Аннотация (русский):
The concept of systemic puppet therapy proposed by the authors is described. Therapeutic work with puppets is a promising method of psychological assistance as part of rehabilitation processes. Its insufficient use is due to its low structurality. The phased application of morphological analysis and synthesis made it possible to streamline the known and develop new effective methods of puppet therapy. The proposed systemic puppet therapy is an ordered polymodal set of static (lining on the table or on the floor of a puppet arranged set) and dynamic (presenting history on behalf of the puppet or staging a performance) methods, individual and group methods, face-to-face and remote forms of work, algorithms for their choice. The size, material and design of puppets, quantitative and qualitative composition of their therapeutic set are justified. Methods of puppet therapy of different degree of structuring and depth of exposure for patients with different level of intelligence are described, including category and scope of application of the technique, instructions to the patient, plan of results discussion, transformation procedure providing therapeutic effect. Implementing a polymodal approach, after working with puppets, patients painted, composed and analysed works of literature and art. The field of puppet therapy intersected with the fields of drama-, mask- and art therapy, body-oriented and verbal therapy, psychodrama and system arrangements. Puppet therapy content included work with feelings and emotions, with the process of communication and social roles, with verbal and non-verbal diagnostics and self-diagnostics, with personal features and a system of relationships, with values and needs, with existential problems of patients. Systemic puppet therapy is applicable to a wide range of nosological categories, therapeutic situations, physical condition, intellectual level, gender and age characteristics of patients. The conditions and examples of application of techniques in the National Medical Research Centre of Rehabilitation and Balneology with the tasks of correcting unproductive attitudes and the system of patient relations, correcting perceptions of oneself; capacity-building and resource search; development of a compliance installation and active participation in rehabilitation are given.

Ключевые слова:
rehabilitation, puppet therapy, puppet theatre, morphological analysis, multi-modal approach

Trends in morbidity and mortality dynamics both in Russia and abroad require constant improvement of prevention, treatment and rehabilitation methods in therapeutic practice [1]. Currently, medicine has adopted an integrative three-component model of the origins of diseases, the biopsychosocial model by Th. Uexkull and W. Wesiak [1; 2], i. e., an important role of mental and social factors has been recognized in the etiology of diseases along with biological factors. Hence an essential component of the rehabilitation process, psychological assistance aimed at emotional support and increasing self-esteem, correction of the “disease pattern” and “health pattern”, reducing the level of depressive and aggressive manifestations, mastering methods of stress management, improving the patient's compliance, etc. [3; 4]. To address these problems, systemic constellations, cognitive and cognitive-behaviour, rational, suggestive and body-oriented therapy, psychodrama [5] and drama therapy [6], mask therapy [7] and art therapy [3; 4; 8; 9], including felt-therapy [10; 11], and other methods of psychotherapy are used. One of the oldest and yet fastest developing areas of psychological care is puppet therapy, which has great opportunities in working with both children [12] and adults [13; 14; 15], in curative [12; 13; 15] and palliative [16] practice. The set of therapeutic methods of work with puppets includes manufacturing of puppets [13; 16], playing with them [12; 17; 18], several forms of fairy tale therapy [19; 20; 21; 22], psychotherapeutic puppet theatre [15; 23], other forms and methods of work. According to the principles of the system approach, when studying the structure of a system (in our case, puppet therapy), it is essential first of all to consider its environment, external setting, higher-order systems which it belongs to. The specific feature of psychotherapeutic work with puppets as a system is its affiliation to two different higher-order systems: - On the one hand, the puppet therapy is a part of the culture related to the phenomenon of the puppet used in religious and mystical rituals, in education and training, reflected in artistic expression, literature and art, - On the other hand, puppet therapy is a part of art therapy and, further, psychotherapy in general, thus obeying the general laws of psychotherapy, as well as any other area of psychotherapy. Manufacturing and use of puppets is known to be a cultural phenomenon for a long time: the oldest of the puppets ever found is 35 thousand years [13, p. 49]. It continues to be observed today in similar forms in ethnographic research. Since prehistoric times, the manufacturing and use of puppets has been intertwined with magical rituals, including those of therapeutic importance. Hence the therapeutic power of puppet therapy, which raises the most ancient layers of the collective unconscious in the patient’s mind. Like in other areas of psychotherapy, there are phenomena of transference and countertransference, the purposeful use of which triggers the mechanisms of psychological rehabilitation. Puppet therapy allows the puppeteer (that is, the patient) to distance themselves from the puppet, thus reducing their fears and anxiety, providing them with the ability to effectively project on the (material) puppet and (ideal) role of their own unconscious needs and attitudes, their further clarification and awareness. During group work, the therapeutic puppet theatre is characterized by an increased impact of the performance on the audience: patients who are close both spatially and socially act both as spectators and as potential actors. The unique relationship between spectators and actors, their significantly greater affinity than in a usual theatre, determines the acute perception of the seen and heard performance. The small size of the group and the intimate atmosphere of the performance contribute to the same effect [15]. This represents a significant advantage of puppet therapy over other theatre therapeutic options [6; 7], which is especially important when working with patients with serious psychological problems that hinder the rehabilitation process. However, notwithstanding its great therapeutic potential, puppet therapy has not yet taken its rightful place in rehabilitation practice, which is partly due to the lack of development of its theoretical framework. The development of puppet therapy based on art theory and culturology, on the one hand, and psychology and psychotherapy, on the other, significantly predetermines its poorly structured nature. This does not allow forming an ordered set of effective protocols for prevention, treatment and rehabilitation based on puppet therapy. The objective of this paper is to provide a more complete description of the structure of therapeutic work with the use of puppets, clarify the list of features and expand the range of methods of puppet therapy. One of the powerful tools for analysis and development of therapy methods, including psychotherapy, is the morphological approach, rooted in ancient philosophical teachings of Asia. In Europe, Ars Magna by Raymundus Lullius is considered its prototype; a similar approach was used by Leonardo da Vinci, and in its modern form was developed by Fritz Zwicky [24]. The morphological method includes stages of morphological analysis and synthesis; it constitutes one of the ways to implement a systematic approach. It allows to identify and describe all possible varieties of the object under study (in our case, therapeutic working techniques using puppets). Method scope, sequence of actions consists in selection of a set of essential features of the technique (step 1); identification of a set of values (versions, varieties) of each of these features (step 2); consideration of all possible combinations of values of selected features (step 3); analysis of the obtained combinations by the criterion of their feasibility (step 4); analysis of the remaining combinations by the criteria of therapeutic efficiency and safety (step 5) [24]. Steps 1 and 2 together represent morphological analysis; steps 3, 4 and 5 represent morphological synthesis. The analysis of therapeutic situations and puppet therapy techniques allowed identifying the following groups of basic features: - Nosological category and therapeutic situation, - Patient (in individual therapy) or group (in group therapy) characteristics, - Characteristics of the puppets used and the stage or playing area, - Number of group members and their interaction scheme, - Characteristics of the working procedure, including the modality of perception of puppets by patients. The phased application of morphological analysis and synthesis made it possible to streamline the known and develop some new effective methods of puppet therapy. The systemic puppet therapy developed by the morphological method includes the following: - Structured set of static (arranging composition of puppets on a table or on the floor) and dynamic (presenting a story on behalf of a puppet or staging a performance) methods of work, - Using imaginary stories taken from literature and from the patient’s life, - Work in visual, audio and tactile modalities and combinations thereof, - Working with inanimate and animated characters, with real and imaginary people and animals, - Methods with different spatial positions of patients and puppets, both vertically and horizontally, - Methods of individual and group work. The methods of puppet therapy with different degrees of structuring and depth of impact for patients with different levels of intellect have been highlighted. Systemic puppet therapy can be effectively used both in person and remotely, which is especially important in times of epidemics and impoverishment, social upheaval and military conflicts, when the possibilities of face-to-face assistance are sharply reduced. The cross-classification of techniques made it possible to create algorithms for selecting features and methods of puppet therapy for the appropriate therapeutic situation and patient characteristics. The combination of the ordered set of techniques and algorithms of their choice allowed to provide development of effective protocols of prevention, treatment and rehabilitation depending on the therapeutic situation. The developed techniques of systemic puppet therapy allowed solving interrelated tasks of psychodiagnostics and psychological correction of patients in the process of their rehabilitation. Puppets are the key element of the therapy, the object that mediates communication between the therapist and patient, the “proxy object”. They can be designed as follows: - Soft (from fur, leather, fabric, threads, ropes, etc. [16]) or hard (from stone, ceramics, bone, wood, plastic, cardboard, paper, etc. [15]), - Single-piece or composite, prefabricated, adjustable, - Desktop puppets, floor-standing puppets, finger puppets, glove puppets, marionettes (controlled by threads), cane frame puppets (controlled by levers) or puppets of other design [13; 14], regular toys are also used [15]. Puppets may have the following sizes: - Small: desktop and finger puppets, - Average: finger and glove puppets, marionettes, - Large: the size of a newborn baby (soft [16] and cane frame type). The size, material and design of puppets largely predetermine the signs, effectiveness and scope of therapeutic techniques. Thus, vivid soft puppets the size of a newborn baby and two cavities (located in the hand and in the head) for control have proved to be well proven in palliative therapy [16]. Below we only describe the techniques using small single-piece desktop puppets that are easy to carry in a “therapeutic suitcase” and disinfect frequently. Quantitative and qualitative composition of the set of puppets is an important factor in the effectiveness and safety of therapy. In terms of quantity, it should not be too small (it restricts the patient’s freedom of choice, causes irritation, sometimes leads to refusal of therapy), nor too large (it leads to delaying the initial stage of acquaintance with the puppets and their selection for subsequent sets and arrangements). We used a set of 60 puppets, comprising the following: - Monochrome and polychrome; brightly and dimly painted objects, - Inanimate and animated objects; people and animals, - Male and female characters; children, adults and old people. The main groups of techniques for this set are described below, indicating the category and scope of the technique, instructions to the patient, plan for results discussion, and a transformation procedure that provides a psychocorrective impact. Generally, intensive rehabilitation in hospital environment envisages for daily sessions, and outpatient rehabilitation implies weekly sessions. The duration of the session is 1.0-1.5 hours for individual and 2-4 hours for group therapy. There are two possible forms of organizing group work: - Small groups, with all the participants of the group actively taking part in the process, while the issues of each participant are reflected in the content of the session, - Large groups, where the participants are partly active (actors) and partly passive (spectators and listeners), gaining experience of participation in the group for subsequent active participation. Playing with puppets without an external objective is usually the initial stage of therapeutic process. For patients with a low level of intelligence (children, debiles, patients suffering from dementia of various etiologies, etc.) or physically weak ones (postoperative and other serious patients confined to bed, etc.), this method is the only available. This game represents an extremely soft therapeutic intervention, offers wide diagnostic capabilities and allows to anticipate the use of more structured techniques in the future. Patients with low intelligence (debiles, patients, suffering from dementia) may be completely indifferent to the presence of puppets, patients with higher intelligence show great interest; patients with low compliance level may turn away or leave, push or throw the puppets, patients with high compliance level start examining, touching, arranging the puppets (usually turning a pile of spilled puppets into some meaningful arrangement, composition); aggressive patients may gnaw and throw the puppets, depressed ones are likely to cry, clutching one or two puppets, introverts are immersed in examining and stacking the puppets, extroverts address others, pointing at the puppets, etc. Free-mode play with puppets, sorting them out, stacking and arranging them, etc., resembles of a small child playing with puppets. This seemingly meaningless activity is actually full of meaning: during the game, a child, adult, or an old person applies the puppets to different people and to themselves, compares them, trying to find symbolic meaning in the puppets that reflect different images of their external and internal world. For intellectual patients, a group of techniques called “Embodying abstract concepts” is well established. Specific techniques for solving specific therapeutic tasks were generated by changing the following parameters: - Name of the set composition, - Type of interaction of the group members when setting a composition: absent, simultaneous or sequential, - Multiplicity of transformation of the composition reflecting the correction process: absent, single or multiple. The processes of comparing and contrasting, identifying similarities and differences of concepts, establishing connections of imaginative and logical thinking, activating interstitial connections required a certain level of development of the patient’s intellectual and creative abilities, abstract-logical and imaginative thinking. These methods were considered as an imaginative nonverbal reflection of the logical verbal method of comparing concepts known in psychodiagnostics and pathopsychology [25]. The therapist instructed the patient as follows: “Choose puppets and arrange them so as they embody a certain concept (‘My heart’, ‘Health’, ‘Trauma’, etc.), 2 concepts (‘Life and death’, ‘Illness and recovery’, ‘Happiness and misery’, etc.), 3 concepts (‘Attack, flight, fainting’, etc.), 4 concepts (‘Birth, life, death, immortality’, etc.)”. The set of concepts was chosen based on the actual problem of the patient. After completing the work, we discussed the process of building compositions together with the patient, that is, how these composition appeared, what was the path of its development (both in real terms, for instance, the process of arranging puppets on the table, and in symbolic terms, for instance, the process of forming individual and collective images). Then we discussed the result of arrangement process: - Overall configuration of the compositions’ system, how do they look together, as a whole, - Configurations of each of the compositions (concept 1, concept 2, etc.), - What is common, similar and what is different and not similar in these compositions, - What are the characters of the compositions: puppets and their position, - What is common, similar and what is different and not similar in the puppets forming the set. The composition of arrangements was transformed (“improved”) at the initiative of the author or therapist and was once again discussed, while trying to correct non-productive psychological attitudes of the patient. During the group work we discussed the consistency of decisions and actions of participants and the intensity of communication associated with it: - Everyone acted independently, on their own, there was no communication, - Actions were not coordinated with all participants or not for all figures; communication was good, but not comprehensive, - Selection and installation of each figure was agreed upon by all group members (the principle of majority or consensus was in force), each member participated in the discussion of each selected and installed figures. This made it possible to identify and correct communication defects and shortcomings, create a sanogenic atmosphere of collaboration with the prospect of further generalization of stereotypes of productive communication among patients. The group of techniques “Playing groups of characters” was used to identify the patient’s attitude to certain characters. It is a tool for researching, comparing and contrasting the similarities and differences of various groups of characters that are personally significant to the author. Groups of characters were placed on the table, while selecting the puppets according to given or developed, explicit or implicit criteria of belonging or non-belonging to this group. Like the previous one, this group of techniques was usually used in the middle of the therapeutic process. The therapist addressed to the patient: “choose the puppets and make arrange them so they depict the following: - 2 groups of characters: “Young and old”, “Doctors and patients”, “Healthy and sick”, “Lucky and unlucky” etc., - 3 groups of characters: “Healthy, sick, recovered”, etc, - 4 groups of characters: “My male friends before, my female friends before, my male friends now, my female friends now, etc.” In doing so, they solved not only psychological but also social rehabilitation tasks. Patients were asked: “What each of these groups could say to other ones, what the answer might be?” The patients’ responses were recorded, then discussed similarly to the description above. During group work, the therapist addressed the group of patients: “We will try to work as a group, try to make common group decisions. Once discussed, we will make a few arrangements of puppets , depicting two, three or four groups of characters.” After all the sets were arranged, they discussed how relations to these groups of characters were developed in the group, whether there were disagreements, how they were resolved, and to what extent the solutions were coordinated. Individual work also included the construction of a “social atom” (according to J. Moreno, it is a person and their immediate environment, significant people [5]) or a static scene (demonstration, exhibition, “instant photo”) from puppets for the following characters: - “Unknown hero” or “random hero”, - For the hero of a literary work or selected plot, - For a specific person from their environment, - For themselves (in this range, the psychological tension and the depth of the patient’s self-disclosure increased). Group work included group performance of the same tasks by patients (with constant feedback). It frequently enabled to identify the pathogenic factors of social and psychological nature: unsuccessful job search, pressure at work, family conflicts, etc. This technique is similar in many aspects to psychodrama by J. Moreno [5] and systemic (family) constellations by B. Hellinger. The above-described set of static methods, presented as an individual or group arrangement of one or more sets of puppets on the table/floor, provided the opportunity to conduct step-by-step therapeutic work with an increasingly deep disclosure of the patient’s personal characteristics and relationship system and approach to their painful problem: free-mode play with puppets, embodiment of abstract concepts, playing groups of characters, construction of a “social atom”. The described increment in psychological tension, increasing the strength and depth of exposure in puppet therapy is similar to increasing the dose in drug therapy. In contrast to static methods (captured by photography), the dynamic methods described below (captured by video) included the presentation of a fairy tale or story from the puppet’s perspective and the staging a puppet theatre performance. To implement the first of these techniques, the patient was asked to play out their individual fairy tale, parable, story, or narrative with the help of puppets (options below are provided in the exercise of increasing tension): - Any story of the patient’s choice, - A story from literature: a narrative, a parable, a fairy tale (recently, more often: the plot of a movie or cartoon), - “A story that happened to me” (both the choice of a story and its transformation in the patient’s mind are of importance in this case), - “My medical history” (possibility to identify and correct the patient’s “disease pattern” and “health pattern”), - “A story of my life” (possibility of identifying the psychosomatic aspect of rehabilitation processes). This technique, depending on the therapeutic situation, may be used either at the beginning or at the end of the therapy programme, and it is suitable for patients of any intellectual level. Further, all participants in the therapy group jointly played out story at the therapist’s or group’s discretion: “earthquake” (a metaphor for an injury or illness, change in the patient’s social status, disability), “packing for a trip”, “big holiday” (a metaphor for completing rehabilitation), etc. Thus, in the “Tale of an unknown hero” technique, patients arranged themselves around a table and were then offered a set of puppets and accessories, pens, pencils and pieces of paper. They were to write down nouns and adjectives. A patient was asked to choose a puppet, and then randomly pick a noun and an adjective: “This is your hero. They are represented by a puppet, and their name consists of the adjective and noun you have picked out. Play out a fairy tale, a story, or any narrative about them. Start like this: once upon a time, in a land far, far away...” After the end of the story and applause, we discussed the following aspects: - Why did a patient choose this particular puppet, what attracted them to it (unattainable ideal, unsatisfied need, especially valued quality, etc.), - Could they (and did they strive to) combine the adjective, noun and puppet, create a combined image; did the hero’s behaviour match the characteristics of the puppet, noun and adjective, or did the patient create something else instead, - Is the patient guided what they are given by nature, or do they want to act contrary to it, - What characterizes the hero’s behaviour (passive-active, meek-aggressive, kind-evil, submissive-dominant, spontaneous-purposeful, etc.), how productive are they, whether they are similar to the patient. The noun and adjective metaphorically represented the limitations of life after an injury or illness, which the puppet representing the patient had to accept and cope with. At the final stages of therapy, a performance of the psychotherapeutic puppet theatre was arranged. To organize the performance, a group of patients was given an offer: “Who would like to act as a Theatre Director and make a stage production?” The patient who volunteered to be the Director was instructed as follows: - “First pick a fairy tale to your liking. Here is a list of 20 Russian folk tales with a brief description. If you can’t find anything suitable, think of any famous fairy tale. If you haven’t found anything suitable and can’t think of anything suitable, come up with your own scenario. It can be a fairy tale, a parable, a story, or any other narrative,” - “Define roles and select performers. Choose puppets, pick up or make all the necessary accessories; cut out the required props from cardboard and paint with markers. Arrange the stage: you can label everything,” - “You can play out a puppet show while sitting at the table. The audience will then sit on the opposite side of the table. Alternatively, you can use both puppets and live actors and play out on the floor; then the audience will form a semicircle in front of the stage,” - “You can play out silently, via pantomime, or using both pantomime and sounds, but no words. Alternatively, your actors can use both movement and conversation, like in real theatre.” After the end of the play and applause, we discussed the following aspects with the spectators (audience): - Movement and speech patterns of actors; who really stepped into a role, and who did not, - Whether the actors obeyed the Director, assisted him, hindered him, - Whether they liked the production, what exactly they liked, what or who caused the strongest feelings, what kind of feelings, why. We discussed the following with the actors: - Whether it was easy or difficult to play the role, and why, - Whether they stepped into a role and were hey able to be an actor internally, - What they felt, what they thought when playing the role. We discussed the following with the Director: - Whether they were able to implement the initial idea, show their creative abilities; whether there were interesting, unusual, original solutions; whether they enjoyed something in particular, when, what feelings it caused, - Who helped them, who hindered them, whether they were able to achieve subordination and how; what were the incentives and punishments, - What is the problem in this story, what caused it, what could be done in this situation, what anyone could do to solve the problem. Discussion of the performance was organized similarly to sharing and processing in psychodrama [5]. When discussing each stage of the performance, first the audience shared their opinions (they were not always present: in small groups all the participants were often the part of the troupe), then the actors, and then the Director. This was followed by the summary of the psychotherapist, their version of the interpretation, not crossing out or correcting, but only supplementing the interpretation of patients. They tried to separate the facts (“What did you see? What did you hear?”) from the interpretations (“What does it mean? What does it say?”). Sometimes discussing the performance leads to the need to organize another performance as “corrections of mistakes”. This possibility should be provided for in the therapy programme. Upon availability of time, a polymodal approach [3] was implemented after working with puppets. Patients drew (surrounding landscapes and scenery, characters and puppets, scenes from the performance), composed (realistic stories and fantastic fairy tales with characters and puppets), analysed suitable works of literature, artwork and cinema (for example, “The Berlin Bride” by Michael Bartlett (2020) about the relationship between a man and a puppet). At the same time, the field of puppet therapy intersected with the spheres of drama [6], mask [7] and art therapy [3, 4], body-oriented and verbal therapy, psychodrama [5] and systemic arrangements. Content of the puppet therapy included work (with deepening tendency) with feelings and emotions, with the process of communication and social roles, with verbal and non-verbal diagnostics and self-diagnostics, with personality traits and system of relations, with values and needs, with existential problems of patients. The described set of techniques was applied during the implementation of the project “Art Therapy as an Element of a Comprehensive Approach to Patient Rehabilitation” based on the National Medical Research Centre for Rehabilitation and Balneology. The puppet therapy sessions lasted for 2 hours and took place in an open group in the spare time in special premises. Patients of the centre visited the group at will. The objectives of the work involved psychotherapeutic support of the rehabilitation process, in particular, correction of non-productive attitudes and patient relationship systems, identification and correction of self-perception; empowerment and searching resource within the internal and external spheres; development of a position that includes compliance mindset and active participation in rehabilitation. These objectives were effectively addressed using the described techniques of puppet therapy in work with patients with injuries, cardiovascular diseases and cancer; two examples are given below. R., 15 years old, rehabilitation after fractures of both arms and legs. R. lost his brother in the same car accident, although R. tried to perform CPR before his death. Severe depression, suicidal tendencies, strong resistance to therapy. Twelve sessions of individual and group puppet therapies were conducted. During the individual work, arranging of puppets was mainly used followed by subsequent discussion and transformation. The group work mainly involved staging puppet theatre plays based on folk tales with increasing depth of psychological impact. As a result of the therapy, a decrease in the severity of depression (according to Beck depression inventory and Zung self-rating depression scale) and attempts to make plans for the future (study, work) were noted. Sh., 40 years old, rehabilitation after combat operations and wounds, lost both brothers. Loss of purpose, existential crisis, severe depression. He underwent three courses of rehabilitation after surgical operations, that is, 3 courses of puppet therapy in 12 sessions. The puppets often caused painful associations with military strategic game, sarcasm and black humour; however, Sh. did not refuse therapy. Puppet therapy was complemented by verbal existential therapy based on the analysis of compositions of puppets. Upon completion of rehabilitation, the patient became more approachable, expanded the circle of acquaintances. His health and physical condition improved significantly, depressive manifestations became less pronounced. Theoretical and practical work conducted allowed drawing the following conclusions. Application of morphological approach to the therapeutic work with puppets allowed arranging a systemic puppet therapy, including a fairly complete structure of therapeutic work with puppets and an ordered set of techniques of individual and group puppet therapy. Due to the combination of the ordered set of techniques and algorithms of their choice, systemic puppet therapy provided development of effective protocols of prevention, treatment and rehabilitation depending on the therapeutic situation. Application of consistent morphological analysis and synthesis allowed not only to order the set of available techniques of puppet therapy, but also to develop new ones with high therapeutic efficiency. The peculiarities of the developed systemic puppet therapy allowed claiming an important place in the processes of psychological rehabilitation, including the solution of interrelated problems of psychodiagnostics and psychocorrection of patients. Systemic puppet therapy is applicable for a wide range of nosological categories, therapeutic situations (prophylaxis, treatment, rehabilitation; curative and palliative care), physical condition and prescribed motion pattern (from complete bed rest up to no restriction of the routine activity), intellectual level (from dementia to highly intellectual patients; patients who do or do not understand the language of medical staff), and gender and age characteristics of patients (men, women; children, adolescents, adults, old people).

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