Shall We Dance?Using Creative Arts Therapies to Promote Play, Social-relatedness and Self-Expression in ASD: Meet Evan a 17-year old dancer, musician and

artist and his motherSuzi Tortora Ed.D.

BC-DMT, CMA, LCAT, LMHCwww.dancingdialogue.com

Profectum: The Power of Play

John Jay College, NYCOctober 18, 2015

“It is through original, real, imaginative, and self-generated exploration that a child explores ways to understand and integrate experiences, and to create new images that support new ways of developing her sense of self. Creativity fosters inner expression.”

Dr. Suzi Tortora(The Dancing Dialogue, 2006)

What distinguishes creative arts therapists from dance, art, and music teachers?

• trained and licensed psychotherapists

• primary goal: create a psychotherapeutic healing environment that supports emotional and psychosocial development

• use creative arts mediums as primary tool for expression

Most Important Message From A Creative Arts Therapeutic Perspective

• The process of art making is the essential core of the experience

• Goal is to create experiences for the ASD child to tell you who s/he is

• Each child’s view and contribution has a place and value

• Experience of art making is a journey of discovery and expression leading to a deeper sense of self

• Emphasis on individual creative aspect of art making rather a final product that they must follow, copy, mirror

Ways of Seeing

Theoretical Principles & Methods

Observe with a dance-like frame of reference:

WHEN OBSERVING THE CHILD

1. What isolated actions is the child doing – how can I link them together like a dance?

WHEN OBSERVING INTERACTIONS

2. What is the dance of interaction - the dancing dialogue - observable between the child and adult?

This dancing dialogue portrays patterns of communication between self and other.

Ways of Seeing

Tortora, 2006

Interactions– spontaneous choreographiesKey Developmental Factors to Consider

• Role of Body Experience in Development

•Multisensory Development

•Development of Attachment

•Language Development

Tortora, 2006

When I look, I am seen, so I exist

- Winnicott (1971/1991)

Developing Relationships/Interactions

• Quality of mother-infant relationship affects infant’s physiology, neurophysiology & psychology (Hofer, 1981, 2003)

• (Porges, 2004)Neurological regulation - developmental process contingent on social -emotional interactions

• “Neuroceptive” sense of safety, established through nonverbal and vocal cues is necessary to support infant’s [improvisational] social engagement

Parent - Child Attachment Relationship Beebe (2004)

• Exchange between mother and infant unfolds during each interaction & is CO-CONSTRUCTED at the NONVERBAL LEVEL involving

a. SELF-REGULATION = how each person is affected by own behavior

b. INTERACTIVE or CO-REGULATION = how each member is affected by the behavior of the other

Language Development as it Relates to Relationships

(Bucci, 1994; Appelman, 2000)

• Nonverbal experiences between infant & caregiver play a significant role

• Transformation

• Organization of experience

• Language

Seven Sensory Systems

• Arousal level• attentive, alert• over - arousal• under - arousal

• Regulation• Physiological• Emotional

Executive Functioning Skills • Control of attention & cognition

– think flexibly– ignore distractions– resist impulses– maintain focus– hold information in mind

• Regulation: Develop self -control– mind– body– emotion

Body-based Regulation of Attention• 3 Phases

– Monitoring self- regulation - attuning to “sensational” voice

– Expressing Intersubjective awareness = awareness of others thoughts & feelings - creating a“shared psychological field”(Stern)

– Successfully engaging in joint activitiesTortora, 2006

Autistic Spectrum Disorder (ASD) through the

Ways of Seeing Lens

Characteristics of ASD• severe language, communication and developmental

delays in all areas of development

• avoidance and detachment

• caused by extreme sensory sensitivities, dis-regulations, and atypical neurological functioning

• approaches the world from a place of self-protection and evasion

• extremely perseverative, filled with unusual and intricate gestures and full body actions

Ways of Seeing Thoughts about ASD• What if children in the autistic spectrum are stuck in this

stage of communication and attachment before verbalization where nonverbal experiences reign?

• They are driven by severe sensory integration sensitivities & the inability to regulate nonverbal input - timing, space, arousal, affect, proprioception.

• Perhaps children with severe communication disorders become driven by bodily sensations.

• Regarding nonverbal behaviors as communications, acts as a precursor to symbolic representation and meaning making. Tortora, 2006

FOR THE AUTISTIC SPECTRUM CHILD PERHAPS

BODY & BODY SENSATIONS

ARE THE REFERENCE POINT

FROM WHICH THEY

DECODE EXPERIENCES

Tortora, 2006

Ways of Seeing Conclusions

• the discharge and regulatory function of the nonverbal stress behaviors supports their use as a communicative element

• nonverbal behaviors can be used to initially interact along the journey towards more adaptive functioning and increased relating

Tortora, 2006

Ways of Seeing Conclusions• Intervention focus:

• create a “neuroceptive” (Porges,2004) environment of safety to ensure comfort level

• use multisensory sensitivity needs as starting point of communication

• enhance/explore physical developmental coordination (Dynamic Process III)

• create environment for free creative self-expressive spirit Tortora, 2006

Movement Qualities in ASD that affect SENSE OF [emotional] SELF

• Affect sense of physical self which in turn affects emotional self

• Little torso differentiation• Personal idiosyncratic actions• Sense of limbs as disconnected/ unrelated to

torso• Lack of fluid coordination/connectedness

between body parts • Difficulty making fluid, sequential actions• Lack of full extension of body parts – stiffness –

not reaching out into space – into environment or even fully with in own kinespheric space

• Toe walking. Tortora, 2006

Movement Qualities in ASD that affect SOCIAL RELATING

(Tortora, 2006)

• Lack of eye contact

• Darting, turning away with body part –Shoulder– torso

• Darting, turning away with full body

• Running through room

• Isolating self in space Tortora, 2006

Movement-based DIFFICULTIES underlying all (SOCIAL) ACTIVITIES

• Modulation- rhythmicity, timing & using gradation

• Body, movement & emotional regulation from active to calm

• KEY GOAL Learn to regulate/moving up & down a

movement spectrum from more active to less active

Tortora, 2006

Ways of Seeing Goal with ASD

• Develop socially engaging interactions by creating a “neuroceptive” sense of safety

• Regulate/moving up & down a movement spectrum from more active to less active

• Establish internal regulation

• Develop a positive sense of selfTortora, 2006

Ways of Seeing Goal with ASD

• Leads to inter-personal regulation & connection

• Leads to possibility of developing intersubjectivity

Tortora, 2006

Principles that guide Ways of Seeing sessions

KEY PRINCIPLES THAT GUIDE EACH SESSION

~ All activities in the session give the mover the opportunity to show the therapist who she/he is.

~ Start where the child is at -- child directed

~ Nonverbal behaviors are expressions of self

~ Observing nonverbal actions tell us important information about how the mover is experiencing, exploring, and learning, about the surroundings

Tortora, 2006

KEY PREMISE:

ALL NONVERBAL ACTS HAVE THE POTENTIAL TO BE COMMUNICATIVE

Go beyond the behavioral aspect of action and ask:

IF THIS BEHAVIOR/ ACTION IS A COMMUNICATIVE ACT, WHAT MIGHT THIS

CHILD BE SAYING?Tortora, 2006

5 Key points to Nonverbal Observation

1. A dictionary type of interpretation should not be used to understand nonverbal actions

2. No nonverbal action or quality is good or bad.

3. Determine if the nonverbal behaviors are motivated by a need to satisfy a sensory related reaction, a social or emotional drive, or both.

Tortora, 2006

5 Key points to Nonverbal Observation

4. Determine if body actions, vocalizations, verbalizations, or a combination or all of these elements are influencing your perceptions of the mover’s behavior.

5. Notice if the nonverbal body action occurs facially, gesturally, posturally, or a combination of all of these expressive modes.

Tortora, 2006

3 questions when observing a child:1. How does relating and moving in that child’s unique

way color their experience?

2. What does it feel like to experience the world through that child’s particular expressive movement repertoire?

3. How can a therapeutic environment be structured to enable the child to experience their way of relating and functioning as a communicative tool, while simultaneously enabling the child, to use that experience to explore new ways of interacting with the environment?

Tortora, 2006

WAYS OF SEEING : Four part procedure in therapeutic process:

1. Match - feel quality through attunement or mirroring.

2. Dialogue through use of these movements.

3. Explore/ expand develop these movements.

4. Verbalize - Move communication from nonverbal to verbal exchange.

Tortora, 2006

Early Detection of ASD related to nonverbal expression:

18-24 months • Timing & phrasing:

– lack of rhythmic exchange in joint attention built from mutual regulation/co-regulation

– lack of cooperative purpose, shared awareness• Facial expression & eye contact:

– lack of cyclic reciprocal expressions (Stern’s mutual reciprocity)

– no build up of emotional arousal– not mirroring expressions of others– no or fleeting eye contact Tortora, 2006

Early Detection of ASD related to nonverbal expression:

18-24 months • Self & other– by 6 month deviants in attention to objects

vs other - sharing in “games” with other– lack of understanding of gestures

• Early movement issues– muscle tone– no protodeclarative pointing – gait peculiarities - toe walking– balance– postural weakness– delay in motor milestones Tortora, 2006

Ways of Seeing: Early Dance/Movement based Intervention for ASD: 18-24 months

• Timing, phrasing & use of space:– slow down actions– transform wandering by connecting through

mobile space– avoid rote play by keeping activities fluid– play with rhythmic emphasis to different parts of

movement phrasing - 2 beat accent to impactive & explosive

Tortora, 2006

Ways of Seeing: Early Dance/Movement based Intervention for ASD: 18-24 months • Facial expression & eye contact:

– exaggerate facial expressions– provide eye contact from different angles,

levels and distances in space

• Early movement issues– activities that provide tactile, proprioceptive, &

vestibular awareness– core strength and full body activities

Tortora, 2006

Ways of Seeing: Early Dance/Movement based Intervention for ASD: 18-24 months

• Self & other– primary caregiver is still key attachment

figure even if not obvious– mirror, attune, transform child’s activity,

object attention into social engagement– model ways to engage encouraging primary

caregiver to try

Tortora, 2006

Where Floortime and Ways of Seeing DMT meet

• Relationship-based — focus on “affect sharing” to relate• Following child’s lead - supporting optimum engagement • Follow fragments of child’s engagement as way in —

expanding social-emotional relating from here• Extend “circles of communication”• Goal is to expand range of interactive experiences and

emotional expressivity • Engage in and encourage spontaneous play, building

upon child’s natural interests• Developmentally focused

Tortora References• Tortora, S. (2015). Mindfulness and movement. In Willard, C. &

Saltzman, A. (Editors). Mindfulness with youth: From the clinic to the classroom. New York: Guildford Press.

•  Tortora, S. (2015). The importance of being seen – Winnicott, Dance Movement Psychotherapy and the embodied experience. In Spelman, M. & Thomson-Salo, F. (Editors). The Winnicott tradition: Lines of development – Evolution of theory and practice over the decades. London, UK:  Karnac.

• Tortora, S. (2013). The essential role of the body in the parent-infant relationship: Nonverbal analysis of attachment . In Bettmann, J. & Friedman, D. (Co-Editors). Attachment-based clinical social work with children and adolescents. New York: Springer.

Tortora References• Tortora, S. (2012). Beyond the face and words. In Beebe, B.,

Cohen, P., Sossin, K.M., Markese, S. (Editors), Mothers, Infants and Young Children of September 11, 2001: A Primary Prevention Project. New York: Routledge.

• Tortora,S. (2010). From the Dance Studio to the Classroom. In Karkou, Vassiliki (Ed.), Arts therapies in schools: Research and practice. London, England: Jessica Kingsley.

• Tortora, S. (2009). Dance Movement Psychotherapy in Early Childhood Treatment. In Chaiklin, S. & Wengrower, H. (Eds.), The Art and Science of Dance/Movement Therapy: Life is Dance. Routledge: New York.

• Tortora, S. (2006) The Dancing Dialogue: Using the Communicative Power of Movement with Young Children. Baltimore, MD: Paul H. Brookes Publishing Company.

Other References• Appelman, E. (2000, April). Attachment experiences transformed into

language. In American Journal of Orthopsychiatry, 70, 2, 192 – 202

• Beebe, B. (2004). Co-constructing mother-infant distress in face-to-face interactions: Contributions of microanalysis. In Zero to Three, 24(5), 40 - 48.

• Bucci, W. (1994). The multiple code theory and the psychoanalytic process: A Framework for research. In Annual of Psychoanalysis, 22, 239 –259.

• Hofer, M. A. (1981). The roots of human behavior: An introduction to the psychobiology of early development. San Francisco: W.H. Freeman and Company.

• Porges, S. (2004, May). Neuroception: A subconscious system for detecting threats and safety. In Zero to Three, 24 (5), 19 – 24.

• Winnicott, D.W. (1991). Playing and reality. London: Routledge/Tavistock. (Original work published 1971).

SUZI TORTORA ED.D., BC-DMT, LCAT CMA Dancing Dialogue PLLC

www.suzitortora.comsuzi@suzitortora.com

80 East 11th Street, NYC, NY 1001426 Main Street, Cold Spring, NY 10516

Tortora, S. (2006) The Dancing Dialogue: Using the Communicative Power of Movement with Young Children

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