Drama Therapy and Eating Disorders: A Historical Perspective and an Overview of a Bolognese Project for Adolescents

Abstract

Objectives:

The authors present a description of a theater workshop (“Metamorphosis Project”), developed at the Bologna Eating Disorders Center.

Design:

The workshops are aimed at young, hospitalized patients, and are largely based on the principles of drama therapy. In this article, this therapeutic modality is introduced by a discussion of the theoretical basis for the use of theater in psychiatry from the points of view of several preeminent psychiatrists, including Freud, Winnicott, Klein, and Moreno.

Results:

Three (3) clinical reports are presented. The satisfaction rate among the first groups of participants was 93%.

Conclusions:

It is suggested that theater can be useful in decreasing defense mechanisms, allowing a patient-focused approach, mitigating specific symptoms, and improving the quality of life during the hospital stay.

Introduction

T he arts, and specifically theater, have always been considered a way to explore human feelings, emotions, and psychologic malaise. Since the days of ancient Greece, theater has played a cathartic role, representing a symbolic reproduction of reality, free of the social conditioning that usually constrains people in their daily lives. Members of the audience identify with the characters on stage, enabling them to feel his or her own fears and sorrows expressed and reflected.

The first explorations in psychotherapy were rooted in the ancient Greek myths and classic plays: for instance, Oedipus and Electra became symbolic manifestations of feelings and impulses that are latent in most individuals. Freudian references to theatrical culture relied mainly on Greek tragedy. Freud's concept of catharsis is discussed in his Studies on Hysteria.¹ Freud considered the imagination as a “middle kingdom,” providing the individual with a relief from the tyranny of his or her own unconscious beliefs. Through the theatrical performance, the artist elaborates and mitigates his daydreams in order to make them accessible to the audience.² References to theater can be found in Beyond the Pleasure Principle,³ where Freud investigated children's play: by playing, a reality that had been lived passively, and may have had negative connotations, could be relived with an active role. The transformation of an event into a recreational activity is possible in spite of the unpleasant feelings that it originally generated.

According to Melanie Klein, play involves the same mechanisms and symbolisms of the dream state: through play, the child explores the outside world and controls his internal world.⁴ The free play of the child, which is rooted in verbal communication, can therefore be considered as free association; for example, Klein used miniature objects that could provide a projective representation of the family and encouraged free associations.^4,5 Winnicott stated that encouraging the child to express himself in play is an important strategy in allowing him to develop and deepen his repertoire of relationships; therefore, play could be considered a form of therapy. So, through play, the child (or adult) explores his environment; through imagination, objective reality can become subjective representation.^6,7

The contribution of Jacob L. Moreno should be mentioned. He was the inventor of psychodrama, a deep action method in which people enact scenes from their lives, dreams, or fantasies in an effort to express unexpressed feelings, gain new insights, and practice new and more satisfying behaviors. Moreno considered spontaneity as intelligence operating in the here and now. In his view, spontaneity propels the individual toward an adequate response to a new situation or a new response to an old situation. The expression of his “improvisational theater” promoted this process by allowing a greater fluidity of speech and the possibility of learning techniques related to the spontaneous use of theater languages. These techniques, when used in compliance with the therapist, can be used in everyday life.^8,9

Theater and psychiatry have been also integrated by Drama therapy, as it appears evident in its first definition of 1979: “the means of helping to understand and alleviate social and psychological problems, mental illness […] through creative structures involving vocal and physical communication.” R. Landy, a renowned American drama therapist, focuses on roles as patterns of behavior that suggest a particular way of thinking, feeling, or acting. He assumes that at least one role the patient needs to play in life is unavailable, poorly developed, or inappropriately aligned with other roles; the objectives of the therapist are to help the patient to identify that role and access it (through representation), eventually expanding his role repertoire.^10,11 The importance of exploring new roles has been stressed also by R. Emunah, who also focuses on containment. In her practice, the scene is intended as a step ahead of the actor's real life—that is, the behaviors, roles, and emotions portrayed in drama become part of one's repertoire, a repertoire that can be drawn upon and appropriately released in life situations; the experience of a new response in the scene facilitates such response in real life. Also, in Emunah's concepts, time can be manipulated in order to ease painful experiences: while the past can be considered a way to comprehend the present, the future holds the possibility of a change. Viewing the present from the vantage of the future (for example, enacting a scene that takes place 5 years from now) permits heightening of the perception of the current situation (reminiscing about the experience of “5 years ago”).¹²

Moreover, S. Snow highlighted the potential uses of performative drama therapy, particularly in repairing the weak self-image of patients. In his view, the process of rehearsal and performance is intense and deeply communal, and provides a real opportunity for growth.^13,14 A key point in drama therapy is the concept of aesthetic distance, a state of balance wherein the patient is able to experience a confluence of thought and feeling.¹⁵ Aesthetic distance prevents overabundance of emotions (underdistance) and excess of rationality (overdistance).¹⁶

The use of experiential and expressive techniques in the treatment of eating disorders (ED) has been increasing in the last decade. ED (like anorexia nervosa, bulimia nervosa, binge eating disorder) are psychiatric disorders characterized by aberrant patterns of eating behavior and weight regulation and by disturbances in attitudes toward weight and distortion of body shape. Their cause is elusive, with social, psychologic, and biologic processes all seeming to play a major part, and they are difficult to treat, with some patients actively resisting attempts to help them.¹⁷ Treatment focuses on two targets: (1) the physical well-being and survival of the patient, and (2) understanding the issues underlying the difficulties with food. Expressive techniques are useful in the second target as they uncover stored feelings and memories of bodily experiences; help people become aware of, understand, and integrate the inner world; and work with a spectrum of difficulties that characterize patients with ED (interpersonal distrust, social insecurity, shame, ineffectiveness, lack of self-awareness, fears of exposure, rejection, perfectionism, and criticism).¹⁸

The purpose of these techniques is to better understand what patients are trying to communicate with a maladaptive behavior and to help them learn new and more satisfying ways to interact with others.¹⁸ In addition, experiential techniques that use nonverbal expression tend to reduce the defenses of the subject: that is, unexpressed feelings may, in time, be expressed and understood.¹⁹ Working with ED, expressive and creative activities are also intended to divest the obsessive thinking about food and body image by helping to direct cognitive activity to other content.²⁰

The arts can therefore elicit the full expression of self, improve the ability to maintain healthy interpersonal relationships, help the individual recognize and express their emotions, and establish contact with one's own resources.²¹ In addition, the arts can improve the expressive possibilities that involve the body and mind with activities that develop an awareness of self as a physical, intellectual, and emotional unit.²²

Theater-based interventions aim to stimulate the processes of expression; the experience of a dramatic performance allows for the patients' communication of emotional states and increases the opportunity for reflecting on and learning from them. It is possible to evoke a gradual emotional awareness through the development of specific techniques of expression (using the body, speech, rhythm, and props) in order to promote more opportunities for communication and processing.

With the following part of the article, the possibilities of theatre as an integration of conventional treatment of ED will be discussed, by presenting a project activated in the Bologna Regional ED Center (Child Neuropsychiatry, Sant'Orsola–Malpighi Hospital) with a description of three clinical reports taken from the authors' experience and publishing a small survey from our first group of participants.

Metamorphosis Project

Theater can play a specific and important function during the multidisciplinary assessment of ED. The drama workshop can assume the function of a frame for actions, emotions, and relationships, becoming a transitional area in which feelings may be understood and patterns of thought can be assimilated. In the hospital setting, particularly in the field of ED, the day is likely to be marked by repetition of the same regimen and rhythms, and often dominated by obsessive thoughts; the drama workshop acts as a setting separate from the patient's hospital routine in order to explore different ways of thinking, perceiving, and interacting that can be applied in everyday life. The workshop thus becomes a setting for change.

In fact, the difficulty in identifying, regulating, and symbolizing emotions has been widely studied in ED; the recovery of awareness of feelings (including the awareness of having a body) is understood to be a key point in supporting these patients' development.²³

The intervention does not focus primarily on food (except particular cases, see below) as it targets the impairment in several domains whose improvement can help in reducing the altered eating pattern.

In sum, theater may be used in the assessment of ED in order to (1) understand what the patient is trying to communicate by maladaptive modalities; (2) help the patient learn new communication skills; (3) reduce the patient's defense mechanisms by nonverbal communication; and (4) redirect the patient's obsessive thoughts about food, diet, and body image to new content. To realize these objectives, the theater workshop aims to stimulate the patient's self-expression and recognition of his or her own feelings; encourage functional interpersonal relationships; develop the patient's awareness of his or her own latent talents and inclinations; and eventually enable the patient to achieve a better integration between the mind and the body.

Materials and Methods

The Bologna Regional ED Center has developed a theater workshop (“Metamorphosis Project”) that is aimed at young, hospitalized patients, and is largely based on the principles of drama therapy and psychodrama as previously discussed.

The project works in accordance with conventional treatment programs (medical and nutritional support, individual psychotherapy, interviews with family, group psychotherapy, and recreational and occupational therapy sessions) and aims to do the following: investigate the themes and fears that are difficult to access during the normal psychoeducational rehabilitation program; to encourage spontaneity and improvisation; to promote self-esteem through the creative process; and to develop the ability to externalize the inner world.

The exercises and plays are patient-focused and follow the guidelines of medical and psychologic personnel, working on specific aspects of personality. Through theater—specifically, the creation and performance of dramatic or comedic plays—it is possible to create a space for both symbolic and verbal communication between patients and the therapist, and consequently, the medical and psychotherapeutic team.

The setting of the workshop is crucial: it is external to the ward—taking place in special classrooms or, when the weather permits, outdoors in gardens—and the therapists have no institutionalized role in the therapeutic project. Therefore, it allows the patient a structured respite from hospital regimentation.

A workshop session is divided into four phases:

• Warm-up (30 minutes): exercises and group games—presentations; participants' interpretations of different types of characters; “Theater of the Oppressed” exercises;²⁴ and bioenergetics—which reduce anxiety and defense mechanisms (mistrust, isolation), and create aesthetic distance.

• Choice of a character: the patient is led to reflect on the similarities and differences between his/her chosen character and him/herself. In this way he/she is facilitated in expanding their repertoire of roles, emotions, and flexibility.

• Development of chosen character: exercises for the development of the patient's chosen character, mediated by social workers during the week, provide stimuli and a channel to divert thought from food obsession.

• Performance: possibly with an audience, which in our department comprises pediatric patients. It embodies the improvement in patient's progresses in spontaneity and loss of perfectionism, is a test in a process of de-alienation and, with the pediatric patients' applause, gives an immediate feedback of joy. By performing, a patient is helped in becoming aware that he or she is more than the food they are eating. An example of performance is the representation of the medical round.

As part of the development of a theatrical scene, other elements can be included in a workshop session, such as fictionalized television commercials, which demystify seductive mass media messages; comedic theater moments, which encourage the patient to accept unpredictable behaviors and personal imperfections and, thereby, experience failure as a harmonic part of the Self; dramatic or comedic scenes that incorporate references to the adolescent's external world (including television); moments of verbalization and reflection that are often concentrated during the greetings prior to the warm-up activities and at closing remarks at the end of the workshop. Each session is concluded with a scream, intended to liberate an unexpressed inner voice.

Case Reports

The case of the sweet and the salty

A male, 15 years old, with a body–mass index (BMI) of 13, was admitted due to severe anorexia nervosa (AN). For the 6-month period prior to his hospitalization, the patient subsisted solely on liquid food supplements, honey, and fruit juices; he could no longer taste salt or solid foods, and showed a phobia of evacuating. Psychotherapeutic and pharmacologic approaches had little effect. It is noteworthy in light of what follows that this patient demonstrated a talent for music prior to his illness.

A role-playing scene was created in the style of an episode of a talk show; included among the guests were: the patient; Mr. Sweet & Salty (played by the leader of the workshop); Miss Semisolid (another patient); and the imaginary brother of the patient, who loved solid and salty foods. In the second part of the talk show, Mr. Sweet & Salty split into the two components (adding a guest interpreted by another therapist), each two of whom interacted with the patient and with his brother. Thus, he could verbalize his aberrant eating pattern and the underlying fears directly with a personification of the phobic objects and he could receive answers from them.

The characters' symbolic qualities emerged out of their concrete identities and each component described its characteristics, inclinations, and preferences. For example, the personification of solids and salt was used as a means to connect with the patient's view of the concepts of strength and power; to highlight this concept, each quality of food was also associated with a musical instrument by the patient. When, aided in these associations by the therapists, the salt was associated with a battery (patient's prior instrument), music allowed him to convey an immediate characterization: the boy had lost his physical vigor, his interests (for instance, playing music), and his normal approach to food at the same time. Through the transitional space created by the participants, a symbolic representation of the patient's obsessions was possible, allowing a dialogue with the patient's internalized voices; his fears were expressed more spontaneously and thus were more comprehensible even to the therapists. When these conflicting feelings were personified, they were made tangible and somewhat malleable, helping the boy to make the decision to start eating again.

Now the patient has made a full recovery and maintains an acceptable BMI of 18; on several occasions, the patient referred to the theatrical experience as important in his decision to begin complying with the therapeutic plan.

The play about Darwinian evolution

A 16-year-old girl with a BMI 13.5 was admitted due to severe AN with alexithymia and depressive comorbidity. Her Draw-the-Family Test did not yield any relevant information. When asked to place the members of her family on a hypothetical evolutionary scale—from less evolved (that is, a monkey) up to more developed—she put her father as a primordial primate and placed her mother standing with outstretched arms directly in front of him, like a wall. The patient was squeezed between the two parents, precluding any attempt to establish her own autonomy or separation. Her brother (a “rebellious” 20-year-old) was placed in front of her mother; her sister (an ex-anorexic patient) was placed at the top of the evolutionary scale. This play was used to stimulate the patient to reflect on her familial dynamics, about the role yielded by each component, her conceptualization of “ideal family” in contrast to her family, and about the importance of her sister who suffered from her own illness some years before. For instance, her mother represented the incommunicableness and the monkey represented the absent paternal figure who does not understand the seriousness of the situation. The role of her brother was also stressed as an example of individualization. At the end of the game, and during psychotherapeutic sessions, she verbalized her will of “being like her sister.” These data were also discussed during family psychotherapy sessions.

Communicating violent experience

This patient, a 12-year-old boy with a BMI of 12.6, had a diagnosis of AN. The patient was a victim of prolonged bullying and physical violence by some classmates for the 6 years he attended school. These classmates used to attack him also because of his physical appearance because he was small, thin, and feminine. The bullying had been experienced as humiliating for the boy and occurred concomitantly with the onset of a restrictive pattern. Although the hospital personnel had been made aware of this history through familial interviews, the boy showed extreme resistance to addressing the issue during his individual sessions. During a play with a school as the setting—a choice encouraged by the workshop leaders with the aim of investigating the underlying conflicts—the patient proposed his own history as a scene. A simple psychodrama was applied; thus, he played himself, then his friends, and finally his perpetrators with the other participants; at the end of the representation he was talking to the other ED patients of his experience with detachment and determination. Albeit with difficulty, the boy eventually began to disclose his traumatic experiences during his individual psychotherapy sessions; he reflected with the psychotherapist about his self-image and the implications that the bullying events and the eating disorder had on his perception of his own body. He improved his motivation and became more compliant to the personnel's advice; this was reflected in clinical improvement.

Results

The first workshops involved 15 patients (14 females and 1 male; mean age 15.3±1.4, ranging from 14 to 19 years old; cases 1 and 2 are included in the sample) admitted to the authors' ED Center (Child Neuropsychiatry Unit, Sant'Orsola Hospital, University of Bologna) with a diagnosis of AN. Patients attended an average of 10 weekly workshops (ranging from 6 to 15 weeks). The described sample does not include patients <14 years of age; those who were unable to participate due to medical reasons; and those who were not willing to join the theatrical group. Some indexes of satisfaction were investigated in a small survey that was completed by each participant before the workshop cycle began and at the end of the last session. Patients could also give a self-evaluation about the following items: spontaneity, teamwork, creativity, expression of feelings, and shyness. Moreover, patients completed the Toronto Alexithymia Scale (TAS-20, a self-report of 20 questions and a 5-point Likert scale, intended to assess affective dysregulation) and the Scale psichiatriche di Autosomministrazione per Fanciulli e Adolescenti (SAFA) test,²⁵ a broad range self-report investigating depression, anxiety, eating patterns, somatic concerns, obsessive–compulsive symptoms in children and adolescents) at the beginning and at the end of the experience. Data were analyzed by the statistical program Statistical Package of Social Sciences, Chicago, IL, USA, for windows software program, version 14.0 integrated with the module Exact Tests (suitable for small samples) that detected statistical significances. The following findings were tabulated: 93% of the participants revealed satisfaction in taking part in the cycle of workshops due to various reasons (Fig. 1); the same patients recommended that other people suffering from ED participate in similar workshops. Furthermore, 71% of the patients reported that the positive feelings experienced during the workshops were accessible to them during their everyday life. A statistically significant improvement was found in the items investigating teamwork (p<0.001) and spontaneity (p<0.01). TAS-20 showed a significant reduction (p<0.05) at the end of the cycle (53±15, borderline range) if compared to the first administration (62±14, alexithymic range). SAFA showed an improvement in obsessive thoughts, mood, and in particular a reduction of anhedony (Table 1).

FIG. 1.

Reasons for being satisfied by the workshops reported by the participants.

Table 1.

Statistically Significant Results of SAFA Test, TAS-20, and Self-Evaluations

N=15	Start	End	p-Value
TAS-20	62±14	53±15	<0.05
SAFA O	58±12	53±12	<0.05
SAFA D	66±13	61±14	<0.05
Anhedonia (SAFA)	67±13	59±15	<0.05
Spontaneity	1.9±1.1	2.9±0.6	<0.01
Teamwork	2.7±0.7	3.7±0.6	<0.001

Toronto Alexithemiaa Scale (TAS)-20: normal values ≤50; borderline values 51–60; pathologic values ≥61.

SAFA, Scale psichiatriche di Autosomministrazione per Fanciulli e Adolescenti; symptoms negation ≤30; tendency to negation 31–40; statistical normality 41–59; basically pathologic symptoms 60–69; pathologic symptoms ≥70.

Surveys (spontaneity, teamwork): from 1 (not at all) to 4 (a lot).

In Table 2, subjective benefits noticed by the 15 patients are listed.

Table 2.

Subjective Benefits Reported by Patients

Subjects	Answer to item: what did you get from our experience?
1	Courage, determination, interest in Arts
2	Fun, freedom
3	A way to express one's emotions
4	A way to overcome shyness
5	Fun
6	No take-home message
7	Spontaneity, serenity, joy
8	Fun
9	Happiness, fun, solidarity
10	A way to express emotions, know oneself, learn how to stay with the others
11	Emotions, energy, creativity, interest in everyday life
12	To understand one's own body, to know about the disease mechanisms
13	Self-esteem, to learn how to stay with the others
14	Self-esteem
15	Decrease of social phobia

Discussion

Conventional approaches and theater can be integrated into the multidisciplinary approach in the treatment of ED, in order to expand the self-awareness of each patient and allow for more effective therapy. By using drama therapy, it is possible to strengthen the ego structure and encourage the perception of self. The healthy expression of self in a protected but stimulating environment can increase the patient's self-confidence and contribute to a more peaceful attitude toward life, which can be useful in reintegrating into school and social contexts. In fact, at the end of workshops, patients showed a reduction of anhedony and reported a renewed interest in everyday life. The reported increase in spontaneity (one of the core targets of our workshops) has important potential implications as it has been identified as a key factor in determining a positive change in the motivation to recover in patients affected by AN.²⁶

Participants reported that feeling free to express themselves and being part of a team were crucial points in enjoying the theater workshops, and that being able to participate in the workshops improved their quality of life during their hospital stay. The flow of information between the therapists and the medical and psychologic personnel permitted a more focused treatment on the needs of each participant, improving the knowledge of the individual dynamics underlying the eating symptom. Moreover, sometimes results were achieved with regard to compliance with their therapeutic plan, and in some cases the core symptoms of aberrant eating behavior could be addressed, as shown by the first clinical report. The experience was seen as a space where obsessive thoughts could be set aside in order to eventually overcome them; this was reflected in an improvement in the SAFA results. During the workshop sessions, the patient is liberated from the role of “the sick one” and allowed to develop a more adaptive method of self-expression. The performance was felt with a sense of freedom, the possibility to have a pediatric audience was perceived as an enjoyable moment and no sense of shame was experienced, even with regard to each participant's own illness. When a hypothetic medical round was performed, the ED patients could be mirrored in their own difficulties and even laugh about what they used to perceive as a difficult moment of their day.

Even when results on ED symptoms are not attained, theater is seen as a positive and joyful experience that the patient looks forward to during the week. The rigidity, distrust, and perfectionism that often inhibit ED patients' self-expression can be mitigated on stage; even the audience—which, in this case, comprised pediatric patients—can enjoy the experience, giving patients positive feedback.

Conclusions

Although few studies have been performed about theater and ED, it has been noticed that theater is a feasible and possibly effective strategy for use in interventions aimed at the prevention of weight-related disorders.²⁷ An approach that integrates drama therapy, psychodrama, and verbal therapy can offer an innovative alternative to traditional group therapy.²⁸

Patients as well as medical and psychologic personnel confirmed the above-described hypothesis about the role of theater in the assessment of ED, giving the authors positive feedback and encouraging reports. Therefore, it is hoped that future research and rigorous studies will investigate the effective role of theater in the assessment of ED.

Footnotes

Acknowledgments

We kindly thank Mrs. Amy Hoch for English language editing.

Disclosure Statement

No competing financial interests exist.

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