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ALL RIVER, Mass. — The two friends were leaving the movie theater when CJ received a phone call from his irate father. The boys rushed to his home, and after the door slammed, his friend heard a series of loud noises, like something being thrown against a hard surface.

The actors froze and the director asked the audience if someone wanted to step into the role of the friend: “What would you have done?”

“This feels so déjà vu,” one of the audience members mumbled under his breath, but didn’t volunteer to get on stage.

Others called out, “go home,” “ask him about it the next day,” “call the cops,” “go home and call my parents.” A volunteer stepped up, mimicking phoning his dad to ask for help.

In between reenactments, the director asked, “Is doing nothing a possibility?” Almost everyone nodded or said yes. “Is everything you’re going to do going to work?”

Finally a slight boy with curly dark hair who rarely looked up when he spoke climbed onto stage. Raising his arms above his head, he mimed breaking down the door to CJ’s house. For a moment, he transformed into a different person.

Fall River, MA -- 08/01/16 -- A participant raises his hand while members of the Trauma Drama troupe perform an interactive therapeutic theatrical exercise on-stage during a Trauma Drama session on August 1, 2016, in Fall River, Massachusetts. (Kayana Szymczak for STAT)
A participant raises his hand while members of the Trauma Drama troupe perform.

And that’s the goal of this whole performance. Called Trauma Drama, it’s a theater-based therapy program for teenagers with severe emotional and behavioral problems.

The idea is that theater can help this group of troubled adolescents regulate their emotions and build skills to cope with trauma.

But it’s an approach that hasn’t gotten much systematic study, despite small programs testing out the potential.

Creative pursuits to work through trauma

Many of the students — who range in age from 15 to 19 — grew up poor, in violent neighborhoods, and have been abused, neglected, and bullied. Such painful experiences cause trauma, which haunts those affected for years or decades, and which is often treated with a combination of talking to a psychotherapist and medication to relieve symptoms like anxiety and depression.

But some therapists are turning to alternatives, like yoga, music, and other creative pursuits to help patients work through trauma. Psychiatrist Dr. Bessel van der Kolk has been one of the pioneers in these efforts toward therapies that engage the body rather than focus exclusively on the mind.

It’s a philosophy built upon van der Kolk’s early work with veterans with post-traumatic stress disorder from the Vietnam War. Over time he came to believe they were “addicted to their trauma,” he said at a psychotherapy conference in Boston in June. He believed that talking about trauma kept it alive, and that patients needed to get in better touch with their bodies instead.

“Trauma is not happening in your brain, it lives in your body,” he said.

Fall River, MA -- 08/01/16 -- Trauma Drama troupe members Simon Davis-Millis (left) and Nicole Craig (right) demonstrate an interactive therapeutic game to Trauma Drama participants on August 1, 2016, in Fall River, Massachusetts. (Kayana Szymczak for STAT)
Troupe members Simon Davis-Millis (left) and Nicole Craig demonstrate a game to Trauma Drama participants.

In the decades since then he has built a clinical practice that draws on techniques including yoga and eye movement therapy to treat traumatized patients.

He founded the Trauma Center at the Justice Resource Institute, outside of Boston, in 1982. Under his guidance, Joseph Spinazzola, executive director of the center, developed Trauma Drama in 2005 for students in Boston Public Schools. After funding ran out in 2010, Spinazzola transitioned it to a semiannual program for youth with complex trauma who are enrolled in residential schools across Massachusetts.

The idea of using techniques like theater to treat trauma, van der Kolk said, came from the biological response to danger. A threatened person typically starts by calling out for help and support. If no one responds, the person defaults to either fighting back or fleeing the location of danger. But if aggression or running away is impossible, the last resort is to shut down.

In those cases, “the body is unable to reset itself to safety or think clearly about a course of action,” said Mimi Sullivan, a psychotherapist and PhD candidate at Widener University, who is writing her dissertation on Trauma Drama.

The students experience the same sort of threatening situations in the scenes, but because they are not in real danger, they are able to react in new ways.

Fall River, MA -- 08/01/16 -- L-R: Trauma Drama troupe members Dave Dorvilier, Nicole Craig, and Kristen Cahill, watch as troupe members rehearse an interactive, therapeutic theatre piece with the theme "family neglect", that they will be performing during next week's Trauma Drama session. (Kayana Szymczak for STAT)
Troupe members Dave Dorvilier, Nicole Craig, and Kristen Cahill (from left) watch as fellow members rehearse a theater piece.

Trained facilitators, called troupe members, begin the scenes, which may portray issues like homophobia, sexting, and teen pregnancy. At a key point, the facilitators freeze and the students have a chance to jump in and act out how they would respond to the situation.

Theater “makes it feel rewarding to do something really scary,” said Sasha Garfunkel, a clinical social worker who helps run the program.

‘Not a standalone form of treatment’

Before each session concludes, the facilitators and students gather in a seated circle on the floor to discuss how the scenes made them feel.

In a debrief of the abusive father scene, some students who had been unresponsive or laughed nervously when the actors were on stage opened up. They said they felt scared, shocked, helpless, anxious, and confused. “I have been in one of those situations before and I was just standing there because I didn’t know what to do,” said one student.

“The acting wasn’t my favorite. It made me uncomfortable, but I got through it,” said another.

The theater approach does risk inflaming students’ personal wounds if a topic on stage hits too close to home, but Trauma Drama takes this into account — scenes are interspersed with lighthearted games to let the tension out of the room. And if a student does feel triggered, he or she can leave the room for that skit.

Fall River, MA -- 08/01/16 -- Trauma Drama troupe members Madeline Panella (left) and Vanessa Medeiros rehearse an interactive, therapeutic theatre piece with the theme "family neglect", that they will be performing during next week's Trauma Drama session. (Kayana Szymczak for STAT)
Troupe members Madeline Panella (left) and Vanessa Medeiros rehearse.

This group of 16 teens meets for 18 weekly sessions this fall, acting out skits, doing teamwork exercises, and playing trust-building games. “It’s not a standalone form of treatment,” emphasized Spinazzola. Alongside these sessions, the Trauma Drama students are receiving multiple types of therapy, including individual therapy and group therapies like bullying intervention and dialectical behavior therapy.

Whether it works is, however, an open question.

Sullivan said her work so far indicates the program has improved students’ capacity to trust others and to manage difficult situations, particularly with adults in their lives. Her findings are based on questionnaires, interviews with students, and physiological data — which measures stress through variations in heart rate and breathing — but they aren’t yet published.

Studies of similar approaches in other places have had mixed results. Dance movement therapy in one study showed benefits to refugees’ mental health; but another study found that role-play and storytelling weren’t helpful for teen refugees. Some small studies have found that theater and yoga are beneficial therapies for people with substance abuse disorders.

Many clinicians, however, are wary of therapies like theater, dance, and art and instead recommend cognitive therapies that help patients modify their thoughts in order to feel and behave differently.

While recognizing that creative arts therapies offer “unique” treatment for trauma, there is little evidence to “support the conclusions of thousands of devoted creative arts therapists,” according to an authoritative guide for clinicians, “Effective Treatments for PTSD,” edited by Edna Foa, a professor of clinical psychology at the University of Pennsylvania.

Fall River, MA -- 08/01/16 -- L-R: Trauma Drama troupe members Sarah Golden Martin, Joe Frank, and Dave Dorvilier, react as troupe members rehearse an interactive, therapeutic theatre piece with the theme "family neglect", that they will be performing during next week's Trauma Drama session. (Kayana Szymczak for STAT)
Troupe members Sarah Golden Martin, Joe Frank, and Dave Dorvilier (from left) react as fellow members rehearse.

“Whether it’s riding a horse or having a dog or body therapy, almost every therapy is going to have some effect,” said Patricia Resick, a psychiatry professor at Duke University.

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Some students may feel their trauma is too “gritty” for this program; others may find it too basic if their previous therapists used theater-based techniques, said Sullivan, who has interviewed many of the students. But most of them say it’s like a “breath of fresh air,” she said.

“They say they feel like themselves for the first time … they find out their own strengths and qualities in themselves they didn’t know they had — for example, they realize they are funny,” she said.

“For real change to take place, the body needs to learn that the danger has passed,” wrote van der Kolk in his recent book, “The Body Keeps the Score.”

When they get up on stage, the students get to step into their worst nightmares — but they are awake, safe, and know it is make-believe. “One of the best ways that we learn is play,” said Dave Dorvilier, codirector of the program. “Here, we are playing games, but they are clinically informed.”

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