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The Arts in Psychotherapy 41 (2014) 467–477

Contents lists available at ScienceDirect

The Arts in Psychotherapy

reativity and dissociation. Dance/movement therapy interventionsor the treatment of compartmentalized dissociation

aia Jorba-Galdos, PhD, MA, R-DMT ∗

aropa University, 2130 Arapahoe Avenue, Boulder, CO 80302, USA

r t i c l e i n f o

rticle history:vailable online 28 September 2014

eywords:issociationreativityantasy-proneness

a b s t r a c t

The purpose of this paper is to investigate the relationship between creativity and compartmentalizeddissociation (CD) and explore clinical implications for treatment. After examining the distinction betweendetachment and CD, the paper presents the main developmental pathways that lead to pathologicalpresentations of CD, highlighting the role of creativity and fantasy proneness. The paper defines thepotential benefits of using creative approaches specifically focusing on dance/movement therapy (DMT)in the treatment of CD. These dance/movement interventions address some of the therapeutic tasks

ance/movement therapyovement repertoire

lters

required for people with CD, such as the identification and mapping of alters and the improvement ofcommunication, collaboration and coordination among them. The paper finally applies choreographicand performance lenses to the integration and mastery of therapeutic transitions, specifically pertainingto the transformation and fusion of alters. In this process, the paper both examines the benefits of theuse of body and movement and also stresses potential caveats in working with this population.

© 2014 Elsevier Ltd. All rights reserved.

ntroduction

Dissociative phenomena have been largely understood both as failure in the normal development of the self (Liotti, 2009) and as defensive mechanism against pain (Ross et al., 2008). Under theseremises, childhood trauma is conceptualized as one of the factors

n the development of pathological dissociation (Chu & De Prince,006; Putnam et al., 1996). Nevertheless, childhood trauma doesot by itself explain the onset of pathological dissociation becausedults with traumatic backgrounds resort to a myriad of copingechanisms. Among other factors, creativity and fantasy proneness

ave been found to contribute to the development of dissociationDalenberg et al., 2012). In this view, dissociation is conceptualizeds a creative defense that over time evolves into an automated, non-olitional and context-dependent response, maximizing survivalnstead of adaptability, even in the absence of threat; what was ansset becomes a liability later in life.

Paradoxically, emotional traumas are also “the probable stimulior new awakenings. . . Even within compulsivity, rigidity, and

bsession, a grounding is established for a struggle against confine-ent. The spurring on of creative forces awakens the excitement

nherent in existence” (Stern, 1988, p. 2). As challenging as it might

∗ Tel.: +1 303 668 6795.E-mail address: laia.jorba@gmail.com

ttp://dx.doi.org/10.1016/j.aip.2014.09.003197-4556/© 2014 Elsevier Ltd. All rights reserved.

be, creative therapeutic approaches such as dance/movement ther-apy (DMT) may be well suited to reverse the traumatic process andtransform a liability into an asset again.

Therefore, the purpose of this paper is to explore the kinshipbetween creativity and dissociation and to propose creative treat-ment interventions using a DMT approach. The paper first definesdissociation and distinguishes detachment and compartmentalizeddissociation (CD). Second, main developmental pathways leadingto pathological presentations of CD are presented. Among the con-tributing factors, the paper highlights the capacity to dissociate,which is moderately but significantly correlated with creativity andfantasy proneness. Then, the paper outlines the potential benefitsof using creative approaches in the treatment of CD and specifi-cally introduces dance/movement interventions as an example toaddress therapeutic tasks with this population.

A brief note on the methodology and data sources: the firstpart of the paper reviews the relevant literature to constructa hypothesis on the correlations between creativity, CD andtherapy approaches. The second part of the paper, where clinicalinterventions are delineated, is drawn from personal experienceworking in private settings with people that have experiencedphysical abuse (mainly domestic violence and sexual assault). All

of my clients were dealing with different ego-states and levels ofdevelopment and autonomy, although none of them had receiveda formal diagnosis of dissociation. Hence, these interventions are atheoretical expansion for clients with more extreme presentations

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1 Because a large number of studies do not distinguish between compartmental-ization and detachment, in this paper the author will use dissociative phenomena asan umbrella term when discussing that literature, and CD will be used when refer-ring specifically to compartmentalized dissociation as defined here. Several classicalstudies on dissociation focused on dissociative identity disorder (DID), previouslyconceptualized as multiple personality disorder (MPD), as the most extreme pre-sentation of dissociative disorders. The author will leave these concepts as they areused because DID can also be understood as the most severe presentation of CD.

2 There are a large variety of concepts used to describe these states such as per-sonalities, self-states, alters, identities, parts, entities, self-representations, etc. Thepreference for one term or another is often linked to particular theoretical stances(ISSD, 2006). Here, the author will interchangeably utilize the terms alter, self-stateand identity. For a larger discussion on this topic, see O’Neill (2009).

3 Although differences between a fragment of self that is non-pathological and afull-blown alter may be easy to establish at the poles, the distinction is not as clear in

68 L. Jorba-Galdos / The Arts in

f segregated ego-states. These preliminary explorations areeant to be the foundation for future case studies and, down the

ine, for a more comprehensive treatment model of CD.

nderstanding the relationship betweenompartmentalization and creativity

issociative disorders: compartmentalization or detachment

The search for what actually constitutes dissociation and howo better assess and treat dissociative disorders has been a constantndeavor in the clinical field for the last three decades (Ross, 1996).sed in broad terms, dissociation could be defined as a “disruptionf and/or discontinuity in the normal integration of consciousness,emory, identity, perception, body representation, motor con-

rol, and behavior” (American Psychiatric Association [APA], 2013,. 291). Dissociative symptoms can be positive, such as intrusions

nto awareness and behavior and loss of the continuous subjec-ive experience of the self (e.g., depersonalization, derealization,dentity confusion and intrusive thoughts), or negative, such as thenability to exert control over mental functions or access informa-ion (e.g., amnesia) (APA, 2013).

The aforementioned experiences are often seen as qualitativelyimilar, i.e., they can be explained by a baseline psychologicalechanism, namely the partial or complete failure of mental inte-

rated functions of a person (Brown, 2006; Cardena, 1994). Theroponents of this unitary continuum or unidimensional modelrganize the dissociative phenomena along a spectrum from theeast intense or non-pathological state (e.g., absorbed states) to theighest level of dissociation (e.g., having a fragmented identity).hese assumptions underlie current assessment tools such as theissociative Disorders Interview Scale (DDIS), the Structured Clin-

cal Interview for DSM-IV Dissociative Disorders (SCIS-D), and theissociative Experiences Scale (DES-II), as well as the diagnosticategories in the DSM, including the fifth edition published in 2013.

The critics of the continuum model state that used broadly, dis-ociation encompasses “almost any kind of symptom involving anlteration in consciousness or a loss of mental or behavioral control”Brown, 2006, p. 9), which obscures the meaning and the appli-ability of the concept. Focusing on its etiology and on specificeurological mechanisms rather than symptoms, several authorsrgue that it is possible and necessary to distinguish detach-ent from compartmentalization (Allen, 2001; Briere, Weathers,

Runtz, 2005; Brown, 2006; Cardena, 1994; Dell, 2009a; Holmest al., 2005; Steele, Dorahy, Van der Hart, & Nijenhuis, 2009; Waller,utnam, & Carlson, 1996). In this view, detachment is defined as anltered state of consciousness that gives rise to a sense of separationrom the person’s emotional experience, sense of self, somatic sen-ations or the world around them (Brown, 2006; Cardena, 1994).ompartmentalization is formalized as a deficit in the ability to con-rol processes, actions and behaviors that normally would be underhe will of the person and that continue to operate normally (i.e.,ble to influence ongoing emotion, cognition and action) (Holmest al., 2005). For instance, dissociative amnesia is the inability tooluntarily recollect memories that could be retrieved under nor-al circumstances, while amnesia due to detachment refers to a

ack of encoding information, which cannot be retrieved becausehe memory does not exist (Allen, 2001; Dell, 2009a; Holmes et al.,005). Even among the supporters of the multidimensional model,ome argue that detachment is not, strictly speaking, dissociationNijenhuis & Van der Hart, 2011; Van der Hart, Nijenhuis, & Steele,

006), while others discuss different types of dissociation (Brown,006; Cardena, 2011; Dalenberg & Paulson, 2009; Dell, 2011).

In summary, although there is not a consensus regarding howtrictly dissociative phenomena should be narrowed down, there

therapy 41 (2014) 467–477

is a general understanding that detachment and compartmental-ization are normally correlated and concurrent but distinguishablemechanisms. This would mean that it is possible to identify clinicalpresentations of detachment without compartmentalization andvice versa, which has implications for treatment (Holmes et al.,2005). Using a very broad framework, if detachment is conceptu-alized as a separation from a sense of self and/or the environment,treatment should focus on grounding and orientation to the self andthe here and now. If compartmentalization is defined as a lack ofintegration experienced as non-volitional intrusions and amnesicbarriers, treatment should aim to decrease those barriers and fosterunity and a sense of wholeness. The latter is the focus of this paper.Thus, the following sections delve into the models that explain theetiology of compartmentalized dissociation (CD)1 and explore itsrelationship with creative capacities, as well as the implications forthe use of DMT in therapy.

Before going further, it may be useful to define what con-stitutes a dissociated or compartmentalized part.2 One of themost classical definitions was advanced by Putnam (1989): altersare “highly discrete states of consciousness organized arounda prevailing affect, sense of self (including body image), witha limited repertoire of behaviors and a set of state dependentmemories” (p. 103). These parts of the self may exist with dif-ferent degrees of autonomy and cross-awareness.3 Although theorganization of self-states is fully discussed elsewhere (Putnam,1989; Ross, 1989), for the purpose of the paper it is worth notic-ing that the most common presentations are the host identity(the one with the most executive control and normally presentfor treatment), child identities (that hold most of the memoriesof trauma), persecutor identities (usually recognized as intro-jects of the original abuser), and protective or helper identities(who counterbalance the internal abusers). This system is dynamicby nature, as it requires constant adaptation and recreation ofalters for the person to maintain homeostasis (Braude, 2000).Additionally, although fragmented parts may remain arrested inchildhood, others evolve simultaneously with the host person-ality or may appear later in the life of the person as a way tocope with life stressors (Raaz, Carlson-Sabelli, & Sabelli, 1993). Itis also important to notice that alters are ego-syntonic (i.e., con-gruent with the history, values, behaviors and the self-image ofthe person) as well as cultural-syntonic (i.e., congruent with cul-tural mythology, beliefs and value systems); in other words, altersare shaped by personal and cultural attributions (Putnam, 1989;Spiegel et al., 2011; Van Duijl, Nijenhuis, Komproe, Gernaat, & de

the middle of the continuum. For an account of the continuum of self-state disordersand the relationship with normal and pathological dissociation, see Dell (2009b).

4 To explore related and suggestive literature on the relationship between culturalJungian archetypes and alter presentations, see Noll (1989), Vincent (2010), andOwen (2011).

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acknowledged in words. Since many DID patients are very creative,they often are able to use these modalities with great ease” (Kluft,

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he development of compartmentalization and the capacity toissociate

A correlation between pathological dissociation in adults andevere trauma in childhood has been found among clinical and non-linical populations (Putnam et al., 1996; Ross et al., 2008; Van derolk et al., 1996).5 In normal development, infants are thought toe born with no perception of unitary self, but with discrete frag-ented states that are highly isolated and differentiated from each

ther (Carlson, Yates, & Sroufe, 2009; Liotti, 2009). If the caregivers able to help the infant modulate transitions between behavioraltates, the child will, over time, internalize the capacity for self-egulation and develop a coherent sense of self.6 If these conditionsre not met, overwhelming traumatic experiences may crystallizehe natural dissociative self of the infant into rigid pathologicalesponses (Carlson et al., 2009; Chu & De Prince, 2006; Liotti, 2009;chore, 2009). Consequently, CD arises from a lack of integrationf the fragmented states of the infant, and only secondarily is iteveloped as a protective mechanism against pain (Liotti, 2009).

Other authors, although generally agreeing with the develop-ental model, stress that not all traumatic childhoods lead to the

ccurrence of CD; a traumatic background may be a necessary butot a sufficient condition (Dell, 2009a; Kluft, 1984; Putnam, 1997).hese etiological models stress personal capacities for dissociation,hich include, among others, the abilities for creativity and imag-

nation (Carlson & Putnam, 1989).

reativity, fantasy proneness and psychopathology

For centuries, the association between creativity and psy-hopathology has been hypothesized and researched withoutonclusive findings.7 Some evidence seems to support the correla-ion between creativity and psychopathology (Acar & Runco, 2012;auronen et al., 2004), although the direction of causality remainsbscure, and methodological problems compromise the general-zability and validity of results (Thys, Sabbe, & De Hert, 2014). Thessue is complex due to the multidimensionality of creativity, diver-ity of creative domains and vast landscape of mental illness.

To date, no research exists regarding the relationship betweenreativity and dissociation. However, there are some studies sup-orting the connection between schizophrenia spectrum disorders,chizotypy clinical presentations and creativity (Batey & Furnham,008; Fisher et al., 2004; Glazer, 2009; Kyaga et al., 2013; Prentky,000–2001; Rybakowski, Klonowska, Patrzala, & Jaracz, 2008).8 At

he same time, some authors have noted similarities between dis-ociative and schizophrenia first-rank symptoms, such as auditorynd somatic hallucinations, passivity experiences (e.g., delusions ofontrol), thought insertions, delusional perceptions, etc. (Cardena

5 The relationship between trauma, PTSD and dissociation is neither direct norimple. Although some proponents argue that PTSD is dissociative per se (Nijenhuis

Van der Hart, 2011; Van der Hart et al., 2006) and others state that DID is aore complex presentation of PTSD (Spiegel, 1993), there is still much to study

egarding the connections and mechanisms of peritraumatic dissociation, PTSD,omplex PTSD and different presentations of dissociative phenomena (Ginzburg,utler, Saltzman, & Koopman, 2009; Lensvelt-Muldersa et al., 2008; Waelde, Silvern,arlson, Fairbank, & Kletter, 2009).6 Coherence does not mean unity, but the ability to sustain an ongoing and gen-

rally unaware dialog between one’s self-states as they are required for an adaptiveehavior. Under a healthy illusion of cohesive personal identity, each self-state func-ions as a part of the whole, even though each state may hold various domains ofsychic functioning such as the capacity to tolerate distress (Bromberg, 2009).7 Excellent historical reviews can be found in Ludwig (1989), Ludwig (1995) andecker (2000–2001).8 See also the monograph compiled by Saas and Schuldberg (2000–2001).

therapy 41 (2014) 467–477 469

& Gleaves, 2007; Dell, 2009a; Ellason & Ross, 1995; Spiegel et al.,2011; Spitzer, Haug, & Freyberger, 1997).9

Another body of literature has focused on fantasy proneness,understood as a propensity for imagination and creation of cogni-tive structures, finding a moderate correlation with pathologicaldissociation, both in clinical and normal populations (Costa &Widiger, 1994; Kwapil, Wrobel, & Pope, 2002; Lynn & Rhue, 1988;Lynn, Rhue, & Green, 1988; Merckelbach, Horselenberg, & Muris,2001; Pekala et al., 1999/2000; Pekala, Angelini, & Kumar, 2001;Rhue & Lynn, 1987; Waldo & Merritt, 2000).10

Other studies have noticed the parallel attributes between dis-sociation and fantasy proneness, such as high hypnotizability,frequent imaginary playmates, inability to differentiate betweenreality and fantasy, alter names from childhood characters andout-of-body experiences (Lynn, Pintar, & Rhue, 1997). Etiologically,isolation and exposure to abuse seem to be common factors inthe development of dissociation and fantasy capacity,11 which areemployed as coping mechanisms against overwhelming emotionsas well as loneliness (Nurcombe, Scott, & Jessop, 2009). While someargue that fantasy proneness may be as important as childhoodtrauma in contributing to the development of dissociation (Pekalaet al., 1999/2000), others demonstrate the secondary importanceof fantasy in relation to trauma history (Dalenberg et al., 2012).Although further research needs to clarify these relationships,“these studies provide increasing support for the idea that abuse isone pathway to fantasy proneness, that abuse and fantasy prone-ness may combine to increase risk of psychopathology, and thata subset of fantasizers appear to be psychologically maladjusted”and have an increased vulnerability to dissociation (Lynn et al.,1997, p. 280).

Creative approaches to psychotherapy

The high capacity for creativity in people suffering DID has beenmentioned in previous studies (Gerity, 1999; Schultz, Braun, &Kluft, 1985). At the same time, the International Society for theStudy of Dissociation Guidelines (2006) highlights the unique rolethat creative therapies12 play with dissociative clients for treatingdissociative disorders. Braun (1986) and Kluft (1999) emphasizethe benefits of art, movement and music therapy in the treatment ofdissociation: “It is difficult to overstate how useful art, music, move-ment, poetry, and occupational therapy can be with DID patients.Often stymied in their verbal expression, these modalities mayprovide a forum for the expression of what cannot be said and

1999, pp. 304–305).

9 The similarity, of course, cannot be overstated because the underlying etiologyand development of the symptoms may differ. Additionally, there is not enoughevidence of neurological similarities between schizophrenia diagnoses and disso-ciative disorders, although some initial research points toward that direction (seeDell, 2009a).

10 For a full discussion on the operationalization of the concept and its connectionto creativity, see Wilson and Barber (1983), Lynn and Rhue (1986, 1988), Barber(2000), Merckelbach et al. (2001), Lack, Kumar, and Arevalo (2003), and Lynn, Meyer,and Shindler (2004).

11 Fantasy proneness, additionally, seems to be related to an environment con-ducive to play and/or imagination, such as parents encouraging a child to engage increative activities (Lynn & Rhue, 1988; Rhue & Lynn, 1987).

12 Creative therapies are normally distinguished from expressive therapy. The firstis an umbrella concept encompassing modalities such as art, music, dance, poetry,and drama; the second is considered a category in itself, intermodal per defini-tion and integrative in purpose; in this sense, the therapist may resort to differentmodalities as needed in the therapy room (Knill, 1994; Malchiodi, 2003). Althoughthe author believes in the basic continuity and interdisciplinary nature of all modal-ities, the focus of this paper is the use of DMT and the specific approach, benefitsand limitations of its application.

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(1990, in Baum, 1993) uses the Kestenberg Movement Profile todevelop interventions for different phases of personality devel-opment. The underlying hypothesis is that integrating movementsequences and qualities previously held by separate alters may

13 For a complete overview of the treatment of dissociation and DID, see Putnam(1989), Ross (1989), Ross (1997), Kluft (1997, 1999), and ISSD (2006).

14 Whether the realistic and/or desirable outcome is strategic/tactical or completeintegration of different identity states is beyond the scope of this article (Crandellet al., 2002; Fine, 1999; Watkins & Watkins, 1997), and it would depend on manyclinical factors such as the level of functionality of the client, as well as culturalfactors. In this regard, Cardena, Van Duijl, Weiner, and Terhune (2009) contrast the

70 L. Jorba-Galdos / The Arts in

Creative therapies share several principles, including a focus onhe external expression of inner experience, emphasis on the pro-ess, the use of experiential or action interventions, the belief ofholeness and health of the person (instead of their pathology),

nd the belief that art expression is a universal human capacity and need. Aside from this common foundation, each modality elicitsifferent processes and is better suited to some clients than othersKnill, 1994). Dissociative disorders add another layer of complexityo the use of art because each part may have their own prefer-nces for certain domains or mediums and even show distinct skillevelopment and technique mastery (Spaletto, 1993).

Creative therapies can make the most of non-verbal expressiveeans by safely communicating painful experiences, both evoking

nd concealing parts of the experiences (Baum, 1993; Baum, Kluft, &eed, 1984; Cohen, 1996; Folman, 2000; Levy, 1995). Thus, they canprovide vital information about past traumatic experiences, cur-ent triggers and stressors, safety issues, and coping strategies. . .efore it can be verbally accessed” (ISSD, 2006, p. 123). Not only israuma mainly encoded in sensorial and perceptual modes, but theizarre experiences of a person with CD are hardly communicablehrough normal language: “What words can one use to adequatelyommunicate phenomena like switching, co-consciousness, a sys-em of highly particularized alters, or internal safe places?” (Cohen,996, p. 532).

Art therapy (Cohen, Mills, & Kijak, 1994; Mills & Cohen, 1993)nd dance/movement therapy (Kluft, Poteat, & Kluft, 1986) haveeen used as assessment tools to screen and to diagnose disso-iative disorders. Creative therapies can also be used to assesshe internal system of alters of the client, as well as to fos-er grounding and containment, cooperation and communicationmong alters, processing of traumatic material, and to assist inntegration (Cohen, 1996; Dawson & Higdon, 1996; ISSD, 2006).

ance/movement therapy as a creative approach

The need to incorporate movement and somatic interventionsnto the treatment of dissociation and DID has already been notedKoch & Fuchs, 2012). Because trauma happens to the body, and it ise-experienced through the body, treatment needs to focus on theody for healing and desomatization (Chefetz, 2000). Paradoxically,ue to the centrality of the body, clients not only tend to have a

ow capacity to identify feelings and sensations, but they may beesitant to explore body symptoms, as well as to move freely for

ear of arousing unconscious material (Ballard, 2002; Baum, 1993):DID patients seem to intuitively appreciate the evocative powerf movement and its ability to reconnect them to their past . . . these of expressive movement can be extremely provocative so muste used cautiously” (Levy, 1995, p. 48).

The artistic medium of dance is the body in action, the primalform to communicate: Movement is our primary medium ofexpression, upon which all other means depend. Speaking, writ-ing, singing, drawing, painting, using any tool or instrument,building, all begin with a movement impulse which is thentransformed into word, tone, line, color or some other material.In every other medium our inner experience is externalized insome material apart from ourselves. In movement expression,the movement of our own body is the material. Material andinstrument and idea are one in the expressively moving body(Mettler, n.d.).

The proximity with the created art product (i.e., the movement

equence) increases the likelihood of arousal and destabilizationBallard, 2002). Movement stands at the opposite pole to freezetates or tonic immobility, the most common responses to traumaBrand, Lanius, Vermetten, Loewenstein, & Spiegel, 2012), and as

therapy 41 (2014) 467–477

such, it is a life affirmative act instead of a survival strategy. Forclients to be able to move and express, they need to have enoughresources to overcome numbness, annihilation or helplessness.Additionally, if movement is progressively used in a creative way,the client is not only able to process trauma by helping the bodyfind its inner resources and wisdom but is also able to interact withthe environment with creative, flexible and adaptive responses.

In the following sections, the paper will focus on DMT asa creative modality in counseling, identifying the potential anduniqueness of this approach in treating CD. First, the limited exist-ing literature on DMT and dissociation is briefly analyzed, findingthat there are no studies focused on clinical tasks specific to CD inindividual settings. Then, the author draws from her clinical experi-ence working with physical trauma victims to develop preliminaryDMT interventions for that specific population. As mentioned in“Introduction” section, this may set a foundation for future casestudies with people diagnosed with CD and for a more compre-hensive model of creative treatments. The paper does not discussthe goals and principles that are consensual in the treatment ofdissociation, but takes them as a framework to integrate DMTinterventions.13 Briefly, it is noted here that CD treatment follows,similar to the work with trauma, a staggered model, which was firstdelineated by Pierre Janet and later elaborated by Herman (Braun,1986; Herman, 1992; ISSD, 2006; ISSTD, 2011; Kluft, 1993, 1999;Putnam, 1989; Steele, Van der Hart, & Nijenhuis, 2001, 2005; Vander Hart et al., 2006; Van der Hart, Van der Kolk, & Boon, 1998).The most basic stages of the model are (a) safety and stabiliza-tion, (b) trauma processing, and (c) identity integration. Beyondthis trauma treatment framework, it is fundamental for the effec-tiveness of therapy for CD to approach and work with the internalsystem of alters, that is, to improve communication, coordination,awareness and functioning, and foster in the client a certain degreeof control of switching between alters (Coons & Bowman, 2001;ISSD, 2006; Kluft, 1999). The ultimate goal of these tasks is theintegrated functioning of the client (ISSD, 2006).14

DMT and dissociation in the literature

Research on DMT and dissociation is still scarce. The initial bodyof literature is mainly preoccupied with the screening and assess-ment of DID. Some studies have tried to identify general movementpatterns in people with DID (Fischer & Chaiklin, 1993), as well asways to identify switching between alters through somatic mark-ers, or to analyze differences in movement repertoires of alters(Connolly, 1994; De Arment, 1993; Kluft et al., 1986). Due to thecomplexity of the definition and assessment of dissociation, thesestudies are preliminary, and no consensus or models have beenadvanced and systematically tested.

From a developmental movement perspective, McCoubrey

Western psychological expectation of self coherence with non-Western culturesthat view the person as a composition of more fragmented identities pollinated withexternal/spiritual entities. Rosik (2000) also discusses the relativistic sense of func-tionality, psychopathology and integration in the self to define healthy individualsin different cultures.

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acilitate integration (Ballard, 2002). This is a suggestive line ofesearch that could be expanded in the future.

Ballard (2002) conducted a pre-post-test study using the DEScale with three clients with DID who were involved in six monthlyMT sessions as an adjunctive treatment. The results for the threeases show an increase of dissociative symptom levels. Theseesults should be taken with caution due to the limited length of thereatment and the size of the sample. It is worth noting how Ballard2002) identifies three different uses of DMT with her three clients:a) anatomical awareness and functional integration, (b) the use ofymbolism and therapeutic relationships, and (c) re-enactment androcess memory. Levy (1995) also notes the beneficial and powerfulse of symbolic action with child alters in a case study of a personiagnosed with DID. This study focuses on the traditional functionsf DMT and does not address the therapeutic tasks needed with CD.

Kissel (2004) identifies the contributions of DMT and neurobi-logy to the treatment of trauma and advances some rationales forhe use of DMT to provide grounding for depersonalization and fos-er integration for compartmentalization, but without advancingpecific interventions. Pierce (2014) delineates a staggered modelo include DMT interventions for the treatment of trauma and dis-ociation, the majority of which are geared toward the regulationf arousal, that is, to prevent detachment and activation symptoms,nstead of addressing CD.

Finally, other studies explore the use of DMT group interven-ions with the dissociative population (Baum, 1991, 1993; Koch &uchs, 2012). Through different interventions (e.g., grounding, mir-oring, building resources, expression of authenticity, work withody memories, use of metaphors, and touch, among others), thesetudies explore the uniqueness of groups and identify four ther-peutic goals for people diagnosed with DID: establishing trusthrough kinesthetic empathy, negotiating social interaction, elici-ing expressive movement and traumatic material, and developing

coherent sense of self.In summary, the above research focused on (a) grounding

nd regulation, (b) anatomical functionality and body integration,nd (c) reenactment of traumatic memories using symbolism andetaphors.15 No studies have analyzed on the use of DMT as a

reative and expressive means to address specific tasks in the treat-ent of compartmentalized dissociation. The purpose of the next

ections of the paper is to identify the main tasks in the treat-ent of CD and define related DMT interventions, which are drawn,

xpanded and adapted from the work with people that have expe-ienced trauma. The emphasis will be on creative capacities, leavingside for now the regulatory and anatomical functions of DMT,hich can be incorporated when developing a more comprehen-

ive model for creative approaches to the treatment of CD. Thelinical tasks that will be examined through the lenses of DMT area) delineating the internal system and expressing the needs andrives of different alters, (b) enlarging the somatic and emotionalepertoire of alters, (c) repairing and/or mastering the past throughollaborative movement projects, and (d) building a dance narra-ive projected into the future. These tasks aim to reconstruct thelient’s “personal history in a manner that is coherent and repara-ive, and to create a prospective story that provides meaning to thexperience of having had multiple personalities” (Raaz et al., 1993,. 170). These interventions are also thought to be applied in private

ractice individual therapy, so they would require some adaptation

f they were to be used in groups or psychiatric settings.16

15 No approach has been developed with DMT that addresses somatoform disso-iative symptoms as described by Nijenhuis (2004).16 For a discussion on the applicability and topics when using DMT in groupsf clients with DID, see Coons and Bradley (1985), Baum (1993), Benjamin andenjamin (1994), and Koch and Fuchs (2012).

therapy 41 (2014) 467–477 471

Therapeutic tasks in dissociation

Delineating the field and expressing needs/drivesAfter the diagnosis is accurately made and the client comes to

terms with it, the need to identify different self-states and identitieswithin a person with CD is paramount to the healing process. Thisprocess is called mapping (Fine, 1991, 1993; Kluft, 1999; Putnam,1989) and it includes lying out not only the alters that the client isaware of but also their relationships to each other. Completing thismap may cover several sessions, as new self-states may appear inthe course of therapy.17

From a tactical treatment approach, instead of mapping thewhole system, the therapist would focus on identifying identitiesthat relate to a specific problem. Alters organize themselves in con-stellations around specific conflicts, encapsulating divergent sidesin oppositional or complementary roles (Putnam et al., 1996; Raazet al., 1993; Spring, 1993). For instance, a specific constellation mayencompass an alter holding the emotional memory, another car-rying the somatic symptoms, and another that has developed acognitive coping mechanism, and so on.

Using the therapeutic room as the canvas and a symbolicexternalized space of the internal state of the person, thedance/movement therapist can assist the client in identifying allof the alters present in the field as they relate to the problem beingaddressed. Dance/movement therapists are better trained to iden-tify subtle changes in the use of the body and space, which canbe markers of switching or different movement signatures of spe-cific alters. As alters emerge in the room, the therapist helps locateeach alter in relation to the others. Objects can be placed to sym-bolize self-states that have been already identified as the clientmoves onto new places in the movement space. Spacing all of theself-states in the room gives the therapist and the client a betteridea of the proximity, tension and degree of aggression/oppositionthat exists between them. Polarization among alters tends to beexpressed through diverging styles, interests, expressive behaviors,animosities or competitive feelings (Dawson & Higdon, 1996), aswell as through body-splits (Baum, 1991, 1993).

The dance/movement therapist is also trained to mirror andkinesthetically attune to different body states of the client, match-ing the intensity, rhythms and use of space. This attunement givespermission to each alter to fully express their drives and needsthrough movement: “although the ultimate goal of therapy is toempower the host and to encourage the alters to work togetherfor the good of the whole, it is ironic that the most effectiveway to do this is to let the alters expand” (Dawson & Higdon,1996, p. 241). Thus, one of the principal tasks is to validate theexperience of each self-state and help them develop and expandtheir movement signature, which is accomplished by the therapistreflecting and mirroring what she sees as gestures and movements,asking the client for clarifications, intensifying some movementsthat are still in pre-effort or the initial stage, etc.

As stated before, the most common response to trauma isimmobility. Thus, it is predictable that clients will need more guid-ance and assistance in exploring movement in the initial stages oftherapy. In the task of eliciting expressive movement, the dancetherapist may develop a very opening or elementary movementof the alter. By observing the therapist’s moves, the mirror neu-

rons of the client are activated, increasing the mobility capacity ofthe client. Gallese (2005) called this process embodied simulation,which is an automatic, implicit, and unconscious internal modeling

17 Kluft (1999) highlights the importance of finding the right rhythm between notforcing the appearance of alters, as this could destabilize the client, and avoidingeliciting them, as this would not address the core issue of the illness. The authormakes good suggestions on how to gain access to different alters.

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Another way to overcome blockages to expanding the move-ment repertoire is by a variant of the doubling technique used indrama therapy (Raaz et al., 1993). In this technique, one alter acts

18 A relevant discussion that cannot be addressed here is the importance of tradi-tional and native healing practices where trance-like dance was used as a mediumto experience altered states of mind and provide ritualistic healing. As noted byEhrenreich (2006), Western psychology is ill prepared to incorporate ecstatic ordance rituals into healing. Although some initial research tries to delineate healthyand pathological trance and cultural altered consciousness (Cardena et al., 2009;Negro, Palladino-Negro, & Rodrigues Louzã, 2002; Ng & Chan, 2004; Van Duijl et al.,2010), there is still little exploration of its application to DMT (Baum, 1993; Serlin,1993).

19 Improvisation can be a medium to expand the alter’s repertoire throughfree movement, master the past through the uncovering of preconscious andunconscious material, or generate new meaning through the creative force of asso-

72 L. Jorba-Galdos / The Arts in

xperience that occurs when the alter observes the actions, emo-ions or sensations of the therapist when they momentarily share aody state. In other words, the alter may be “not only observing butancing in a neurological sense” (Batson, 2013, p. 68). This initialovement is progressively developed by the alters showing and/or

eaching the therapist the nuances of their movement signature.he therapist, at the same time, through questions and movementlarifications, helps the alter to build their personal capacity forelf-expression. If the therapist does not want to take on the alters’ovement, she can help them overcome the blockage to move

y asking them to imagine how they would move before actuallyoving, activating the neuronal precursors of movement.

nlarging the alters’ repertoireAfter increasing the tolerance of movement expression, the

ntroduction of new movements can be encouraged. To study theovement signature of each part and expand their capacity to uti-

ize their bodies in space, the dance/movement therapist can use aramework such as the Kestenberg Movement Profile, Laban Move-

ent Analysis or a simplified variant of this framework (Bartenieff Lewis, 1980; Kestenberg, 1967; Kestenberg & Sossin, 1979; Laban,960). The goal is to analyze movement patterns in space, time,ffort and shape, also observing the articulation of body partsnd degrees of flow restrictions, with the intent to progressivelyractice new ways to relate to these factors. Beyond movement,he therapist can also focus on different ways to view experiences,uch as noticing cognition, emotion, movement, the five senses andnteroception (Ogden, Minton, & Pain, 2006) or Behavior, Affect,ensation and Knowledge (BASK model) (Braun, 1988). Then, theherapist helps the self-states to identify any lacking dimensionsnd embody them.

The purpose to expand each alter’s repertoire is already anntent to overcome dissociation by making the boundaries betweenhe alters thinner. Baum (1993) hypothesized that integrating

ovement patterns and qualities that were previously assignedo separate states/alters could promote integration. As noted byther clinicians, (Fine, 1991, 1993; Van der Hart & Boon, 1997)f the expansion of the repertoire is large enough, spontaneousntegrations may happen because each of the alters hold a moreomplete perception of their experience, and there is no reason forheir separate existence.

The overall process of repertoire enlargement may start by wit-essing other alters’ movement signatures and then trying themn: “it is important that each alter, over time, have an opportunityo explore new movement repertoire and witness the repertoiref the rest of the system. Mirroring and echoing can be particularools in helping the patient see and integrate various aspects of theelf” (Ballard, 2002, p. 28).

Another way to explore new movements is through improvisa-ion. There is a tension between improvisation and semi-structuredr directed movement. Although creativity may need bothMeekums, 2002), delving into the unknown of improvisationith people who have already experience their own life as inter-ally chaotic may be too overwhelming. Following McNiff (1981),mphasis, as much as the person needs to let go of control and per-ectionism to increase creativity, high emotional disturbance andhaotic openness produces insecurity and stress and is ultimatelyon-productive. The toleration of spontaneity and formlessnessre at the same time the means and the content of much of thereative work with dissociative clients. Unlike a fixed dissociativeesponse to environmental stimuli, the creative process may fosterhe client’s capacity to remain in the chaos by increasingly expand-

ng the person’s openness to experience, encouraging their fluidttention and curiosity. It is also true that improvisation can leado altered states of consciousness (Pickett & Sonnen, 1993). Howo facilitate controlled improvisation non conducive to dissociative

therapy 41 (2014) 467–477

trance states is what the therapist should consider by assessing thegeneral functionality of the client, their ego-strength, the capacityfor self-reflection, the client’s life circumstances and stressors, theexistence of comorbid conditions, and self-regulatory skills.18

If the client is capable of exploring through improvisation,and given that in previous treatment stages cross-awareness hasalready been reached, alters may start playing with new movementpatterns, as well as sharing their skills, capacities and movementswith each other. Free body movement can be conducive to self-observation, but it also may be the medium through which alterscould apply different capacities and talents to a shared project,in this case, the development of choreographed sequences. It hasbeen noticed that collaboration in common tasks not only fostersrespect for each alters’ capacities, but decreases internal conflictand increases functionality (Dawson & Higdon, 1996).19

In the same way that alters may present themselves with dif-ferent body gestures, postures and movement repertoires, it is alsocommon to identify body parts holding dissociated pieces. Hence,one of the most important tasks in treating CD is to help these bodyparts function in a way that is not chaotic, but emphasizes coordina-tion and collaboration. This means to find a way to dance together:“a group member physically expressed an internal conflict betweentwo alters, one self-destructive and the other an inner self helper. . . as a struggle between the right and the left sides of her body.Her right hand reached toward her throat as her left hand pulledit away” (Baum, 1993, p. 134). Paying attention to both the needsand functions of each of the opposing alters, the client explores anew movement that integrates both, allowing for soloist time andfinding a chorus tune that feels satisfactory.20

Another approach to enlarge the movement repertoire can beattending to transitions. Switching between alters can happenabruptly or take several minutes (Connolly, 1994; De Arment, 1993;Kluft, 1999). Paying attention to the process of switching forcesthe alter to analyze not only the triggers, but most importantly, tonotice what changes somatically from one state to the other. Usingagain the idea of the room-canvas where the map of the alters ispainted, the dance/movement therapist can assist alters to transi-tion to other spots in the room where another alter has been locatedby noticing changes in the use of movement, space, time, effort, etc.,and by identifying somatic markers of switching. It is critical in thisprocess to control speed because slowing the movement down reg-ulates the exposure to triggers as well as arousal, helps the clientnotice other dimensions of experience (i.e., thoughts and emotionsthat come with movement), and allows identification of the exactsequence of switching. Hence, the client progressively gains controlover the process of switching.

ciationism. The latter two topics are discussed in following sections of the paper.20 The symbol of the orchestra is taken from the work of Pickett and Sonnen (1993).

The authors use classical music compositions as a symbolic representation of the lifeinside the dissociative client, listening to the music performed by an orchestra helpsalters finding strategies for collaboration without silencing any of the voices.

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dissociation, as shown in previous sections.Thus, the therapist may use these interventions with caution,

trying to avoid both minimization and validation of the client’s

L. Jorba-Galdos / The Arts in P

s a double, articulating thoughts, movement and/or feelings thatnother alter may be not able to express or may not be aware of.or instance, internal helpers or protectors may assist child altersn vocalizing affects and thoughts. Ideally, at the end of the pro-ess the alters would be able to use different vocabulary at theame time; they would be able to describe the movement whileoving, move while feeling, and in a synchronized way, vocalize

houghts and images with movement. This has the additional ben-fit of simultaneously engaging different areas of the brain, thusurthering integration.

astering the past, restoring unsatisfied needsOne of the most important tasks in treating CD is to process or

etabolize the initial traumatic experiences in a way that is notetraumatizing, but rather integrative to the client. This abreactiverocess has been largely discussed in relation to dissociative dis-rders (Boon, 1997; ISSD, 2006; Kluft, 1997; Van der Hart, Steele,oon, & Brown, 1993). From the author’s point of view, this treat-ent phase is necessary if significant improvements are to be seen

n the clients’ symptoms and quality of life. However, instead ofiscussing this task that has been extensively studied, this paperocuses on other creative interventions, substitution and symbolicechniques that can be applied in parallel with processing and/orfter some traumatic memories have already been processed. Thesenterventions focus on modifying the course of the original traumand make memories more acceptable, “either by changing the con-ent of the traumatic memory itself, or by altering aspects of thelready transformed narrative recall” (Van der Hart et al., 1993,.172).

This can be accomplished by reenacting the traumatic mem-ry as if it were a dramatic scene, where the alters that hold partsf the specific memory can rewrite the script and play it out. Otherlters with higher functioning or regulatory skills, such as the innerelper, may be present by observing and assisting in the scene.o control exposure to traumatic material, the movers may firstnly use gestures and postures, slow motion and freeze scenes, andntroduce voices when each part feels more comfortable with the

ovement. By moving different alters alternatively across a spe-ific scene (or segment of a scene) and by playing out differentutcomes, alters regain power and control of the situation, whichelps them overcome the hopelessness they felt in the originalrauma. As the alter feels more and more empowered, the fantasynd recreation of the scene may also evolve. For instance, the childlter may first want to harm the parental figure that abused them.s the child sees this outcome and processes part of the anger, theeed for attachment and love toward their parent emerges, andhe scene is transformed in a way that the parental figure mayot be hurt, but brought into court to be held responsible. Alter-atively, the client–host may be the witness and/or the director ofhe scene, where objects can be used instead of alters to explore,n a less intense manner, the past. It is not uncommon that a sub-onstellation of alters may simultaneously include the child–victimnd the internalized-perpetrator. Understanding the purpose of theerpetrator and replaying scenes of trauma in which the perpetra-or and victim alters are invited to dialog with the mediation ofthers may also be effective (Raaz et al., 1993). This work can onlye effective when agreements on safety, as well as a basic sense ofespect among alters, are already established.

Symbolic actions are paramount when dealing with the actualvents is too overwhelming. Working with metaphors allows forhe juxtaposition of unrelated/distorted elements, making newonnections that could not be reached by reason alone (Cohen,

996), as well as expressing the chaos of the internal life of thelient. From a simple physical movement, the therapist assistshe client to develop a symbolic image (Sandel, 1993), verbalizehat they could not express before, and apply that learning to

therapy 41 (2014) 467–477 473

their concrete experience again. As stated by Chaiklin and Schmais(1993), the goals in using metaphors are to integrate words, expe-rience and movement; externalize inner thoughts and feelings;expand the symbolic repertoire; recall parts of the significant past;resolve conflict through action; and gain insight. Metaphors canbe elicited through free association in movement (Koch & Fuchs,2012), relaxation and imagery (Dunn, 1988; Levy, 2005), and usingfantasy through visualization (Levy, 2005).21

If the first approach to master the past was through substitutionand symbolic actions, the second approach is to focus on repairingthe cognitive distortions and/or addressing the needs that were notfulfilled. Because many cognitive distortions may emerge after theprocessing of the traumatic memory (Fine, 1991, 1999; Van der Hartet al., 1993), it is relevant to address them in this stage of therapythrough movement and dramatization. For instance, beliefs such as“it was my fault” or “it didn’t happen to me,” can be explored andexternalized by different alters and characters in a scene. Sharpen-ing the capacity to observe those beliefs and gaining some distancefrom them through their dramatization and movement expressionmay open the possibility to try new scripts of beliefs and statementsthat are more accurate or realistic to what actually happened.

The space can also be utilized as a container and regulationstructure, for example, using a smaller or bigger movement space ifan alter feels too exposed or trapped, respectively; devoting spotsin the room as a safe platform to have a break and to observe whatis going on at any stage of the process; or, finally, reserving a spacefor negotiation, where conflicting alters can dialog and find com-mon grounds. This way, the client has greater control of the processthrough spatial use, titrating the intensity of the session and prac-ticing regulatory skills that may be needed in the process of therapyand in day-to-day life.

If instead of cognitive distortions the focus is on addressing theneeds of the survivor, the moving scenes may be created to providecorrective experiences regarding nurturance, protection, support,limits, etc. (Crandell, Morrison, & Willis, 2002); the “primary goal isto develop a believable antidote experience that honors the needsand feelings that were not honored in the original trauma” (p. 68).For instance, if a child is left alone crying in the closet, the aim is tofind the most acute need of the child at that time; in this case, it maybe validation of their terror and nurturance for safety. Thus, otheralters, such as the internal helper, may be invited to provide thoseneeds. A powerful method to crystallize those images is to identifya movement and a statement for each of the characters/alters, inother words, embodying the message that each characters/alterscarries, such as “I’m here to protect you.” Creating and enactingpositive images through movement and dramatization allows elab-oration of “models that can become guiding forces” in the client’slife (Halprin, 2003, p. 21).

When using substitution and symbolic techniques, there are twopotential dangers. The first is to invalidate the original memory(Van der Hart et al., 1993), i.e., to not give the client enough timeto process and grieve their real experience, which may be viewedas minimizing the past. The second is to create images that theclient interprets as real memories; in the process of creating newmaterial, it would not be uncommon for the victim to fill amnesicgaps with made up scenes, which could then be taken as accu-rate recollections (Brown, Scheflin, & Hammond, 1998). This is ofspecial importance due to the link between fantasy-proneness and

21 For a complete analysis of the importance of metaphor and its application withdance and movement interventions, see Baum (1993), Meekums (2002), Halprin(2003), and Koch and Fuchs (2012).

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74 L. Jorba-Galdos / The Arts in

antasies as realities. It may be better to resort to these approacheshen some processing of memories has already been accom-lished, so that the survivor can retain the original memory asart of the narrative of the self. Other strategies involve presenting

nterventions and treatment goals to the client with as muchransparency and clarity as possible, which may lessen the undueonfidence of retrieved memories (Brown et al., 1998; Van der Hartt al., 1993).22

rojecting to the futureThe experiences of clients with dissociation are characterized by

isruption and discontinuity of relationships, memory, identities,nd body experience (APA, 2013). The creative process of recons-ructing personal narratives from images, memories and feelingshat have been explored through therapy supports the psycholog-cal need of meaning making and integration of the self (Halprin,999). This parallels the effort of the composer or choreographer

n their intent to build a piece that fosters the integration of oldaterial and the transformation into something new and inspiring.owever, it is also the effort of the performer, who, through practic-

ng and consolidating new behaviors and movements, is capable ofranscending the past and is able to be reborn into a more integratednd whole human being.

This task does not necessarily come at the end of treatment, butvery time there is a transition or need for a substantial change.hus, the choreography to develop may be as short as a movementequence lasting for few seconds or as long as a full piece withifferent sections and encompassing a longer timeline of the client’s

ife.In each of these sequences there are, at least, three different

ections: understanding and honoring the past, recognizing theresent, and projecting to the future. For instance, the client maye interested in thematically exploring their relationship to angernd develop a pathway of the strategies different alters resortedo manage anger. In looking at the past, the client may understandrom a wider perspective how these strategies helped them sur-ive by relating to anger differently (thus, honoring each alter’strengths and symbolically taking those strengths on the journey).ext the client may assess and recognize how all of those skillsre now available and reachable in a more coherent and consciousay. Finally, the client projects into the future desires and goals

nd builds, little by little, the path that will lead them there. Tak-ng a wider perspective, the person may want to focus on one alterhroughout the process of therapy. It is not uncommon for differentlters to either fuse with the host or evolve and get older as therapyrogresses. Thus, helping the client understand the developmentalransitions that different alters may be going through is also useful.he timeline of the overall life of the client is another major projecto approach, with possible focus on the client’s strength of survivals well as focus on identifying the emergence and disappearancef different self-states. Another approach, most likely closer to thend of the treatment, will aim at making sense of the whole tra-ectory of therapy, recognizing what has been and remains to beccomplished, resulting in a featured performance to describe the

ransformative healing journey of the client (Ballard, 2002).

One specific performance for clients with CD is preparing theitual of fusion or integration of different alters. The ritual is impor-ant because the client is saying goodbye to parts of their rich inner

22 The purpose of these interventions is not to uncover memories, but to attend tonsatisfied needs, empower the client and get as much closure as possible. Regard-

ess of the accuracy and/or veracity of the material presented, all parts of it must beddressed to some degree or another to gain resolution and healing (Kluft, 1999).mages and fantasies should be treated as means to reach this goal, not as the goaltself.

therapy 41 (2014) 467–477

world that, although chaotic and dysfunctional, were known andhelped the client survive. Letting go of the past involves, as a big partof the process, grieving alters that are being left behind. Althoughsome spontaneous fusion may happen through the therapeuticwork, as mentioned above, preparing for rituals that include imagesof fusion and movement may be helpful at appropriate times for amore complete integration (Kluft, 1993).

Choreographing these pieces assists in slowing down theexpressive process and identifying inner conflicts. Of course, in anytransition in which the client is in pre-effort and learning mode,there can be as much hope as fear. Improving and rehearsing thepiece toward a final performance helps the client move from hesi-tation to mastery expression. Body language and gestures expandprogressively, helping to consolidate a larger repertoire. The clientmight gain not only agency as well as physical and psychologicalintegration and resolution but also esthetic satisfaction from anartistic product that reflects part of their life, which furthers theirsense of completion and wholeness.

Conclusions

This paper has explored the connections between compart-mentalization and creativity. Given the understanding that CDis a creative mechanism that becomes dysfunctional, the authorsuggested that creative therapies can help reverse the process.Focusing on dance and movement, the paper expanded and adaptedtrauma DMT interventions to address specific tasks in the treat-ment of CD. Among those interventions, the paper delineated theuse of dance and movement to identify alters and map the inter-nal system of the client. The paper also provided some enteringpoints to help different alters enlarge their personal repertoire andstart accepting, collaborating and ultimately coordinating together.Additionally, the paper described mechanisms and techniques tomaster the past through restoring unfulfilled needs. Finally, chore-ographic and performance lenses were applied to integrate andmaster therapeutic transitions, specifically pertaining to transfor-mation and fusion of the alters.

The author has raised cautions on the use of body interventionsbecause they can either increase arousal or be difficult to imple-ment due to the client’s tendency to resort to immobility responses.Therapists should be ready to use both regulatory and groundingtechniques to modulate arousal, as well as utilize bridging tech-niques, as described in the paper above, to empower the client withinitial movement that can be further expanded.

The paper has also cautioned the reader on the minimiza-tion/invalidation of memories and the possibility that the clientmay confuse fantasy creations with original memories. Some basicways to address this have been provided, but an informed therapistmay have a good grasp on the debate of false memories, which hasbeen central to the treatment of trauma and dissociation. From theauthor’s point of view, regardless of the accuracy of the memory, itis important to process and work with memories to foster completehealing, as long as the intent is clear to the client.

The topics and interventions discussed are conceptualizedunder a private practice approach with individuals with CD. A nat-ural step forward in this line of research could seek to test thesetheoretical interventions in a case study and identify further issuesto consider in applying movement creativity to the treatment ofCD. A further theoretical development would be to delineate a fulltreatment model through DMT lenses, including grounding, regu-lation, and memory processing techniques. Future research could

also examine the application of these mechanisms with groups orinvestigate the pros and/or cons of using DMT as a central or adjunc-tive therapy in psychiatric inpatient settings. Other studies maybenefit from focusing on the relationship between creativity and

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ultural presentations of alters, exploring the integration of tra-itional uses of trance/healing dances in therapeutic treatment. Itould be fundamental for future research to specifically examine

omatoform dissociation or physically related symptoms of CD.Within all of the possible studies, it would be relevant to observe

he applicability and limitations of this creative, somatic approachith clients who experience different levels of functionality and

go-strength. Perceiving the lack of integration of the self, the indi-idual may present a full-blown dissociation or different degreesf dissociate ego-states. It is to be expected that the approach withhese types of clients may differ.

Although movement has a very unique contribution to and rela-ionship with trauma work, the interventions developed here are,n some cases, inspired by the work of other art therapists. Likewise,he preliminary interventions offered here may be of inspiration forther creative approaches or a blended creative treatment modelhat uses different modalities. Because creative interventions arey definition infinite, the interventions offered in this paper areeant to be an inspirational starting point for a rich and growing

eld.

cknowledgements

The author would like to gratefully acknowledge Dr. Christinealdwell, Matt Allen and Karen Jensen for their generous, uncon-itional support and guidance in the writing and development ofhis article.

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