Case Stories for Art Therapy
ADHD
(Attention-Deficit/Hyperactivity Disorder)
Smitheman-Brown, V., & Church, R. R. (1996). Mandala Drawing: Facilitating Creative Growth in Children with ADD or ADHD. Art Therapy, 13(4), 252–260.
Amy is 13 years old and has been diagnosed with Attention-Deficit Hyperactivity Disorder. All her life, she has been experiencing significant attentional difficulties and impulsive behaviours. Each art therapy session began with a circular drawing or mandala for 5 minutes as a means of relaxing and centering. She usually began drawing from the centre of the circle and drew whatever she wished. Amy would sometimes continue working on her mandala for longer than 5 minutes. Only when she feels her circular drawing is complete, does she move on to creating a new artwork in any art medium for the rest of the session. Over the course of her art therapy sessions, she completed 20 mandala exercises. While previously she had not been known to draw a full human figure, her drawings began to exhibit a full body schema with arms, legs and body. She began to demonstrate her ability to attend to detail and produce a more integrated drawing and include more environmental details in her work as she gained strength in her ability to focus and control impulsive behaviors.
The choice of the mandala is related to the work of Jung (1972), R. Kellogg (1969), and J. Kellogg (1978, 1984). All concur that the use of the mandala is an experience that often creates a calming and relaxing effect on the artist. Jung began painting mandalas in 1916 and regarded the form as “corresponding to the microcosmic nature of the psyche” (1965, p. 196). Rhoda Kellogg’s work describes the mandala as the first emergent form in creative expression after the scribble stage. The ability to draw a circle appears to be crucial to pictorial development (Kellogg, 1969). According to the extensive work of Joan Kellogg, mandalas offer a channel for creativity and provide maps of inner growth. The mandala form presents a structural device on which to concentrate and can be approached as a drawing of ongoing process (Kellogg, 1978, 1984).
Autism Spectrum Disorder
Durrani, H. (2020). Sensory-Based Relational Art Therapy Approach (S-BRATA): A Framework for Art Therapy With Children With ASD. Art Therapy, 1–9.
6-year-old Taj, was a shy boy with a glazed look in his eyes. Taj could verbalize but not use language functionally. He perseverated on nursery rhymes and seemed enclosed in his own world apparently disinterested in communication outside it. The foremost aspect of working with a child with autism is to establish a sense of safety by anticipating the stress levels of the child (Martin, 2009a). Taj’s mother sat in the sessions until he was comfortable being alone with the art therapist. Instead of actively seeking his engagement or holding back, the art therapist worked with art materials in another part of the room, not insisting he reciprocate.
This eventually drew Taj’s attention and encouraged him to willingly engage in sensory artmaking (picture of paint and foam smeared on mirror). Consequently, he became increasingly comfortable, initiating touch during artmaking with foam indicating that holding back of active engagement had allowed him space and time to feel safe, a prerequisite for attachment formation. In session 11, Taj was comfortable enough throughout the session that he allowed the art therapist to draw on his hand. Taj’s mother was happy with his progress as he was beginning to approach other children in the park, repeat words and use some functional language.
Entire sessions may be only dedicated to sensory play or activities other than artmaking because the child is not ready or motivated to engage with art materials. Flexibility in approach is emphasized and allows for inclusion of play, drama, and music in the sessions when the therapist might need to attune to the child using different media. The tactics of holding back engagement may be considered unique to the field of art therapy and are recommended to instill a sense of safety for the child.
These techniques may result in long periods of minimal interaction between child and therapist especially in the initial sessions but may be necessary for the child to feel safe. As it pertains to attachment, Sensory-Based Relational Art Therapy Approach positions the therapist as an attachment figure. Evans and Dubowski (2001) recommended a treatment approach based on reciprocal cueing while also paying attention to rhythm and body language. They referred to this communication as proto-conversations in that the therapist’s response gives meaning to the client’s vocalizations and results in verbal/nonverbal dialogue. This reciprocity also includes embodied intelligence and interpersonal connectedness that facilitate a sense of awareness in the therapist of the emotional state of the child (Belkofer & Nolan, 2016). Kossak (2015) identified that the arts can achieve entrainment, or experiencing the state of another through deep connectivity through activities that involve sensory integration and kinesthetic movement. When a therapist can attune to the sensory and emotional state of the child, the therapist’s self-awareness of countertransference feelings, anxiety, and breathing patterns in the session can offer important nonverbal information to help tailor the intervention.
Burnout/Compassion Fatigue
Tjasink, M., & Soosaipillai, G. (2018). Art therapy to reduce burnout in oncology and palliative care doctors: a pilot study. International Journal of Art Therapy, 1–9.
8 trainee doctors participated in 6 sessions structured and divided into three broad themes pertinent to burnout:
(1) Self-awareness and self-care.
(2) Collegial connection and the organisation.
(3) Reflecting on death, bereavement and finding meaning.
Made in session 4 is another group painting about shared experiences of the challenges of their jobs. This piece is a combined clock and compass that have lost their use and make no sense. It reflects a sense of chaos, lack of direction and impossible pressure. The process of collaborative art making in sessions that focused on organisational issues helped participants to achieve a very real sense of being in and working on something together. It facilitated a realisation that they were not alone in their difficulties as well as the sense of being able to address these together.
In session 5, Matt made a mixed media work depicting a difficult but ultimately meaningful journey with a young bowel cancer patient. The patient is represented by the glittery gem in the centre and is described as unique and precious. It was by holding on to the individual identity of this patient that the doctor was able to create and maintain a sense of meaning and purpose during this challenging and sad case. Most participants reported not having previously spoken about the patients they reflected on in these final sessions. Some had been holding on to unresolved feelings and thoughts for years. Using image making as a starting point allowed a more oblique approach than talking alone and eased the difficulty of engaging with the emotive material. Quiet time making images also facilitated a slowing down and a clearing (Rappaport, 2014) which allowed and supported this rare and unfamiliar opportunity to reflect. As well as easing the verbal reflection and sharing that followed, this process also added depth and nuance. The act of remembering and creating artwork in response to the memory of past patients also had a ritualistic element. Some doctors reported relief and a sense of resolution at finally being able to mark their patient’s death in this way.
Cancer Patient
Czamanski-Cohen, J., Wiley, J. F., Sela, N., Caspi, O., & Weihs, K. (2019). The role of emotional processing in art therapy (REPAT) for breast cancer patients. Journal of Psychosocial Oncology, 1–13.
Mun had just completed her primary treatment for breast cancer. She participated in 8 weekly art therapy sessions aimed at emotion processing. All sessions started with a ten-minute rapport building discussion and continued with 50 minutes of art making in a calm and supportive environment. Art materials were on the table and after the art therapist provided a brief explanation of the use of the materials participants were encouraged to explore the diverse materials and use them for expression as they wished. Each session had a different topic tailored to incrementally increase the level of emotional engagement and exploration. The art therapist encouraged participants to refrain from conversation and instrumental music was played to encourage introspective experiences.
The sessions ended with 30 minutes of processing and discussion in which the art therapist requested each participant to share and briefly present their work and group participants responded and/or provided support. Mun found participating was helpful in enabling her to discuss things that were previously a barrier for her, that the group helped in “opening her eyes” to things that she did not notice before, getting in touch with difficult emotions and processing her experience with breast cancer. Mun drew a scene from her experience getting a biopsy. This was drawn inside a mouth, symbolic for her sharing this experience for the first time. She also included the words “scream, shout, fear, alone, tired, nurse, hero, not hard, almost over, Mommy”. For Mun, the group provided an opportunity to draw her thoughts and feelings, her present and her past.
This was a safe place in which she could express herself, and frequently only later did she really understand what she drew, “it’s like magic and healing for the soul” Individuals coping with cancer need resources to cope with the psycho-social challenges that come with diagnosis and treatment. Art making has the potential to address the difficulties cancer patients have in verbalizing emotional experiences related to cancer diagnosis and treatment, which arise from the need to reorganize the self, to revise interpersonal relationships, and to process physical and psychological shifts that occur during and following cancer.
Complex Trauma
Stace, S. M. (2014). Therapeutic Doll Making in Art Psychotherapy for Complex Trauma. Art Therapy, 31(1), 12–20.
Jess is a woman in her mid thirties who self-referred to art therapy, saying that she wanted to work on issues that stemmed from her traumatic childhood. Jess had been diagnosed as having posttraumatic stress disorder (PTSD) and depression and had a complex trauma history. During her first session Jess briefly disclosed a history of family violence that was mainly perpetrated by her father and child sexual abuse perpetrated by her brother.
Jess was introduced to the idea of making a doll during her ninth session. She made 6 dolls in total. The interpretations of meaning and their representations (discussed later) were identified by Jess alone and do not include any projections on my part as her therapist.
For her fourth doll, Jess wrapped yarn around a piece of fabric to make a doll’s body that was both soft and firm. She said that this quality represented her feelings of weakness along with the strengths she must possess. The doll’s pliability reminded Jess of the malleability of her connection with her feelings, due to years of dissociating and self-medicating. Jess named the doll Self-Esteem. After making this doll, she reflected on its meaning. Jess realized that she had not yet completely acknowledged that she must have possessed great strength to have survived her childhood trauma and not take her own life, as many others have done. Jess understood that her low self-esteem was not her own doing and that her brother and parents were responsible. With this insight, we discussed the difference between internal and external locus of control. Jess realized that an internal locus of control would be more helpful for her. As we considered the doll’s appearance, I asked Jess about its arms. Jess said she had wrapped the doll’s arms around its torso in an attempt to self-soothe. Only then did Jess realize that she had given the doll extra-long arms. This unintentional distortion conveyed significant meaning to Jess as she now recognized that she was capable of taking care of herself and did not need to rely on others to be cared for. The tangible three-dimensional representation of distortion made this realization achievable and all the more profound. Jess felt the need to be gentle with this doll and realized it was because her self-esteem was fragile. What she really needed was to be gentle with herself. Holding the doll tenderly, she told me she felt like she did not deserve to possess something so precious. At the same time she did not want to put the doll down. I asked Jess if these comments or feelings paralleled her life in any way. She then realized that she did not want to “put herself down” any longer.
Jess said, “I am worth loving. I need to care for myself, heal, and be empowered to be who I can be.” At the end of this discussion, Jess began to play gently—swaying with her doll in dance-like movement. Then she comforted, preened, and kissed her doll and decided to take her home. Jess’s self-esteem was supported as she gained insight and was able to focus on her strengths and positive attributes and to consequently develop a more positive sense of self and identity.
Dementia
Tucknott-Cohen, T., & Ehresman, C. (2016). Art Therapy for an Individual With Late Stage Dementia: A Clinical Case Description. Art Therapy, 33(1), 41–45. doi:10.1080/07421656.2016.1127710
Uncle Wan is in his late 80s diagnosed with advanced dementia due to Alzheimer’s, living in a long-term care home for older adults. He attended weekly 45-minute art therapy sessions for 17 consecutive weeks.
In the late phases of dementia of the Alzheimer’s type, individuals may be unable to communicate verbally and may use gestures and facial expressions rather than language (Rogers & Lasprilla, 2006; “Treatment of Dementia,” 2007). Uncle Wan was struggling with anxiety, living with an altered sense of reality, and had diminished verbal skills but still managed to communicate through art while enjoying the process. With little continuity between sessions, the importance of in-the-moment art therapy is vital. Uncle Wan’s art-making provided a range of ways to communicate, such as expressing agitation through the physicality of art making. In his sixth session, Uncle Wan was yelling and seemed especially agitated. He ceased shouting and appeared to calm himself when the art therapist drew a circle for him in light green, the color of his choice.
He used the strength of his entire body to make repetitive marks in an upward motion. As he firmly held the paper with one hand and drew with the other, even his legs would move from the force of his effortful strokes, such that art-making was a sensory-motor release for him, the motions he was making appeared to be cathartic. In the end, no white could be seen in the circle he had started with, as he had used up most of the ink of the marker making forceful upward strokes. Art therapy provides engaging processes for emotional healing, and also provides an opportunity to improve quality of life for those with dementia. Art making can act as an important means to reinforce the emotional, perceptual, conceptual, and motor systems of people with dementia, while placing an emphasis on their strengths (Miller, 2008). Furthermore, art making involves several sensory modalities and engages complex cognitive mechanisms, such as internal imagery and decision-making processes (Lusebrink, 2004). It is this engagement and activation that has the potential to delay the progression of neuronal death in dementia cases (Verghese et al., 2003). Therefore, art therapy is an ideal, holistic intervention for those with dementia that could be implemented in conjunction with medications and physical therapies (Cummings, 2008; Miller, 2008).
Loss/ Grief
Arnold, R. (2019). Navigating Loss Through Creativity: Influences of Bereavement on Creativity and Professional Practice in Art Therapy. Art Therapy, 1–10.
After the loss of her father, Bonnie, in her mid-50s, created altered books that incorporated old papers from her father. Bonnie compiled “a mixture of stuff I found from drawers”, “what I had around,” which included a mix of found objects and “notes and something my dad painted” to create her altered books, and adding string to her paintings without regard to having any actual plan. It reflected how she felt, “overwhelmed and disconnected and in pieces”.
Creating an artwork from all these separate pieces helped guide her “back to the whole”. The grieving body holds sensory energies that seek resolution. Bonnie described feeling “restless,” but found a space in the art making to engage in a “flow” experience. Additionally, the act of “wrapping” materials was considered a way to physically discharge her grief. each participant found new developments in understanding her changed relationship with the deceased through the use of creative materials. This was viewed in one respect through Bonnie’s bird imagery, which she summarized as a creative symbolization of the lost physical relationship she once had with her father. “Wherever I put birds is my dad.”