The Lexicon of Pain: Highlighting the Advantages of Applied Theater in Pediatrics through the Lens of Psychodynamic Therapy
Volume 10, Issue 1, Pages 126-140
Abstract
Applied theater for health and well-being suggests itself as an effective tool for social and emotional interaction and communication of emotions, developing creativity, imagination, and regulation of emotions during hospitalization. This paper aims to explore the value of communicating emotions through applied theater and storytelling in pediatrics and its potential in clinical practice in a discussion through the lens of psychodynamic therapy. We will explore the intersections, synergies, and possible collaborations between the theatrical form as a condition for openness and verbalizing pain and therapy as a method of processing and dealing with emotions. We discuss fictional stories told by children during applied theater and storytelling research interventions in hospitals as case studies through the lens of psychodynamic therapy with children. We explore these stories by using interdisciplinary, synthetic, and dialectic analysis between the researcher-artist and the psychodynamic therapist. We ask if the stories that hospitalized children create within theatrical interventions can help adults and clinical staff understand better the children’s lexicon of pain, leading to sensitive healthcare. The rich narrative discussion of the case studies indicates that applied theater in hospitals enhanced well-being support in children and as gateways for improved care. The core themes that emerged include empowerment, synergies and exchanges of emotions, emotional reassurance, and imagination. This analysis of hospitalized children’s stories from a psychodynamic therapist’s point of view has scope for informing alternative, nonmedical activities with children in the hospital and those who would benefit from clinical therapy and the performing arts.
摘要
用于健康和福祉的应用戏剧表明它是住院期间社交和情感互动和情感交流、发展创造力、想象和情绪调节的有效工具。在本文中，我们将其定义为一种治疗性的复杂艺术实践。本文旨在通过心理动力学治疗的视角进行讨论，探讨通过应用戏剧和叙事在儿科中交流情感的治疗价值及其在临床实践中的潜力。我们将探索戏剧形式之间的交叉、协同作用和可能的合作。戏剧形式是开放和表达痛苦的条件，而治疗是处理和处理情绪的方法。我们通过儿童心理动力学治疗的视角，讨论医院应用戏剧和叙事干预期间儿童讲述的虚构故事，并将之作为案例研究。我们通过研究艺术家和心理动力学治疗师之间的跨学科、综合和辩证分析来探索这些故事。我们询问住院儿童在戏剧介入中创造的故事是否可以帮助成人和临床工作人员更好地理解儿童的疼痛词汇，从而带来敏感的医疗保健。案例研究的丰富叙述性讨论表明，医院中的应用戏剧增强对儿童的福祉支持，并为改善护理提供了途径。出现的核心主题包括赋权、情感协同和交流、情感安慰，以及想象。从心理动力学治疗师的角度对住院儿童的故事进行分析，可以为住院儿童以及将从临床治疗和表演艺术中受益的人提供替代性非医疗活动的信息。
Keywords
applied theater, psychodynamic therapy, pediatrics, storytelling, healthcare.
关键词
应用戏剧, 心理动力治疗, 儿科, 叙事, 保健.
History
Received 30 August 2024
Accepted 30 August 2024
Open Access
This is an open access article.
Introduction
Illness is a crucial aspect of a child’s life. Pain, both physical and emotional, is a central element of a child’s illness experience. Unspoken and concealed pain cause some of the worst children’s experiences in healthcare (Pelander & Leino-Kilpi, 2010). One of the significant problems with concealed pain and unspoken emotions is that children cannot always find the words to locate and describe their pain. This problem leads to a difficulty of sharing how they feel with healthcare professionals, which can challenge successful cooperation in the healing process (Carter & Simons, 2014). We should not, however, assume that pain does not exist when pain is not verbalized and that there is no physical and emotional suffering when patients are silent (Lascaratou, 2007).
Research shows that people in suffering are often highly creative in expressing how they feel through the arts, symbols, and performance. Paying attention to their creative language of pain can open a world of new meanings, informing us how they are experiencing suffering (Bourke, 2012). A narrative review about the alternative and nonmedical approaches to child anxiety in procedural care show that artistic interventions can effectively help children communicate their emotions with adults and cope with the challenges of hospitalization (Maagero et al., 2023). Offering artistic and playful tools such as theatrical bedside performances in children’s care is known to positively affect hospitalized children’s minds and well-being, providing creative opportunities to normalize hospital experiences both in inpatient and outpatient areas as well as positively engaging children with learning during their hospital stay (Sextou, 2023). Yet, psychodynamic therapy is rooted in the exploration of the unconscious mind, emotional development, and the relationship dynamics between children and their caregivers, including medical personnel. While studies regarding the effectiveness of the creative arts are on the forefront of arts-in-health research, little attention has been paid to the inherent opportunities to combine applied theater performance and psychodynamic therapy toward a more empathetic and sensitive approach to children’s care. Central to both disciplines are new ways of experiencing life in difficulty, contributing to a more compassionate and personalized care environment.
The paper builds upon the first author’s 2023 work, Applied Theatre in Paediatrics. Children, Stories and Synergies of Emotions. In collaboration with the second author, we employ aspects of psychodynamic theories to explore arts-based change processes challenging arts, health, and therapy intersections. This publication represents a significant step toward articulating the transformative potential of arts-based methodologies and art therapies that has scope to support future research, especially transdisciplinary mixed methods approach. We adopt a dialectic approach bringing together theoretical and methodological background in drama and theater in educational and healthcare contexts (first author) and in Psychodynamic Therapy (second author). Our complementing backgrounds and experience led to a desire to blend some of the core principles of applied theater such as intimate audience participation, presence, and synergistic interplay in the fictional world with psychodynamic therapy. In our approach, we will consider potential practical connections between applied theater with children specifically in healthcare settings (Sextou, 2016, 2023) through the lens of psychodynamic therapy (Freud, 1913; Klein, 1946), drawing on examples of active listening of people’s stories in therapy (Kiosses, 2021).
We will consider as case studies three specific stories told by hospitalized children during an arts-based research project in a hospital in England. We will discuss what happens in the bedside theater performance in hospital. We will explore how the children’s expression of words through stories during intimate performance may become complemented by the insights we gain from psychodynamic therapy, delving into their subconscious and emotional processes. We are also looking at how applied theater in pediatrics as a model can open new possibilities for actors and therapists to work with children collaboratively in the future. We see this research paper as an opportunity for collaboration and interdisciplinary learning.
Our paper will unfold in five main parts: definitions of our approach, case studies and analysis, emerging themes, implications for practice in healthcare, and a conclusion.
Applied Theater and Psychodynamic Therapy: Our Approach
Definitions
Applied theater in pediatrics is a performative art that aims to improve hospitalized children’s well-being. Evidence shows that the integration of applied theater in hospital settings offers a multifaceted approach to supporting the emotional, educational, and psychological needs of hospitalized children. It enhances their hospital experience, aids in emotional regulation, maintains educational engagement, and improves communication within families, contributing to a more holistic approach to pediatric care (Sextou, 2022a). Applied theater involves interactive and participatory forms of theater such as acting, improvisation, and storytelling. In a hospital setting, these activities can provide children with a creative outlet to express their emotions and give them agency in an environment where they often feel powerless due to medical procedures and routines.
Applied theater in pediatrics, however, is distinct from formal therapy practices like drama therapy or psychodrama, and although theater in hospital is a practice for patients, it aims to make theater, not therapy. The artist focuses on acting, the dramatic process, and the depth of characterization and audience participation that can be achieved during a short-scale performance. The hospitalized children are considered by the therapist as “patients” or “clients,” but we, the artists, treat them as theater audiences. What is experienced during the performance such as relaxation, creativity, distraction from illness, and self-expression are merely aspects of what is lived within the fictional worlds of stories. These benefits can influence the participants’ well-being as a potentially important strategy of preparing children for treatments and procedures and diverting their minds from anticipatory anxiety, which is always a positive outcome (Sextou, 2016). Therefore, in this paper, we discuss the therapeutic benefits of using applied theater in pediatrics as a natural byproduct of audience participation within fiction rather than the main intention.
With audience participation in mind, psychodynamic therapy lenses are used in this paper to understand the emotional and psychological processes in hospitalized children when they participate in bedside theater performances. At its core, psychodynamic therapy in pediatrics is about understanding the child’s deep-seated internal world—their thoughts, emotions, fears, and fantasies—and how these internal experiences interact with their external reality. This form of therapy is distinguished by its emphasis on the developmental perspective, recognizing that children’s psychological processes are continually evolving and are significantly influenced by their experiences (Freud, 1913; Klein, 1946). This therapeutic approach posits that unconscious processes, stemming from traumatic childhood experiences, play a crucial role in shaping behavior and emotional well-being and influence a person’s thoughts and actions (Freud, 1923). Thus, in the context of pediatrics, the developmental perspective is crucial as children’s responses to hospitalization, including traumatic experiences, can shape their future mental health. Modern psychodynamic therapy often integrates techniques from other therapeutic modalities, such as play therapy, and creative activities where children can express thoughts and feelings that might be too complex or distressing to articulate verbally. Such creative expressions allow for the exploration of their emotional world and unconscious mind in a nonthreatening way (Axline, 1947; Winnicott, 1971).
In summary, applied theater in pediatrics complements clinical practice by using arts-based methodologies and practices, while psychodynamic therapy supports clinical interventions by helping children understand their inner selves and heal.
How Applied Theater was Carried Out?
The stories discussed in our article were collected during the “Rocket-Arts” applied theater project at Birmingham Women’s and Children’s Hospital NHS Trust in England. Rocket-Arts used mixed-media including storytelling performance, puppetry, and objects theater with miniature Playmobil toys, a 3D installation, and digital toy-based animation films as resources. The project aimed to investigate the effects of embodied performance and mediated tools on the social and emotional well-being of children and on their engagement with education during their hospital stay.
On the hospital wards, we introduced children to a portable space 3D rocket of 6.5-foot height with an interior where we presented them with Playmobil toys, waiting for the children to animate them. An actress worked with children bedside, animating the toys by following the storyline of Rocket-Arts. The story presented a therapy dog in a hospital setting where they meet with a child-patient and together they escape from the hospital into space. Together they visit planets, they see magical space animals, and they go on adventures. An animation film titled Here I Am Flying was also produced on YouTube for those children who had not the opportunity to work with artists 1:2:1 during the pandemic but they could download the film on the hospital’s devices (Sextou, 2022b).
The performance was flexible and open to changes, subject to the child’s ability for interplay for making a story of their own. Children used paper proformas and a flexible story-making guide (Howitt & Cramer, 2017). In their stories, children imagined or reimagined events that recombine elements of their lived experience and imagination (Boyd, 2009). With help from an actor or hospital teacher, children tried to express their subjective experience of being in hospital in their own words. What each child means by their story is complex because each child has a different “lexicon” of emotions that describes and communicates feelings (Grosse et al., 2021). Therefore, we cannot be clear how the child describes feelings. However, we accept that stories become the platform for the child to process mediated representations of lived experience (Alrutz, 2015). We take children’s stories seriously because these stories are what we have available to use and to understand, or assume that we know, how children feel.
Case Studies and Analysis
In dialogue with the artistic work, we will use psychodynamic theory to further explore the sensations, the meanings, and the hidden truths of children’s worlds as communicated through the Rocket-Arts stories–case studies. We ask if these stories continue as extensions of the children, providing a means to understand aspects of the children’s feelings during hospitalization.
Pseudonyms were assigned to hide the child-participants’ real identity. We would encourage the reader to be open to observing their sensations and make their meanings while reading the stories. Meaning is personal subject to interpretation.
Jane: The Piano Is on Fire
It is late at night. A spaceship in the shape of a banana is landing in the park. I can see it from my window. Aliens are coming out of the spaceship. They are four-legged creatures with long, thin arms. They are carrying a piano with them. A princess and a prince are hopping down from the spaceship. The aliens are running back into the spaceship. The princess is playing the piano. She is not bad. The prince is singing. His voice is amazing. Curious monkeys are gathering around the piano. I can see their yellow eyes sparkling in the dark. They are playing hide-and-seek and duck, duck, and goose. The princess is upset. “Stop it!” The monkeys are running up and down the piano keys. “Stop it!” The monkeys are eating the piano. “Go away!” The monkeys want to break the piano. “Go away!” The monkeys want to burn the piano. “Get lost!” The piano is on fire! I can see the fire. I see the smoke. I hear it crackle. I can feel the heat. “Get lost!” The monkeys ran at the speed of a rocket! The prince and his princess are crying… they are not happy. They want to hide. The moon is out in the sky. “The moon makes you fly!” says the princess. “Let’s go home,” says the prince. The prince and the princess are lifted into the sky.
Jane’s narrative (Sextou, 2023, p. 33) may reflect deeper psychological processes, as understood through various psychodynamic theories. The burning piano, emblematic of chaos and destruction, could symbolize Jane’s internal distress and powerlessness stemming from her hospitalization. This interpretation aligns with Freud’s theory of symbolism in the unconscious, where dreamlike narratives often reveal repressed emotions and desires (Freud, 1913). The intense imagery of a burning piano might represent Jane’s subconscious fears or unexpressed emotions about her illness and hospital experience. Exploring defense mechanisms, Freud also noted that displacement and projection could be operative in such narratives (Freud, 2014). Jane’s emotions regarding her hospitalization might be displaced onto the piano, allowing her to express feelings indirectly in the fictional and nonjudgmental net of the story. This could be a safer way for her to deal with difficult emotions, where emotions can be shared without taking the risk of judgment and criticism. Even more, by opening herself to the possibility of “flying back home,” she may be searching for an “escape” from her illness as a psychological space and from the hospital as a physical space. Although this may still be speculation, it almost seems that Jane rehearsed her escape within the fictional conditions of drama. That could potentially imply a wishful discharge from the hospital and a return to her normality.
From the perspective of Object Relations theory, the story could be interpreted as reflecting disturbances in Jane’s internalized relationships, particularly if her hospitalization has led to separation from primary caregivers (Klein, 1946). The story’s chaotic theme might mirror disruptions in her internal world and relational dynamics. Incorporating Erik Erikson’s stages of psychosocial development, Jane’s narrative could be contextualized within her developmental stage. Depending on her age, her hospitalization might be influencing her sense of autonomy, initiative, or identity, which are critical in childhood and adolescence (Erikson, 1959). Attachment theory, as proposed by Bowlby, suggests that Jane’s story might also express her feelings of security or insecurity regarding her attachments, potentially disrupted by her illness (Bowlby, 1969). The fiery destruction in her story could symbolize her internal state of insecurity or anxiety. Utilizing concepts from narrative therapy, which views people as separate from their problems, Jane’s story could be seen as a potential space for re-authoring her experience, transforming the narrative to one of empowerment or resilience (White & Epston, 1990). Lastly, considering Jane’s context as a hospitalized child, theories from play therapy could be particularly relevant. As Axline (1947) emphasized, play is a natural medium for children to express and process feelings. Jane’s story, in this light, could be a form of symbolic play, providing a psychological space to explore complex emotions in a safe and distanced manner. By doing that, the art form becomes a gateway to the articulation of unspoken emotions.
Alex: My Grandfather’s Wellies
Once upon a time, a pair of wellies was in a village shop. They were waiting and waiting for someone to buy them. One day a man went into the shop. He had a long white beard. He pointed to the wellies and said, "Ah, these I like!" He tried them on, and they fit all right. It was autumn, the sun was shining, and it was beautiful. He lived close to the park. There was a lake there. He put on his boots, took his basket and poles, and went to the park. Wellies were happy. The wellies were fishing buddies with the man. One day the man fell from a cliff and couldn’t walk. His foot was swollen. It could be broken. “Ah, just what I needed,” he said between his teeth. He called for help, and his brother came and carried him home. He couldn’t walk and did not go fishing that day. His boots were sad. The next day the man was not well. He stayed in bed. The doctor visited him and ordered, “Stay at home!” His wellies were stuck in his room with him. One day the man died. It was winter. So his boots got angry, and he walked away. “We can go anywhere,” they said. They walked on the road, went to the park, and jumped in the snow. They got all muddy! They returned home to dry off. The house was quiet. “Why did you die?”
In the poignant narrative “My Grandfather’s Wellies,” detailed in Sextou (2023, p. 39), a child weaves a tale that captures the essence of loss. Viewed through the lens of modern psychodynamic theories, the story offers deep insights into the child’s inner world. Through the lens of Relational Psychodynamic, the evolving dynamics between the wellies and the old man symbolize the child’s own relational experiences. This perspective, which emphasizes the mutual influence and the interplay of relationships on the individual’s soul, could suggest that the wellies represent the child’s grandfather as a significant figure in the child’s life—and their impact on the child’s emotional development. The narrative progression from attachment to loss and eventual independence echoes the child’s internalization of these changing relational dynamics, a process that is particularly profound in the restrictive and often unsettling environment of a hospital (Mitchell & Black, 1995).
Simultaneously, the narrative aligns seamlessly with the principles of Self Psychology, and the concepts of mirroring and self-cohesion. The wellies, initially an object of joy and companionship for the elderly man, might metaphorically represent aspects of the child’s self, including their need for acknowledgement and validation. The loss of the man, symbolizing a severance of this mirroring relationship, propels the wellies, and by extension, the child, into a journey of self-discovery. This journey may reflect the child’s struggle and eventual adaptation to a new sense of self, shaped by the experiences of loss—a common psychological process in pediatric patients coping with the realities of hospitalization and illness (Kohut, 1971).
From an artistic perspective, Alex’s grief leads to the storytelling experience. Alex was admitted to the hospital when he learned about his grandfather’s death. He told this story a few weeks after he had received the news. Within the context of grief, the wellies may have become a transitional object after death, a means of both holding on and letting go (Gibson, 2008). The grandfather’s wellies may be holders of memories of Alex, which he recalled and possessed in his story. The wellies become a symbolic object, a point of connection where the child and the old man could both be together in fiction for as long as the child needed this comfort in his story. Moreover, applied theater enabled the child to be a creative storyteller, something that he would not be expected to do as a patient. By doing that, the art form empowers the participant to relocate their attention away from their emotional pain (grief in Alex’s case) and toward the invitation to participate as a creative storyteller who can share their emotions in fiction. The identity of the child is shifted from a patient to a creator.
Sheila: A Moon Made of Cheese
The astronaut looked out of the spaceship to see the moon had turned into cheese. Yummy! The astronaut likes cheese on pasta. She jumped out of the spacecraft, onto the cheese, and dived into the cheese holes. There was a fat mouse. His tummy was full of cheese. “What are you doing?” the astronaut asked the mouse. “I have my dinner,” said the mouse. The mouse ate all the cheese he wanted and ran away. A big marshmallow man tried to get the mouse. “What are you doing?” the astronaut asked the big marshmallow man. “I am trying to make me some dinner,” said the marshmallow man. The astronaut cut a piece of cheese and offered it to the marshmallow man. He ate all the cheese he wanted and ran away. A monster came to catch the marshmallow man. The beast was hungry and looking for biscuits and sweets. “What are you doing?” the astronaut asked the beast. “I have marshmallow with my banana pie,” said the monster. The monster had big ears and a big nose but was very skinny. The astronaut cut a piece of cheese and offered it to him. The monster ate all the cheese he wanted and fell asleep. There was enough cheese for everyone on the moon. So, after that, the astronaut had a big piece of milky cheese and jumped back into the spaceship to bring her home to Earth.
In her imaginative story “A Moon Made of Cheese,” as described in Sextou (2023, p. 35), Sheila presents a narrative that is rich in psychodynamic interpretation. The moon transformed into cheese may symbolize Sheila’s intrinsic longing for comfort and security amidst the unfamiliarity of a hospital environment. This theme aligns with Freud’s understanding of symbolism, where the comforting nature of cheese might represent Sheila’s yearning for the familiar aspects of home, which has been disrupted by her stay in the hospital (Freud, 1913). Klein’s Object Relations theory suggests that children use play and fantasy as means to manage their internal world of emotions and fears (Klein, 1946). Sheila’s playful and fantastical narrative could, thus, be seen as a mechanism to make her hospital experience less threatening, enabling her to cope with feelings of anxiety or insecurity. This imaginative narrative provides her with a space to transform her real-life experiences into something more manageable and less intimidating.
From the perspective of Bowlby’s Attachment Theory, the story’s abundance theme—enough cheese for everyone—might reflect Sheila’s need for nurturance and emotional assurance in an environment where she might feel insecure or anxious (Bowlby, 1969). The story may become a metaphorical expression of her desire for emotional sustenance and care. Incorporating Anna Freud’s concepts of defense mechanisms, the imaginative and humorous elements of Sheila’s story could be viewed as adaptive mechanisms. These mechanisms, such as sublimation and humor, are ways children manage stress and anxiety (Freud, 1936). The story, in this context, becomes a medium for Sheila to deal with the challenging emotions related to her hospitalization. Consistent with Axline’s principles of play therapy, the narrative serves as a tool for Sheila to express complex feelings and explore themes of adventure, nourishment, and control, countering her potential feelings of powerlessness in the hospital setting (Axline, 1947). Additionally, narrative therapy, which focuses on re-authoring one’s experience, provides a lens to view Sheila’s story as an opportunity to reimagine her hospital experience. By creating a narrative filled with abundance and adventure, she shifts from a passive patient role to that of an active, resourceful character (White & Epston, 1990). Sheila engaged in storytelling, giving her agency and confidence to lead the story. By doing that, the interplay between the actor and the child enabled Sheila to communicate how she felt, demonstrating that interaction in storytelling enhances creativity and imagination to help children unconsciously feel better during struggles.
Emerging Themes
Four interrelated themes emerged from the discussion of the three case studies through the combined lens of psychodynamic therapy and applied theater. Key areas include (1) empowerment, (2) synergies and exchanges of emotions, (3) imagination, and (4) emotional reassurance.
Empowerment
By engaging in applied theater, Jane, Alex, and Sheila were provided with a platform to assert their identities beyond their illnesses, echoing principles of positive psychology focused on fostering well-being and resilience rather than addressing pathology alone. This is an interesting observation because children’s reality is marked by illness. Children often think “I am ill, and I can’t play” or “I should not play while being in hospital.” However, Jane, Alex, and Sheila’s stories contradict the sense of inability and compliance that one would expect to see in a hospital. The three children were evidently empowered by the intimate performance to feel able and to want to change their behavior from a passive patient to an active storyteller. Performance was an opportunity to empower the children to find the power they have within them rather than imposing power over them, permitting them to be playful and curious as a child that is not defined by their illness. Empowerment in this therapeutic context transcends mere participation; it involves recognizing and nurturing the inherent strengths and capabilities of children even in the face of illness (Gatta et al., 2019). This empowerment affects the emotional, cognitive, and social domains of a child’s development. The three children are recognized by the actor as creative participants, co-storytellers rather than as ill children, defined by their poor health. The actor introduces a story created with imagination. The synergistic interplay between the actor and the child allows the child to rethink what they are capable of when they are ill. In practice, empowerment through applied theater and psychodynamic therapy should inform every aspect of therapeutic intervention. Clinicians and actors can cooperate more successfully in the healing process by fostering empowerment and encouraging reflection on the children’s skills and strengths demonstrated through theater participation, reinforcing the child’s sense of efficacy and resilience.
Synergies and Expressions of Emotions
The three stories we discuss are creative revelations of interaction between the child and the actor. The outcome of this synergy is communicating emotional expressions. These children recalled and recreated their theatrical bedside experience in their own words. They found a lexicon to exchange relevant emotions during illness through active participation. This leads us to think that exchanges of emotions draw on audience participation through theater as an interplay therapy practice. In a way, the actor creates a safe fictional space for the child to escape from the hospital reality through their imagination and to explore emotions. The psychodynamic therapist’s role is to facilitate emotional insight and processing, focusing on emotional growth and understanding. The actor had no intention of helping Jane develop healthier coping mechanisms as a therapist would do. However, through synergistic storytelling and play in performance, the actor enabled Jane to communicate the psychological impact of her illness. As a result, Jane used the home (“Let’s go home”) as a theme that describes or explores belonging and as a possible way of helping her cope with her illness, giving her hope, escape, and a sense of normality. This is a particularly interesting area that requests further discussion about theater in hospitals as a gateway and an opportunity for clinical therapy with hospitalized children when they need it.
Expanding upon this, the symbiotic relationship between actors and audiences in hospital illuminates a profound avenue for emotional literacy and expression through stories. It fosters a dialogic space where emotions are not only expressed verbally but also validated and explored within a narrative framework. This narrative exploration may serve as a reflective mirror for children, allowing them to process and make sense of their emotional experiences in a structured yet flexible manner. Moreover, the act of storytelling within applied theater offers a unique mechanism for externalization, where children can project their feelings onto characters and scenarios, thereby distancing themselves from direct emotional distress. This externalization provides a “therapeutic” detachment, allowing children to engage with their emotions more objectively and with less personal vulnerability.
Simultaneously, this process nurtures a sense of agency and self-efficacy in children as they navigate through their narratives, often leading to a rescripting of their emotional experiences toward more positive outcomes. It underscores the transformative power of applied theater as a method for psychosocial therapy, where emotional expressions catalyze a journey of self-discovery and empowerment. It calls for a deeper integration of arts-based participatory practices in pediatric care, advocating for a therapeutic paradigm that honors the complexity of children’s emotional worlds and their inherent capacity for creativity and resilience.
Imagination
Within the three stories, we observed that children used a fiction/dream mode and used multiple layers of protection in their imagined stories. From the artist’s viewpoint, fiction creates nonjudgmental conditions and permits the participants to be who they want to be by choosing a character and playing “in-role.” The child in the hospital is identified by their identity of being ill. For the artist, the child is identified by the identity of being a child in difficulty but still someone who retains their ability to imagine, reimagine, reinvent, and recreate their worlds through the lens of fiction and fantasy.
Jane, Alex, and Sheila accepted the dramatic condition of the story as another way to experience their stay in the hospital. They lived the unreal in a new imaginative dimension. The children’s imagination led to a possible recreation of their worries and a celebration of their ability to be humorous and bold while remaining aware of the existence of their pain and what it causes. Expanding on this, the role of imagination in therapeutic settings can be further illuminated by integrating theories of cognitive and emotional development. Imagination not only facilitates emotional catharsis but also supports cognitive flexibility, allowing children to explore alternative perspectives and solutions. Winnicott’s concept of the transitional object and transitional space offers a valuable framework here, suggesting that imaginative play in therapy provides a “transitional space” where internal and external realities converge, enabling children to navigate and reconcile these realms more effectively (Winnicott, 1971). This space is essential for psychological growth and resilience, offering a sandbox for experimenting with emotions, narratives, and self-identity. Moreover, imaginative engagement in applied theater enables children to become aware of their emotions and imaginative constructs. This awareness fosters a sense of agency and mastery over one’s narrative, contributing to a stronger self-concept. It is yet to be examined how telling stories during performance could distance children from their immediate concerns, providing a unique opportunity to reframe and possibly reshape their narratives toward more empowering outcomes.
Emotional Reassurance
Drawing on Bowlby’s (1969) attachment theory on young children’s emotional development, the caregiver must be responsive to the child’s physical, social, and emotional needs, and the caregiver and child must engage in mutually enjoyable interactions. Responsiveness is a primary determinant of attachment offering a sense of emotional reassurance, safety, and trust that affects a child throughout their life. Jane, Alex, and Sheila appear to have trusted the actor who was responsive to the children’s ideas, needs, and suggestions during the performance, concentrated on the interplay relationship with the actor, and felt protected from the eyes of others on the hospital ward within fiction. This argument leads us to think that interaction, responsiveness, and the exploration of emotional learning within the safety of the fictional allows the participant actor and child to bring their own histories into the stories.
Of prime importance to therapy is the emotional holding and containment about how therapists provide emotional reassurance and nonjudgmental space. This could include the concept of “holding” in psychodynamic therapy, where the therapist supports the child to feel safe while exploring difficult emotions. From the therapist’s perspective, each story in this paper could become a journey of emotional validation through understanding the behaviors of illness. Intersections and collaboration between artistic expression and therapy may become a significant enhancement to the acceptance of interdisciplinary practice and research, an area that requests further exploration.
In our view, the emotional reassurance provided in these therapeutic contexts goes beyond mere comfort. It involves a profound engagement with the child’s inner world, affirming their feelings and experiences in a manner that could potentially foster emotional resilience and healing. Active participation in theatrical activity not only serves as a safe space for expression but also as a medium through which children can reconstruct their experiences, often making sense of their emotions and the world around them in empowering ways. This therapeutic alliance is crucial for emotional reassurance as it embodies the principles of attunement and empathetic reflection, key components in fostering a sense of security and belonging.
What Are the Implications for Clinical Practice?
Applied theater practice in pediatrics creates meaningful opportunities for children to express how they feel about their hospital experience. In exchange, the stories children can create in synergy with actors in hospitals can offer clinical staff a chance to understand their patients’ worlds better and assess their emotional needs better toward a more informed and sensitive care. Applied theater as an art form can offer a nonmedical and noninvasive approach to the training of nurses the possibilities of developing more culturally sensitive care (Schoenhofer & Boykin, 2022). Building on that, actors who work with children in hospitals can offer clinical and healthcare professional guidance on understanding children’s emotional worlds through participation in bedside theater and storytelling alongside physical recovery. The application of storytelling and theatrical techniques allows healthcare providers to deepen their level of empathy and connection with pediatric patients. This method goes beyond conventional clinical interactions, creating a space where children feel comfortable expressing their innermost feelings. Such an approach is pivotal in building trust and a supportive relationship between the child and the healthcare professional, significantly impacting the child’s recovery journey and overall well-being.
Concluding Thoughts
Applied theater practice in pediatrics seen through the lenses of psychodynamic therapy points toward a holistic care model that caters to the complex needs of hospitalized children. Whereas many people think of the arts as an undermined aspect of healthcare provisions, this paper makes a holistic proposition that focuses on the powers of participatory bedside theater as a form of synergistic storytelling that can make a difference in the lives of hospitalized children. It allows them to express their voices, share their realities, and regulate how they experience illness and hospitalization in informal and indirect ways.
Although the sample of stories we discussed is limited, we have strong indications to believe that by adopting arts-based creative methodologies healthcare professionals can offer children a hospital experience marked by joy, expressive freedom, and empowerment, ultimately transforming the hospital into a place where physical healing is accompanied by emotional and psychological growth.
Effective implementation of this innovative approach requires interdisciplinary collaboration, uniting medical professionals, creative artists, and educators. This collaborative effort fosters the development of care strategies that are uniquely tailored to pediatric patients, ensuring a well-rounded approach to healthcare that addresses all dimensions of a child’s well-being. Beyond merely supplementing traditional medical treatments, applied theater practice offers a transformative approach to care, one that embraces the healing potential of narrative and creativity.
We recommend further investigation into the integrated field of applied theater, storytelling, and psychodynamic therapy in clinical practice, exploring how actors, therapists, and healthcare professionals can foster an environment that not only heals the body but also inspires, educates, and nurtures the spirits and souls of young patients through the theater art. This approach champions a vision of healthcare where the arts are not peripheral but central to child-centered care, offering a beacon of hope and a source of strength for children navigating the challenges of illness and hospitalization.
About the Authors
Persephone Sextou is a Professor in Performing Arts (Applied Theatre for Health and Wellbeing) at Leeds Beckett University in England and previously a professor at Canterbury Christ Church University and Birmingham Newman University. She also taught drama/theater education at universities in Greece. With a PhD from Goldsmiths University of London, Professor Sextou’s funded research has pioneered the conceptualization and development of a ground-breaking applied theater model of direct benefit to hospitalized children’s well-being gaining international impact. She is a leading expert in interdisciplinary, mixed-methodologies, arts-based, Arts & Health Research. Sextou is currently a visiting professor at New South Wales University Sydney in Australia and a research collaborator with Professor Michael Balfour in the Future Stories study (ARC grant) using VR with young people in hospitals. She was previously a visiting professor at Griffith University in Australia. She has a successful record of over 50 publications in English and Greek, of which five are monographs, and citations in nine languages. Her books Applied Theatre in Pediatrics: Stories, Children and Synergies of Emotions (Routledge, 2023) and Theatre for Children in Hospital: The Gift of Compassion (Intellect, 2016) have influenced parliamentary and scholarly debates about the practice and policy of the arts in healthcare globally. Personal website: https://www.persephonesextou.co.uk/.
Stelios Kiosses is a psychotherapist and the Clinical Lead for Edison Education. He manages a multidisciplinary team ensuring the delivery and integration of evidence-based clinical and therapeutic practices and provides extensive training and supervision to associate therapists and formal work experience of graduate psychologists. He studied psychodynamic counseling and clinical supervision at the University of Oxford and was previously trained in psychotherapy and experimental psychology at Sussex University. He is an associate member of the American Psychological Association and a member of both the British Association for Counselling and Psychotherapy and the British Psychological Society. He is a member of Corpus Christi College Oxford and a research collaborator with Professor Robin Murphy’s Computational Psychopathology Research Group based at the University of Oxford. Stelios currently teaches at Harvard University Extension School. He was originally appointed as an honorary senior lecturer at the Department of Psychiatry of the University of Birmingham teaching on the MS in Psychiatry (Family and Mental Health). In his public role he has acted as a UK TV psychologist and presenter for Channel 4’s hit series The Hoarder Next Door and currently is patron of the Prince’s Foundation School of Traditional Arts, one of HRH Prince of Wales core charities. Personal website: https://www.stelioskiosses.com/.
Author to whom correspondence should be addressed; E-Mail: p.sextou@leedsbeckett.ac.uk. ORCID ID: https://orcid.org/0000-0002-0884-7041.
†These authors contributed equally to this work.
Conflicts of Interest
The authors declare no conflict of interest.
References
Alrutz, M. (2015). Digital storytelling, applied theatre, & youth: Performing possibility. Routledge. | |
Axline, V. M. (1947). Play therapy: The inner dynamics of childhood. Houghton Mifflin. | |
Bourke, J. (2012). Languages of pain. Lancet, 379(9835), 2420–2421. | |
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. Basic Books. | |
Boyd, B. (2009). On the origin of stories: Evolution, cognition, and fiction. The Belknap Press of Harvard University. | |
Carter, B., & Simons, J. (2014). Stories of children’s pain: Linking evidence to practice. Sage. | |
Erikson, E. H. (1959). Identity and the life cycle. W. W. Norton & Company. | |
Freud, S. (1913). The Interpretation of Dreams. Macmillan Co. | |
Freud, S. (1923). The ego and the id. In The standard edition of the complete psychological works of Sigmund Freud, volume XIX (1923–1925): The ego and the id and other works (pp. 1–66). | |
Freud, A. (1936). The ego and the mechanisms of defense. International Universities Press. | |
Freud, S. (2014). The neuro-psychoses of defense. White Press. | |
Gatta, M., Miscioscia, M., Svanellini, L., Spoto, A., Difronzo, M., de Sauma, M., & Ferruzza, E. (2019). Effectiveness of brief psychodynamic therapy with children and adolescents: An outcome study. Frontiers in Pediatrics, 20(7), 501. | |
Gibson, M. (2008). Objects of the dead. Mourning and memory in everyday life. Melbourne University Press. | |
Grosse, G., Streubel, B., Gunzenhauser, C., & Saalbach, H. (2021). Let’s talk about emotions: The development of children’s emotion vocabulary from 4 to 11 years of age. Affective Science, 2, 150–162. https://doi.org/10.1007/s42761-021-00040-2 | |
Howitt, D., & Cramer, D. (2017). Understanding statistics in psychology with SPSS (7th ed.). Pearson Education. | |
Kiosses, S. (2021). The power of talking: Stories from the therapy room. Phoenix Publishing House. | |
Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110. | |
Kohut, H. (1971). The analysis of the self. International Universities Press. | |
Lascaratou, C. (2007). The language of pain. John Benjamins Publishing. | |
Maagero, L. H., Grainger, C., & Sextou, P. (2023). Can arts-based interventions reduce children’s peri-operative anxiety in paediatrics? A discussion of representative studies. Applied Theatre Research, 11(2), 141–154. | |
Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. Basic Books. | |
Pelander, T., & Leino-Kilpi, H. (2010). Children’s best and worst experiences during hospitalisation. Scandinavian Journal of Caring Sciences, 24(4), 726–733. | |
Schoenhofer, S. O., & Boykin, A. (2022). Storytelling: A strategy for caring connection in creative nursing leadership. Nurse Leader, 20(4), 349–351. | |
Sextou, P. (2016). Theatre for children in hospital. The gift of compassion. Intellect. | |
Sextou, P. (2022a). Theatre in paediatrics: Can participatory performance mitigate educational, emotional and social consequences of missing out school during hospitalisation? Research in Drama Education: The Journal of Applied Theatre and Performance, 27(1), 88–105. https://doi.org/10.1080/13569783.2021.1940914 | |
Sextou, P. (2022b). Here I am flying! A bespoke animation film for children in hospital. Available online at: https://www.youtube.com/watch?v=azF6HlI0r2w | |
Sextou, P. (2023). Applied theatre in paediatrics: Stories, children and synergies of emotions. Routledge. | |
Winnicott, D. W. (1971). Playing and reality. Tavistock Publications. | |
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. W. W. Norton & Company. |
