Explainer – The creative arts therapies and bodies living with/in ongoing pain

Amanda E. Woodford

Chronic pain is like a fine thread broken in the middle of a stitched line, it’s impossible to tie the ends back into place. Instead, the maker needs to work with the thread and base fabric in a new way, thus creating something unique.

Whether we are describing complex regional pain, pelvic pain, chronic lower-back pain, or other painful experiences that last or recur for more than three months (Treede et al., 2019) chronic pain is complex. The special treatment and care needed to support people living with these pain-filled experiences is similarly complicated (Roillet, 2020).

Creative arts therapists are well positioned to contribute to this custom-made care through non-pharmacological creative therapeutic interventions. We do so in the hope of enhancing quality of life, understanding more about the experience of pain, and lessening or, most importantly, not worsening it.

Lessening stress, and enhancing engagement and ability in an arts-based therapeutic context

Lessening stress, be it physical or emotional, is an ethical form of care when working therapeutically with bodies in pain (Woodford, 2023). Emotions impact on physical pain and vice versa. Negative representations of pain can increase pain ratings (Gandhi et al., 2020), whereas positive experiences lessen negative affect, and minimise pain and anxiety (Ahmad & Zakaria, 2015). Working with what is liked makes connections possible, promoting a capacity to stay with challenging content, and offer ease, comfort, and calm through pleasant encounters (Woodford, 2023). We do not avoid uncomfortable or dissonant content; rather, when working with joy, and pleasure in artsmaking, staying with the difficult can become possible and manageable.

Traumatic experiences are a stressor for pain becoming chronic (Beal et al., 2020). Someone living with/in pain may experience a trauma-related response to an approach we commonly use in our therapeutic approaches, which is to ask: “How does that feel in your body?” or “When you sense into your body, what do you feel or notice?” Worse still might be the suggestion to draw a body map or whole-body outline and place sensations, feelings, or emotions within (Fritsche, 2014; O’Neill & Moss, 2015; Malchiodi, 2020). Such an invitation can stop an inquiry in its tracks, eliciting a range of negative responses from a body with/in pain and in increase in pain. As trauma-informed expressive arts therapist Cathy Malchiodi (2020) says, “being in one’s body after a traumatic event is challenging and the likes of body tracing can evoke distress and needless re-traumatisation” (p.209).

Fortunately, we have research that shows alternative and successful creative ways of being with the body, pain, disability, ‘felt sensing’, and emotions. These include small, artistically formed 3D bodies to hold painful experiences, which are not a direct representation of the body with/in pain (Woodford, 2023); therapeutic garments made to fit the part of the body in pain, which can be worn and removed as needed (Yi, 2021; Woodford, 2023); engaging with a beloved ancestor’s items and allowing the felt sense to occur naturally, then exploring further through visual art creations, called felt sense artworks (Kepes, 2024). Interestingly, closeness to the body can be gained through time and working with distance from the body. Likewise, artwork made by companion-therapists, offered to client-inquirers with/in pain with therapeutic intent, can provide actions, feelings, or articulations that are not possible for the person in pain (see ‘Skin touched from a distance, by an artist with therapeutic presence’, Woodford, 2023, pp.377–382). Eventually, that person might progress to a closeness with their body that is sufficiently comfortable and enabling.

Metaphors can play a significant role in achieving a greater connection with the body, or enable ways of understanding and communicating painful experiences. Small details discovered in artistic representations can become helpful metaphorical storytelling opportunities (Cross, 2022). “Metaphorical orientation of expressive therapy processes allows for the expression of chronic pain’s unspoken trauma, creates opportunities for new realities and identities for clients to emerge, and enhances clients’ capability for being more attuned to themselves, their pain, and ways to live well with it” (Cross, 2022, Conclusion).

It is valuable to find creative therapeutic ways to promote manageability and energy. Fatigue is usual for people living with pain (Boggero, 2017). When a person is feeling less pain, they may over-extend themselves, leading to debilitating pain flare-ups.

Chronic pain is not experienced in a vacuum; it is multifactorial, with biological, psychological, and social factors. An intersubjective, extended view of pain can be gained by noticing the whole body and how it interacts with the world (Woodford, 2023). Or similarly, an ‘enactive’ approach proposes pain as “a relational and emergent process of sense-making through a lived body that is inseparable from the world that shapes us” (Stilwell & Harman, 2019, p.637). Incorporating pain education into our professional development when inquiring alongside people with/in pain is significant. Understanding the biological factors of pain lessens the risk of causing more pain, debilitation, or disability.

The benefit of sharing pain-related experiences and knowings through artful forms

Joletta Belton, pain advocate and research partner, who makes sense of pain through science and stories, says that “lived experience is a valid and a valuable way of knowing pain” and that “telling these stories is empowering” (personal communication, 22–23 March 2024). When we tell the stories of our lived experience using the arts, knowledge comes through the senses (Heimer, 2016). Stories become layers of colour, shapes, sounds, movements, as well as words. The richness of experiences is aired in the open for contemplation, held in the likes of paper surfaces, a stream of poetic words or a mandala circle, or dipped in wax and stitched onto a shirt. When these stories are reflected on further, the ground of knowledge-shifting-into-action is turned. Sharing in a one-to-one therapeutic session or in a small group, we receive responses from a witness that can offer alternative perspectives or clarify what is already known. When we read the pain-related stories of others, we might notice similarities. Within this noticing, feelings of aloneness with pain and debilitation or disability lessen. We feel understood. Knowing about how pain feels in our body, the ability to describe the pain and the impact it has on our lives, as well as what we need, are golden shimmers. Our voice seems to become stronger when we speak to others, maybe family, friends, or medical practitioners, about our pains and needs, outside of the therapy space.

As arts-based therapist-inquirer-researchers, we can use our skills to support the sharing of lived-experience stories through such channels as graphic novel production and graphic medicine (see Drawn and Quarterly, https://drawnandquarterly.com, for examples); the creation of multimodal representations of pain to be taken to medical appointments; the contribution of creative media to support pain researchers in their papers and presentations; and providing submissions for lived-experience story ‘call-outs’ from researchers and pain societies.

In our research, education and practice, lived-experience stories matter. As arts-based practitioners and researchers, we offer a uniqueness in the area of qualitative and post-qualitative inquiries (Green, 2023) that directly connects to the facilitation of our practice with bodies with/in pain.

Considered spaces of practice and gathering to support bodies with/in pain

Our spaces of practice carry an artistic sensitivity to the qualities of things (Dewey, 1934). The style of arts-based therapy spaces varies greatly, depending on the ways we work therapeutically with the arts and on our personalities. When we create these spaces, it is helpful to know that people living with/in pain can have a heightened sensitivity to touch (Mosabbir, 2023), and may experience more pain from holding their body with tension. Comfort is desirable.

For children and young people, our spaces can be engaging, playful, and less adult-like, with interesting objects, familiar artsmaking items, inviting places to lounge or move within. Sadly, “without access to pain management, the quality of life for children and adolescents with chronic pain is severely impacted. Compared to their peers, children with chronic pain report higher levels of physical disability, anxiety, depression, sleep problems and poor academic performance” (World Health Organization, 2021, para.1).

Australian infant mental health consultant, child psychotherapist, and arts therapist Dr Emma van Daal describes the positive impact of the materiality of our therapeutic spaces: “The furniture and soft furnishings are conceived as vital agents in processing trauma – they become objects that soothe, hold, and protect” (2023, para.3). This seems appropriate for adults too, with different surfaces to work upon, ways to warm painful bodies, to soothe heightened nervous systems, to sit, stand, or lie. The spaces we create and the modes, materials, and tools we offer can create positive experiences while unfolding pain-filled stories.

In our places of education and venues for events, too, we can continue to support our CAT community who live with/in pain. Ideally, we can create opportunities to make and move, to find ways to be comfortable, to avoid sitting for long periods; we can offer invitations for participation, and understand the need for adaption. Some of our higher-education providers are also offering their courses online. The skills of practising therapeutically with the arts in online and virtual spaces, gaining skills of working with distance, are valuable for future work in the area of pain. An ability to be flexible with how we meet others, when travel impacts pain and vice versa, is more inclusive than having a physical studio or therapy room available.

To close

Our arts-based style of therapy is best suited to people who are interested in the creative modes we offer and who want to engage in therapy in this way. Single-modality therapists will likely suit people with a keen interest in that specific mode. Multimodality, with therapists trained in creative arts therapy or expressive arts therapy, able to dip into numerous creative modes (Moy, 2023), can be beneficial to our client-inquirers with multiple creative interests. Shifts in modality can offer opportunities, foster engagement, and promote curiosity. Our diversity of approach can support a variety of needs to meet abilities/disabilities and ages, and we can contribute to multidisciplinary team services.

Understanding the benefit of ongoing arts practices, we can support artistic identity and the arts for well-being, outside of the time-constrained therapy setting. A regular arts practice can be a form of pain self-management and self-care (Cross, 2022; Elwood, 2022).

When creative arts therapists hold the experiences of people living with ongoing pain, the shape of the holding depends on the inquirer, the therapeutic companion, and the environment. Experiences of pain are woven into or appear out of materials. Needs are held by modalities, materials, and processes. We engage metaphors, we make with our bodies, we come to know more. Knowing about pain, and linking these metaphors to an individual’s experiences, can provide clarification and validation. We hold carefully and creatively, as experiences of PAIN are brought to the surface to be seen, understood, and shared.