Scholarly article on topic 'Expressive bodies: demented persons' communication in a dance therapy context'

Expressive bodies: demented persons' communication in a dance therapy context Academic research paper on "Psychology"

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Academic research paper on topic "Expressive bodies: demented persons' communication in a dance therapy context"

Expressive bodies: demented persons' communication in a therapy context

Krister Nystrom & Sonja Olin Lauritzen

Stockholm University, Sweden

abstract Dementia is a disease that brings with it various limitations in the afflicted person's communication with others. The purpose of this study is to explore, not the limitations, but the capacity of the demented person to communicate under conditions that differ from the everyday life of the care institution. Group dance therapy sessions with elderly, demented persons were video-taped and analysed with a focus on how verbal and non-verbal modes of communication were used by the participants. The ways the demented persons use body movements, free dance movements, speech and singing in different combinations is described and discussed in terms of different expressive modes, where body movements are used to substitute or support speech as well as to express thoughts, memories and emotions. The results from the study indicate that under conditions that allow for different modes of expression, the communication of the demented person can be found to be rich and varied in expression and content.

keywords body movement; communication; dance therapy; dementia

address Sonja Olin Lauritzen, Department of Education, Stockholm University, 106 91 Stockholm, Sweden. [Tel: +46 8 162006; fax: +46 8 158354; e-mail:]


Some diseases bring with them limitations in the afflicted person's capacity to communicate with others. Dementia is an example of such a disease, a syndrome which is estimated to affect about 6-8 percent of the (growing) population over 65 years of age in contemporary western societies (Adolfsson et al., 1988; Lobo et al., 2000). The ways this disease develops and affects the wellbeing of the individual varies with different types of dementia, and also between individuals. Some common traits can, however, be identified, such as memory impairments as well as cognitive and personality deficits. The demented person can suffer from 'aphasia', pathological

health: An Interdisciplinary Journal for the .Social .Study of Health, Illness and Medicine

Copyright © 2005 SAGE Publications (London, Thousand Oaks and New Delhi) DOI: 10.1177/1363459305052902 1363-4593;Vol 9(3): 297-317

changes in the ability to speak, 'agnosia', impairment in the ability to identify things and 'apraxia', inability to do voluntary body movement, disturbances that will affect the patient's life in various ways, often increasingly so as the disease progresses.

One of the consequences of dementia is that it will affect the demented person's communication with others in everyday life. A common image in media and public discourse is the demented person as passive, somehow isolated in his or her own world. What this means for the afflicted person, and for his or her relations to others is of course well known to many people with a demented person in the family as well as to nursing staff. This image is also reflected in the debate about care (or lack of care) of demented patients. However, the demented person's communication with others has not been researched to any great extent to date. Research on patients with dementia in institutions indicates that the relationship between the demented patient and care staff is imbued with uncertainty related to the process of communication. Some studies have shed light on the difficulties experienced by nursing staff when they try to interpret the non-verbal expressions of the demented patient (Asplund, 1991; Ekman, 1993; Hart and Wells, 1997; Acton et al., 1999; Burgio et al., 2001). When nursing staff have to rely only on the non-verbal expressions of the patient, for instance when feeding patients, this can cause various dilemmas as well as ethical conflicts in the everyday life of the care institution (Jansson, 1993). Less severely demented persons living in their own homes, however, seem to develop strategies to compensate for the limitations caused by the disease and their changed perceptions of the life-world, and to cope with the threats to their perceived order and control in everyday life (Nygard, 1996).

Questions can be raised not only about the limitations in demented persons' communication with others, but also about their capacity to communicate, which is the focus of this article. To understand the communication of the demented person, it can be of particular interest to look at the modes of expression used by demented persons as well as how different contexts and conditions will help them to use their capacity to communicate (or hinder). Here, we want to look into how alternative contexts of communication, other than those of the everyday life of the care institution, might allow for a better understanding of the demented person's capacity to communicate with others. One alternative type of context can be found in the traditions of expressive therapies, where a variety of expressive modes can be used more freely than in everyday communication. Group dance therapy is an expressive therapy that has been used in some projects in Swedish nursing homes for demented elderly persons to promote their communication with each other and the staff. This article discusses the experiences from one of these projects (Nystrom, 2002), a study of the patterns of interaction emerging through a series of dance therapy sessions with elderly demented persons.

Dance therapy as an arena for communication

Dance therapy is a psychodynamic method, in general theoretically based in an object-relation tradition in which human beings are understood to have a fundamental urge for communication (Guntrip, 1968; Winnicott, 1971). In dance therapy, the purpose is not to teach people to dance, but to promote the wellbeing of the individual by increasing the range of his or her movement repertoire. The therapeutical process is focused on the use of body movements to promote both physical and mental integration in the individual, which means that much of the work takes place at a non-verbal level. Speech is given a somewhat subordinate role to body movements, gestures and other non-verbal expressions, even if speech does occur. The dance therapy session is thus carried out predominantly through dance and body movements, which gives the relation between the patient and the therapist a non-verbal character.

Some of the therapists involved in the development of dance therapy through the years have written about their experiences, and the ways dance therapy seemed to help people with various impairments (Chaiklin, 1975; Lewis, 1984). The method was first developed in the 1940s by the dancer Marian Chace. Her achievements with dance and body movements among the seriously ill mental patients contributed to a more profound understanding of the communicative aspect of body movements (Chaiklin, 1975).

Also Schilder (1950), among others, has emphasized that changes in the movement repertoire of a person may also affect mental aspects of the personality. These processes were explored by Marian Chace in her clinical practice, and summarized by Chaiklin in the following way:

Since muscular activity expressing emotion is the substratum of dance, and since dance is a means of structuring and organizing such activity, it might be supposed that the dance could be a potent means of communication with, and re-integration of, the seriously ill mental patient. (Chaiklin, 1975: 71)

Dance therapy has been used also to promote the capacity to communicate in other groups of people with impaired capacity to use verbal language, based on the idea that the non-verbal dimensions of dance therapy would be a way to facilitate expressions of emotional experiences. Davis (1981) studied the characteristics of body movements in schizophrenic patients, and one of her findings was that fragmented body movements could be understood as reflecting a serious dysfunction in the personality. Dance therapy has also been used among children with emotional disturbances, to help children to express their experiences (Leventhal, 1982; Gronlund, 1994). Further, music and repetitions of rhythmic movements have been found to be beneficial in the treatment of people with reduced mental capacity (Levy, 1988). When it comes to dance therapy with elderly people, Marian Chace was one of the pioneers, and others have followed in her footsteps. Studies in this field have, however,

focused mainly on the elderly person's physical capacity, and physical aspects of the therapeutic process (Garnet, 1974; Kaplan Westbrook and McKibben, 1989; Hirsch, 1990), rather than on communicative aspects, which are addressed in this article.

A fundamental point of departure in dance therapy is thus that dance can be seen as communication. One of the ways the non-verbal dimensions of this communication has been described and analysed within the dance therapy tradition is in terms of synchrony and symbolization. Synchrony refers to three aspects of the body movement: space, rhythm and effort (Schmais, 1985). Spatial synchrony is a total imitation, when someone responds by simultaneously following the other person's movements using the same parts of the body, for example if one person raises their arm the other person raises their arm in a similar way. Rhythmical synchrony refers to a simultaneous sharing of rhythm with any part of the body, for instance when one person is stamping a rhythm with their feet while another person is clapping the same rhythm with their hands. When people use the same effort in body movements, with the same or different parts of the body, this is called effort synchrony. Symbolization refers to the way the experiences of the individual, such as emotions or thoughts, are mediated and transformed into bodily movements and bodily expressions. The analysis of these dimensions has proved to be useful to capture the subtle and varied aspects of the non-verbal communicative process, in the development of the dance therapy method as well as in research in this field.

Non-verbal dimensions of communication

In social science research on communication through the last decades, there has been a growing interest in the non-verbal dimensions of communication, which has shed light on body movements, gestures and other nonverbal expressions as fundamental aspects of communication (Trager, 1958; Scheflen, 1964; Condon and Ogston, 1967; Kendon, 1970,1977;Argyle, 1988; Goodwin, 2000). In the understanding of non-verbal communication, the importance of the context is a central theme. The body movement cannot be separated from the person who performs the movement, or from the where and when in the wider context of the interaction (Birdwhistell, 1970). The body movement is thus to be interpreted as an expression of the individual in interaction with others and within the wider cultural context.

A fundamental aspect of face-to-face interaction, as it emerges from moment to moment, is that it is always characterized by ambiguities as well as potentials (Goffman, 1961; Linell, 1998). The individual may have intentions prior to communication, but these will not determine the unfolding process of communication, which means that the contributions to communication will be given meaning in the ongoing dialogues. In contemporary research on communication in a dialogical tradition, communication is understood as a joint construction in the sense that all participants

contribute to the communicative process and its meaning. 'Communicative projects are not individual but require the contribution by the other interlocutor for their completion' (Linell, 1998: 45), which applies just as much to actions and non-verbal behaviour as to verbal communication (Linell, 1998: 45).

Much of the research on non-verbal communication has focused on phenomena such as synchrony (Scheflen, 1964; Condon and Ogston, 1967; Kendon, 1970,1977,1979), prosody in speech (Trager, 1958) and gestures (Ekman and Friesen, 1969; Argyle, 1988; Hyden and Poelsson, 2002). Interestingly, non-verbal communication has by some researchers been argued to resemble a dance (Condon, 1969; Birdwhistell, 1970; Kendon, 1970) referring to how speech and movements are intertwined in interaction. Also, dance has been used as an example to illuminate the 'elusory' expressive power of body movements (Radley, 1995).

In research on non-verbal communication and in the dance therapy tradition, there are similar interests in the finely grained bodily face-to-face interaction between individuals, which is reflected in the use of concepts such as synchrony and symbolization. To explore the communication of demented persons, we have chosen to take our point of departure in a dialogical perspective as a wider frame to understand communicative processes, and to draw on the concepts of synchrony and symbolization to capture the demented persons' communication in the dance therapy context.

The study

Aim and method

The aim of the study reported here was to explore demented, elderly persons' communication through a series of group therapy sessions, with a focus on how verbal and non-verbal modes of communication are used by the participants through the therapy sessions. A series of ten dance therapy sessions with a group of seven elderly persons afflicted with dementia were video-recorded, to be able to capture speech as well as body movements,1 and also to be able to describe these modes of communication at a micro level. The participants were six women and one man, all over 70 years of age. They all had a dementia diagnoses, with varying limitations in their capacity to communicate, and lived in a nursing home for elderly demented people. The dance therapy sessions took place at the nursing home, once a week for ten weeks, with one of the nursing staff present to help and support the participants whenever needed. Consent to participation was given by the guardians of these seven participants.2

The therapist (Krister Nystrom) has a long experience of dance therapy, also with elderly persons. In this project, he is a therapist as well as a researcher. This dual role of course raises some methodological questions. Physically being in the dance therapy group through all sessions was a way to gain information about the group processes that would otherwise have

been more or less impossible to access just by observation, as much of the interaction is subtle and non-verbal. Being part of the process can on the other hand be problematic. The researcher has to somehow disentangle his or her experiences as a therapist from descriptions of the group processes that would form the material to be analysed. One way to do this was to video-tape all the therapy sessions and make the video-films, as well as the transcriptions of these films, subject to an analysis that could be 'reinterpreted' and discussed between the researchers.

The video-taped dance therapy sessions were transcribed in the following way: first the verbal dimension was transcribed for each utterance (including singing and humming). Then a second line was added in which the non-verbal dimension of the same utterance is described, in terms of body movements, posture and how the participants and the therapist turned to or from each other, as is shown in the following example:

Birgit dances with the therapist when she leans towards the window and looks

out. She bends a little forward and points upwards with her right hand and makes

a circular gesture with her hand.

Therapist: Yes, I think it is the sun.

The therapist leans forward and looks in the same direction.

Birgit: (laughs)

Birgit turns to the therapist while she is laughing.

Video-film offers specific advantages, such as richness and permanence of data (Bottorff, 1994). When transcribed, the film is transformed into a text. Ochs (1979) argues that converting video-film into text does not mean that the problems of the analysis are avoided, just moved forward. One problem can be that transcriptions can contain too much information and are therefore difficult to follow. Another problem is that information can be lost in the process of transcription. This is a reason why the researcher's observations in the situation to be studied, in addition to video-taping, can be valuable. To deal with these problems, we first looked at the video-films of the whole sessions, in detail, which formed the basis for the analysis, and then went on to read the transcripts in combination with repeated looking at sequences of the films. Even so, the analysis of the demented person's communication is imbued with uncertainty. First, these demented persons' contributions to the communication were often vague, fragmented or in different ways 'uncompleted'. Second, analysis of non-verbal communication is always problematic as body movement, gestures, etc. observed on video-film can be interpreted in different ways and ascribed different meanings.

Here, we have chosen to identify and describe not single body movements per se, but sequences of interaction where verbal and non-verbal expressions are used together in different ways as contributions to communication, which we will elaborate on in the next section. This means

that body movements have been understood within the context of a sequence of interaction. In the earlier example above, a short sequence is transcribed where Birgit interrupts the ongoing dance to make a gesture. When the single gesture, the circular hand movement, is interpreted within the context of the whole sequence of interaction, it is possible to understand this gesture as a substitute for the word 'sun', and her laughter can be understood partly as a confirmation of the therapist's interpretation and maybe also as an expression of embarrassment when she cannot find the word herself. In the analysis of the entire material, the identification of sequences to be analysed as well as the interpretations of the communication in these sequences was discussed between the two of us until we reached agreement.

Analysis of communication in the dance therapy sessions

The material was analysed in two steps. First, to capture the participants' interaction with each other and with the therapist, all initiatives to interaction and responses to these initiatives, verbal as well as non-verbal, were identified. In group dance therapy, there is implicitly an 'affordance' to take initiatives to, and to explore, interaction with other participants in the group. Here, we refer to initiative as how someone directs her- or himself as a bodily being to another person, drawing on Merleau-Ponty's (1945) concept of 'the incarnated and intentional subject', where the initiative is understood to appear in the actions of the subject as a 'whole' way of addressing oneself verbally and with body movements.

Through the 10 dance therapy sessions, most initiatives addressed to the whole group were taken by the therapist, as part of his professional role to start and end the sessions, to activate the group and to facilitate encounters between the participants. When the therapist verbally or non-verbally encouraged the participants to take initiatives, this did most often not lead on to any activity. The group dynamics could best be described as stillness, and the participants typically turned their gaze to the therapist who would break the silence after a moment. The participants' responses to the therapist's initiatives were typically simultaneous verbal and non-verbal expressions, most frequently characterized by spatial synchrony, followed by rhythmical synchrony. Effort synchrony was less common, which can be due to the fact that the participants much of the time sat on chairs, which makes it difficult to observe effort synchrony. When dancing on their feet, effort synchrony is present more obviously.

A typical pattern is that these initiatives from the therapist to the group functioned as a 'warming-up' to generate activity among the participants. The participants also initiated interaction, verbally or non-verbally, not to the entire group, but to other participants. Interestingly, the one participant who most frequently took initiatives to interact with others was the only male participant. This, and the fact that the therapist is a man, of course raises questions about gender issues. It is reasonable to think that initiatives

and responses in this dance therapy setting can be understood as influenced by the participants' earlier experiences of 'social dancing', and models for how women wait to be invited to dance and for men to take initiatives inherent in social dance. The initiatives taken through the dance therapy sessions were often fairly vague, and not always responded to in any observable way. However, more clear responses were observed ranging from minimal responses leading to no further interaction to longer sequences of interaction revealing a variety of ways in how the participants used verbal and non-verbal means of communication.

In a second step, the longer sequences of interaction that were identified were analysed with a focus on how verbal and non-verbal means of communication were used together to express or symbolize experiences, thoughts or feelings. The analysis revealed some different ways this was done, here described as types of expressive mode. In the remains of this article, we will discuss three types of expressive mode, here called speech-dialogue, song-and-music dialogue and movement fantasy.

Different expressive modes Speech dialogue

The seven participants vary in their capacity to use speech in their communication with others, ranging from more or less no coherent language to a fairly full capacity to express themselves in a way that is understandable for others, though often disturbed by memory difficulties. Speech is thus used by the participants in the therapy sessions, but in different ways and often not easy to follow.

Verbal dialogues took place mostly between the therapist and the participants, rarely just between the participants. Only one participant (Erik) approached others than the therapist verbally more regularly. Other participants also occasionally tried to initiate conversations with others, usually without getting any clear responses. The participants often failed to find the proper words when they turned to or responded to each other, and sometimes the utterances were in a too low voice. In these situations, the therapist could function as a 'co-ordinator' of the communication in the group by interpreting and clarifying utterances from one participant to the others. (In this process, there is of course always a risk that the therapist misunderstands what the participant is trying to express, or that he does not understand at all.)

The speech dialogues that did develop in the sessions were typically supported by other means of expression. The following example is typical. This sequence starts when Erik initiates a dialogue with the therapist about ageing by saying 'maybe I will be a hundred years' in a joking manner. The therapist laughs and asks what Erik would do if he lives that long. 'An old man comes and dances,' Erik says, and goes on (a short pause is indicated with (...)):

Erik: More

Erik looks in front of himself

Therapist: No, it's too little, you want some more (years)

The therapist looks at Ella and moves his head

Erik: No, we don't inter (. . .) question how many (. . .)

Erik makes a powerful movement with his arms, looks at the therapist, then in front of himself again

Therapist: No

The therapist shakes his head, with the same effort, and looks at Erik Erik: I feel like 15 years

Erik makes a strong movement towards his chest Therapist: Wow (. . .)

The therapist looks at Erik and moves his hand to Erik's shoulder Erik: In the heart

Erik moves his head and points to his heart

Therapist: In your heart you are 15 years, and in your body

The therapist looks at Erik and moves his head and keeps his hands together in front of himself

Erik: And 60

Erik points at his right thigh and laughs Therapist: 60

The therapist smiles and looks at Erik Erik: (. . .) not all (. . .)

Erik holds his hand in front of himself and moves one finger back and forth many times

Therapist: You are happy that you can move, not everybody can move even a finger (. . .)

The therapist looks at Erik's finger, turns to Erik who moves his head down Erik: No

Here, the dialogue comes to an end and the therapist turns to the group.

This dialogue has been initiated by Erik, and he is the one who carries it forward while the therapist reflects back on what Erik says. There is a clear turn-taking pattern: Erik expresses fragments of thoughts that the therapist interprets, which Erik in turn responds to. In this sense, the understanding of what Erik wants to communicate develops through the speech dialogue as a joint construction. Erik uses words to express how young he feels at heart, even if his body is getting old, and his body movements both

reinforce what he is saying and substitute what he is unable to express verbally.

The whole conversation has a humorous character. The therapist puts a hand on Erik's shoulder after he has joked with him by saying 'wow', and in this way he expresses a physical as well as emotional closeness. Erik 'rebukes' the therapist verbally, 'we don't question', and non-verbally as he moves his arms and looks at the therapist, indicating that he finds the therapist too curious.The therapist synchronizes his body movements with Erik's, and they are in contact with each other through their physical position as well as their verbal conversation. At the end of this excerpt, we see that Erik has difficulties saying whatever he wants to say, and uses a gesture, moving one finger in front of him several times when saying 'not all....', to express something. The therapist interprets Erik's gesture by suggesting that Erik is still happy that he can 'move a finger', something which not everybody can do. What we see here is how Erik, just as most of the participants, compensates his lack of words with gestures and body movements. Erik uses body movements to symbolize what he cannot say, which in turn is interpreted by the therapist. In this sequence, Erik actively involves himself in a conversation revolving around existential themes, ageing and longevity, and uses body movements to symbolize issues of ageing, and perhaps also to make these somewhat abstract themes more concrete.

This example demonstrates how a speech dialogue can develop, within the dance therapy context. All participants try to use words in their interaction with each other and the therapist, but when words are lacking they use bodily expressions. Individual verbal shortcomings, which tend to obstruct the understanding of the interaction, are compensated in different ways, the most common being the use of body movements or the therapist's 'translations' by offering his understanding of what is being said. Also, the verbal expressions are most often 'supported' by non-verbal expressions, something that also seemed to help the participants to understand what was said or communicated by others. The analysis reveals that when speech is supported by other expressions, dialogues with a variety of contents can evolve. One could say that the bodily expressions are 'at hand' as non-verbal resources when they lack words.

Song-and-music dialogues

Through the 10 sessions, the therapist tries to activate the group by asking or encouraging the participant to follow his body movements or songs that he initiates. The purpose of these initiatives is to facilitate encounters with the participants, and between the participants. The therapist can initiate new dances and songs, but also try to capture body movements in the group, for instance by bodily 'mirroring' one of the participants movements or by attuning himself to movements in the group by synchronizing movements. Often, if some of the participants danced together on the floor, the others would sit on their chairs and support the dancers with synchronous

movements, clapping or joint singing, like an 'orchestra'. In these situations, the spatial synchrony was most common. One conclusion is that these demented participants seem initially to need the therapist's initiatives as a 'warming-up' in the joint group activities, to be able go on to more individual initiatives directed to other participants.

Song and music are integrated with body movements in the dance therapy sessions, and here we want to look more specifically at how song and music are used in the process of communication. The songs used in the dance therapy sessions vary from one session to another, but are by and large traditional Swedish songs, well known to most people, but can also be song 'invented' in the situation. Sometimes, it also happens that a participant improvises a song together with the therapist. The music is tape-recordings of a broad repertoire from classical music to African drums. In the dance therapy context, music also refers to improvised rhythmical sequences created by hand clapping or drumming on one's own body. The songs are mostly combined with body movements in the same rhythm. The idea is that in song and music activities the participants can express feelings and moods.

The next example illustrates how singing is used in the therapy sessions. The therapist has come up to Olga (after having danced with another participant). Olga wears a red scarf around her body, and the therapist initiates interaction by asking her if she wants him to wear a black one. The therapist looks at Olga while he adjusts a black scarf around his head, and then stretches his hands towards her. Olga immediately starts to sing a well-known Swedish song from the 1960s. (Italics indicate singing or humming.)

Olga: Don't cry Ann-Marie

Olga starts to sing and holds the therapist's hand and looks in front of her

Therapist: Don't cry Ann-Marie (.. .) how does it go on

The therapist leans towards Olga and hums

Olga: After a year I'll be home

Olga sings and holds the therapist's hand

Therapist: After a year I'll be home again

The therapist changes the rhythm a little and keeps both Olga's hands when

looking at her

Olga: If something would happen

The therapist and Olga dance together holding both hands, looking into each

other's eyes

Therapist: If something would happen then say (. . .)

The therapist takes some steps backwards looking at Olga

Olga: Don't cry (. ..)

Olga dances forwards looking at the therapist

Therapist: Ann-Marie

The two go on holding hands when dancing and having eye contact Olga: In a year I'm home again. Exactly so. Olga looks at the therapist smiling

Therapist: Good, you remembered it, would you like to take it again (.. .)

The therapist dances, lets go of Olga's hands, and adjusts the black cloth on his head

Olga: Don't cry Ann-Marie

Olga sings in a higher pitch and with a stronger dynamic, she looks down and then at the therapist

Therapist: Home again (. . .)

The therapist moves and adapts his bigger movements to Olga's higher pitch Olga: Ooooooooo

Olga starts to hum strongly, and the therapist takes big dance steps. The dialogue then comes to an end.

In this dialogue Olga and the therapist together try to remember the song initiated by Olga. When she has found a short phrase, the therapist repeats this phrase and she confirms that she recognizes the song by saying 'exactly so'. As they move from one song-line to the next, confirmation takes place step by step. Olga sings one line, and the therapist then repeats and confirms this line to her. When Olga tries to remember the song, the therapist tries to support her by humming the fragments of the tune that she is beginning to sing. Olga starts again to sing the phrase 'Don't cry Ann-Marie, in a year I'm home again in a higher pitch and more dynamically. The therapist reinforces this by his dance movements, which Olga to some extent follows, and the therapist responds with effort synchrony. What we see here is that the therapist tries to synchronize his movements and the rhythm to Olga, and through the sequence the dialogue is kept together by the rhythm of the song and by their body movements.

Here, the therapist and Olga are involved in a close interaction, which is non-verbally reinforced by body movements and by the scarves they are wearing. One could reflect on the role of the black scarf, which perhaps inspires Olga to remember fragments of a song that has an emotional theme of sorrow, loss and reunion. Also, the tape-recorded music used before this sequence had a somewhat melancholy character, just as the song Olga remembers. Similar to the example with Erik, there is an existential theme in this sequence and these fragments of a song can be seen as being used to communicate emotions of loss and sorrow and symbolically to express these deeper existential themes.

The music and the songs seem to stimulate the participants' memories of song fragments, particularly when the singing is accompanied by body

movements. The participants often respond to the singing and humming of the others. In this sense, singing and music function as vehicles for the interaction in the group. Most of all, the singing and music seem to function as reminders of feelings, and are used by the participants to express feelings when they have no words. Both the content of the lyrics and the melody seem to evoke various feelings, often sadness, and the singing reflects these feelings.

In the song-and-music dialogues, the uniting function of the rhythm is essential. Through rhythm, the 'speech' in songs is organized in a different way. The rhythm functions as a support and a co-ordination of movements and speech in the form of lyrics. Music is in a sense perceived in a more 'direct' way; it does not first have to be processed at an intellectual level. Of particular interest is that in song-and-music dialogues, singing can be seen as a combination of speech and music (Langer, 1942). The examples in this study indicate that, combined with music, songs evoke memories and emotions beyond the words being used.

Movement fantasy

Dance in group dance therapy refers to all kinds of free body movements, even if structured dance steps used in social dancing, such as waltz, are sometimes also used. The analysis of these dance therapy sessions demonstrates how the participants can create improvised sequences of small dances, or fragments of dances, which we here call movement fantasy, where the participants communicate their feelings and thoughts. The next example describes a sequence when Birgit is dancing. This dance follows after an activity where the therapist has invited all the other participants to dance, one at a time, except Birgit. He now turns to Birgit. When this sequence starts, the participants are sitting on chairs in a circle, and the therapist is standing in the middle.

Therapist: Well Birgit shall we also dance a little, you and me?

The therapist gets up and holds his hands, as in a Spanish dance, towards Birgit

Birgit: U-u-uu

Birgit, sitting down, takes hold of her chair and starts to make sounds

Therapist: Look, here she comes and wants to scare me, I think she is dangerous,

yes (. . .)

The therapist holds his arms in front of himself, crouching a little. Birgit gets on

her feet crouching

Oh, I think this is a fright-dance, she is frightening (. . .)

The therapist stands still, crouching. Birgit dances around him.

Birgit: Yes this is dangerous

Birgit turns and makes a gesture towards her chin

Therapist: Yes you are terrifying (. . .)

The therapist lifts his hands clapping. Birgit follows and they dance a Spanish dance stamping on the floor

Birgit: Yes - the ear fell down, do you understand, one gets a little anxious, you see - no (. ..)

Birgit goes to one corner of the room, stops there, holding her hands down

Therapist: Come, Birgit, let's dance high, let's sail in the air

The therapist lifts his arms high up, changes his dynamics and tempo, and Birgit

turns to him

Birgit: (. ..) small (. . .) clouds (. . .) small cat (.. .)

Brigit moves her left arm in front of herself, leaning somewhat forward

Therapist: Yes, the little cat is with us, let's dance with the cat

The therapist dances with arm movements, Birgit turns round, one arm over the

head, smiling

Birgit: La-la-la

Birgit takes her arm down, starts to hum a waltz, lifting the other arm over her head. The therapist moves behind Birgit.

Here, the therapist takes an initiative, verbally, to the dance with Birgit. Through this sequence the therapist leads the verbal dialogue and Birgit takes the role of the one who answers. At a non-verbal level, Birgit takes several initiatives, and here the roles are reversed. The therapist first lifts his hands as to start a Spanish dance, but Birgit does not follow. She starts to do the 'scary' sounds, which is accompanied with body movements. Perhaps she perceives the lifted hands of the therapist as a threat and therefore responds with the scary sounds. She then joins in the Spanish dance, and she moves rhythmically clapping her hands, with a powerful expression. The attention of the others is directed towards Birgit and the therapist in a fairly focused way, as an audience, that in a way also contributes to the interaction.

When Birgit starts to do her sounds, the therapist responds to Birgit's initiative, and they involve themselves in a playful dialogue, both pretending to be scared. In this dialogue, Birgit crouches just like the therapist does, and she responds with rhythmic as well as spatial synchrony. When the therapist increases the tempo, Birgit directly follows, which shows how they interact also through this change of tempo. Here, they are in a moment-to-moment interaction with each other. Birgit's little laughs show that the scary dance contains playfulness and a sense of humour. The therapist asks if she is frightening, and she replies 'yes it is dangerous', but the quality of her voice reveals that it is a joke. When the therapist responds playfully as if being scared, Birgit also acts scared. The therapist can then be the one with

the threatening initiatives. So, they take turns in 'threatening' each other. Through this sequence, the therapist picks up on Birgit's initiatives, and by responding to her in joining into the 'fantasy'-performance, the dialogue is continued. Here, Birgit is using movements and sounds to express threat. In this dance the therapist and Birgit playfully act to show that they are 'terrified', but small laughs escape from Birgit showing that it is fun and that they share the pleasure of the play. Emotionally the 'scary dance' in this way contains both fear and pleasure. The dance ends when the therapist makes a gesture towards a chair and Birgit sits down, but later on in the session she performs another short make-believe game, being a cat.

The interpretation of the sequence is that Birgit wants to play or joke together with the therapist in the dance and that her gestures of threat are a sham or a game. Birgit has severely reduced ability to speak, but in the dance therapy sessions she demonstrates an ability to communicate feelings and thoughts through this mode of expression where body movements, humming and singing as well as words are used together. Bodily expressions are here used to symbolize emotions and experiences.

The analysis shows that in a movement fantasy, the participants can express themselves more independently of the therapist and other participants, but also in close interaction with others. The movement fantasy seems to offer opportunities to re-create and transform experiences within the frame of play and free movements. Of particular interest is that the participants are stimulated to imitate movements when watching each other, also when they do not take any initiatives of their own. It is evident that memories and fragments of imaginations are communicated in these movement fantasies, as bodily symbolizations of the participant's experiences.

The non-verbal dimension of communication is most conspicuous in the movement fantasy mode of expression. The relation between the participants as they create the movement fantasy and the ways the participants stay in touch with each other through body movements is striking. Also, in this expressive mode the individual participants seem to take initiatives more independently of the activities of the others in the group. The sequences of improvised dance or movement fantasy, which are described here, seem to offer playful ways of expressing oneself, through symbolic body movements. These sequences are linked together and supported by the therapist through his questions and body movements, to help create longer bodily expressed 'stories', which can be created by the individual, supported by the group and the therapist, or collectively created in the group. This 'dramaturgical' role of the therapist seems to be important to structure and keep the communication going, and to avoid a more chaotic pattern of communication. With the support offered by the interaction with the therapist and the others in the group, the participants can continue to develop their fantasy body movements, and not withdraw into isolation or a state of confusion. All together the demented persons appear to be more 'present' in the interaction in this expressive mode.

health: 9(3) Discussion

The special conditions for communication offered in the dance therapy context are characterized by the way this arena is located somewhere between fantasy and reality, with an atmosphere that permits a wide range of thoughts and emotions to be expressed in a symbolic way, thus affording an 'intermediate area' in Winnicott's terms (1971). What are the communicative modes used by demented elderly persons under these conditions?

The analysis reveals some interesting patterns in the communication in the dance therapy context. This study is limited to one series of dance therapy sessions with seven participants, but some of the patterns in how body movements and speech are being used together can be discussed at a more general level. Through the dance therapy sessions, the demented persons responded predominantly with different types of synchronic body movement. As Kendon (1970) argues, synchrony is at the core of any encounter between people, and we would say that this is even more so for demented persons. What is indicated here is that synchrony seems to function as a fundamental means to help the demented person to stay in the interactive field. Of interest is also that body movements, synchronic or not, do not just accompany the spoken word. They are used together as an integrated whole and for different communicative purposes: to support, to express and to respond in interaction with others. This is of course a more general feature of interpersonal communication (Goodwin, 2000), but the demented person's use of body movements is of particular interest as body movements seem to play an even more fundamental role in their communication with others due to the limitations created by the dementia condition.

We have seen that body movements are used to replace speech, and in various combinations with speech, when words are missing or as ways of expressions in their own right. The 'speech dialogues' illuminate how body movements are used to support or substitute the spoken words that are frequently lacking for the demented persons. Songs and music seem to generate memories and thoughts, which are expressed verbally as well as in body movements, as we have seen in the 'song-and-music dialogues'. Here, the combination of the tune and rhythm of the music, and the song as 'speech' (Langer, 1942), seems to be of particular interest, as vehicles for memories and expressions of emotional experiences. Also, the song-and-music dialogues function to sustain interaction through longer sequences, which often seems to be fundamental to allow for the demented person to express him- or herself. In 'fantasy' body movements there are additional possibilities to express experiences more freely and playfully, when the participants are free to use body movements, rhythm and also improvised humming and singing in their own personal combinations. In this expressive mode, the therapist's interpretations and responses to a large extent seem to help develop and maintain the interaction and to facilitate experiences and reflections to be expressed, as emerging embodied 'stories'.

According to Merleau-Ponty (1945), we understand each other in a more immediate way at a bodily level. At an ontological level, the 'whole' of the personality is to be found in the body, which he refers to as the 'the incarnated (embodied) subject'. Body movements can in this sense be regarded as initiatives from a body ego, or with Merleau-Ponty's words, an embodied subject. We have seen that persons afflicted with dementia use body movements to communicate thoughts and feelings symbolically. Within the dance therapy tradition, it is argued that the shaping of feelings or thoughts by symbolic body movements contribute to an understanding of the individual, through reflection and analysis of the symbolic expression (Schmais, 1985). In these dance therapy sessions, various existential themes have emerged, revolving around issues of ageing, loneliness and loss of dear ones as well as bodily capacity: how long can you live, how old do we feel, the possibility to feel young at heart despite an old body and to accept your destiny. These themes seem to emerge when the participants could use a range of expressive modes. Or, one could argue, the demented persons seem to try hard to communicate these themes, and can do so when 'helped' by the possibilities to use body movements in a variety of ways. One conclusion is that to sing and dance, despite old age, even if this is done in a more modest way, can be a way to express embodied experiences and to facilitate communication with others.

The analysis of the demented persons' communication in dance therapy raises some more general questions related to the study of health and illness in contemporary society. A first question has to do with the privilege of spoken language in western societies. This privilege creates problems for persons who are limited in their capacity to express themselves verbally due to illness (as we have discussed in this study of demented persons), but also in research on the experiences of these people. In our study, the research context, dance therapy, was chosen to facilitate the use of nonverbal communication and to allow for expressions of experiences and emotions among persons who are limited in their capacity to remember, to organize their thoughts and experiences as well as to use verbal language. We could see that demented persons have a capacity to use a wide range of communicative means, given the opportunity in the dance therapy context, and that the use of a variety of expressive modes seems to promote their creativity and activity as well as expressions of thoughts and feelings.

Our point is that the choice of research contexts (such as the setting and the tasks given to the participants) creates possibilities as well as limitations. It is reasonable to think that studies of other types of illness than dementia, as well as studies of experiences that are not easily captured in ordinary conversation, could benefit from a use of more varied research contexts that go beyond the spoken language limitations. Other examples can be found in studies where pictures or images are used to facilitate reflection and expressions of experiences in areas that are not easily 'spoken about', for instance in research on pain (Bendelow, 2000) or acute illness (Radley

and Taylor, 2003). Also, the collection and analysis of data, as well as the communication of research findings, could be discussed in terms of a spoken language privilege. In the research process, we are in various ways limited to the use of verbal language. In this study we have used transcripts of verbal as well as non-verbal communication, together with detailed descriptions of the sequences of interaction that are analysed, as one way to convey our findings. How to capture the richness of human communication is still a problem, as much of the richness of data disappears when the 'analogue symbolic system' of non-verbal communication is translated into the 'digital symbolic system' of a text.

A second question concerns the ways a dialogical perspective can offer an avenue to explore the dynamics in the construction of illness and deviance. In the care of demented persons in contemporary society, similar to other groups of patients, the individual is assessed primarily from a default model, where limitations in the communicative capacity of the patient play an important role. (This default model can be understood as embedded in the social activities of the care institution, as well as in cultural traditions, and thus largely taken for granted.) In this study, the observations of the demented persons' activities in the dance therapy sessions over a period of time helped us to identify even quite subtle expressions of thoughts, wishes and experiences as these were revealed in communication with others. We would like to argue that a dialogical perspective, with a focus on interaction and the joint construction of the communicative processes, could contribute to an understanding of the capacity of 'the patient'. This could mean a shift from a focus on the limitations caused by illness and handicap to a more profound understanding of the world of the ill person.

1. Due to the character of the demented persons' communicative patterns, we will here use the word body movement to capture all types of movement, and not differentiate between body movements and for instance gestures.

2. To include people who due to illness cannot fully understand the meaning of their participation in a research project of course raises ethical questions. One of these questions concerns the researcher's right to video-tape persons who cannot themselves fully give their informed consent. In this study, the demented person's participation in the dance therapy sessions at the nursing home was in many ways similar to other regular activities that were part of the nursing home programme to stimulate the persons living there. Staff and guardians were informed about the project, and also about the possibility to withdraw from the project at any time if they wished to. All agreed that the demented participants could benefit from the dance therapy activity, just as from other activities provided for them.


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Author biographies

Krister nystrom, PhD in Education, is a practising dance therapist and also teaches at the University College of Dance in Stockholm. His research interest is in dance therapy and in studies of the elderly as well as people afflicted with dementia.

sonja olin lauritzen, PhD and Professor at the Department of Education, Stockholm University. Her research interest is in lay understandings of health and illness and in communication in clinical settings.