Hotline Development

On February 5th, Ilene Serlin was asked to supervise a group of psychologists from Beijing on their hotline consultations. Their focus had been on case presentations; suddenly the group faced a new challenge, they were asked to supervise a group of counselors who were serving on the hotline. The supervisors told Serlin that they were also facing their own exhaustion, caregiver burnout, and their own domestic and work challenges (Figley, 1995; Forester, 2007; Freudenberger, 1975).

The psychologists reported that callers on the hotline were full of anxiety. Families were taking their panic and fear out on each other, and domestic violence was spiking. One said that at her university each caller had only a one-half hour to talk, and there was no continuity between calls. This situation, therefore, called for a short-term crisis model; the first step being to stabilize and hold out hope for the caller.

What Could Help in Such a Short Amount of Time?

We created a 15-minute videotape for the supervisors that the hotline callers could see on their phones. First, the video helped the psychologists with their own compassion fatigue and fears. Second, it helped callers begin to feel the strength and support to begin to let their bodies and emotions come alive again. Discerning, naming, and expressing their emotions helped them move through places where they were stuck as they reached out into space and toward each other.

The creative challenge, therefore, was how to create an embodied experience via a two-dimensional medium.

Other interesting questions emerged. Does a video call allow for the attunement and physicality of attunement between the client and the therapist? Can we build that attunement (Johnson et al., 2009) through a screen? On the one hand, we have all been trained to focus on the lived experience of the therapeutic relationship as a key to change. On the other hand, recent research on the role of mirror neurons in the creation of empathy suggests that even mirroring movements through the screen can be effective (Buk, 2009). What about cultural differences; perhaps we build attunement through shared song, story or myth (Howard, 1991)?

Below is this first video we created to try to address some of these questions: https://youtu.be/hdBtWI0jW0Q

The video became part of the first installment from our home institute of the China

Institute of Psychology. Serlin and Zhou began to work together on a weekly series of video productions. We called it the “Heart Series.” It began with each person holding her hands held in the shape of a heart, then reaching toward another on a Zoom screen with the hands still in a heart shape. Then we brought back heart energy from the other person, the back-and-forth becoming a giving/receiving slow comforting movement of rocking. The horizontal movement kept the same rhythm but became vertical, as participants began to reach upward, mirroring each other. As they reached upward, they asked to reach for Hope (Frankl, 1959; Maddi & Hightower, 1999; Serlin & Cannon, 2004; Calhoun & Tedeschi, 2006; Joseph & Linley, 2006). Each week and each new episode the hope continued to grow, until in springtime the movements changed to reflect the spring. Hope grew roots and sprouted little green shoots. The shoots grew into a tree with branches and young leaves. A well-known Chinese poem with the lines: “Yangtze River is warming” and “Ducks are swimming in the river” introduced new movements that were lighter and more fluid. The movements tell a story in which a seed of hope is planted despite the despair and the horror.

What makes this series different from exercise is that the movements are combined with psychological themes to express emotions. As the emotions are embedded in symbolic movements, such as reaching upward for hope or vigorously reaching down to plant the seeds, the participants had a chance to experience emotional shifts without needing to name or share them verbally with others. This can allow for greater freedom of expression and release. It can allow people to bring their hearts together, overcoming fear and anxiety. The telling of the story is a way to express and reshape their narratives (May, 1975; Deri, 1988; Feinstein & Krippner, 1988; Lieblich & Josselson, 1997; Pennebaker, 2000), awaken the lived body and life energy and develop resilience (Carey, 2006; Serlin & Speiser, 2007; Haen, 2009; Levine, 2009).

Meanwhile, in Beijing, Zhou had started online support groups for therapists, doctors, social workers, business coaches, charity professionals, hotline volunteers, and pastoral care leaders. As people began to experience the reality of danger, the reality of the quarantine began to be felt. Panic, anxiety, and depression soared. Families living in close quarters were often traumatized, taking out their frustration and fear on each other with domestic violence and child abuse. With a vision of encouraging the leaders to serve effectively in the time of great need, Zhou immediately initiated and engaged three-hour daily knowledge and skill sharing sessions in which DMT was taught and integrated with other counseling skills. After the first 21 days, the frequency of meetings decreased according to the reduction in symptoms. It is now team taught and meets once a week.

Kin Aesthetic Imagining

The method we use, the integration existential/humanistic psychology and dance movement therapy, is KI (Serlin, 2006). KI, derived from the Greek word “kinaesthesia,” is a process in which sensations and expressions arising from bodily-felt movement become a nonverbal expressive text like poetry, or “action poesis”; and verbal imagery, which, like poetry, moves away from rational, linear to creative, symbolic writing, and speaking.

The basic process has three parts:

1. Warm-up—Check-in, introductions, orientation to the event. We begin with an introduction to normalize and de-stigmatize their experience by explaining it as a “normal response to an abnormal situation” (Pfefferbaum et al., 2001). The stress and emotions get stuck in the body, and movement can help them regain strength and energy. Movements of grounding, moving body parts and the whole body, energizing the flow, exploring boundaries, creating safe space, reaching out, connecting with others.

2. Development of the theme:

   During this time, we pick up on themes that arise in the warm-up and explore them using movement structures. Working with images as though they are dream images, we develop them through amplification, intensification, and repetition. The energy level and affect deepen during this time until there is a new insight or resolution.

   During the training for the China hotline, these themes emerged as important. We explored in movement participants’ strengths and vulnerabilities in pairs (using mirroring), and switched roles. We explored family dynamics of conflict between parents and children during shelter in place, using role-play with movements to experience the “naughty” child, the “strict” parents, and other conflicts in their lives. We asked: “What is the function of your vulnerabilities”? The use of creativity to create improvisations helps participants imagine a different future, so we encourage play and stories to enhance resiliency (Gregerson, 2007).

3. Reflection: What did I learn or understand through this experience. Sharing and in pairs or group, verbally or through artwork or poetry.

   If trauma is primarily nonverbal or in the body, then nonverbal therapies, such as the creative arts therapies, are well-suited to address nonverbal trauma. Art therapist Linda Gantt and Louis Tinnin suggest three lines of research to support the fact that trauma is in the body. The first comes from the evolutionary advantage from having an instinctive, fight/flight reaction to trauma. The second comes from recent brain research on neuroimaging processes in the brain, and the third from the relationship of alexithymia to posttraumatic dissociation (Gantt & Tinnin, 2009, p. 148). An inability to speak, to convey one’s experience, means that symbolic language such as the arts might be a channel for communication. A trauma experienced in the body as numbness or shock is addressed through Somatic Psychology, a new field derived from Hanna (1995). Somatic Psychology works to identify and release traumatic experiences that are stuck in the body, often outside the range of ordinary consciousness. It builds on the subjective awareness of one’s own sensory–motor condition and processes to help heal trauma in the body. However, one problem with encountering the embodied trauma of another as a somatic therapist is that the therapist herself can begin to experience this trauma in her own body as vicarious traumatization or compassion fatigue (Figley, 1995).

Compassion Fatigue and Regeneration

When we heard that the doctors in Wuhan were working in two-week shifts with only short rest breaks, we felt that our priority had to be to take care of them. They were exhausted, full of emotions, drained, suffering from burnout (Freudenberger, 1975). They were not able to take good care of themselves (Barnett et al., 2007). Feeling empathy for others in the body, they also experienced overload in the body. Their bodies shut down and lost some ability to feel compassion, resulting in compassion fatigue.

Compassion regeneration, or the capacity to feel compassion again, is also in the body. Once the body is shut down, it needs a sensitive approach to re-awaken. Learning to care for oneself and trust oneself is the first step to caring and trusting others again.

After a two-hour KI demonstration online by Serlin with 33 therapists in attendance on February 6th, participants started thinking and integrating KI in their practice. Twenty-two proposed that they would want to learn more KI first for themselves so they could survive better during this period. They said that talking about anxiety was not as helpful as shaking it off in KI, an agreement shared by many of those who attended KI sessions.

We would have wanted to collect data, but we were much more focused on immediate needs. However, some of the psychologists gave the following feedback: Xiao, a PhD from Fuller and a new returning therapist to Beijing, expressed her preference for DMT in a We Chat call with Zhou: “It is so interesting to use DMT in my sessions with couples. I have practiced breathing techniques with my clients before, but it is rather boring. DMT is a new option and an interesting option. I like it a lot. I wish we could continue to do DMT face to face after this all ends.”

“Creating safe space in DMT demo by Ilene helps me deal better with my kids at home. I play with them with DMT ideas of building up safe place at home and I could transfer the same notion when I work with my clients. I now sleep better after a long day’s work,” said James, a local therapist.

“I shared what I learned even though very little with my colleagues here in Wuhan and we can practice on ourselves first since we seem to struggle with anxiety after days of hotline service,” Huan, a hotline volunteer in Wuhan shared after a long week.

The Train the Trainer group started out as a cross-disciplinary team with 23 participants. doctors from the military and mental health hospital joined therapists who were very interested in learning KI skills to incorporate into their own counseling sessions. They were taught how to use KI for therapy, self-care, and self-development. Three therapists in the team reported that they use KI in individual counseling sessions with four clients with deep trauma. A therapist described a client who had severe insomnia, anxiety, depression, and was unable to sleep for days. The therapist helped her to shake these symptoms, feeling strength with strong steps on the floor. Kicking forward and backward helped her express the anger underlying her depression. The use of polarized movement qualities, such as lightness and up, strength and down, expanded her range of both movement and emotional expression. After some simple exercises, the woman said she could sleep for the first time in a long time.

A second group comprised 13 pastoral care workers who used KI skills for crisis intervention and their own self-discovery. This group started January 26th with sessions lasting three hours a day. It focused on skills that included grounding, setting boundaries, and self-care. Through an online group, the members are currently helping 53 women in quarantine without social support who live in remote rural areas of China.

During the self-discovery stage of their training, KI methods were integrated into a process of sharing patterns of thinking, behaving, emotions, relationships, social and spiritual patterns. Movement can explore strengths and weaknesses. Movement can explore fear of death, and the choice to live. Using movements of strength and commitment, each person felt the existential moment of choosing life, commitment to change, and breakthrough. Through mirroring, attunement, and shared rhythms, the group addressed existential issues of loneliness and connection.

The self-discovery model has six stages:

1. Self-awareness

   Know yourself

2. Self-acceptance

   Know your strengths and vulnerabilities.

   Knowing and sharing oneself is discouraged in China. Both at home and at school children are told that they have to be #1; that they are “no good.” Their upbringing teaches them to be very competitive. It is therefore difficult for them to show others their vulnerability in case it is criticized or exploited.

3. Personal breakthrough—can you change to another pattern, get out of your comfort zone?

4. Understand others

5. Accept others

6. Influence others—journey of leadership in Chinese culture

Movement Can Heal

Dissociated body experiences are a common feature of trauma (Forester, 2007). In trauma, the capacity to process experience may become dissociated or fragmented. We can try to help the participant feel more integrated if they become grounded and strong enough to contain all the fragments and re-integrate them. We are careful, therefore, in our movement sequences to consider the transitions from sitting to standing; from gradually integrating movements that bring together the fragments. We use polarities to express and integrate opposites. We work with polarities in movement, simple ones such as up and down, in and out. We experience direct and indirect flow, best communicated through images such as water.

What is it about the use of polarities that is healing? First, polarities are archetypal movements that underly all organic processes. Flowers open and close, snail shells are a spiral. Open and close are early developmental movements of a baby, and cross-cultural folk dances are based on circles and spirals (Serlin, 1993). Psychologies based on principles of organic growth were developed and taught by Serlin’s teachers Irmgard Bartenieff (1980) and Laura Perls (Serlin & Shane, 1999), both of whom worked through the body. Because we movement therapists believe that authentic movement is organic, we tried to make our movements organically alive. The movements were not mechanical nor utilitarian (goal-oriented or data-driven), but rather intended to awaken life force and flow. Second, the polarities are useful to create careful structures in which to re-introduce movement qualitative dynamics and range of motion to a traumatized body. Third, going back and forth between polarities and crossing diagonally through the middle brings opposites and fragments together, creating a more integrated and stronger self. By naming the movements and images, we connect our logical/linear parts of the brain to our nonverbal, image-based neural modes of processing, strengthening balance and stability (Schore, 2002; Siegel, 2006; Gantt & Tinnin, 2009, p. 150). This strong, integrated sense of self is necessary to hold the extremely intense emotions and confrontation with mortality.

Embodied enactments can be a powerful way to understand and reframe situations. Through role play, participants can gain perspective on their situation. One Chinese counselor told the story of a family that was in lockdown mode, living in a small space. The parents were getting increasingly irritated at their children who were running around and playing. For the role play, the parents had to play while the children cooked dinner. In a short time, the parents—who had a lot of fun during the role play—said that they now understood what fun it was to play and were more tolerant of their children. The children, on the other hand, understood that cooking was not fun and had more empathy for their parents. In the end, they all played and cooked together.

Trauma Informed Dance Movement Therapy

Our model corresponds to the three-phase model in the guidelines of the International Society for the Study of Traumatic Stress (Foa, Keane, & Friedman, 2009). We normally start with stabilization, as it becomes clear the extent to which most of us need to be grounded and stabilized. We use imagery to help participants understand the concept of grounding. Many cultures have widespread use of the image of the tree or the Tree of Life, so we use that to feel the support of the ground underneath. From there we may suggest putting roots into the earth, feeling the life force radiate up through the legs. We may feel the growth of a solid tree trunk, yet one that can be both flexible and strong. We talk about resilience. We make art or artful movements from broken branches (Serlin 2008; 2012a; 2012b). As we narrate this story together, we can help participants create a more coherent and positive narrative of their experiences. After sufficient grounding and safety, we move on to explore emotions in the body, and reconnection to space and others. We are always careful to make sure that participants can experience and return to inner safe space and stability if the movements become too intense. We end with understanding and reflection, coming back to the self and the circle, and perhaps clarifying the next steps in our personal journeys of healing.

Conclusion

The arts can provide symbolic nonverbal ways to work with unspeakable trauma, natural and manmade disasters, refugee immigration, and caregiver burnout. They can provide trauma recovery on hotlines as well as in person, giving help to any person struggling with COVID to consulting to groups for training the trainer. From an existential perspective, they can help us confront death, terror, loneliness, and help to find meaning. Building on creativity, they can facilitate posttraumatic growth (Calhoun & Tedeschi, 2006), growth through adversity (Joseph & Linley, 2006), hardiness (Maddi & Hightower, 1999), optimism and resilience. Used to build resiliency in a whole person context (Serlin, 2007; 2010), they can bring together body, speech, mind and spirit.