Tag: anxiety

TREATING PAIN & ANXIETY WITH MINDFULNESS & IMPROV

Margot Escott, LICSW, RfG-CP

I have been a licensed social worker for over 35 and trained in Mindfulness 30 years ago and have been teaching and performing Improvisational theater for the past 12 years.  In my clinical practice, I combine cognitive behavioral therapy with mindfulness and applied improvisation to help people heal their chronic pain and anxiety among other complaints. Applied improv is a wonderful tool to help people living with behavioral issues such as anxiety and coping with chronic issues like pain and anxiety. Discovering improv has not only benefited my life but those of my patients.

Let’s discuss the case of my recent client, Carla, a 63-year-old, former nurse.  She has been seen in my practice since February 2022.

She received a BSA in nursing and owned a Home Infusion Center for 24 years. She was forced to take early retirement due to an accident. She has been happily married for 30 years.

Carla suffered an accident in 2018 that led to a spinal fusion and subsequent pain in her lower back and generalized anxiety. She reported a history of depression that started after her accident and timely correlated with the use of morphine. Her daily pain is not controlled with morphine and other medications.

My training has included pain management, and mindfulness training and I’ve found that using improvisational theatre games is very useful. When the patient is focused, they often become unaware of their pain, and the production of endorphins and dopamine increase feelings of well-being.

Because of her sense of humor, self-confidence, and intelligence, I decided to introduce mindfulness, meditation, and improv games quickly into her treatment. However, not all of my patients have such high self-confidence. Many of my clients struggle with social anxiety and it often takes several sessions for them to develop a trusting, therapeutic relationship with their therapist before we can try some of these experiential techniques. But they can also be helped with Improvisational Games.

At our first session, I introduced the concept of mindfulness and meditation. We explored the idea of being in the present. When she started to experience anxiety, I asked her to say to herself “be here now.” I used a technique called “body scan,” where I led her to relax each part of her body, from the top of her head to her feet. The Viola Spolin exercise called “Feeling Self with Self “, teaches students to connect with their bodies and produces calm feelings as well. We worked on her breathing and the idea that her thoughts of anxiety and fear would dissipate through focused breathing as we increased the time of each silent meditation. I directed her into a two-minute silent meditation. She reported that even after such a short time, she was feeling more relaxed.

In session two I introduced the improv concept of “Yes, and.” This is a concept that teaches you one of the basic skills of improv. It is about agreeing with your scene partner and accepting whatever they say to you. For example, your improv partner says “I heard you just returned from Mars.” You accept their thought (the Yes) that you went to Mars and add to that statement (the and). You might respond with, “Yes, and  I’ll be spending Thanksgiving and Christmas back on Mars.”

We also taught the Gibberish exercise and games. Gibberish is a Spolin exercise that she developed while working with Neva Boyd at Hull House. Their students were immigrant children from all over Europe and spoke many different languages. Gibberish is exactly what it sounds like! The player speaks in a non-sensical language made up of vowels and consonants. Gibberish allowed the children to be able to communicate with each other while using facial expressions and miming to be understood.

Like most newcomers to improv, she was concerned about “doing it wrong,” but was able to overcome that with the improv concept that “nothing is wrong or a mistake when we improvise.” This idea that there are no failures in improv and that you can’t get things wrong decreases the anxiety or performance stress when they understand that no matter what they do it’s going to be a gift to their partner, me a therapist, or the other students if they’re in group therapy. Quite often I teach the “Ta-Da “

A fun way to overcome a perceived mistake is the “Ta-Da” exercise. This is a movement combined with the words “ta-da”. They throw their hands up in the air and in a loud voice say “Ta-Da”! I frequently observed that when one person says the Ta-Da and breaks the ice, soon everyone is using that little phrase and laughing at themselves.

These interventions produced laughter and smiles from Carla. Laughter increases Dopamine levels, which decreases feelings of sadness.

We began meeting bi-weekly as she had many doctor appointments and physical therapy at a therapeutic indoor pool with licensed physical therapists. In our fourth session, we played the game “Tiger, Martian. Cow.” In this exercise, the player is required to change their facial expression, use specific body movements, and make a sound as either a tiger, a Martian, or a cow. When making these faces and sounds like a tiger, my patience “get out of their head” and just relax into the game. It’s very hard to have stressful thoughts when you’re involved in such a game. Carla and other of my patients find that this exercise takes them away from those anxiety-provoking thoughts and leads them into the relaxation response.

We increased the time of the meditation to seven minutes, with the suggestion that she practice this daily (the caveat being that if she didn’t practice, she wouldn’t be graded or judged).

In the following session, we played the Fortunately/Unfortunately a storytelling game that requires focus and active listening. Then I introduced a two-person scene game with a Who, What, and Where. Carla threw herself into this experience. She described how much better she felt at the end of this session.

Over the next few sessions, we played Spolin’s exercise Mirror and Follow the Follower at the beginning of each meeting. Carla found this game particularly calming.

Carla was seeing multiple pain specialists about injections to decrease pain and possible surgery.  She was disappointed that her injections weren’t helping with the pain. And, there was no evidence that the suggested surgery would be successful, which led to the “What If” game. This is used in CBT to help a patient go to the very worst scenario when they have fear about an event that may or may not happen. This reinforces the use of meditation which Carla is currently practicing for ten minutes, usually twice a day.

In our fifth month of treatment, I asked Carla if she was feeling any benefit from the improv. She responded “It makes me laugh! I feel less anxious and forget the pain.” She is one of several patients who have reported this after doing improv in therapy.

Many researchers are investigating and measuring the impact that improvisational theatre games have in psychotherapy with individuals, couples, and families.  The results are encouraging and we hope that Improv Therapy will someday be considered a creative arts therapy like music, art, and drama.

Another improv technique is called Story Spine, attributed to Kenn Adams.

This is a form of telling a story where one could use flashcards for each part of the story.  I use this method when working with improv groups for people with Parkinson’s disease and their care partners and clients with mild dementia. The flash card has the beginning line for the first player, “Once upon a time..” and the player completes that thought. The next player adds to the story with the line “Every day”. The point of this tool is to provide a model for a well-constructed story with a beginning that establishes a routine, an event that breaks the routine, a middle that shows the consequence of having broken the routine, a climax that sets the resolution to the story in motion, and the resolution. It goes like this:

• Once upon a time…
• Every day…
• But, one day…
• Because of that…
• Because of that…
• Because of that…
• Until, finally…
• And, ever since then…

These are just a few of the many improvisational theater games that I use in my practice. There is growing research among psychologists and doctors on the psychological and physical benefits of improv and those are included in the Resources below.

If you are a clinician and have ever thought about using applied improv, there are many sources you can go to, especially the book “Rehearsals for Growth, which you can find at  www.rehearsalforgrowth.com. Dr. Daniel Wiener, a psychologist who studied improv with Keith Johnstone, wrote this groundbreaking book in 1994. He has a training program for clinicians to understand and use applied improv in their practices.

In this book he illuminates the connection between theater and therapy, shows how performing improvisation enriches our understanding of social behavior, and enables players to experience greater freedom of expression and power based on cooperation, imagination, and spontaneity.

Over 160 improv games, modified for use in psychotherapy, are described, along with a score of case examples. As a recognized “Drama Therapy of /Relationships” Rehearsals for Growth continues to evolve as a helpful method that may be used in combination with nearly all other psychotherapy and counseling approaches.

BIBLIOGRAPHY or RESOURCES?

Benson, Herbert & Miriam Z. Kipper. (1975) The Relaxation Response. William Morrow and Company.

Boyd, Neva.  (June 1, 1975) Handbook of Recreational Games. Dover Publications

Campbell, J., & Christopher, J. (2012). Teaching mindfulness to create effective counselors. Journal of Mental Health Counseling, 34, 213–226.

DeKoven, B. (1978). The Well-Played Game.  Anchor Books. Garden City, New York.

DeMichele, Mary & Kuenneke, (2021) Scott. Short-Form, Comedy Improv Affects the Functional Connectivity in the Brain of Adolescents with Complex

Developmental Trauma as Measured by qEEG, NeuroRegulation, Vol 8 No 1

Felsman, P., Gunawardena, S., Seifert, C. M. (2020). Improv experience promotes divergent thinking, uncertainty, and affective well-being. Thinking Skills and Creativity, 35, 100632.Golding, M. (2014). Listen Harder. ISBN-13:978-1497418028.

Jagodowski, T., Pasquesi, D., & Victor, P. (2015). Improvisation at the speed of life. Chicago, IL: Solo Roma.

Kornfield, Jack. (1993). A Path with a Heart. Bantam.

Krueger, K. R., Murphy, J. W., & Bink, A. B. (2019). Thera-prov: a pilot study of improv used to treat anxiety and depression. Journal of Mental Health, 28(6), 621-626.

Romanelli A. Tishby &. Moran, G. (2016). Coming home to myself. School of Social Work and Social Welfare, Hebrew University, Israel Mt. Scopus, Jerusalem, 9190501.

Spolin, V. (1999). Improvisation for the Theater (3rd ed.). Evanston IL: Northwestern University.

Wiener, D.J. & Oxford, L.K. (2003) Action therapy with families and groups. Washington, DC. APA

Wiener, D. J. (1994) Rehearsals for Growth. New York. W.W. Norton.