Art Therapy Practice

Art Therapy Practice

Introduction

Trauma and loss are some of the incidences with life-long consequences to the victim. Research claims that victims have a higher probability of developing PTSD, depression, and behavioral problems than others (McTavish, 2018). Intervention for mental and physical conditions resulting from trauma and loss involves a myriad of techniques. This paper examines an expanding practice, art therapy. It includes an examination of the attachment theory to offer an understanding of early attachment disruptions resulting from trauma and loss. The paper also provides debate hypotheses regarding the use of art therapy and some ethical considerations and potential dilemmas arising from the intervention that focuses on children and adolescents.

Art Therapy Practice

Art therapy is a growing practice in mental health. This paper will utilize the following definition of the method: “the purposeful use of visual arts materials and media in intervention, counseling, psychotherapy, and rehabilitation” (Malchiodi, 2008 as cited in McTavish, 2018). The choice of art media, interaction with it, and the creation of images gives essential information about the cognitive, physical, and emotional aspects of peoples’ lives (Hinz et al., 2017). In other words, the utilization of art provides an opportunity for one to communicate, non-verbally, essential information about oneself. Such information may have remained unconscious in one’s mind, and it may involve events experienced way back in childhood. Art therapists utilize this discovery to foster a relationship between them and their clients in which art acts as the medium. The therapist can make decisions on how to help his/her client by assessing their needs. Different modalities can facilitate this form of communication, including sculptures, paintings, and carvings. The idea is to let the client project his/her feelings or thoughts through art. The therapist can make meaning of the art and help the client realize details of their lives that remain hidden unconsciously in their minds. Through evidence, the therapist can also choose the best approach to intervene in the client’s situation based on the message constructed. Research continues to support the value of art therapy in mental illness treatment.

The choice of art in the treatment of mental illnesses involving trauma is not an arbitrary practice. Instead, it is a practice supported by scientific reasoning. McTavish (2018) has reviewed research that points out that early traumatic events occur during a developmental stage that the child lacks verbal communication. During that stage, only non-verbal communication is present for the child to express his/her feelings/thoughts. Therefore, the client can only communicate their feelings/thoughts non-verbally. Also, traumatic experiences affect the development of language, making it challenging for the victim to express their feelings. Modalities such as drawing and carving, therefore, give the victim a way of relating their experiences.

Further, children explore their environments in an explorative manner through play, art, and similar ways (McTavish, 2018). It is not a matter of mere choice; therefore, doctors use art therapy to aid those affected by traumatic experiences early in life. Knight (1998) says that while the creations of arts enable the client to express their unconscious processes, the therapist can choose how to approach the attachment problem. Art materials, according to this author, provide sensual and tactile characteristics that unify the therapist and the victim in a creative process that helps face the problem from one point of view. This statement invites an investigation of the attachment component of art therapy.

Adverse childhood experiences, or developmental traumas, result from neglect, sexual and physical abuse, psychological abuse, and care giver-related injuries. For instance, the mother may be experiencing domestic violence, and the father/mother may be abusing drugs, one or both parents may be having a mental illness, etc. Such conditions produce social, behavioral, and psychiatric problems to the child, which necessitates psychological treatment (McTavish, 2018). To a great extent, such conditions create attachment disruption, meaning that the child does not have a secure base from which they can explore their world. The impacts of this disruption are life-long and increase with the number of adverse experiences faced by the child. From that perspective, it is worth considering childhood trauma and loss as an attachment issue with severe implications for the child. Hence, it is worth analyzing the attachment theory to gain an understanding of its impact on art therapy. The secure base is a concept within the attachment theory that signifies that the child develops trust with their caregiver depending on the availability and consistency of response such that the caregiver is always available when the child needs them. It contrasts insecure attachment, which signifies that the child cannot rely on the caregiver to give them comfort when they need it (Flaherty & Sadler, 2011).

The Attachment Theory

The attachment theory is a product of different researchers, including John Bowlby (1907-1990), Mary Ainsworth (1913-1999), and Mary Main (born 1943). It explains the development of physical, emotional, and cognitive abilities and the factors that affect such growth. The main ideas within this theory are attachment and the secure base. Attachment here is a growing child-caregiver connection spanning a lifetime. The link is an evolutionary phenomenon designed to help the child to survive by deriving protection and safety from the caregiver whenever the child needs the same. With time, the child develops a specific relationship with the caregiver. Organs such as the skin play a role in this development as it is through it that the child and the caregiver can touch. The caregiver becomes the attachment figure with whom the child develops a specific relationship within a particular location. The attachment figure and the place/setting together constitute the secure base in which the child is comfortable. The caregiver’s availability promotes a perception that the child is safe to explore the world. As such, the more available the attachment figure is, the less the child strains and the freer they are to examine the rest of the world. On the other hand, if the attachment figure is not available and reliable all the time, the child tends to develop a greater need for them, and the less they are free to explore the rest of the world (Fitton, 2012). Attachment and the secure base facilitate the development of the following aspects.

Affection, or emotions, develops as the child bonds with the caregiver. The emotions consist of observable or demonstrable characteristics that could be happiness, mourning, grief, etc. These emotions develop depending on the availability and responsiveness of the caregiver. Behaviors communicate the child’s needs. For example, crying signals the need for protection. Psychic development refers to the knowledge and trust of others that the child perceives as his/her attachment figure. The nervous system, intellectual potential, language, and competency grow as a result of the attachment between the child and the caregiver. Through skin contact, the child develops an attachment to his/her caregiver that helps them to distinguish their usual caregivers from others. The secure base is the part of the affection that grows with the physical and psychological presence of the attachment figure. Disruption from any of these aspects may produce life-long impacts for the child. Art therapy provides an opportunity for the trauma-affected child to access parts of the brain that do not complete their development as a result of disconnection from the caregiver; parent/guardian. Therefore, it is vital for the intervention to take place as early as possible (Hinz et al., 2017).

Today, scientists have expanded the attachment theory to explain how childhood connections between the child and the caregiver influence the development of the brain. The type of attachment, secure or insecure, affects neural plasticity. Some brain cells may or may not find useful depending on the kind of attachment experienced. By studying the brain structures that form due to secure or insecure attachments, scientists can monitor the changes that take place throughout life. Since the brain is an adaptable organ, it can change depending on the type of attachment available (McTavish, 2018). Therefore, the provision of a favorable environment may affect the functioning of the brain. This discovery is vital for art therapy and other modern approaches to children with trauma and related events. The following discussion highlights some of the common interventions for children with traumatic experiences.

Neurobiological Approaches to Child and Adolescent Development

According to McTavish (2018), “Trauma-focused Cognitive Behavioral Therapy, Cognitive Behavioral Intervention for Trauma in Schools, and Trauma Systems Therapy are the treatments with the hugest evidence base” (Garro et al., 2011 as cited in McTavish, 2018). The following section offers a brief explanation of the different approaches.

Trauma-Focused Cognitive Behavioral Therapy

de Arellano et al. (2014) define TF-CBT as a conjoint parent-child treatment. According to these authors, the method employs cognitive-behavioral principles, as well as exposure techniques, to treat depression, PTSD, and behavioral problems. By reviewing ten randomized controlled trials, the authors found TF-CBT to have a high level of evidence. The authors say that the method had produced positive outcomes regarding PTSD. It was inconclusive, in the context of the studies examined by the authors, to argue that the treatment was effective in depression and behavioral problems (de Arellano et al., 2014). However, the authors used the evidence to challenge the inclusion of TF-CBT in the insurance system.

Cognitive Behavioral Intervention for Trauma in Schools

CBITS is a school-based treatment focusing on children who have experienced traumatizing events. The program aims to reduce depression, PTSD symptoms, and behavioral challenges to improve coping skills and academic performance, among other functions.

Trauma Systems Therapy

TST consists of a phase-based intervention program aimed to address the needs of a traumatizing and caregiver system. The complicated system consists of children or adolescents who always face reminders of their traumatic events and caregivers who cannot protect the children from those reminders. The implementation of TST takes place in foster care settings, juvenile justice systems, residential treatment centers, and other settings involved in the child welfare system (CEBC, n.d.).

Art Therapy in the Context of Trauma and Loss

According to McTavish (2018), most studies on art therapy focus on the mother-child relationship, which is not available in a child welfare system. Notwithstanding this absence, it is possible to replace the mother-child attachment with a client-therapist connection, which can then assist in the study of the efficacy of art therapy (McTavish, 2018). It is important to note here that child welfare programs are not the same as a home setting. Children who occupy these environments have undergone traumatizing experiences earlier in life and, therefore, suffer depression, PTSD, and other maltreatment disorders. A significant number of such children have substantiated cases of child maltreatment, abuse, and neglect. Some victims die while receiving treatment (McTavish, 2018). One area where researchers have investigated the efficacy of art therapy is the projective drawing assessment, where participants undergo a drawing assessment lesson to examine their attachment security patterns. By comparing the client’s image with the indicators on the predetermined rating scales, the assessor can relate past attachment disruptions experienced by the client. The interaction between the client and the therapist during the lesson facilitates the development of trust between them, which then facilitates the sharing of memories that the client may not have recognized. In other words, drawing assessments help to assess attachment difficulties within the client. Research suggests that expressive play participants can form healthy relationships with others (McTavish, 2018). An essential part of art therapy is the intersubjectivity phenomenon, where the therapists fuse the client’s emotions with their own, internally. The process of combining one’s feelings with another’s (referred to as emotional attunement) creates an empathetic response that strengthens a secure client-therapist relationship (McTavish, 2018). With time, the client can regain their ability to form healthy relationships.

The use of sensory media is an essential part of art therapy practice. The Expressive Therapies Continuum offers neural media with which the client can interact to engage their sensory processing channels. Since the right side of the brain stores non-verbal memories, it is the part that impairs with traumatizing events. The best way to access that part is through sensory media (Hinz & Lusebrink, 2009, as cited in McTavish, 2018).

The Debate Hypothesis

One of the key findings of this research is that attachment plays a significant role in the development of personality, physical, and mental properties, which affect the likelihood of a client seeking psychiatric treatment. In other words, a child who fully interacts with his/her attachment figure – the caregiver – should have a lower tendency to developmental and physical health complications that the one who does not fully cooperate with their caregiver. By translating this finding, the following hypothesis ensues from this research: that secure attachment positively correlates with few or no mental and physical illnesses throughout the client’s life. By reversing the order of this hypothesis, one may also claim that physical and mental health directly correlates with secure attachment. Therefore, it would also be true to argue that insecure attachment directly connects with high instances of psychological and physical illness.

The second key finding is that early childhood is the period in which the significant development of the brain takes place. Disruption to this development may result from traumatizing events, loss, and other forms of separation. Since these disruptions affect the ability of the child to complete the formation of the brain, it affects the general strength of the child to develop fully as an adult. From this finding, one can offer the following hypothesis: individuals with secure attachment have a higher chance of survival and intellectual capability than individuals with an insecure attachment.  Development may assume diverse forms, including sexual, psychological, etc. Life fulfillment will occur more readily among securely attached people, not those suffering from an insecure attachment.

The other key finding is that the right side of the brain is instrumental in language development. Below the age of two years, the child tends to use non-verbal communication to send messages to the caregiver. Art therapy engages the part of the brain that is responsible for non-verbal communication processes. As such, the intervention helps process severe instances in the life of the child that coincides with the period in which the client used non-verbal communication. However, the technique can work for clients of all ages. Since early childhood offers the most impact on development, it is vital to avoid disruption during this period to give the child the highest development outcomes.

Along with this finding, one may present the following hypothesis: prevention of trauma is more important in development than intervention because prevention allows the acquisition of the highest development possible. Intervention, although it is necessary, can only reconstruct what the client lost to trauma and loss or separation. Prevention is paramount.

Ethical Considerations

Art therapy, like any other healthcare provision activity, must adhere to the core moral values. Such include beneficence, autonomy, and nonmaleficence (American Art Therapy Association, 2013). The therapist and their clients interact respectfully.  They acknowledge the freedom of each other to make decisions regarding their healthcare. As such, the interaction should proceed with an acknowledgment that every participant has the freedom to express their ideas. That requirement involves the request for informed consent from the client. It also requires the therapist to provide adequate information and clarity to the client (American Art Therapy Association, 2013). The therapist must not share private details with other therapists. The use of social media has created a new challenge for therapists who may tend to share their experiences with others in a similar or a different specialty. Sharing of client information may constitute a violation of the law regarding confidentiality. Therefore, the therapist should maintain a distinction between professional and social discourse and should only share what is permissible under the law. For the therapist to uphold a secure relationship with the client, he/she should practice integrity. That means that the therapist follows the set code of ethics and conduct that, among others, requires them to maintain honesty.

Ethical Dilemmas

Therapists interact with different clients who have differing mental, physical, and emotional challenges. Often, the client is in contact with relatives or family members who show concern for the client’s situation. Depending on the circumstance, the family/relatives may request the therapist to withhold some information from the client to avoid upsetting them. Such a request contradicts the principle of autonomy, which requires the therapist to let the client make decisions about his/her situation from an informed stance. When such an issue occurs, it constitutes an ethical dilemma. The therapist struggles with two sides in which any decision made could hinder the maintenance of the ethical principles outlined for the therapist. A related problem pertains to the disclosure of misconduct by colleagues or partners. One may feel that doing so constitutes betrayal.

Conclusion

This research examined art therapy and its connection to the attachment theory in attachment disruptions from trauma and loss. It gives some ethical considerations and potential dilemmas regarding the use of art therapy among children and adolescents. The discussion includes findings on art therapy and debate hypotheses on the topic.

References

American Art Therapy Association. (2013). Ethical principles for art therapists. Alexandria, VA: Author

Boronska, T. (2000). Art therapy with two sibling groups using an attachment framework. International Journal of Art Therapy: Inscape, 5(1), 2-10.

CEBC. Trauma Systems Therapy. Retrieved 31 March 2020, from https://www.cebc4cw.org/program/trauma-systems-therapy-tst/detailed

de Arellano, M. A. R., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., … & Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: Assessing the evidence. Psychiatric Services, 65(5), 591-602.

Fitton, V. A. (2012). Attachment theory: History, research, and practice. Psychoanalytic Social Work, 19(1-2), 121-143.

Flaherty, S. C., & Sadler, L. S. (2011). A review of attachment theory in the context of adolescent parenting. Journal of Pediatric Health Care, 25(2), 114-121.

Hinz, L., Riccardi, M., Gotshall, K., & Nan, J. (2017). Experimenting with the expressive therapies continuum: Reflection upon an arts-based assessment through heart and mind. In Workshop presented at the 48th annual conference of the American Art Therapy Association, Albuquerque, NM.

Knight, S. H. E. I. L. A. (1998). Art therapy and the importance of skin when working with attachment difficulties. Development and Diversity: New Applications in Art Therapy. London, Free Association Books.

McTavish, J. Q. (2018). Using Trauma and Attachment-Informed Art Therapy to Promote Healing in Children in the Welfare System: A Literature Review.