تئاتر برای، توسط و با بیماران فیبرومیالژیا - بررسی ابراز هیجانی با استفاده از تفسیر های ویدئویی

Abstract The healing function of theater is reflected in all human cultures. Today, therapists and scientists work with psychodrama and drama therapy, often describing theater as the art form closest to life itself. In a unique cooperation between professional actors and a dance movement therapist/pain researcher, patients with fibromyalgia have first been trained in body and voice expression and thereafter acted out a drama onstage together with professional actors. A video interpretation technique was used to help patients interpret their own emotional expressions towards other actors and evaluate their perceived pain and self-rated health. The results of this feasibility study show that the variation of emotional expression from video interpretation is dependent upon whether or not the patient acts with an actor. The intensity of emotional expression increases significantly when acting together with a professional actor. The results also show an increase in self-rated health and a decrease in pain after 3 months of using this theater-based technique. A correlation between strong emotional expression and decreased pain was also observed. However, when patients did not actively participate in a theater play, their self-estimated pain was not significantly decreased. In this study, the cross-fertilization of culture/expressive arts and health care is presented as a new resource for pain treatment. In particular there may be a link between intense emotional expressions when acting with professional actors and decreased perceptions of pain. The paper also discusses the potential therapeutic value of working with professional actors in the treatment of other pain patients. Hopefully, this theater-related method can contribute to developing collaboration between actors and creative art therapists and stimulate controlled studies of evidence-based science.

Introduction The idea that theater has a healing effect has been discussed by numerous researchers and it has been used in all epochs and cultures (Bates, 1988, Emunah, 1994, Snow, 1996 and Snow, 2003). The healing powers that have been discussed can be the result of, among other factors, the theater's similarity with real life (Snow, 2003). In drama therapy (Jones, 1996) and psychodrama (Kedem-Tahar and Kellermann, 1996 and Moreno, 1987) different forms of improvisation are used as a part of therapy, and the therapy group itself, which is comprised of patients, acts as an audience for the performance. Recent developments, however, have moved towards a therapeutic theater in which the patients perform in front of a general public. The patient groups have included people with different psychiatric diagnoses, traumatized war veterans, individuals with post-traumatic stress syndrome, people with mental handicaps, and the elderly (Emunah, 1994, Emunah and Johnson, 1983 and Moneta and Rousseau, 2008). Being able to perform in front of an audience in this context can further confirm the patients’ new images of themselves, which are reinforced within the play (Snow, 2003). It is, however, important to bear in mind that when theater is used with a therapeutic purpose and when a play is performed in front of the general public, the patients’ resultant experiences need to be followed up (Landy, 1986 and Landy, 1993). What has not been widely discussed in literature is how professional actors, with their unique knowledge, can help patients who have difficulty with expressing their emotions to get their voices heard. Actors have access to knowledge and techniques that can be used by patients to strengthen their emotional expression, with the help of both voice and body, and thereby influence their pain and their abilities to set boundaries for unpleasant movement patterns (Kut et al., 2007). In this population group, where long-term pain is common, the decrease in body awareness is a risk factor for developing limitless movement patterns (Bojner Horwitz, Theorell, & Anderberg, 2003). Fibromyalgia is a disorder that affects mostly middle-aged women and that causes pain throughout the entire body (Wolfe et al., 1990). Oversensitivity to pain is another factor that characterizes these patients (Kosek, Ekholm, & Hansson, 1996). Numerous studies have discussed how perturbations in the patients’ pain management system may develop through, among other factors, an imbalance in the body's stress axes (Crofford et al., 1996, Crofford, 1998 and Griep et al., 1998). Strong negative life experiences (Anderberg, 1999, Anderberg et al., 2000 and Katon et al., 2001) can affect the body's pain management through, among other things, repeated early stimulation of stress hormones and the overwhelming of the body's ability to recover. Many researchers have recently uncovered a link between the sympathetic nervous system and the stress reaction, especially in fibromyalgia patients. A “sympathetic hyperactivity” in the sympathetic portion of the autonomic nervous system as well as perturbation in the HPA-axis (Griep et al., 1998, Crofford et al., 1994, Van Houdenhove et al., 2005 and Van Houdenhove and Luyton, 2006) has been put forward as an explanation for both difficulties in pain relief and pain oversensitivity in fibromyalgia patients (Martinez-Lavin, 2007). This perturbation in the stress axes has its origin in disturbances of certain neurotransmitters (catecholamines). Unexpressed strong negative life experiences, daily stress hassles, and emotions that affect the body's memory that remain as unresolved problems, with muscular tension as a result, have been discussed as one of the causes of this hyperactivity (Anderberg, 1999), and is in this study used as a hypotheses to explain the patients pain perception. That some fibromyalgia patients have difficulty putting their feelings into words, named as alexithymia (Sifneos, 1973), is also something a number of researchers have found ( Lumley et al., 1997, Sayar et al., 2004 and Sivik, 1993). In one study, 15% of the fibromyalgia patients were found to have alexithymia ( Pedrosa et al., 2008). Especially the dimension of alexithymia that is associated with identifying feelings and to express anger seems to be associated with fibromyalgia ( Gulec et al., 2004 and Sayar et al., 2004). During the last decades, alexithymia has been discussed in conjunction with overwhelming stress and muscular tension in the development of chronic pain ( Feryal & Saatcioglu, 2006) as well as in conjunction to depression, ongoing pain, experimental pain and illness behaviour ( Huber et al., 2009, Hughes, 2006, Thieme et al., 2004 and Van Houdenhove and Luyton, 2006). At least for some of these patients, it may be that alexithymia has its source in patients’ difficulties in identifying and expressing their emotions, especially anger, because of fear of separation or conflict (Gulec et al., 2004). They therefore use emotional avoidance strategies (Van Middentorp et al., 2008). It may be that it is better to be quiet than risk too big changes in your life. Prolonged fear causes stress reactions, which, in turn, cause muscular tension, which, over a prolonged period of time, can transform into pain (Anderberg et al., 2000, Broderick et al., 2005, Crofford et al., 1994, Egle et al., 2004, Griep et al., 1998, Van Houdenhove et al., 2005 and Van Middendorp et al., 2009). Language and abstract thought is successively built up during the first years of life with the help of the mirroring of the infant's emotional expressions, nuances of movement, and vegetative reactions. Development moves from a sensational experience to an emotion and onwards to a thought/word. If the emotional reaction is not translated into an expression/word, it may instead remain in the body, with pain as a consequence (Bojner Horwitz, 2004, Bojner Horwitz et al., 2004 and Kirsch and Bernardy, 2007). Nuances of gestures and emotional patterns of movement are lacking, with stiff, robotic body movements as a consequence. However, if the individual, with help in the form of discussion or artistic expression, can learn to express their emotions and set boundaries for their environment, a release of tension can occur, which in turn most likely may result in pain reduction. Related to the patients’ problem with identifying their own feelings, it may also be difficult to identify other people's feelings, which in turn increase the need of setting boundaries (Gulec et al., 2004 and Sayar et al., 2004). A new method of using theater as a form of therapy is the “theater-related method” (TRM) in which patients, in conjunction with professional actors, explore a text from an existing manuscript and dramatize it. Through engaging with the text, the patients act with a professional actor and through this get the opportunity to find an outlet for their emotional and physical expression. The actor collaborates with a dance therapist/pain researcher and guides the patients through new possibilities of expression through both voice and body. The patients also get feedback through seeing themselves on video and examining their emotional expressions on film in order to get an objective perspective of themselves. The TRM consists of a closed group of patients whose dramatizations take place in a theater in Stockholm. To work with emotionally charged texts and to try to discover which emotional expressions belong where, especially with which gestures, vocal expressions, and movements, can perhaps open up a locked emotional space and relieve the pressure on the body's memory and the autonomic nervous system, which can reduce pain in fibromyalgia patients. To do this, using professional actors in a theater-related method with the purpose of helping patients access their emotional expression has not been used with fibromyalgia patients. This feasibility study presents a new artistic form of treatment for patients with fibromyalgia which involves the cooperation of dance therapist/pain researchers and professional actors. The primary purpose is to explore the outcome after fibromyalgia patients’ participation in a theater-related method (TRM). The study explores fibromyalgia patients’ perceived health and pain as well as validates whether patients’ own emotional expression correlates with general health and pain, measured with video interpretation. The study also explores whether theatrical play, when the patients are passively watching a play in the theater, differ from actively participating in the described TRM, in terms of the patients’ perceived health and pain.

Results The descriptive analysis of all data is presented in Table 1. Table 1. Descriptive analyses of the different variables in the theater related method (TRM). n Mean Standard deviation Median Minimum Maximum Video interpretation Acting with a professional actor 7 6.9 1.3 7.0 5.0 8.0 Acting without a professional actor 7 4.6 1.0 5.0 3.0 6.0 Dancing emotions evoked from Medea 7 4.3 1.7 5.0 2.0 7.0 Pain intensity Baseline 7 5.1 1.8 5.0 3.0 8.0 After 3 months treatment 7 3.3 1.4 3.0 2.0 6.0 After 3 months follow-up 7 2.7 1.4 2.0 1.0 5.0 Before theater 7 4.3 3.3 3.0 1.0 8.0 After theater 7 4.6 3.2 5.0 1.0 8.0 Self-rated health Baseline 7 4.3 1.7 5.0 1.0 6.0 After 3 months treatment 7 6.4 1.4 7.0 5.0 8.0 After 3 months follow-up 7 7.3 1.7 8.0 5.0 9.0 Before theater 7 6.0 1.8 5.0 5.0 10.0 After theater 7 5.7 2.4 7.0 1.0 8.0 Video interpretation at month 3, pain intensity and self-rated health at month 3 and at a follow-up at month 6 and pain intensity and self-rated health before and after viewing the theatrical play Medealand. Table options Video interpretation: evaluation of emotional expression Estimates of the patients’ emotional expression, as interpreted from the video films (Films 1, 2 and 3) differed in terms of the emotion strength (p = 0.01). The patients’ interpretation of the strength of their emotional expressions increased significantly after the patients performed with an actor, as compared with when they have performed without an actor and with when they expressed their emotions through dance. There was a significant difference between films, with regard to the estimates of emotional expression, when they were overall tested for any difference (p = 0.01). Subsequently, post hoc test revealed that the performance of a text with and without an actor differed in the emotional expression (p = 0.02). Post hoc comparison also showed that performance with an actor compared with the performance of the dance, also was statistical significant (p = 0.04) ( Fig. 1). Presentation of the fibromyalgia patients’ intensity of emotional expressions ... Fig. 1. Presentation of the fibromyalgia patients’ intensity of emotional expressions interpreted from video films after TRM at month 3. Film 1: acting with a professional actor, Film 2: acting without an actor and Film 3: dancing emotions evoked from Medea (n = 7). Figure options The validity issues are previously explored and discussed in Bojner Horwitz (2004), where the video interpretation technique is suitable for both patients and therapist in prospective interventional studies to measure changes (using qualitative variables) in movement patterns and body language over time. Self-rated health and pain Self-rated health was significantly changed over time (p = 0.01). Post hoc test indicated that self-rated health was statistically increased 3 months after treatment (p = 0.07) compared to baseline and was maintained at 3-month follow-up at month 6 (p = 0.01) ( Fig. 2a). (a) Presentation of the fibromyalgia patients self-rated health at baseline, ... Fig. 2. (a) Presentation of the fibromyalgia patients self-rated health at baseline, after end of TRM at month 3 and after a follow-up at month 6 (n = 7). (b) Presentation of the fibromyalgia patients pain intensity at baseline, after end of TRM at month 3 and after a follow-up at month 6 (n = 7). Figure options The pain intensity was significantly changed over time (p = 0.002). Post hoc test revealed that the pain intensity was decreased 3 months after treatment (p = 0.03) and maintained at 3-month follow-up at month 6 (p = 0.02) ( Fig. 2b). Correlation between emotional expression and pain The decrease in the experience of pain as measured after 3 and 6 months is related to an increased emotional expression in the performance with an actor (−0.62), (−0.67) as compared with the performance without an actor (−0.12), (−0.04), and with dance (0.56), (0.52). There was no observed correlation between self-rated health and an increase in emotional expression. A visit to the theater Medealand No significant difference was measured between self-rated health and pain before and after the patients had seen the play Medealand (Table 1). Prescription for cultural activities The patients visited the following cultural activities during the follow-up period from month 3 to month 6: theater performances, dance performances, music concerts, art exhibitions, and museum visits. The mean visit was one cultural activity per week, and the theater and dance performances were the most commonly attended cultural activities. Discussion After the fibromyalgia patients had taken part in the theater-related method (TRM), their self-assessments show a statistically significant perception of reduced pain (p = 0.03) and also a perceived health improvement (p = 0.07). At the 3-month follow-up (month 6), there was both a statistically significant improvement in perceived health (p = 0.01) and reduction in perceived pain compared to baseline (p = 0.002). In this group of seven fibromyalgia patients, it can be concluded that the effect of the theater treatment was very good; however, the study did not have a control group, and it can therefore be debated whether performing a given script in the theater was the most significant cause of health improvement for the patients. Another issue that may have reduced the level of scientific evidence is that patients, who were willing to participate in the study, were those who already were at the point of improving in pain and self-rated health. Anyhow, these explorative results suggest that the design of the intervention could be valuable in future studies. By being allowed to enter into a role whose characteristics were strongly emotionally charged from the beginning (Medea), patients could allow themselves to dare to leave their own habitual roles in a new way by manifesting their emotions more overtly. Role taking, a concept that Mead has discussed (Mead, 1934), implies that, already as children, people react in the same manner that others have reacted to them in the same situation. This suggests that the patient's interpretation of Medea reflects both the patients’ own interpretation of the role as written, and also the way she has experienced others behaving in situations that are emotionally charged. In this sense the patient may be projecting behaviour that was mirrored earlier in life. Playing the emotionally charged character of Medea thereby allows the patient to express an objective interpretation of her subjective self. Patients also draw on their affective memory in interpreting a role such as Medea, as told to use their own negative life events as being a part of their expressions. This is in line with Stanislavski's concept of “affective memory” (1936), which suggests that the memory from an actor's own past can help to bring a character's emotional expressions to life, called “living the present through the past.” Many patients with fibromyalgia have perceived strong negative life events (Anderberg et al., 2000, Walker et al., 1997a and Walker et al., 1997b), and through the preparation with the 10-stage program, body memories and life experiences from such negative life events has been identified and recognized. A role offering less emotional intensity would probably not have offered the same opportunities for patients’ to express their feelings. Expressing strong emotions such as anger reduces muscle tension more than if the expression is more neutral, which most likely also affects the perception of pain at a deeper level. Interestingly, findings from other studies have shown that inhibition of anger predicts heightened pain in the everyday life of female fibromyalgia patients (Van Middendorp et al., 2009). Kut et al. (2007) have also shown that self-perceived role identity can modulate pain and role playing strategies may be of value in new pain management strategies. Patients’ understanding of their own emotional expression, measured using the video interpretation, varied depending upon whether or not they were performing with an actor. Patients experienced a significant increase in their emotional expression, that is, an increase in the strength of emotion when compared to performing without an actor or when dancing. Conveying emotions through a given script via the voice (Film 1) is considered more emotionally charged by the patients than emotions conveyed through dancing (Film 3). The objective with this study was to measure the degree of emotional expression interpreted from video film and not to evaluate if dance was emotionally charged or not. During the treatment period, the patients were trained to express different emotions with their voices and not directly trained to express emotions through bodily movements. Nevertheless, emotional expressions through the voice require bodily contact, which the patients had been trained for in the 10-stage preparation program. The voice, like the body, is affected by pain and fatigue, and the ability to verbally express emotion can diminish with long-term pain. On the other hand, the voice and body can be strengthened through contact with emotions, with the help of guided theatrical performance (Christie, Hood, & Griffin, 2006). What happens in the meeting of patient and actor that causes the emotional expression to increase significantly in strength? Constant attention from someone who listens to her emotional expression (in this case the actor) appears to affect a patient's own understanding of her strength of emotion (as expressed through video interpretation). The fibromyalgia patients in the group noted that they lacked someone in their lives who was willing to listen and support them in the later years of their illness. The average symptom duration for the group was 11 years, which suggests that these patients’ ability to express their emotions may have been weakened (Bojner Horwitz, in press). The strong expression of emotion when interacting with an actor, as measured with video interpretation, can be related to a decrease in pain after 3 months (r = −0.63, p = 0.14) and also at month 6 (r = −0.67, p = 0.10). This indicates that the expression of strong emotions could explain the decrease of the experience of pain. Although researchers have discussed the degree of alexithymia (Sifneos, 1973) in fibromyalgia patients (Bojner Horwitz, 2004, Lumley et al., 1997, Pedrosa et al., 2008 and Sivik, 1993), the difficulty of identifying feelings rather than verbalizing feelings seems to be the problem for some fibromyalgia patients (Gulec et al., 2004 and Sayar et al., 2004). By helping fibromyalgia patients to recognize feelings through a given emotionally charged sentence from a manuscript may trigger this identification process. According to Kut et al. (2007), different role characters can also help to modulate pain, i.e. by trigger pain receptors through “weak” role characters. Broderick et al. (2005) found that written emotional expression also produces health benefits in fibromyalgia patients. This growing body of literature suggests that there may be combinations of written and verbal expression of emotions, particularly strong emotions that help reduce pain in fibromyalgia patients. After completing the TRM, patients saw a play with the same theme as they performed, Medealand. The patients’ self-reported pain and health status showed no change after having seen the play; in other words, the positive effect of the TRM was not heightened by seeing the play. Perhaps the results would have been different if the patients had begun the study by seeing the play. The issue of how patients were affected by seeing the play Medealand, compared with actively performing a given part of the play was highlighted in the interview study ( Bojner Horwitz, in press). The results of the study indicate the presence of a “recognition factor”: an opening for therapeutic treatment if offered directly after seeing the play. Health may also benefit from visiting a theater if patients feel safe in the environment in which the follow-up discussion takes place. However, it is important to note that therapeutic theater play requires play leaders with therapeutic competence, as was the case in this study. Recent cultural health research highlights the brain's plasticity in discussing the influence of culture (Grimby, Eriksson, Nilsson, & Själund, 2003). Patients’ behavioral change as evidenced in the video interpretation may also be an effect of acting out strong emotions and a possible manifestation of the brain's plasticity (Bojner Horwitz, 2004). Video interpretation gave patients the opportunity to gain an objective understanding of their own strong emotional expression and even understand that they can change their own emotional expressions and even their own health. Interviews indicated that most patients had never expressed strong emotions of hate and anger, which acting in the theater play allowed them to do. Seeing this on video film could also have affected their perception of pain and health. Kirsch and Bernardy (2007) demonstrated that there is no congruence between fibromyalgia patients’ emotional experience and their affective expression measured with videotaped psychodynamic interviews. This is in line with earlier studies using video interpretation technique to detect differences in a fibromyalgia patient's body image and self-image (Bojner Horwitz et al., 2003 and Bojner Horwitz et al., 2004). This incongruence may be ameliorated by patients’ interpretations from video films of their acting in a theatrical play. There are potentially unique resources within the acting profession that can be used to increase fibromyalgia patients’ health and reduce their pain through the expression of strong emotions. Working with professional actors differs from, for instance, working with drama therapists in that it seems to be less threatening to the patient (Bojner Horwitz, in press). This is the only study that has examined pain patients who have elicited strong emotional expressions through acting out a given script and subsequently experienced diminished pain and better self-perceived health. In this study stress theory is used to explain fibromyalgia patients’ pain perception and oversensitivity. In particular, a stress model that explains HPA-axis perturbations as a result of long-term stress overload with unexpressed emotions is argued to be the established model best suited to analysis of this clinical evidence. Future research could include larger studies with control groups for scientific verification. This TRM can hopefully contribute to further cooperation between actors and therapists in the creative arts and stimulate more research projects teaming culture and health. Cross-fertilization between cultural therapies and expressive art forms could perhaps reduce society's health costs for long-term pain treatment.