Thriving with chronic pain: A newly qualified Dramatherapist’s journey towards learning their body’s language

Introduction

For me, becoming a Dramatherapist was one of the most obvious paths to walk down – an ethereal calling to become what I was always meant to be. However, walking, whether metaphorically or physically, can be challenging. I felt great trepidation towards pursuing the goal of becoming a Dramatherapist, as I feared my body may not be a reliable ally. Within Dramatherapy, the body speaks when words are insufficient; I was consumed with the prospect that my body’s language would not be enough (Malchiodi, 2020).

After outlining my methodological approach and identifying how my body associates with chronic pain, I will contextualise my body within society and what brought me to training as a Dramatherapist. I intend to delineate my initial engagement during training, marking how this new world needed me to reconsider my chronic pain, the way my body moves and the way I treat it in return. I will then traverse the terrain of the implications generated from having a differently abled body in training and with clients. This will be in order to curate an image of what I believe needs to be confronted, changed and challenged. Moving on from the essential acknowledgement of the effects of chronic pain, I will explore the transition from surviving to thriving, through finding my voice and space in the Dramatherapy community, where I was shown that although my practice might be different, it is as valid as that of able-bodied therapists.

Methodology

Methodologies must be chosen to fit the work; the work should not contort to fit the requirements of an allocated methodology. Otherwise, that could forge a parallel process with how individuals with a disability feel in society, having to make themselves fit a mould of predetermined acceptability. Autoethnography is my methodology of choice: it demands authenticity, bravery and reflexivity from those who use it; this is complementary to how I wish to present my narrative (Harnden, 2018; Sikes, 2022). Autoethnography seeks to elucidate unseen and unheard narratives (Bird, 2017). I was initially left uncertain as to whether my narrative would be credible in and of itself. However, the validity in autoethnography is found within truthful excavation of selfhood within the context of complex societal matrices; disability must not be excluded. There is a fear, that by making myself visible, I risk being re-othered by the world and jeopardising acceptance by my new profession. However, risk frequently accompanies significant journeys. Autoethnography will be applied as a means to differentiate between essential transparency and indulgent narration in order to seek constructive universality. It is my hope that through co-adventuring with autoethnography, I will be empowered to speak my truth in an accessible manner: a truth someone else may need to hear.

The pain

With autoethnography, it is essential for the author to situate themselves either adjacent to or directly within their writing, acknowledging that the context of the author inevitably has inextricable implications. The manner that I am positioning myself within this article is through my pain as a conduit through which I interact with the world. My chronic pain originated from a motorcycle accident at 16 years old, exacerbated by a fall during my undergraduate degree in rehearsals, followed by a number of years of working a physical job with individuals with autism – all of which heavily impacted my lower back. Lower back pain is stated as being the most prevalent cause of disability (Wippert et al., 2022).

Years of psychologically annexing these injuries led to the muscles fusing around my lower spine. My body’s attempt to protect me from further damage, using my muscles to cushion my spine in order to hold my vertebrae in place, caused me to unconsciously react to all pain as if it was life-threatening. Nervous system signals can get misinterpreted due to physical and psychological trauma, ultimately altering perceptions of danger through hypersensitivity, leaving the already wounded more susceptible to further pain (Van der Kolk, 2015; Tsur, 2022).

The pain that all of us experience is multifaceted and layered. With this in mind, it is pertinent to note a factor of my chronic pain which moved into the foreground during my final year of my Dramatherapy training: endometriosis. This condition causes the womb lining to thicken and extend beyond its typical boundaries, causing excessive menstrual bleeding, severe cramps, back pain, a regular inability to carry out daily tasks and a difficulty in getting pregnant (NHS, 2022). 1 in 10 women in the United Kingdom suffer with endometriosis, which is thought to have a high co-morbidity with poor mental health due to the pervasive symptoms combined with the stress of fighting for a diagnosis and treatment (Delanerolle et al., 2021). However, it is also one of the most underdiagnosed diseases (Chopra, 2020). A potential influencing factor of this could be due to an intersection of oppression. Women and menstruation appear to be a commonly disregarded aspect in medical research, garnering a mere 2.4% of publicly funded medical research (UK Health Research Analysis; Medical Research Council, 2014). This neglect can lead to isolation, helplessness and a worsening of symptoms, due to not receiving the support and healthcare interventions required.

These elements have forged my ailments and impact my daily and professional life. Consequences of injuries and disease are that I have to take care towards pain management through the use of scheduled and specialist pain relief, physiotherapy, cautious calculations of physical activity, medical treatments and, when necessary, the assistance of a walking stick. When your body goes against the grain of perceived acceptability, sensations of anger, shame and guilt are capable of consuming you. The somatic response of shame can even result in the intensification of chronic pain (Cohen, 2011).

My body and I have been burdened with the shame of having a differently abled body for many years. I have felt the need to mask my chronic pain, leading it to worsen as I forsake my needs for the benefit of a neglectful society, becoming complicit with gaslighting myself in the same way as medical systems frequently did. However, if I was going to be an inclusive therapist, I knew I needed to greet my body with the same flexibility of practice and respect as I would a client – something had to change. With the drive to train in this profession, I needed to reframe my relationship towards my chronic pain, moving from shame and mere survival to not only accepting my body, but celebrating it so that I can thrive.

Context

My body does not exist in a vacuum, it is bombarded with images of what is expected each day and each time I need to make adjustments to make the world fit my needs. Ableism is a pervasive intrusion of toxic beliefs – that people who move differently are not equal to, as visible or as capable as those who do not experience chronic pain or have a disability (Campbell, 2012). It is pertinent to mark that I exist with a level of privilege in this world as a white, cis-gendered and educated woman. This undoubtedly results in my lived experience of chronic pain not necessarily being compounded by additional vulnerabilities (Beck, 2020). Non-visible disabilities are defined as those that do not present with a visual marker of impairment, such as mental health disorders, brain injuries, chronic fatigue and chronic pain (Cook, 2021). Due to the fact that I do not always require a walking stick and this often-indetectable nature of chronic pain, I can pass as an able-bodied person, providing me with an element of privilege as I can withhold knowledge of my pain from those around me. It can, however, illicit discomfort due to the frequency of needing to disclose my limitations and the required alterations to my practice, invoking a sense of shame within me.

The way a person with a disability navigates the world can largely be influenced by the lens that society views them with. The medical model of disability places the onus on the person who has a disability to shapeshift for society (Dupr, 2012). The social model of disability relocates the focus onto society, whereby society must renegotiate a world built for ‘able-bodied’ individuals in order to be accessible, physically and psychologically (Beck, 2020). The consequences of living in a society where value is placed arbitrarily on normalised skillsets lead me to feel incomplete, resulting in a deeply rooted sense of failure. This failure percolates, turns septic and transforms into toxic shame. When shame becomes a second language, empowerment and community can be saviours in cleansing these wounds (Herman, 2015).

The stigma of using mobility equipment is arguably lifting. In theory, glimmers of hope are portrayed through policies and legislation being implemented across working environments. Key legislative improvements have come from the ‘Equality Act’ (Legislation.gov, 2010) and the government’s ‘New National Disability Strategy’ (Gov.uk, 2021), which promotes greater workplace support. There does remain a discrepancy between words and actions, presenting a sense of in-congruency. Banners of inclusivity are flown, but logistical components are routinely neglected, such as inadequate equipment, poor access and misguided able-bodied expectations.

As a person who experiences menstruation, there is an additional layer of shame placed upon my pain. As menstruation remains a taboo subject across many cultures, adjustments are largely neglected in the workplace (Sitar, 2018). Shame envelops me when faced with disclosing additional needs in relation to menstruation: resting due to cramps, appointments that necessitate absences and sick leave when it becomes too much. The diagnosis of this disease at this detrimental stage of my training simultaneously formed a sense of relief and grief. After years of desperation for answers and believing I imagined my pain, I finally knew. However, I realised my battle with endometriosis was a saga that was just beginning. Bimonthly biopsies, medical examinations and hormone treatments put me on the verge of both a resolution and becoming a Dramatherapist.

Pre-training

Before I jump too far ahead in my journey, I would like to honour the seed that it all grew from. Dramatherapy was an intervention that had sparked my curiosity and passion for many years before I applied for the training. I perpetually delayed engagement with training as I felt my body and mind were not a safe enough space for myself and, therefore, my future clients. To attempt to prepare myself for this journey, I devoured any literature I could on the subject and submerged myself within it. The literature I encountered spoke of how the body acts as a conduit for communication; this appeared to me a foundational element of Dramatherapy practice (Russo, 2018). This notion intimidated me, as the level of physicality that was presented as the standard was not sustainable for me. The more I learned through abstract and non-embodied means, the further I drifted, spiralling deeper into the narrative that this career was reserved for those who are able-bodied and do not experience chronic pain.

Throughout months in physiotherapy, after my latest health regression in 2017, all I could focus on was the phrase ‘fitness to practice’ – a looming banner of exclusion awaiting me. Fitness to practice is an essential criterion to being accepted for training and to adhere to the Health Care Professions Council’s (HCPC) standards of practice (HCPC, 2018). However, in the position of pre-studentship, I lacked a definition of what this truly looked like; my mind metaphorised it into a monster and anxiety capitalised on the vagueness it evoked. This fear grew, and my hope for a future as a Dramatherapist diminished: could I ever sustainably hold fitness to practice?

My first step was confiding in those who I felt safe with. I worked closely with a music therapist, who I first uttered the words ‘am I fit enough to practice?’ to. Wounds of the flesh and wounds of the mind, do they disqualify me from the helping profession? They took me under their wing in a number of ways and gave me the confidence to bring my fear to a university open day. There, I told my future course lead my doubts, questioning whether someone can be a Dramatherapist and need a walking stick. I was met with acceptance and confusion, as the answer of yes seemed so obvious to them. Curious and suspicious of this talk of inclusivity after a lifetime of social conditioning and the actions of those in power around me, I began to reach out to a wider community of Dramatherapists.

Searching online, I came across an organisation called Dramatherapy Southwest, a regional association of Dramatherapists founded in 1989. Their aims are to connect Dramatherapists in order to facilitate creativity, community and collaboration. I reached out to Dramatherapy Southwest and inquired whether it was appropriate for me to attend their conference, despite not being in training or a qualified therapist. I was taken aback when the chairperson at the time invited me in. At the 2017 Dramatherapy Southwest conference, I was able to talk to qualified Dramatherapists and former lecturers from the Dramatherapy course in Exeter and hear about each individual’s journey to qualifying. The one reoccurring motif was that none of them had anything in common. Yes, they all became Dramatherapists, but how they reached that point and what they carried with them varied immensely. I was heartened to find that there were therapists who experienced chronic pain, had mobility issues or a past that presented itself in their present. Hearing them discuss the trials and tribulations of navigating their training and practice filled me with not only optimism but also a confirmation that I was not imagining how difficult it would be to train with my body. It was going to be strenuous; it was going to be demanding, but it was not impossible.

In training

Stunned, I was accepted on to the course, and from the very beginning, immersion took place. I dived deep into the process, unsure if I would swim or drown. Training as a therapist is always going to be accompanied with discomfort: we are not only absorbing new knowledge and holding clients for the first time, but also excavating our most entrenched behaviours and analysing historical patterns (Urmanche et al., 2021). This psychic confrontation is synonymous with growth, potentially acting as a palpable route to feeling compassion towards my own pain and body; if I remain open to the process, I could learn my body’s language for the first time.

My brain has been programmed to identify and adapt circumstances to fit my body, leading to a pattern of hypersensitivity, anticipating when I will be made to feel inadequate and othered next. Due to the suspense this neurological functioning creates, my chronic pain is exasperated. Stress is a pervasive amplifier of chronic pain; therefore, in times of emotional turbulence, my pain is intensified (Wippert et al., 2022). It is suggested that this is a consequence of the neuro-endocrine system being activated by the stress responses, which plays a part in influencing both pain receptors and perception of pain (Wippert et al., 2022; Van der Kolk, 2015). This is magnified further if an individual has experienced trauma. Due to its stress-inducing qualities, trauma induces a hypersensitivity to sensory data (Tsur, 2022). The result of this is that my back acts as a barometer, indicating and guiding me towards areas of psychic tension that need addressing. This was the inaugural barrier I was confronted with at the start of my training.

Feeling so immensely powerless within my nervous system and societal conditioning, I sought to reclaim agency through renegotiating my surroundings to fit my requirements. I knew if I did not, the longevity of my training and practice would forever face limitations. The first calculated alteration for my body was purchasing a folding chair with no legs; this enabled me to sit on the floor with all my peers during activities, providing a visual marker of equality and preventing me from feeling othered. This has been invaluable to me during training, dramatically decreasing my pain within the university day. Although my peers and lecturers accepted this with apparent ease, allowing me to feel part of the group and not a perpetual outsider, I felt embarrassed to need such an aid. Consequently, facing this fear of a visual marker of difference, I began to build my confidence towards addressing my chronic pain and becoming an advocate for myself.

All aspects of my training have been challenging in a variety of joyful and frustrating ways; however, a phobia of sorts was born when beginning to engage with the embodiment phase of Sue Jennings’ (2005) Embodiment Projection Role. Initially curated from phases children progress through, it provides a framework of stages to be revisited in later life, if developmental gaps are present (Jennings, 2002). Embodiment is chronologically first, as children initially explore life through movement and senses; Projection represents seeking transitional objects as an extension of the self; Role is a growth in the complexity of expressed narratives and life rehearsals through play (Jennings, 2002; Powell, 2014). It is common practice to match these stages with creative activities, such as Embodiment to movement, Projection to puppets and Role to role-play (Dickinson and Bailey, 2021).

I believe this apprehension was, in part, due to my experiences of trauma. My body had not always been a safe space to be in; therefore, it felt intimidating and, at times, detrimentally unsafe (Malchiodi, 2020). Embodiment is capable of making an individual feel as if they must revisit the site of their trauma (Malchiodi, 2020). For those who experience chronic pain, that site is also on fire. Placing aside historical narratives that can curtail curiosity, a significant contributor to my resistance to embody was whether I was acting fraudulently. On most days, I was not capable of expending the type of dynamic agency experienced by lecturers and peers, who by comparison moved with relative ease, creativity and energy. Although I was never directly told my manner of embodying was not good enough, I was never told it was enough or shown examples of the non-normative forms of embodiment. When society has been conditioning me to believe that I am not enough my whole adult life, not having it made explicit that disabled bodies are adequate intensified my internalised shame.

Observing peers in free flow movement, undulating with each breath and skimming across the air, my sense of inadequacy swelled. I began to covet a body that fitted into what I thought was described in literature as authentic movement. With this sensation of ineffectiveness, society’s narrative of inferiority is invited into the room. When lecturers, peers and visiting practitioners led exercises that incorporated movement-based instructions, I was frequently left feeling like less than a second thought. Occasionally, a phrase of ‘adapt this to your body’s needs’ was thrown as an offering of attempted inclusivity. However, with society’s ideologies weighing as a burden on my shoulders, it felt ill-conceived: it is down to me to adapt their activity, as opposed to pre-considering how different bodies move. This mirrors how the medical model of disability functions in the world. I believe this sensation was magnified through the hypersensitivity that can be forged through navigating a world that was not built for people with disabilities. With discrimination round each corner, a person can will discrimination into existence in any context. Therefore, it is difficult to determine whether this language represented a micro-aggression or whether I have simply been conditioned to suspect exclusion. However, my body’s lived experiences established the lens, perhaps providing a valuable insight into how clients with disabilities may feel when presented with vague embodied language.

It is not enough for an institution, a workplace or an individual to not discriminate against those with reduced movement; I believe they need to consistently address it, articulate it, and name that stillness is still a valid form of embodiment. It is not enough to hope a person knows their body is welcome, we need to invite them in. This is because individuals can become so accustomed to society’s shame and exclusionary narratives that we can carry it like a shroud, permeating one’s vision of what their body ‘should’ be capable of. In my training, it was never merely one act of acceptance that I needed to trust that I deserved to be there; consistency was what I desired. When the lifts are out of order on my training site, I retract in my pride of being a woman with chronic pain, receding into being a victim, just how society appears to like it. Ambiguity over whether an occurrence or ethos is an act of micro-aggression causes an individual to be discriminated against twice, once in their mind and once in reality.

I vividly recall the first time at university where I needed to leave early because of the intense pain I was in. I felt in my heart that no-one would believe me, I envisioned accusations of hypochondria, at best or liar, at worst. I was suspicious of the offerings of acceptance that I received from the lecturers; my paranoia was activated. By trialling advocating for myself by honouring my limits at university, I was able to put to bed the fantasy generated by societally curated paranoia; through naming it, I could begin to tame it (Siegel, 2010). Through being believed, I was able to have my internalised narrative challenged; I was not less of a person because I could not ignore my pain. This acceptance started to generate a newfound sense of safety; perhaps I could begin to use my voice to educate others as well as empower myself.

I began holding my voice within the university walls; however, that is only one element of the training. Commencing work in the field as a trainee Dramatherapist required its own negotiation. Battling internalised societal shame, I urged myself to summon a voice to advocate for myself. Although it is exhausting to ‘come out’ in each new placement, it is essential to bring attention to our needs. Despite the fact that trainees are not always the placement’s priority, we need to respect ourselves by not putting our bodies into situations that are dangerous; it will only serve burnouts, breakdowns and, ultimately, endanger clients. Each time I added my walking stick into my risk assessment, I would feel the swell of impending rejections. However, it is the first step in making real-life alterations that will affect the quality and ethical dimensions of our work. Rejections may emerge; however, each of my placements has made every effort to consult me in regard to the suitability of clients, accessibility of spaces and sought to understand what implications may need addressing from being a therapist with chronic pain.

Through the Dramatherapy training programme, I have been shown how to be a translator for my body. Cultivating my voice throughout the 2-year training allowed me to challenge narratives of inadequacies that have been created from society and cultivated within my psyche. Accepting that some days I cannot do what I want to do, on those days rest is not failure: it is necessary to sustain an ethical practice. Finding my own definition of embodiment empowered me to reject falsities of ideal authenticity. As it turns out, the language my body was speaking was something to listen to, not shun. It provided me with unique information about what I needed. When emotionally exhausted, my body whispers to me with shooting pains up my spine. When absorbed in unidentified countertransference, it alerts me through intense stiffness. Even my womb has something important to say. It was only through detoxifying my relationship with my body and chronic pain, through defending it and defining it, that I was able to start to listen.

Present and future

While researching, writing and contemplating this article, my daily pain escalated – highlighting the power of psychic attention. With my symptoms becoming aggravated, I found myself lingering within resistance, as if inactive rumination could provide relief. Perhaps if I spent this much time thinking about what my body can do and the joys it experiences, will that enable my bodily celebration to multiply too? Contained within this aforementioned lingering avoidance, I found shame-based narratives strengthen, internal dialogues convincing me that despite autoethnography finding its validity within truth, that my truth is not worth hearing. This could be the reactivation of societal shame orientating around chronic pain, perhaps a manifestation of imposter syndrome as a newly qualified Dramatherapist writing for a journal. Whatever the cause, belligerently forging a path into the unknown unveiled itself as a way forward; using my body as an act of political defiance allowed me to rebel against pervasive avoidance.

Being in the room with clients creates additional uncertainty. We may wish to always be able to take the plunge and be alongside the client while they are under the table, but sometimes narrating their location and what you can see and feel can be enough to let them know you are still witnessing them. This in itself generates supplementary internal discords; the sensation of not being a good enough therapist plagues all therapists, we are not special within our self-doubt. Although it can feel toxic and unsettling, it can act as a signal towards always questioning one’s practice, finding new ways of meeting clients’ needs that are not detrimental to our bodies. How can we expect our clients to honour their bodies if we do not honour our own?

Having the strength to rinse and repeat this cycle is exhausting, but with each repetition, it becomes less painful. My voice gets louder and I experience a sense of pride in what my body can do. Future implications for my clinical practice are still being processed; some will not unveil themselves for a long time to come. In the present, I am witnessing that through accepting my body and pain, I can possibly lead by example, modelling that although a person’s journey can be filled with strife, we have not failed.

Detoxifying intrinsic shame takes time. I am only just starting to see a brighter future as a Dramatherapist, one where I have the confidence to redirect the shame where it belongs, towards a society that cultivates discrimination like wheat. Through accessing community, knowledge, clinical experience, not treating my body as an enemy and empowering my voice, I have begun the journey of transcending mere surviving, in favour of thriving; catapulting beyond caution towards curiosity. My journey may not look like yours, nor yours mine, but they are most certainly equally as valid.