Introduction

The United States is facing a public health crisis. Akin to a bull in a china shop, the opioid epidemic leaves families shattered, seeking restoration. Now more than ever a careful examination of the state of affairs and the effective contributions of dance/movement therapists is in order. According to the New York City Department of Health (DOH), opioid overdose is the leading cause of accidental death in New York City and in the nation. In 2016 alone, 80% of overdose deaths in New York City involved heroin, prescription painkillers, and/or fentanyl, a powerful synthetic opioid (NYC DOH, 2017). On a national level, the Center for Disease Control and Prevention cites more than 183,000 prescription opioid-related deaths from 1999 to 2015 (Center for Disease Control and Prevention, 2016a, b) and in 2016 these figures continued to rise sharply upward with an estimated 31% of overdose deaths related to fentanyl and synthetic opioids (National Institute on Drug Abuse, 2017). While NYC Health + Hospitals diagnoses more than 50,000 patients with a substance use disorder (SUD) annually, fewer than 4,000 patients receive addiction treatment (HealingNYC Book, 2017). This gap leaves individuals with the marked inability to receive care regardless of need or motivation.

Among individuals struggling with SUD, those residing in forensic settings across the nation are also at risk. Among prison inmates, roughly 30 percent are diagnosed with co-occurring SUD and mental health disorder. This figure jumps to an estimated 72 percent in jail settings. Despite this data, only 10 percent of these individuals receive substance treatment and merely 11.4 percent receive care for co-occurring illness (The Council of State Governments Justice Center, 2017). With such staggering numbers, it is of concern that individuals who are admitted for inpatient psychiatric care from the community or jail are struggling with comorbid SUDs, and yet the substance issues are often not on the radar. Dance/movement therapists, particularly those working on inpatient settings, possess a unique opportunity to identify substance use issues and mobilize an effective treatment response during a critical window of time.

Creatively Screen for Risky Behavior

Group therapies are integral to treatment programming on inpatient psychiatric units. All psychiatric hospitals accredited by Joint Commission provide psychological, social work, nursing, and therapeutic services for patients (The Joint Commission, 2014) and among these services, the modality of dance/movement therapy (DMT) is not only an aspect of programming but a prime service to screen for substance use and explore risky behavior through restorative movement dialogue. In each DMT session, the therapist can develop creative patient-to-patient feedback and provide structured treatment interventions during an acute stage of treatment. Structured interventions are essential for individuals at risk of recidivism and who are struggling with severe disorders (Council of State Governments Justice Center, 2017). At the start of the DMT session, it is important to establish physical movement is a pathway to recovery that enables the restoration of self-awareness, a skill that is hindered through the use of drugs and alcohol (Thomson, 1997). When a patient spontaneously suggests that dance or movement reminds him of “being in the club”, therapists are encouraged to view this as an invitation to provide structured play and to help deepen the patient’s awareness of and associations with dance, body, and substance use. When a patient gestures as if he’s drinking alcohol or smoking marijuana in the session, the therapist is encouraged to assess how his peers respond to this social action and then provide an opportunity for group members to contemplate and resolve the situation in real time.

Because opioid use directly impacts the ability to form healthy relationships to self and others, it is crucial that the therapist view these gestures as an opportunity to gain insight, repair, and restore  while cultivating a safe environment in order for patients to be honest and real. In addition to illicit substances, the DMT group can highlight a patient’s relationship to prescription medication as well, such as prescription opioids, which in the short term can alleviate pain yet in the long term can introduce severe side effects and risks (Centers for Disease Control, 2016a, b). DMT provides natural opportunities to identify a range of feelings and sources of pain, creatively move through themes of escape and ambivalence, and confront, tolerate, or manage discomfort. Patterned movement and gestures that arise in group can be interpreted as efforts to deny, desensitize, or displace unwanted experiences (Caldwell, 1996). These movement metaphors create self-soothing alternatives. While perhaps comforting, these body patterns may not serve as useful or healthy for the patient. An example of not useful or unhealthy body patterns may be movement that is constricted or passive and lacking spacial awareness or free flow, while the breath is shallow and thus impeding emotional flow (Thomson, 1997). Therapists can screen for such movement patterns and verbal cues, setting the foundation for later exploration of substance use concerns as safety and trust are established.

Embody Resistance and Motivation

Despite established safety and trust, certain patients will not spontaneously speak of their substance histories and may require the therapist to initiate the conversation. Individuals with co-occurring disorders may perceive threat or fear loss of control by working in the body using spontanesou movement. In order to inspire safety and participation, music can be introduced to stimulate movement patterns reminiscent of being under the influence, thus providing an opportunity to address behaviors (Thomson, 1997). Alternatively, sitting in silence with existing sensations can be a powerful catalyst for the development of witnessing self and others. Quiet moments dedicated to perceiving inner sensations can lead to increased mindfulness of change in the body (Plevin, 1999) and greater awareness of how they present among others. Seeking to build motivation and strengthen patients’ commitment to change, motivational interviewing (MI) is an effective approach for engaging clients with comorbid illnesses (Miller & Rollnick, 2002) and is considered compatible not only for dance/movement therapists but health practitioners across disciplines (Klasson, 2014). MI implements open-ended questions by affirming, reflecting, summarizing dialogue, and generally treating patients as capable (Miller & Rollnick, 2013). Qualitative questions such as what change(s) are you considering? and how important is it that you make this change? may be posed by the clinician during a DMT session to explore readiness for change in substance use behavior (Indiana SBIRT, 2017). These questions can be presented prior to movement experientials, in tandem with movement itself, or as a post-movement debriefing. Dance/movement therapists are encouraged to sharpen these explicit tools and seize opportunities to weave MI interventions with dance/movement throughout the session. Movement interventions involve attuning to patients in the body, exploring patterns and change, and posing questions that strengthen their commitment to change which are then bolstered in the body and movement. DMT reflects the present, a task that individuals with chronic substance use often find difficult to tolerate. By mirroring the body, DMT provides real space in real time for individuals to identify and differentiate their actions, feelings, sensations, and thoughts. MI has many applications in SUD and aligns with a common DMT view of seeing patients as they are and supporting how they intend to move forward in recovery.

As patients respond to DMT interventions, therapists may consider melding creative discussion of addiction resources by simultaneously talking and moving through the exploration of when, why, and how to use naloxone, or incorporating Screening, Brief Intervention, and Referral to Treatment (SBIRT). This melding approach can become part of regular practice beyond traditional DMT techniques. For example, by considering a patient’s addiction history at the forefront, therapists are more likely to screen, hone interventions, and pursue opportunities for further effective substance treatment. Themes that arise in DMT can be transformed from discussion into symbolic movement that is openly explored in meaningful and connecting ways. DMT providers interested in accessing examples of evidence-based questions relevant for use with patients are directed to find free SBIRT Applications available for iOS devices on iTunes, and a free 4-h online interactive SBIRT training program is offered by Center for Practice Innovations which is approved by New York State Office of Alcoholism and Substance Abuse Services (OASAS). For SBIRT strategies from other states, visit the OASAS website www.oasas.ny.gov and find direct links to Colorado, Connecticut, Massachusetts, Oregon, and Texas.

Bridge DMT and Referral for Treatment

Beyond the DMT group itself, critical steps must be taken post-session. To foster SUD treatment linkage, the therapist needs to highlight relevant comorbid issues to the treatment team, advocating the necessity for immediate and future support. A challenge therapists may find is that discussion can lead to a dead-end if members of the team are not aware of regional resources. Medication Assisted Treatment (MAT) is an evidence-based practice that bridges biological and behavioral components of addiction, combining medication, behavioral therapies, and social support to sustain recovery (Missouri Department of Mental Health, 2017). While MAT is a recommended course of treatment for individuals with opioid addiction, those with primary psychotic/mood disorders are likely to receive treatment for the acute thought or mood symptoms leaving the secondary substance issue to be managed on an outpatient level. Although inpatient medical units have the potential to initiate treatment at an acute level, physicians are often unfamiliar with MAT, creating a barriers for screening and referral (Hassamal et al., 2017). Critically, individuals with opioid use disorder are 10 times more likely to die in the general medical setting compared to the general population (Hser et al., 2017). Severely mentally ill individuals, with chronic psychotic disorders such as schizophrenia are especially vulnerable to providers overlooking SUD care. DMT providers can give these patients a much needed voice and encourage referrals to MAT clinics or related services.

Preemptive dialogue with members of the team will highlight the need for referrals to substance treatment in the community and enhance treatment linkage, a positive step toward filling the gap. Examples of useful online referral resources can be searched by state, such as California Department of Health Care Services which provides an SBIRT referral to treatment directory (California Department of Health Care Services, 2017) as well as MATSdirectory.com where dance/movement therapists can proactively search for state funded rehabilitation services. Each region may have limited data online, however, and therapists are encouraged to proactively build their own database of region-specific MAT resources. Innovative approaches are now being called for due to the high rate of morbidity and mortality (Hser et al., 2017) and dance/movement therapists can respond to this by immediately contributing. If we succeed in addressing every patient's substance history starting at the inpatient level, we may continue to discover many positive opportunities and contribute to the healing of the nation’s opioid crisis.

Conclusion

Dance/movement therapists possess a unique role on the inpatient unit by witnessing, supporting, and advocating for patients through the creative group therapy process, and further embodying the role of liaison between group context and treatment team meetings. In this role, dance/movement therapists have the opportunity to enhance engagement—not only of patients but fellow providers—in evidence-based strategies to SUD care. During the inpatient DMT session, therapists are encouraged to cultivate discussion of how substances may have led to hospitalization or incarceration. When a patient acknowledges a substance history, the therapist is encouraged to honor the stage of recovery and provide movement experientials and verbal debriefing that lead to new insights and potential for change. DMT organically incorporates recovery models of managing oneself one moment at a time. As such, the DMT process provides an opportunity to be profoundly seen and accepted without judgment—a new and unusual experience for many. Post session, therapists are encouraged to convey relevant information to fellow members of the treatment team, not only to cultivate greater awareness among clinicians but to encourage referral for treatment moving forward. Perhaps comparable to the Japanese art form kintsugi, the method of repairing broken ceramics with golden joinery, DMT is the glue-like lacquer poised to integrate fragmented pieces in our society and provide opportunity for restoration.