the ‘psychotherapeutic use of movement and dance through which a person can engage creatively in a process to further their emotional, cognitive, physical and social integration’, implying the creative engagement of a person in a process which uses movement and dance psychotherapeutically; a process that will further and aim to integrate the emotional, cognitive, physical and social aspects of a client. This includes emotions or feeling states, thinking mind, body or physicality and a person’s relation to the environment.
I suggest Goodill’s definition makes the discipline accessible in general terms, mentioning the core elements of DMP and their intention; while the ADMPUK definition is more specific and descriptive of the psychotherapeutic process, methods and goals of DMP, and how a person is creatively engaged in it.
I. 4 Effectiveness of DMP for clients with Dementia
In 2001, in North London, UK, a DMT programme using Links Movement and Communication (LMC) was launched, aimed at enhancing communication and mobility amongst clients with dementia through a qualitative approach (Kowarzik, in Payne 1996, p.18). This study suggested that DMP could ‘offer an holistic approach combining engagement, assessment, and care for people with dementia all in one’ (ibid.) However, Kowarzik (1996) suggests more in-depth research must take place to validate the tool used.
R. Coaten, registered DMP (RDMP) has recently published a PhD thesis developing the ‘Creative Care’ approach, investigating the use of DMP on persons with dementia, care-staff, and embodied practices. Some objectives are improving mobility; affirming identity; supporting affective communication; increasing observed ‘well-being’ and extending the range and quality of care relationships. (Coaten, 2009, pp. ii) Coaten proposes a study to better inform care-staff psychologically about how to engage, building ‘bridges of understanding’ between the ‘known’ and the ‘not yet known’. (ibid.)
Care-staff need to be more accepting that communications and behaviours expressed through ‘strangeness’ and ‘otherness’ can be better understood and related to as having meaning and importance. This is a paradigm shift away from bio-medical thinking, placing the onus on care-staff becoming more adept at communicating and finding meaning in so-called ‘non-sense’. Embodied practices support remaining individual capacities and communication skills and by way of this, ‘Personhood’. (Kitwood and Bredin, 1992, pp. 274 in Coaten, 2009, pp.ii).
Personhood is the standing or status that is bestowed upon one human being by others, in the context of relationship and social being implying recognition, respect and trust (Kitwood, 1997, p. 8); the concept informs the work of professionals in the field of dementia care.
Coaten’s DMP work was in a mental-health hospital ward in England. He studied a single DMP session through qualitative and quantitative methods, recording it on video (VTR) and using Dementia Care Mapping (DCM), an observational tool developed by the Bradford Dementia Group in UK to evaluate the quality of care for people with a dementia. (Alzheimer’s Australia Ltd, 2010) with the impact on care-staff studied. Analysis of results yielded thirty-three linked themes leading to five further meta-themes. ‘DCM results indicated significant effects on raising and supporting observed ‘well-being’, consistent with other sessions of a similar type’. (Crichton, 1997, Perrin, 1998 in Coaten, 2009).
The concept of ‘Building Bridges of Understanding’ is located at the heart of Coaten’s approach in a diagram , and closely related to five other key concepts, each emerging from fieldwork aspects in his study:
1) Building relationships through embodied practices.
He explains these concepts are held together by eight ‘relational and communication processes that are taken together: subjective, inter-subjective, reflexive and dialectical. These processes include: interpreting, clarifying, intuiting, repeating, differentiating, supporting, nurturing and encouraging’. (Coaten, 2009, pp. 303).
DMP relies on the verbal and non-verbal creation of a ‘therapeutic relationship’ (Chaiklin and Schmais, 1986) which the ADMP currently refers to as ‘developing a trusting relationship’ or ‘tuning-in’, within a context of body movement and embodied practice (ADMPUK, 2002 in Coaten, 2009). This is accomplished by visually and kinaesthetically perceiving a client’s movement expressions and through affective, empathic interactions established on a movement level (Chaiklin, 1993 pp. 79). It requires the DMP to attend to the person’s movements and their physical presence and to tune in to the person. (Coaten, 2009)
Melsom (1999 in Coaten 2009, pp. 126), cited four aspects of DMP that make it unique within other psycho-social interventions in the bio-medical setting:
• the incorporation of the body into the psychotherapeutic process.
According to Dr. Coaten, these four aspects are also valuable because they draw attention to the embodied and special nature of the psychotherapeutic process as practised by DMPs, and I will demonstrate these points in my clinical work.
In my experience, Coaten’s Creative Care approach is a very useful and effective tool in the DMP work with elderly clients with dementia because it includes embodied practices, the concept of personhood, considers care-staff, and promotes communication and enjoyment in the client’s experience of a DMP group.
I. 5 The DMP Group and Loss
Group psychotherapy is directed towards stranger groups of clients who come together at regular intervals for the purposes of treatment and change that began with the work of J.H. Pratt and Adler (Dreikurs, 1959 in Walrond-Skinner, 1986, p. 161) and then developed into three subdivions: Moreno’s action-based methods; Freud’s psychoanalytic approach; and the humanistic client-centered approach of Rogers. (Walrond-Skinner, 1986, pp. 161) These were later developed by Burrow, Foulkes, Jungian psychotherapists, and Yalom.
Helen Payne (1992, pp. 184) documented results of a qualitative collaborative research study to the question of how DMT trainees experienced a DMT Personal Development (PD) group on their training and whether it linked to practice, in the context of research by an international survey comparing arts and psychotherapies programmes with PD, experiential or training group component. The group was tailored for trainees rather than as a method to transfer to client practice.
A group process includes dynamic interactions between group members, tasks, functions and roles as manifested in their reciprocal relationships and verbal or non-verbal communication (Walrond-Skinner, 1986, pp.160). Payne (1992) discovered that the themes of ‘leaving, loss, and endings’ were significant. I selected five of her research findings and suggestions for the DMP practitioner working on the theme of loss in a group process:
1. A DMP must understand how context, conflict, absence, loss, endings
and presence impact on a group process. (Payne, 2006, pp. 202)
I believe these findings are relevant to the DMP practitioner working with older persons with dementia and will demonstrate these points in my clinical work.
II. 1 Introducing the Clinical Setting and Group Referral
Clients over 65 years of age, with diagnoses of different types of dementia are usually referred to the Day Hospital by a service they have previously contacted, such as the CMHT. Once referred, a client is asked to attend an assessment and subsequently is offered a place to take part in therapeutic activities. Ardern (2002, pp. 29) considers a client as potentially suitable for psychodynamic therapy would fulfill the following criteria: Demonstrate an awareness that neurotic symptoms have meaning, are motivated to change, accept a degree of personal responsibility, digest and tolerate interpretation, and are realistic about the fact that this form of treatment requires time.
Fulfilling this criteria was not possible in the context of the Day Hospital; provided clients may suffer long or short-term memory loss that affects their capacity for remembering certain events occurring during a session. In advanced stages, persons with dementia loose awareness of the therapeutic process’s progression. The group of clients that were eventually selected for referral for DMP fulfilled two main criteria: Being in the first stages of dementia, this is remaining stable compared to clients in later stages of the illness; and clients who were cognitively functional and able to verbalize coherently in general terms. The line-manager saw this as an area of opportunity for client work.
II. 2 The Physical Space
A part of being a safe and effective practitioner is to be aware of the physical space where the DMP sessions are going to take place. The Day Hospital made a space available promptly. There were two options and joint decision with my line-manager was made in favour of the most spacious area. I walked into the therapy room considering possible uses for the space. The room, in the shape of a square, is spacious and overlooks in a diagonal a big glass window leading to a tiny terrace. The window allowed plenty of light in. The room is wide enough to fit several pieces of furniture and at least six large chairs with cushions and a small, round table. Enlarged replicas of old newspaper front pages decorate the walls. Headings such as “The queen is crowned”, “Peace”, or “Everest Conquered” may be read. I noticed a mirror and artefacts such as a porcelain doll, a 1940’s miniature car replica, hairpins, a sand clock and a bouquet of large coloured plastic flowers. There was a suitable stereo and CD player.
I took a deep breath, pressed my fists tightly and released tension in my hands. I observed the weight on my feet on the floor. A brief moment of awareness of my location in space and time became a weekly routine for making myself available and ready for work with clients. This meant being present and alert; observing my own embodied responses. As a DMP, my body is inextricably involved in the therapeutic process, and also informs it.
In a later interview with my line manager I was informed that all rooms within the Day Hospital had been previously risk-assessed, a lifestyle factor observed in the assessment and management of risk factors in the prevention of dementia (Patterson et. al., 2008). Recommendations for the assessment and management of risk factors for, and the primary prevention of, AD include genetic, vascular, lifestyle and medication risk factors. (Ibid, p. 550) The first encounter with my clients was to take place within the next seven days. A co- worker who is also a trained nurse would accompany our group. Weekly, one- hour sessions were scheduled over a period of six months, and were included in the care plan of a selection of five and eventually four clients. There were going to be two breaks, the first after four sessions and the second for two weeks during Easter.
II. 3 Clinical Examples
I will now present a few clinical vignettes and identify the losses involved in the DMP therapeutic group process with my clients.
II. 3. A Session 1
Our session started 11:00 a.m. on a Tuesday. Five clients over 65 years of age: Sean, Peter, Rose, Lily and Amy, had been brought into the space by co-worker Frank. Seven chairs had been placed in a circle facing each other, as it was more comfortable for the group to sit than to stand during a session. This was adapted from Marian Chace’s primary structure of a circle, from which ‘forms of relating can develop’ (Chaiklin, 1993 pp.87). Her idea was inspired in ancient tribal societies and group dancing for healing or rites of passage, encouraging group interaction, dance and movement. A circle format fosters an atmosphere of safety, predictability and acceptance that will encourage the release of fear and anxiety (Schwab et. al., 1985).
The Chacian structure of a DMP session includes a warm-up, development and closure (Chaiklin, 1993). The one I used was informed by a sequence and therapeutic objectives suggested by Arakawa-Davies . Time was administrated as follows: a 5 minute pre-warm-up, where clients are encouraged to function in a customary social manner by exchanging greetings and ‘small talk’ (Arakawa-Davies, 1997); a 10 minute warm-up, which mobilizes the group’s capacity for emotional expression and social interaction; 30 minutes for central or theme development, and 15 minutes for an ending or closure that resolves the work of each session so clients may leave comfortably, having a meaningful verbal exchange and acknowledging each individual. (Chaiklin, 1993).
I asked a simple check-in question: “How do you feel today…?” Answers were brief. “…Stiff.” Said Rose, the third one to speak. She felt stiffness in the neck, attributing it to watching T.V. and remaining in the same position for a long period of time. The group nodded in agreement. There was a C.D. on the recorder and Frank stood to press play. The group enjoyed the music, songs from the 40s and 50s. I encouraged them to begin our warm-up moving with Rose so we could help her relieve the stiffness from her neck. I initiated head movements slowly: first up and down and then from side to side, in a steady, rhythmic action. Eye contact emerged as a result. The group’s reactions included a wide opening of the eyes, rising of eyebrows and lively facial gestures, in recognition and awareness of others, in some cases accompanied by laughter.
As part of the warm-up, I used a ‘name game’ (Harris, 2009) encouraging the group to say their names and choose a movement to go along with it while I observed their movement efforts (Moore, 2009). Laban’s system of movement analysis (1972) came in and out of focus as sessions progressed. I initiated a short movement sequence while saying my name, slowly opening the palms of my hands. Action continued clockwise.
Peter said his name and extended his right arm up and down in a light and bound flow. Sean followed, in a direct movement, showing the rest of the group his two thumbs facing up. Rose was visibly agitated, moving in an indirect and bound way while sitting on the chair, indecisive of a movement to share; Lily said ‘I’m sorry, I’m stupid, I don’t understand you’, and Amy moved her hands a very light and sustained effort; she spoke very softly and smiled. Leadership was shifted and the group could choose ‘who they wished to follow, to be near, or to avoid’ (Chaiklin 1993, p. 87). This worked for a brief amount of time, until they looked back at me, urging for some direction both verbally and non-verbally. I started to feel their anxiety in my own body as a form of somatic countertransference.
During this stage, clients may feel apprehensive, wondering about DMP or what might be uncovered during therapy, and whether the therapist can be trusted to contain or hold these difficult feelings (Meekums, 2002). Our session went on for about 35 minutes. Sometimes I found it difficult to understand Sean, as his head was tilted down and his speech was low. I turned to Frank for clarification, but it was not clear to him either. The group decided on a greeting that was used on that session to say goodbye and every following session to open and close the group.
II. 3. B Session 4
In a brief meeting before the session Frank notified me Peter was absent. During the session I asked the group if we should move his chair. They decided to give me the responsibility of resolving what to do with it. I had a strong sense they were asking if we could hold the group together if one of them was absent. Frank put the chair aside and we sat in a closer circle. As we moved during the name game (Harris, 2009) Amy said: “We know each other, but we don’t remember our names”. Rose and Lily agreed. The group today experienced the theme of loss. Amy was verbalizing a major aspect of living with a dementing condition: loss of memory and cognitive abilities. The group then demanded some kind of modeling or leadership. I verbally encouraged them to initiate occupational movements they knew from their previous jobs, as suggested in supervision. Sean actively participated by lightly gliding his arms in a square shape, and felt sufficiently held in the space to describe a difficult past experience with a machine at work, resulting in the partial loss of two fingers from his left hand. This was a shocking moment where the loss was visual, and the group fell silent as our session ended.
II. 3. C Session 7
During the ‘name game’, Sean spoke his name while intertwining his fingers and wiggled his thumbs playfully towards me. They reminded me of a pair of ant’s antennae. He repeated the movement facing Lily, and then Amy. I intertwined my fingers, holding my arms closer to my core than the way Sean was moving and wiggled my thumbs playfully at Frank and Peter, to my left and right. As an embodied response I felt very energetic, and smiled. Amy and Lily responded to Sean’s interaction as we shared ‘rhythmic group activity’ (Chaiklin, 1993) following his leadership. A group of people moving together gain a feeling of more strength and security than any one individual can feel alone (Ibid, pp.80), they felt ready to share a movement and maintain eye contact for a brief amount of time.
II. 3. D Session 11
Rose had been discharged the week before. Lily announced her discharge from the Day Hospital within two weeks. Sean was very quiet. The group had lost one of the participants and another would leave in the near future. It seemed Sean’s silence reflected the group’s protest for the loss of a group member.
Peter sang lyrics to ‘When You’re Smiling’, and Lily compared herself to Amy, trying to make a steady rhythm with her feet on the floor, clap, or make sounds with a beanbag like she did. Lily kept calling herself ‘stupid’ and Amy reacted. “I hate it when you call yourself stupid”, she replied. I verbally encouraged Lily to realize the things that she could do and was good at. “We’ve all got talents”, said Frank. Lily’s body became tense and her hands held the arms of the chair tightly, she felt ‘unpleasurable tension’ in her body, possibly related to a loss of independence.
Supervision encouraged me to create a space of permissiveness, in order to develop group trust. Lily and I maintained eye contact briefly. She finally said: “I would like to get up and dance but others will think it is a waste of time”. I reflected this back to her asking why. Peter said: “I can join you”. So they stood up and danced in the middle of our circle, holding each other as a couple taking rhythmic steps forward and backward. It was a beautiful sight. Eventually, they allowed me join them and we formed a small circle while the rest of the group observed from their chairs. There was a feeling of lightness and easiness of breath in the room.
II. 3. E Session 13
Lily would be discharged that week. She noticed Amy’s absence. Frank reminded her that Amy was notified of her discharge the previous week, but forgot it. Lily sat quietly in a remote state, her gaze was indirect and her body bound (Laban, 1972) and very still, as she experienced the loss of Amy in the group.
I slowly introduced a bright coloured, folded prop that I used to ‘explore fully participants’ potential for movement and sensory stimulation’. (Coaten, 2002, pp. 390) and placed it in the middle of the circle. “I would like to see what it is”, said Peter. Props include age-appropriate music reflecting diverse tastes, materials such as silk scarves, circles of stretchy elastic and lengths of different coloured fabrics, hoops, hats, masks, canes, and feathers. (Ibid.) Peter took the prop in his hand and opened it to discover it was a large, bright parachute. The group contributed until it was fully open and extended it as much as possible. They even experimented with kooshballs and tossed them at the middle of the parachute, allowing them to fly in the air while they gazed at them from their seats. Sean laughed in awe. It seemed the group had found something that brought them together. As an intervention, I named this and the group nodded.
A kooshball flew over Peter’s head and fell between him and the back of his chair. He made a light and sudden movement, lifting his hands. His facial expression changed, looking surprised. “That was unexpected, Peter” I intervened, making eye contact and matching his emotional and bodily response with my eyes open wide and an open facial expression. The group laughed and breathed deeper, becoming visibly relaxed. Our relationship was progressing from the initial tension or anxiety to one where we could share a connection and respond to each other in movement and dance, promoting a feeling of comfort and safety in the room.
Supervision encouraged me to think on my own embodied responses, and in this moment, holding the parachute with the group and experiencing kooshballs flying in the air above us, my embodied response was to inhale deeply, allowing my arms to extend in free flow (Moore, 2009) with the oscillating movement of the prop. The group engaged in this symbolic act and was immersed in or ‘incubating’ (Meekums, 2002, pp.17) their creative process.
II. 3. F Session 16
Two months had gone by since our first group session. Rose, Lily and Amy were discharged by the last week of January. Sean and Peter experienced the loss of three group members, while Eve and Bridget joined our group. That morning they decided to toss beanbags. Frank and I reminded them to make safe throws by aiming at the receiver’s hands. Eve was in a stable state and, using a strong effort of weight and a direct effort of space (Laban, 1972) tossed a beanbag further than Peter or Sean could reach. It fell out of sight and Frank stood up to find it. I named this movement metaphor by saying: “We lost a beanbag. I wonder if the group feels a bit lost today”.
He broke eye contact with the group and looked down saying “I do feel a bit lost”. Bridget asked: “Why are you lost?” “I am not lost, I just feel lost”, he replied. Peter seemed to have lost his breath as well, and the space around him, his ‘kinesphere’ (Bartenieff, 1980) seemed to shrink. I intervened verbally; asking if was related to changes we experienced as a group. Sean reflected: “The people in the group have changed, and also the material that we used has changed”. Our therapeutic movement relationship had developed in such a way that it encouraged Sean to internalize, notice and express changes in the group.
II. 3. G Session 18
After throwing beanbags forcefully for several sessions, Eve started to direct them towards me. Eve was concerned that if she expressed this dramatically she would “throw a beanbag to my face”. She moved forward suddenly, spoke loudly and pointed her finger directly at me saying: “You are doing nothing, I feel nothing, this is nothing”. Keeping strong, direct eye contact. Her anger was a form of transference, as she was locating her fantasies –in the form of fears- in me (Ardern, 2002, pp. 27).
My supervision group allowed me to understand that my own countertransference was felt in my own embodied responses. I could feel myself wanting to block her attack, retaliate (Winnicott, 1971), build an invisible wall between us, or say something back. I felt hurt and vulnerable and wanted to say all I had worked to be there with her in that room, in that moment. My own personal history of feeling verbally or physically attacked came to mind. I later took these concerns to personal therapy and worked towards healing and overcoming them, but in that moment I looked back at her, attuning to her bodily tension but standing my ground, this is, not retaliating, even when this attack was so difficult for me to stand (Winnicott, 1971, pp.123).
I then initiated a movement sequence by tossing a beanbag forcefully towards the centre of our circle. The group felt confident to experience throwing beanbags in a sudden, direct and strong manner; this is with a punch action drive (Laban, 1971 in Adrian, 2008, pp. 75). Beanbags were thrown like a thunderstorm releasing an incredible amount of energy, and in the emerging of this anger the group experienced a sense of being in control. We shaped it in a safe yet expressive movement. They decided to continue their active interactions by exchanging beanbags.
II. 3. H Session 20
The last session before a break was lively. Bridget was very upset; she had lost a pair of scissors and a wedding gift she had kept for years. The group empathized verbally with this loss.
Peter and Frank had left the room as Peter suffered from incontinence; this was very anxiety provoking for him. That day I brought two scarves as props and initiated a sequence with different movement efforts, inspired from basic effort action combinations (Laban, 1971). Dab and wring were the ones that appeared the most. Negotiations went on as to what and when props were used. The group decided all props would be placed in the middle of our circle. Peter kicked a piece of tinsel. “He plays for Chelsea!” said Frank, spontaneously.
The group experienced a moment of mutual sharing and group cohesion. “It seems Peter found something he is very good at” I intervened. The group celebrated and laughed in acknowledgement as they realized that in the experience of loss, some things can be found.
II. 3. I Session 22
“Peter passed away last night”, said Angela, my line manager. “You must not tell the group until I have spoken with his family”. It was a sudden death from a heart attack. The moment of disappearance is one of radical change, a birth not into life but into death. This is a birth we cannot attend and there is nothing we can say or hear about it (Orbach, 1999, pp. 129).
It was 10:50. I sat frozen, speechless, feeling very real pain in my body. My mind reached in a million directions at the same time, in my first experience of the passing away of a client. Frank and I extended our usual meeting as he described previous experiences in this situation and comforted me: “Peter is with his wife now, that is what he always wanted”. I collapsed, but completely trusted and relied on Frank’s experience and was sure that together we could hold the group space (Winnincott, 1968).
The group seemed cheerful. There was a sense of timelessness in the room, as we interacted in rhythmic group activity (Chaiklin, 1993). Not telling the group about Peter’s death seemed unnatural and difficult, I thought, and later took these painful feelings to personal therapy. Towards the end of the session Sean metaphorically moved his arms like a bird taking a slow, sustained flight. It was as if Peter was this bird, taking flight from the group, leaving a sense of lightness behind him.
II.3. J Session 23
I delivered the news. Bridget was absent. Sean shivered, his body froze in shock and his first reaction was denial. Eve stood up from her chair and touched his arm. Sean gave her a gentle kiss on the cheek.
The group mourned the loss of Peter by asking me to place beanbags on his empty chair and a vase of beautiful plastic flowers to the side, and writing “In Memory of Peter” on paper. Sean held it tightly. He said: “I think this is enough, what else would you add Sofia?” I spoke, very slowly: “I remember… Peter pulling beanbags with his cane, a kooshball falling behind his chair, I remember… when he played for Chelsea.” My voice trembled. Sean kept direct eye contact with me and smiled for a brief second as the powerful countertransference I felt evoked a tear in my eyes. Eve changed places twice, and then put her glasses on Peter’s chair. Our ending took time and the loss was felt by all. We gathered the props, pulled our chairs closer together –including Peter’s- and held hands tightly for the last time. Sean would be discharged that afternoon. Our group was ending.
III. 1 Supervision
Supervision was a thinking, reflective space where I unpacked the parallel process of therapist and clients. Off-site weekly supervision at university adapted a psychodynamic model to DMP. As a supervisee, I presented a ‘description of therapy sessions’ (Langs, 1994, pp.39) in my supervision group. I also brought questions that had to do with defining the role of the co-worker, and if clients were affected by experiencing him in two different roles. He was group leader within the Day Hospital in other sessions. My supervisor was the ‘objective’ or ‘intersubjective’ view (Cavell, 1998, pp. 451), and would offer loosely structured comments (Langs, 1994) on my work and related ‘issues of theory, as well as a variety of extraneous comments on a range of possible topics’ (Langs, 1994, pp.39). I critically reflected on my observations on clients and their interactions. Supervision at the Day Hospital encouraged me to start the warm-up with occupational movements that included actions that older persons already knew. My supervisors clarified that a co-worker will also provide or destroy a ‘holding environment’ (Phillips, 1998); so open communication and teamwork between Frank and I was essential, bearing in mind the complexities of co-facilitation (Bates, 1997).
My supervision groups helped me realize the importance of naming events and reflecting them back to my client group as they occurred, even when the meaning of this individual and group symbolism was not yet clear to either them or me as a therapist, (Meekums, 2002) as in the case of the first time the parachute prop was used. For example, the group had verbalized a movement metaphor created with a lost beanbag, ‘facilitating the complex interplay between the embodied experience of movement, projected symbolism through the use of props, affect and verbalization; involving the integration of the intuitive, affective right-brain functions and the logical, linguistic left-brain functions’ (Meekums, 2002, pp. 25) expressing their sense of being lost as a group. In supervision I reflected if they were perhaps clinging to a structure, wondering if they could trust the group and their therapist to contain and manage changes, and questioned if this new dynamic was going to work. This reflects Payne’s (2006) suggestions on the importance of a DMP’s understanding of feelings of loss and how loss itself impacts in a group process.
For example, I brought both aspects of the mother together for Eve: the internal and external object. Drawing her rage on to me provided the needed transitional object, an outside object that could be destroyed by this anger. Eve felt that her mother, her internal object, could never survive her angry attack. The analyst, the analytic technique, and the analytic setting all come in surviving or not surviving the client’s destructive attacks (Winnicott, 1971, pp. 122). Eve experienced a destruction of her external object, and loss of it.
Losses I observed during the group process with clients with dementia started from session 1, with the expression in movement of ‘unpleasurable tension’ in Freudian terms that was related to anxiety and possibly to a loss of security and uncertainty for experiencing a new situation. In session 4, the loss of memory and cognitive abilities voiced by a group member and acknowledged by others echoed what Greene (2004) refers to as the loss for performing daily tasks, which was also visibly evidenced by Sean showing the partial physical loss of his two fingers. In session 11, Lily’s comparisons to Amy evidenced her anger upon facing her loss of independence (Ardern, 2004), which is one of the major losses that clients with AD face. In session 20, Bridget’s loss of a pair of scissors and a wedding gift echo what Kitwood (1999) refers to as an old grief erupting to the present that brings overwhelming feelings of sorrow and loss in the client.
Supervision taught me to understand, hold, and contain difficult transferences of grief, anger and mourning. My supervision groups held my own embodied responses and countertransference (Dosamantes, 2007), and my supervisors were clinically sensitive to refer me to my own personal therapy in order to aid me in further personal development (Govoni and Pallaro, in Payne 2008, pp. 36).
III. 2 Personal Reflections
When Peter passed away I was in a place of mourning, a painful place. I took it to supervision, personal therapy, and my support network at university and placement. Walsh, Nichols, and Comack (1991) found that most psychotherapists were reluctant to use their colleagues for personal support at work because they believed they would be stigmatized for their problems and perceived by their colleagues as untrustworthy.
I moved with peers at university, allowing myself to show vulnerability. The dance was painful as I mourned both my client’s and my own personal losses. As Payne (2006) suggests, I was exercising the capacity to track my own feelings and movement in the therapeutic relationship, promoting an awareness of my own unconscious somatic countertransference.
As a therapist, holding loss for a group may feel overwhelming, a very heavy weight to carry. I reflected on the process mainly by using movement as discussed in supervision, and considering my own self-care (Carroll, Gilroy, and Murra, 1999). I moved my body to start letting this weight go, allowing it to transform and become like Sean’s movement metaphor of the bird talking flight.
III. 3. Limitations and Projection of the Work
My clinical work was discussed briefly with Angela every week and in
detail in supervision. I applied a Clinical Outcomes Routine Evaluation
(CORE) to Sean and Peter during the first week of January. This was problematic
because the questionnaire had thirty-four statements, and they found it
exhausting. Limitations of the work included the fact that three members
of the original group were discharged within the first two months. The
unavailability of accessing appropriate modes of evaluation on time was
another. They were not adapted for older persons. CORE-10, with only ten
statements, was not available at the Day Hospital until a couple of months
later. This is the one I applied after this session but it was too late
for Peter to answer. Outcomes included a slight drop in clinical scores.
The day applied may have affected the results, as Sean had recently received
Loss in a DMP group with dementia is experienced on many levels. Both the client and therapist feel it. Fear of loss may touch our deepest fears and force us, as a group, to observe issues that could have been long neglected. It is very important to create a support network through work with DMP in a multi-disciplinary team to provide adequate support for clients with dementia in terms of them adapting to life’s challenges and losses, past and present. Being lost, in a sense, could be an invitation to adapt to the unknown when embarking in a DMP process, and the therapist needs to develop her skills to be able to respond and support clients with dementia, fulfilling their particular needs.
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Moving Towards Creative Care (Coaten, 2009)
The structure of DMP sessions with senile dementia clients. (Arakawa-Davies,
of Bisakha Sarker and Diane Amans rehearsing their piece for this conference.