Discussion on the therapeutic properties of art continued from previous post…..

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Art as a symbolic language and the use of symbols, images and metaphors to heal and understand; ‘art making as therapy’ and ‘art therapy’ and trauma informed art interventions…..

OLYMPUS DIGITAL CAMERA(The Wallpaper, oil painting, 2005)

We now know, not only what we have known empirically for a very long time, but also through more recent and current research findings, that art making has a positive effect on our embodied mind and our well being and growth in general. Engaging in art making can be inherently therapeutic and conducive to facilitating neuroplasticity; however, art as therapy is distinguished from art therapy, although it could perhaps be viewed on a continuum. In chapter one of Art Therapy and Clinical Neuroscience Noah Hass-Cohen  claims that ‘the action of art-making is a unique way in which art therapy helps clients resolve, in the here and now, responses to residual fears and memories of disturbing events. Therapy interventions that have the potential to rewire the brain also have the power to recondition such traumatic residues. For art therapists, it makes sense that the excitatory and pleasurable effects of art-making and the ability to distance oneself from a tangible image can mitigate the fear of being re-traumatized (2008, Jessica Kingsley Publishers, Kindle Edition).

To begin with, research findings support that art therapy treatment interventions utilize the integrative capacity of the brain to create a more coherent self, to generate deeper insight, and therefore, to potentially facilitate positive change. Therapeutic treatment interventions are now based on understanding of neurobiology, the development of the brain, and the way our brain stores and retrieves traumatic memories. We now know that art processes can facilitate the non-verbal expressions of the right hemisphere and can give us the opportunity to discover meaning in the symbolic and metaphorical language of this hemisphere. Creation of art allows us to contain experience and dialogue with the metaphors, images and symbols depicted or communicated through art, and so ultimately, the process of making art can contribute to emotional reparation and personal growth. Alan Schore and many others have greatly contributed to the discussion of right brain, non-verbal, symbolic and unconscious communication and the important role of the right hemisphere in development and in therapy. The application of brain imaging has greatly expanded the understanding of the different functions and structures of the brain, which are involved in the processing of motor, visual, and somatosensory information, and has allowed the observation of areas and functions activated during different emotional states and activities and during the formation of memories. Lusebrink (1990, 1991) has studied the relationship between the processes of art expressions and brain functions. He has found, for instance, that the basic level of interventions with art media is through sensory stimulation; more specifically, he has found that visual feature recognition and spatial placement are processed by the ventral and dorsal branches of the visual information processing system. He suggests that ‘mood-state drawings’ echo the differences in the activation of different brain areas in emotional states. Malchiodi writes that the field (of art therapy) has widely embraced discoveries about art and the brain, information that supports ‘the application of specific art-based approaches in the amelioration of stress, integration of trauma memories, treatment of Alzheimer’s disease and dementia, reduction in pain and fatigue perception, and improvement in quality of life, especially for those challenged by disability or illness’ (Cathy Malchiodi, PhD, © 2013 Cathy Malchiodi).

Secondly, as mentioned above ‘art as therapy’ is distinguished from ‘art therapy’, even though it could be viewed on a continuum. There are many definitions of art therapy. One definition of art therapy is based on the idea that art is a means of symbolic communication. This approach, often referred to as art psychotherapy, emphasizes the products–drawings, paintings, and other art expressions–as helpful in communicating issues, emotions, and conflicts. The art image becomes significant in enhancing verbal exchange between the person and the therapist and in achieving insight; resolving conflicts; solving problems; and formulating new perceptions that in turn lead to positive changes, growth, and healing. In reality, art as therapy and art psychotherapy are used together in varying degrees’ (International Art Therapy Organization). However, art therapy is separated from self-help art making and art creation in that there is a helping professional who assists healing and change. A relation is created between the therapist and the individual seeking help or change, and a dynamic interaction takes place between the art process, the art products and the dyad (therapist-client), which allows a purposeful dialogue to emerge. Art therapy is recognized by many as an intervention that facilitates the expression of mind-body connectivity through the remediation of acute and chronic stress (Achterberg et al. 1994; Hass-Cohen 2003; Kaplan 2000; Lusebrink 2004, cited in Art Therapy and Clinical   Neuroscience, 2008, Kindle Edition). Malchiodi writes that ‘art as therapy’ embodies the idea that art making is, in and of itself, therapeutic and that the creative process is a growth-producing experience. She provides examples to support the inherent therapeutic role of art making (e.g. art education with children with disabilities, community art programs for groups, shelters or neighborhoods with economic or social challenges, and art studios for people with mental illness) and claims that they ‘seem to have similar goals and objectives and often produce the same outcomes as those programs defined as art therapy’. Malchiodi defines ‘art therapy’ as the application of the visual arts and the creative process within a therapeutic relationship, to support, maintain, and improve the psychosocial, physical, cognitive and spiritual health of individuals of all ages’. She claims it is based on current and emerging research that art making is a health-enhancing practice and describes art therapists as ‘credentialed professionals who purposively use specific art-based approaches with children, adults, groups and families to support, maintain, and improve overall health, physical, emotional and cognitive functioning, interpersonal skills, personal development, and quality of life’ (Cathy Malchiodi, PhD, © 2013 Cathy Malchiodi).

Art is a means of symbolic communication and expression of emotions, personality, and many other aspects of our human experience. Through symbols, images and metaphors we can express and depict memories and emotions and a single image or symbol can contain a group of connected memories or/ and emotions. Like in dreams in art an image or a symbol can contain so much information, meaning and emotion that it can become an object of deeper exploration and can allow deeper insight, which can promote healing. Art allows multi level understanding and one image can unlock deeply buried memories or dissociated fear or pain; therefore, art products can communicate a lot of important information relevant to therapy. Images and symbols can become containers of memories and emotions and can generate a complex verbal narrative. It is amazing how an image can narrate or contain a complex story and how one picture can simultaneously represent an event, an emotion, the perpetrator or a personality trait of the feared object and so on. A simple image of a building may represent or encapsulate all that took place within its walls and allow a coherent narrative to gradually emerge as the individual explores, deconstructs and reconstructs experience and reaches deeper understanding. Discovering meaning in the symbolic and metaphorical language of the non-verbal right-hemisphere is pertinent to therapy in many settings, both when working with psychological issues and / or complex trauma and when working with patients in clinical settings (cancer, AIDS, etc). Symbols, images and metaphors play an important role in therapy both during assessment and during treatment. Also, art making and activities can initially elicit metaphorical communication, which can then facilitate the processing of material with all age groups and especially children. Art making can also assist emotional regulation and provide an outlet to difficult emotions like rage or terror through a process called sublimation, mentioned in my previous post. Art also provides one more means to interact with disturbing or overwhelming material. Emotional regulation and reduction in negative affect may increase survivors’ ability to tolerate traumatic memories, which in turn can allow habituation and revaluation of the material and capacity to construct a more coherent narrative. Erin King-West and Noah Hass-Cohen write that ‘habituation is most often brought about by repeated exposure to the memories in states of gradually increasing calm and relaxation. Effective therapy therefore involves reductions in negative experiences and increases in positive ones’ (2008, cited in Art Therapy and Clinical Neuroscience, Kindle Edition). In this book Erin King-West and Noah Hass-Cohen refer to a complex-trauma survivor’s attempts to regulate emotions through art. They write ‘in repeated attempts to regulate affect, Jo produced hundreds of intense color drawings representing what Spring (2001) considers a PTSD special artistic language. For C-PTSD survivors, this increased capacity to generate imagery is in itself a measure of therapeutic change (Brewin et al. 1996; Klorer 2001, cited in Art Therapy and Clinical   Neuroscience, 2008 Kindle Edition). They continue ‘Jo used several visual schemas to represent affective and perceptual states. Disjointed stick figures illustrated Jo’s tension and frustration. Spiral lines for the trunk and appendages spoke about her hyper vigilant perceptual alterations. Gingerbread men outlines, at times left empty or filled with color, pointed to struggles with self-identity. Along with her words, the images revealed her trauma-driven self-representations’ (2008, cited in Art Therapy and Clinical Neuroscience, Kindle Edition).

Moreover, art is used more and more often in trauma informed interventions and approaches. Children and adolescents, in particular, are attracted to making depictions and are often more attracted to using art as a language than to verbal communication, especially, when it comes to difficult memories, emotions or other issues. Art also allows children or adult clients to share as much of the meaning of their art as they choose or are able to decipher and understand at any particular time. The product can also be revisited and re-explored as the therapeutic work proceeds. When a negative experience (event, emotion) is illustrated, it is then in some sense external to the individual, it has become an object, and thus, the material can be explored from a safe distance, often protecting the individual from overwhelming material or emotions. Through creating images ‘it is possible to externalize and objectify experience so that it becomes possible to reflect upon it’ (http://www.sagepub.com/upm-data/9585_019726ch1.pdf). Artistic expressions of children and adolescents also bypass ‘don’t tell’ messages and threats that traumatized children and adults have received in many ways. Topics and events that they have been forbidden to verbalize may surface spontaneously in art. Adolescents and children can let the therapist know what is going on in their lives by visual representations of emotions and circumstances. Art therapy is a nonthreatening form of treatment for children and it generates awareness that can also assist the therapist in both protecting and supporting the client. In her book, Neurobiologically Informed Trauma Therapy with Children and Adolescents: Understanding Mechanisms of Change, Linda Chapman discusses a neurobiological understanding of trauma and presents a theoretically grounded model for the treatment of children and adolescents. She discusses how art can bypass left-brain activity and utilize regions of the brain where traumatic memories are stored. The model of treatment developed here is grounded in the physical, psychological, and cognitive reactions children and teenagers have to traumatic experiences and the consequences of these experiences http://www.internationalarttherapy.org/whatisarttherapy.html. Chapman writes about the creation of a neuro-developmental model of art therapy (NDAT), which facilitates the activation of the right hemisphere of the brain to help children and teenagers that have been exposed to violence, abuse and chronic trauma in general, ‘to create a nonverbal narrative of the patient’s experience through drawings that can be translated into a verbal narrative of the event’. Briefly, the NDAT model has four treatment phases. The first phase consists of helping the child learn how to relate to others without being out of control and to separate him/ herself from the past. In the second phase, the goal is regulations of emotions. Children initially use structured media (pencils, markers, collage, wood) or unstructured media.(watercolors, clay and various brushes). Then the young client is asked to switch media, colors, and paint every other minute. By providing different media during the intervention, Chapman writes that she enables the client to focus on drawing and on the present as a break from negative past experiences. After that, Chapman asks safe questions about the drawings because, as mentioned above, children may not feel comfortable talking about their issues or traumatic memories. In the third phase she tries to build cognitive homeostasis, which means ‘having a cognitive understanding of the past and utilizing cognition-driven behavior’. Chapman refers to this phase as ‘redefining, reclaiming, and practicing’. During the final phase of the treatment the child or adolescent has learnt to cope with the past and the therapist helps the child develop a support system. She also provides psycho-education about the different stages of development, explaining, for instance, that toddlers and preschoolers cannot remember their experience in detail or discussing peer pressure with school-age children and parent separation and independence issues with adolescents.

Furthermore, art provides us with an additional important means of communication, which is more accessible to children and people with diverse and special needs. Survivors of complex trauma are often ‘mute’ and art can provide an alternative means of expression of buried and non verbal implicit memories. Daniel Siegel writes that ‘we must keep in mind that only a part of memory can be translated into the language-based packets of information people use to tell their life stories to others. Learning to be open to many layers of communication is a fundamental part of getting to know another person’s life’ (The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are) Finally, even though in our society verbal communication is highly valued, our human experience cannot all be reduced to words. The following extract expresses a lot of points I have referred to in this brief text so far. The writer supports that ‘although human communication may take many forms, in a society such as ours words tend to dominate. Not only are words the main means by which we exchange information about the world in which we live, but words are, for most people, the main means they have available for expressing and communicating their experience of that world. It is through words that most of us, in our daily lives at least, attempt to shape and give meaning to experience. Human experience cannot, however, be entirely reduced to words. Expressing how it feels to love or hate, to be traumatized or to suffer depression may involve far more than struggling to find the ‘right’ words. Some experiences and emotional states are beyond words. This is particularly relevant where difficulties originate in early infancy, a time when we experience the world in advance of any ability to describe it in words. It is here that art therapy offers a way of overcoming the frustration, terror and isolation such experiences may engender, by providing an alternative medium for expression and communication through which feelings might be conveyed and understood. Art therapy may prove helpful to people with a wide range of needs and difficulties for a number of reasons. In the context of a supportive relationship making images, and thinking and feeling in images, which among other things involves the use of the imagination and the taking of risks, can further a person’s emotional growth, self-esteem, psychological and social integration (http://www.sagepub.com/upm-data/9585_019726ch1.pdf)

Tonya Alexandri, November 9th, 2014

‘Art tells the truth’ (Edith Kramer)

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From Friedl Dicker-Brandeis to Edith Kramer to Cathy Malchiodi

While engaging in my own art work recently I began re-thinking of how self expression through artistic means has the potential to heal, to help us recover material, to deepen our knowledge of self and others, to help us transform or/ and overcome pain, to document even, but also how our art tells the truth about us and often about our circumstances and social context, Edith Kramer (1916-2014) believed that ‘Art tells the truth’. Sadly, Edith Kramer, an early pioneer in the field of art therapy, passed away this year at the age of 98 (her official website address is in the Links part of this site, where you can view her art and read her articles and about her). Edith Kramer escaped to the USA from Austria as a political refugee just before World War II (1938). In Europe Kramer had studied art with Friedl Dicker Brandeis (1898- 1944) and had worked with her in Prague helping children whose parents were refugees and was probably influenced by her philosophy and outlook on life. Friedl Dicker and her husband were deported to a camp called Terezin, known as Theresiendstadt, in 1942. They were instructed to pack only 50 kilos. Dicker chose to pack a few clothes only and fill the rest of her weight quota with art supplies not only for her own artistic needs, but to ensure that she would have the necessary art supplies to teach art to the children she expected to meet at the ghetto. Dicker nurtured and taught hundreds of traumatized children as it turned out and her work reflected a form of art therapy because she helped children use art as a way to express their emotions and to cope with their internment in the concentration camp. In the USA Kramer taught art first at the Little Red School House in New York City and later at the Wiltwyck School for Boys, where she applied psychoanalytic theory to her work and was given the title ‘art therapist’. She supported that there is a connection between making art and the Freudian concept of sublimation, which summarily could be defined as a process in which destructive or self-destructive feelings or urges are transformed through art or work into socially productive and acceptable outcomes. Edith Kramer was also the founder of the graduate program at New York University, has authored seminal papers and books, and is a renowned social realist painter, sculptor, print-maker and mosaicist.  Her work Art Therapy in a Children’s Community and Art as Therapy with Children have become material read in art therapy courses and programs. Kramer writes ‘My therapeutic medium is as old as mankind. Since human society has existed the arts have helped man to reconcile the eternal conflict between the individual’s instinctual urges and the demands of society. Thus, all art is therapeutic in the broadest sense of the word. The artist who applies modern psychology in the field of art has to adapt his methods to the medium so that the therapeutic value of art is heightened by the introduction of therapeutic thinking, not destroyed or weakened by the introduction of concepts and methods that might be incompatible with the inner laws of artistic creation’. Edith Kramer also believed and supported the idea that the art process, in itself, as well as, the final art product, are both healing factors and people benefit from both. She is also known for her concept ‘the therapist’s third hand’ (I have discussed this elsewhere on this site). Cathy Malchiodi writes that ‘the third hand can be summed up as the therapist’s ability to facilitate a person’s artistic process’ (for instance, intervening or helping the individual mix colours, choose material, cut out pictures, etc. She continues ‘To me, the “third hand” exemplifies our modern-day interpersonal neurobiology paradigms of attunement and empathy, Daniel Siegel’s over-arching concept of ‘mindsight’ and Daniel Goleman’s ideas about ‘focus’ and ‘emotional intelligence’.

So, reading about Edith Kramer and viewing her work again brought me to Cathy Malchiodi’s site, where I also found a very useful article in which Malchiodi discusses Developmental Trauma and Trauma-Informed Art Therapy (TI-AT) and interventions for children and adolescents, which I’d like to refer to briefly. It is apparent that in order to provide and apply trauma informed intervention understanding the effects of chronic trauma on every aspect of one’s experience is essential, in this case on every aspect of a young person’s life. Malchiodi writes ‘in 2005 Bessel van der Kolk and colleagues proposed developmental trauma disorder (DTD) to more accurately describe children and youth who present a range of difficulties as a result of exposure to early, chronic and severe trauma. These individuals may have experienced developmentally adverse trauma involving abandonment, physical abuse or assault, sexual abuse or assault, emotional abuse, witnessing violence or death, and/or coercion or betrayal. Understandably, these types of repeated events cause feelings of rage, fear, shame, defeat, and withdrawal; they are reactions to years filled with adverse and inhumane treatment by parents, family members, caregivers, or others who impact these children’s lives’. Children, like adults who have suffered complex trauma, have problems with emotional regulation because they have probably never been helped to resolve difficult feelings like anger, grief or fear, but also because their amygdala in the lower parts of the brain (limbic system) have in some sense ‘hijacked’ their frontal cortex, because this is how humans are wired to react when dealing with adversities and traumatic experience. Furthermore, young survivors of trauma will have attachment and trust issues and may have difficulty paying attention and learning, and behaving in an appropriate or adaptive manner. Allan Schore has written that negative early attachments with care givers impacts infants’ brain development, especially, the right hemisphere, which as a result, influences one’s attachments and relationships and capacity to regulate emotions. Alan Schore has written that negative early attachments with care givers impact the developing brain, especially, in the right hemisphere, which subsequently influences one’s capacity to regulate emotions and one’s future attachmentsAlan Schore has written that negative early attachments with care givers impact the developing brain, especially, in the right hemisphere, which subsequently influences one’s capacity to regulate emotions and one’s future attachmentsHelping children understand this through psychoeducation, providing therapy and a safe environment can facilitate healing and restoration.

Malchiodi provides a list of recommendations based on her work with children from violent homes, abused children, and youth who witness homicides. Summarily, (you can read more on her website) she suggests a) establishing safety (internal sense and support systems); b) teaching children how to regulate and moderate arousal; c) helping them rebuilt trust and re-establish attachment with positive adult role models and  learn how to empathize and interact with peers in a healthier way; d) enhancing brain’s functioning because prolonged trauma has a negative impact on both cortical and cognitive functioning, which of course impacts children’s capacity for learning and problem solving, which in turn impacts their sense of self and e) enhance children’s adaptive and coping skills, and ultimately help children and adolescents transform and  construct meaningful lives.

Cathy Malchiodi also explains that Trauma-Informed Practice addresses the neurological, biological, psychological and social effects of trauma in the individual and recognizes the interrelation between trauma and its symptomatology and the possibility that traditional service delivery may exacerbate symptoms, trigger and re-traumatize survivors of trauma. One can read more on this and what Trauma-Informed programs & services represent at http://mentalhealth.samhsa.gov/nctic/trauma.asp. Finally, Malchiodi’s article refers to the role of trauma informed art therapy and expressive arts therapy in working with trauma survivors and PTSD. She writes ‘most children I have worked with over the years have been chronically abused and neglected. As a result, these children generally have a variety of severe trauma reactions (hyperarousal, avoidance, dissociation, and intrusive memories), learning and psychosocial challenges, and attachment difficulties. In many cases, psychodynamic and cognitive behavioural strategies alone cannot address the reactions of children whose cognitive, developmental, and interpersonal skills are compromised by multiple traumatic experiences’. She defines Trauma-Informed Art Therapy and Trauma-Informed Expressive Arts Therapy as ‘the integration of neuroscience and neurodevelopment, somatic approaches, mindfulness practices, and resilience enhancement, using art making as the core approach’.

Since young children may not yet have the means or the words to express their experience art creation can help them (and adult survivors) integrate implicit (sensory) fragmented traumatic memories and explicit (declarative) memories, as discussed more extensively elsewhere. Art is also something that most or at least a lot of children, if they have not been shamed or criticised for their efforts, enjoy doing in any case. Most children like to use art material and they are still at an age when they worry less about the end result and can benefit more from the process. And art is not only a useful approach in therapy but I think in educational settings, as well, where I believe it is underutilized. Being a language teacher for many years I repeatedly found that when writing tasks were linked to art activities or when writing projects required illustrating the number of children to do their homework or engage more enthusiastically with the writing tasks was always higher. In some sense artistic expression facilitated the language learning process. Over the years I found that not only did I get more students involved in writing tasks and elicited more enthusiasm on their part, but their performance in the particular language skill improved. Furthermore, displaying their colourful work around the school boosted their confidence and made writing tasks, even for students who were reluctant or less interested or who found writing more difficult, a more appealing activity.

Tonya Kyriazis-Alexandri, October 30th, 2014

References

Edith Kramer (2002) Art as Therapy: Collected Papers by Edith Kramer, Edited by Lani Alaine Gerity, Jessica Kingsley Publishers

Edith Kramer, Retrieved in 29 October, 2014 from http://www.edithkramer.com/ Edith _Kramer_ Art_ Therapy html.   Elsby,

Friedl Dicker Brandeis, Life in Art and Teaching, Retrieved on 29 October, 2014 from http://makarovainit.com/friedl/home.html

Goldman Rubin, S. (2000), Fireflies in the Dark: The Story of Friedl Dicker Brandeis and the Children of Terezin

Malchiodi, C. (1998) Understanding Children’s Drawings, The Guilford Press

Malchiodi, C. Trauma-Informed Art Therapy (TI-AT) and Trauma-Informed Expressive Arts Therapy. Retrieved on 28 October, 2014 from http://www.cathymalchiodi.com/Trauma Informed Art Therapy.html

Malchiodi, C.(March 6, 2012) Trauma-Informed Expressive Arts Therapy. New York: Sussex Publications/ Psychology Today

‘The process of drawing, painting or constructing is a complex experience in which the child brings together diverse elements of his environment to make a meaningful whole. In the process of selecting, interpreting and reforming these elements, he has given us more than a picture; he has given us a part of himself’ (Lowenfeld, 1947, cited in Malchiodi, 1998)

Untitled_Panorama9-bigA collage of some of my students’ Christmas cards-artwork offered to me