Joined in dance

Body and mind are inseparable. When emotions are too painful, too threatening for our personal or interpersonal cohesion, we tend to block them from consciousness. But in time, the emotions often break through as physical symptoms.

At the British Association for Performing Arts Medicine, we see people who tend to think and communicate through their bodies. There is a physical bias in performance arts training that makes it easier to talk about the body and to express difficulties through the physical domain. Consideration of possible emotional factors may be omitted, to avoid discomfort and shame. But complex symptoms can become untreatable if the emotional and existential dimensions are neglected. Treating the physical presentation alone will never be enough.

Here, we outline our approach, and how it differs from more conventional modalities which attend to physical diagnosis and conscious thought processes only. We're aiming for 'resilience' which goes beyond simply coping. Recovery is not about restoring the status quo – it's an opportunity to 'bounce forward' to a new and stronger position.

'It takes a certain courage to say to a patient that it's not all physical…'

Throughout my medical training and career, I was always deeply interested in the important and complex interactions between the mind and the body. It was with this mindset that I went into the specialty of long-term pain management, establishing a multi-disciplinary pain management clinic at one of London's teaching hospitals.

From the beginning, I was fortunate to be able to bring into our team a psychotherapist who helped us to understand our patients, and indeed our own reactions to them, in some depth. Our psychotherapist helped us to understand how previous experiences and unconscious thoughts and motivations could be fundamentally important to the physical presentations and potential recoveries of our patients, especially those with disabling emotional distress that added complexity to their conditions.

Of course, our particular service was ostensibly for patients who inevitably viewed their problem to be one of physical pain. Almost invariably, our patients felt their problems to be in the physical domain only. Our psychotherapist was at her very best clinically when she had the courage to act outside some of the stricter disciplinary constraints of the school of psychodynamic psychotherapy from which she came. She was able to set aside the theory-led objections – for example to meeting the patient outside the strict confines of the consulting room, both physically and metaphorically – and to be more responsive to the needs of the patient as perceived and presented by them as she worked with patients during briefs interventions.

Some of our less complex patients could benefit from working with one of our Cognitive Behavioural Therapy (CBT) psychologists, who did good work, often with groups of patients. And CBT could often bring short-term relief of tension to our more 'complex' patients. But we seldom saw long-term benefit. Many of those patients who exhibited greater mind-body 'complexity', which they experienced only as physical symptoms, could not benefit from CBT or even tolerate it because their difficulties were not accessible in the domain of conscious thought.

It is still these 'complex' patients who I often find to be the most interesting. People with complex symptoms generally defy physical and conventional psychological diagnostic processes. Often, their presentations seem bizarre and inexplicable. Their difficulties cannot be helped if taken simply at conscious, face value. I'm thinking, for example, of a young woman who told us that she had fibromyalgia, but only in the left-hand side of her body. This corresponded, our therapist showed us, with how she presented to us as one half talented oboist, but the other half a conflicted person with a very troubled childhood.

Or the promising young actor, marked out for a stellar career – if it weren't for the disabling pains which now came to dominate his life. This young man seemed still very attached still to his parents, themselves actors. Perhaps, envisioning a career much more successful than those of his parents, deep-down he sensed a fragility in them and feared that, paradoxically, his success might threaten to destroy them and his relationship with them. Having no ability to experience that dilemma consciously in order to process it, his pain syndrome came as an unconscious solution to his unresolvable dilemma.

I am not a psychologist, and I have to keep these conjectures to myself. It is for others to work with the patient psychologically. But an ability to sense people's emotional tensions and deep hurts can help me to understand their real needs, and refer them appropriately, rather than resorting to endless physical treatments which can only make matters worse in one way or another. What I can say, perhaps, is 'I think that the problem lies in the balance between your body and your mind'. And if I get this right, then the patient sometimes smiles. Perhaps, deep down, they have perceived this much already.

Then, if I'm lucky, they will accept an offer to see 'my good friend and colleague, a psychologist, who I think will be able to help you'. I must hope that this colleague can see the patient as soon as possible, before the window of opportunity has closed again. Then they have a chance of salvation.

An important point for any of us – teacher, physiotherapist, psychologist, doctor – is that it takes a certain courage to consider with a student or patient that we believe 'it's not all physical'. To openly accept that non-conscious thoughts and emotions can be so powerful and exert so much influence over us. In doing so, we must be prepared to reveal just a little of our own inner workings, and thus acknowledge that we too are vulnerable and imperfect human beings, so as to make space for the client to perceive this process too.

More recently, working as a clinician for musicians and dancers, some of whom have career-halting conditions which lack entirely physical explanations, I have come to work with Monia as a collaborator. We have presented at meetings together on several occasions, outlining our ideas, which can come together surprisingly closely. I believe, as Monia herself points out, that truly talented musicians and dancers, in addition to technical prowess, must have within them a deep and powerful inner emotional existence, to truly bring their performances to life. But if their way of performance has become cut off from their real emotional lives, then inexplicable physical symptoms may result.

I admire the depth of understanding and insight Monia has for our patients, and the very positive responses of her patients. These clients are cut off from those thoughts, motivations and experiences which do not seem to conform with their self-image – constructed so as to conform with their perceptions of the norms expected by the people, organisations or even society around them. And I do believe that it is Monia's practice of existential-phenomenological counselling psychology – which attaches equal significance to conscious and unconscious thought and implicit motivations with special attention to embodied, emotional, contextual and systemic factors – that gives our patients the best chance of recovery when they present only in the physical domain.

Anthony Ordman

'Performers with these complex symptoms are not just sick – they are empty, anxious, scared, stuck and disconnected'

Merleau-Ponty argued that 'The perceiving mind is an incarnated body'. We are a mind and a body which are inseparable and interdependent, a whole person.

Yet the mindset that has dominated Western science since René Descartes is dualism, the view that the mind (as well as our perceptions of self and others) are independent of the body. This position is that it assumes that we can treat the body in separation from the mind, and the mind in separation from strong feelings that go beyond conscious thought.

In my experience, though, the vocal cords, the larynx and the jaw of a singer, or the shoulders, arms and hands of an instrumentalist, don't work properly unless they are brought to life by emotions. And if these emotions are difficult, performers may not be able to access them through their bodies or entertain them in their mind. Then we have an impasse – unless the split is identified and addressed, nothing more can be done for them at the conservatoire.

These feelings may have been dissociated from conscious awareness, but they haven't magically disappeared. They deaden performers' vitality, confidence and resilience, and will eventually force their way out as disturbances in their bodies.

Considering mind and body separately is problematic: it negatively affects both performance and also the health of performers (Rink et al., 2017; Dogantan-Dack, 2017). John Crawford, Violin Professor at Trinity Laban, says:

'in such situations energy cannot flow 'from the inside out', and is undoubtedly one of the main factors in the increasing number of students needing physiotherapy and suffering from blockages of various kinds. Often the poor student is given the impression that there is something wrong with their 'body', apparently a thing separate from them, which needs to be fixed through 'exercises'. If I have nothing genuine to say, to express, my energy doesn't flow: in fact it may well move in the wrong direction – inwards, the opposite of expression, which by definition is a sending out. We call this wrong direction 'tension' – a player pulling on themselves in a desperate attempt to follow someone else's idea and try to 'get it right'. And then they have to add the idea of relaxing to the already multiplying list of things to do.' (Crawford, 2020).

Counselling psychology recognises that the old model of dualism of Descartes is also unsuited to clinical practice. A better way of thinking that emerged in the 20th Century is complexity – mind and body are different dimensions of existence, different but not separable. As Anthony emphasises, body and mind always interact and respond together, and as such both need to be carefully addressed. The mind and the body are a continuum, parts of a whole. Focus needs to be on the whole person – healing literally means 'making whole'.

Medical symptoms are existential. By existential, I mean the unity and totality of physical, psychological, cognitive, emotional, discursive, social and cultural aspects. These include family, friends, the academy, educators and coaches. The cognitive-behavioural model only considers conscious thought and may not be aware of powerful subconscious forces which can cause such havoc in a performer. Performers presenting to us with these complex symptoms are not just sick – they are empty, anxious, scared, stuck and disconnected. They have lost a sense of purpose, of value and meaning, and even of self (Spinelli, 2015).

I completely agree with Anthony that as clinicians we must go cross the mind-body divide and embrace complexity. For me this is one of the main concerns and strengths of existential-phenomenological psychology. The wisdom of Socrates taught us that the unexamined life is not worth living. Why? Because it is dangerous, it can make us very sick and destroy careers. Our human capacity to achieve self-awareness is the key to sustainable artistry, health and resilience as fully-fledged human beings. The emphasis on experiences felt in the body – on embodied rather than conceptual or explanatory dimensions – has clinical as well as ethical and emancipatory value for patients. It places the undivided totality of their first-person lived experience at the centre, rather than the external diagnostic expertise of the clinician. It also has significant artistic value: optimal performance is dependent upon performers' capacity to embody emotional, cognitive and motor aspects into a unified whole.

Monia Brizzi

Dr Anthony Ordman FFPMRCA. FRCP is a UK specialist in pain medicine and an assessing clinician at the British Association for Performing Arts Medicine (BAPAM) in London. He set up a multidisciplinary NHS teaching hospital pain clinic which addressed patients' physical and emotional need in parallel. He is Past President of the Royal Society of Medicine's Pain Medicine Section.

Monia Brizzi is a Chartered Psychologist, Associate Fellow of the British Psychological Society, counselling psychologist and an assessing clinician at the British Association for Performing Arts Medicine (BAPAM) in London. She provides specialist psychological assessment and treatment to professional performers and those in training. Monia consults in complex mental health and the psychological dimensions of physical and chronic conditions.

This article is based on a collaborative paper they presented at the 2022 annual conference of the Australian Society for Performing Arts Healthcare.

Image: 'Cross the Divide' at the Westminster Bridge entrance of St Thomas' Hospital London sculpture by Rick Kirby. It embodies collaboration between disciplines and patients-clinicians

Key sources

Crawford, J. (2020) Self-expression is the key to tension-free string playing. The Strad, 9 September. In Leech-Wilkinson, D., Challenging Performance.

Doğantan-Dack, M. (2017). Expressive freedom in classical performance: insights from a pianist-researcher. In Rink, J., Gaunt, H., Williamon, A. (Eds.) Musicians in the Making (pp. 131-135). New York: Oxford University Press.

Merleau-Ponty, M. (1962) The Phenomenology of Perception. London: Routledge.

Rink, J., Gaunt, H., Williamon, A. (2017: xxiii). Introduction. Musicians in the Making. NewYork: Oxford University Press.

Spinelli, E. (2015). Practicing Existential Psychotherapy: The relational World. Second Edition. London: Sage.