Establishing Relationships with Children with Autism Spectrum Disorders through Dance Movement Psychotherapy: A Case Study using Artistic Inquiry
Foteini Athanasiadou, freelance dance movement psychotherapist, Brighton, UK
Vicky Karkou, Edge Hill University, UK
Patrick by the Window
Patrick was referred for Dance Movement Psychotherapy (DMP) because he did not interact with his classmates. andHe appeared able to participated in classroom group activities only when he was requested to and only for small periods of time. His verbal abilities were limited and he usually spent his time on his own, wandering with no apparent aim apparently without aim. Patrick hads a diagnosis of Autism Spectrum Disorder (ASD).
When Patrick arrived in the therapy room he moved directly towards the window and started looking through it. The therapist felt that ‘holding’ Patrick’s desire to stand by the window and watch through it (i.e. accepting his immediate experience) could be the starting point of their in-between relationship. Just standing with him by the window and mirroring his light and quick hand movements helped them to connect with each other...
A Different Kind of Method
This chapter describes a case study series of case studies in which we explored how DMP can support children with ASD to establish relationships. The case study was framed through Here we use artistic enquiry, a research methodology otherwise known as arts-based research, in an attempt to avoid an over reliance on the use of numbers and words. We hoped that this way we could , and so come closer to the non-verbal language often preferred by children with ASD. Our explorations will reliedy heavily on the use of artistic means and movement-based means in particular.
Artistic enquiry is a new methodological genre in postmodern qualitative enquiry (Finley 2005; Leavy 2009). Here researchers, who attempt a researchn exploration through artistic enquiry, use artistic methods to gather, analyse and present data, follow a creative process for their overall design, and analyse and synthesise data through their ‘aesthetic values’ (Hervey 2000).
Artistic enquiry[1][p2] is underpinned by social constructionist ideas (Schwandt 2000) and, as such, it was seen asis especially suited to the small scale detailed analysis of relationships of this study. Social constructionism argues that knowledge is created through experience and within context, while the contenxt (in this case the development of our developing relationships) remains open to multiple ‘truths’ and interpretations of meaning. In addition, artistic enquiry allows space for ‘aesthetic values’ including intuition, embodiment, creativity, kinaesthetic empathy, imagery, emotions and inspiration. Hervey (2000; 2004) distinguishes six phases of the creative process. However, the creative process does not follow a prescribed, linear sequence, but the researcher is immersed in a ‘spiral process’ (Meekums 1993), going back to the data, finding new material, making new associations, until she is satisfied with the meanings emerged.
As an initial example (see Image 1), here is an image which relates the therapist's experience of her meeting with Patrick as he stood by the window.
Image 1 inserted about here
Image 1
The thick lines and the use of a warm yellow colour (that was used in the original drawing) depict my experience of wanting to provide attentive care and support to Patrick. The drop-like shapes (appearing pink in the original drawing) depict Patrick’s initial hand movements, which became more distinct in the course of time. I felt like a mother who pays close attention to her infant and celebrates her infant’s every single tiny effort to initiate action.
Interpersonal Relatedness
Interpersonal relatedness is often seen as the core of human existence, enabling people to make sense of the world and acting as an important therapeutic agent within most forms of psychotherapy (Clarkson 2003; Yalom 2005). Through this perspective, one argues that hHumans are born with an innate ability and need to interact and share their experience with their significant others (Bowlby 1988; Hobson1993; Kugiumutzakis 1993; Meltzoff 1990; Powers and Trevarthen 2009; Stern 1985). Both Ciccone (2012) and Stern (1985) for example, claim that wWithin a meaningful relationship the infant slowly develops an experience (and then a sense) of self, gradually feeling (and then considering) herself as a separate entity from her parent/caregiver (Ciccone 2012; Stern 1985). Furthermore, it has been argued that t The infant's self-regulatory, physical, emotional, cognitive and social skills all become integrated and further developed within a relational context (Greenspan and Wieder 2006; Stern 2012; Trevarthenet al. 1998; Wengrower 2010).
ASD and Relationships
ASD is associated with impairments in social understanding and interaction, verbal and non-verbal communication, imagination, understanding another person’s motives and thinking, and sharing experiences with other people (Hobson 1993; Wing 1996; Wing and Gould 1979; Trevarthen et al. 1998). Resistance to change, anxiety, stereotyped behaviour, lack of motivation and even depression and self-injury are often correlated with a diagnosis of ASD (Wing 1981; Hobson 1993; Sigman and Capps 1997). Deficits in social reciprocity have been observed in children with autistic features under three years old (Trevarthen and Daniel 2005; Stone et al. 1999; Wimpory et al. 2000). It has also been argued that cChildren on the autistic spectrum have difficulties with reciprocal interactions, such as ‘protodeclarative pointing’[1], ‘joint attention’[2]and ‘social referencing’[3] (Hobson 2003; Trevarthen et al. 1998). In typical development it is these information-based reciprocal interactions through which a child learns how to respond to objects and events in practical, emotional and social ways. Deficits in symbolic representation (such as symbolic play (Baron-Cohen et al. 1996; Mundy et al. 1987)), imitation (Rogers and Pennington 1991), and language (Hobson 1993; Trevarthen et al. 1998) are also often part of an autistic presentation.
Despite the diverse presentation of these symptoms, aAll children with ASD appear to have difficulties with interpersonal relatedness. But, there is evidence that suggests that children with ASD do form basic attachment relationships with their significant others (Hobson 1993; Trevarthen et al. 1998) and relate emotionally to other people (Cesaroni and Garber 1991). Children with ASD often lack the organised impulse and structured understanding of how they can respond and relate to other people, but not the desire to relate to others (Sigman and Capps 1997; Trevarthen et al. 1998).
Many interaction models (Alvarez, Reid and Hodges 1999; Burford 1991; Greenspan and Wieder 2006; Trevarthen et al. for overview 1998) suggest that child-led interactions (which follow the child’s motives, interests and rhythms) are particularly effective when relating to children with ASD. Non-verbal modes of communication can support children with ASD to become more available to reciprocal experience (Trevarthen et al. 1998). Elements of ‘proximal communication’ (such as physical interaction with the child, minimum use of verbal language and following the child's lead) have been proved successful in developing social interaction skills in children with ASD (Whittaker 1996).
Dance Movement Psychotherapy (DMP), Relationships and ASD
DMP acknowledges, builds and relies upon bridges of communication beyond the verbal. It works with the whole person (Karkou and Sanderson 2006; Karkou et al 2010). DMP practice is greatly influenced by our emerging understanding of innate infant intersubjectivity: the early impulses displayed by both carer and infant to share, explore and co-regulate mental and affective states through diverse verbal and non-verbal modes of communication, e.g. sound, gestures, words (Meltzoff and Brooks 2007; Stern 2005; Trevarthen 2005). True to the interactive ideas of Chace (Chaiklin and Schmais 1986), the DMP practitioner acknowledges therapy as the interchange between the therapist’s and client’s subjective experience and considers the collection of their in-between interactions in the present moment as a factor for therapeutic change and growth.
One significant aim when working with children with ASD is that of building a body image (Erfer 1995)[VK3]. According to Erfer (1995), w Within a regular developmental trajectory, developing a body image supports the baby to distinguish herself from the environment (including other people). This functional distinction is integral to the ability to form relationships (Erfer 1995). Similarly, Stern (1985) argues that an infant slowly builds a sense of core self from her birth until six months of age. During this period, an infant comes to understand that she is physically separate from the caregiver and therefore is able to start building a subjective experience. With felt subjectivity comes the possibility of entering the domain of ‘intersubjective relatedness’.
It is therefore possible that cChildren with ASD can be supported in their development of their sense of physical self through sensorimotor-based activities, extensively used within . DMP practicecan support children with ASD in sensory-motor integration (Scharounet al. 2014). Erfer (1995) argues that it is indeed It is through sensorimotor activities that a child becomes able to build a body image and develop her self-concept[VK4] (Erfer 1995). Dance movement psychotherapists working with children on the autism spectrum stress the importance for these children to experience their body as a whole first and later explore different body parts[VK5] (Sherborne 2001; Tortora 2006). Others describe how children with autism can become slowly more aware of themselves (and consequently more communicative) through touching their body parts (Adler 1970; Erfer 1995; Siegel 1963). In our case study, sensorimotor-based activities helped the children to explore their body, their body’s possibilities and limitations and eventually build a stronger body image. It is important for us to note here that many children with ASD suffer from hypersensitivities including a hypersensitivity (sometimes aversion) to physical touch. This wasreality is taken under significant consideration in this caseby dance movement psychotherapists as it is specifically relevant to their practice. The therapist tried to be is always sensitive to, and led by the child – she accepteds the child’s choice in involvement in sensorimotor-based activities and followeds the child’s particular way, preferences, and style. [VK6]In addition, the therapist supporteds this involvement by the use of props and sensitive movement suggestions, allowing for diverse possibilities as relevant, and potentially empowering, to each child. The possibilities for sensorimotor-based activities are endless. There are a great many ways to support and empower a child in movement exploration.
The literature suggests that cChildren with ASD can develop their social awareness and communication skills through imitation (Katagiri, Inada and Kamio 2010; Nadel and Peze 1993). However, dance movement psychotherapists do not simply imitate the other person’s movements, but 'mirror'[4] the person’s muscle tension, body shapes, movement rhythms and qualities using the same or different body parts[VK7]. While the therapist is aware not to intrude into the individual’s personal space and way of moving, she acquires valuable information about the other person's experience through ‘kinaesthetic empathy’, a term introduced by Berger (1972), cited in Fischman (2009). As early as 1970, Adler (1970) offereds a visual documentation of how two girls with ASD gradually becaome responsive to her through mirroring. More recently, Tortora (2006) describes how she progressively built a relationship with a boy on the autism spectrum through matching and attuning to the boy’s actions and rhythms.
Erfer (19950 argues that tThrough ‘mirroring’ the therapist acknowledges the child’s way of being and accepts her unique way of expressing emotions, thoughts, needs and desires. The child, feeling accepted and confident, can transfers her focus from inner reality to external environment and therefore, is more likely to start interacting with people (Erfer 1995). Wengrower (2010), in a multiple case study with children diagnosed with ASD or PDD, describes how ‘mirroring’ has led to mutual interactions between the therapist and the child and enabled the therapist to empathise better with the child.
Building a therapeutic relationship through 'mirroring' resonates[p8]with[p9] the intersubjective experiences between a caregiver and a baby in healthy development, described by Stern (1985) and Trevarthen (2005). From birth, the caregiver tunes into the baby’s facial expressions, gestures, rhythms and sounds promoting reciprocal interaction and social dialogue. Once this type of relatedness is established, and their in-between relationship is enriched through quality interaction, caregiver and baby will be ready to share their attention towards an external object. This is the moment in development that Trevarthen et al. (1998) describe as the transition from primary intersubjectivity to secondary intersubjectivity.
Within our case study we incorporated play into our DMP interventions. For us here, this took the form of sensorimotor play using objects (e.g. throwing and catching the ball), embodied play (e.g. walking on all-fours and trying to catch each other), and symbolic play, e.g. the ‘policeman game’ (described below). Psychotherapeutic literature suggests that dDuring these play activities the children seemed fairly more active and involved in the group process. Axline (1971) and Winnicott (2005) for example, regard Pplay ais a central feature of child development and the modality by which children express their emotions, concerns, and construct their thinking (Axline 1971; Winnicott 2005). In their psychodynamic-informed intervention for children with ASD, Alvarez et al (1999) involved play as they found it integral for each child's development and self-expression. Moore (2008) argues that children on the autism spectrum can find enjoyment, and gradually develop their social skills, through play.
Due to the fact that there is not sufficient literature regarding DMP and play, we searched for the use of play in Dramatherapy and found the EPR model (Jennings 1999) informative and suitable for adapting for our case study. The EPR model outlines a developmental progression, a useful structure with which to assess and describe a child's pathway towards confident, skilful social interaction. The EPR model consists of three stages: ‘Embodiment’ - play includes physical exploration through the senses; ‘Projection’ - at this stage the child relates more to her external environment through toys and objects and starts using them symbolically; and ‘Role’ - at this stage the child plays with different roles and starts to identify more strongly with particular options.
The Case Study...
Three Children
Our study took place in a special school for children with ASD[5]. After a careful referral process, three classmates between 6-7 years old were chosen to participate in the study[6]. We shall call them Patrick, Ben and Phillip[7] . You have already been introduced to Patrick in the first contact with the dance movement psychotherapist (the first author of this chapter)at the beginning of his first session.
The DMP intervention
The DMP intervention consisted of eight group sessions that took place once a week for 50 minutes. Each session was loosely structured around warm-up, mid-phase and closure.
The intervention was informed and inspired by a range of different movement approaches includinincluding: g,the Chace[8] interactive model of DMP (Chaiklin and Schmais 1986) and Sherborne Developmental Movement[9] (Sherborne 2001). The intervention was given support by intersubjectivity theory (Meltzoff and Brooks 2007; Stern 2005; Trevarthen 2005) and the developmental structure within the Embodiment-Projection-Role model (Jennings, 1999). While interweaving these various influences and ideas, the intervention remained essentially person-centred (Rogers, 1967). Each session included spontaneous interactions and activities as suggested by the children and supported by the therapist.
Session 1: We introduced ourselves, explored the therapeutic space and familiarised ourselves with the camera.
Sessions 2-4: We explored ways of moving together. The children seemed interested in using props and interacting with me. From session four onwards, the children were more involved in the ‘warm-up’ phase than in previous sessions. Here, we played with shaping a circle and moving in or away from its centre.
Sessions 5 and 6: The children started to become involved in group activities. Moreover, a ‘closure’ phase became more apparent than earlier in the sessions - with all the children joining the relaxation play and sharing ‘goodbye’ movements.
Sessions 7 and 8: Group interactions became much lengthier than in previous sessions. The children seemed more aware and determined regarding what they want to do. Ben and Philip develop attentiveness towards Patrick and me.
Data Generation, Somatic Response and tThe Power of Subjectivity
Data generation took place within and after the eight DMP group sessions within the overall research frame of artistic enquiry (Hervey 2000). Three different methods were used for the generation of the data: (a) video recordings of the sessions; (b) multiple records of the therapist's somatic responses to the session-based interactions (including drawings of a body figure, and written and video recordings); and (c) written reflections based upon observations, feelings and ideas relating to our central study question: ‘how can DMP support children with ASD to establish relationships?’ This led to the collection of multiple types of data (visual, kinaesthetic and textual). Triangulation, between these modes of data, intended to increase the trustworthiness of the study (Batavia, 2001). Text-based data was analyzed using ‘thematic analysis’ (Braun and Clarke, 2006). For the visual and kinaesthetic data the therapist/researcher engaged in ‘dialoguing’ with the data - as suggested by Hervey (2000). The findings of this case study were presented in the form of narratives and drawings (which are presented below) and through a recorded movement piece.