In a recent intake session with a prospective client, I asked my standard question about prior experiences in therapy. “Yes, I’ve been in therapy before,” she said, “In fact, I’ve been in art therapy for several months now.” Intrigued, I asked her to tell me more. “Well, I got an adult coloring book for my birthday, and I’ve really enjoyed it.”
I managed to nod supportively while my thoughts went off to the races. Are those coloring books lining the bargain bins at Target really what’s become of the once venerable field of art therapy? Do they have any therapeutic value, or has the methodology developed in the mid-20th century to help promote children’s emotional and cognitive development devolved into a fad of filling in outlines of mandalas? Surely there’ve been recent developments more transformative than this. In fact, I realized that even though I’d been seeing the term expressive arts therapy increasingly bandied about in recent years, I wasn’t really sure what it meant.
To bring myself up to date, I reached out to Cathy Malchiodi, a Kentucky-based art therapist and author of more than 20 books on the topic, including The Art Therapy Sourcebook and the recently released, What to Do When Children Clam Up in Psychotherapy. As president of Art Therapy Without Borders and founder of The Trauma Informed Practices and Expressive Arts Therapy Institute, Malchiodi has her finger on the pulse of the profession and is at the forefront of a growing movement to treat returning combat veterans with art and expressive arts therapy.
More than quell my fears about a promising therapeutic approach turning into a fad, she opened my eyes to the many important advances being made at the intersection of trauma, creativity, and the expressive arts.
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RH: How is art therapy different from expressive arts therapy?
MALCHIODI: Art therapy integrates visual arts and the psychotherapeutic process, while the newer field of expressive arts therapy adds movement, sound, music, play, and drama. I’ve started using both in the last decade. For example, I normally start a session now with movement. I might spend five to seven minutes with a client when they first come in, doing some stretching, maybe some chair yoga, or just some bilateral movement where they’re moving both sides of their body. Creating this moment of attunement, and warming up the body, is especially helpful for clients who’ve survived trauma.
RH: Isn’t art therapy typically associated with children and in-patient populations?
MALCHIODI: When people hear I do art therapy, they often say, “You must do a lot of work with children,” and yes, that’s part of the continuum. But this work can help people of all ages process and recover from trauma. Take one of my typical clients: an active-duty soldier in her early 30s. Along with a physically abusive childhood, she developed PTSD with body reactions after two tours of combat. We’ll do some movement at the start of sessions, and often she’ll say something like “I have a tight feeling in my chest and my shoulders.” We might work with that a little bit through movement, but we might also take it to the next level, which would be me saying, “Show me through colors, shapes, and lines what that feeling in your body looks like. Don’t worry about making it into art, just put something on the paper.” I call this mark-making.
Next, I might ask her if she feels comfortable with drawing an outline of the body. Then I’ll say, “Can you show me where that feeling is in the body? If it feels like it’s outside the body, that’s okay. You can transfer that to the image too.” And then if that feels comfortable, I’ll ask, “What kind of story would that image tell me if it could talk? If it’s a worry, what does that worry say?”
What I’m trying to do is help her work through her trauma at a kinesthetic and a perceptual level of expression, as well as a cognitive one. Of course with some people, we may never get to that cognitive level, because they don’t need to tell the actual story. But if they do, it’s usually quite safe for them to tell it in the third person, as if that image was talking.
Thirty years ago, when I worked with abused children who didn’t want to talk, I quickly learned that they could talk about anything in the third person. But you could also switch to the first person when you had something really positive that you wanted the kids to embrace.
RH: Do you feel the general public’s recent obsession with adult coloring books—which are often promoted as art therapy—cheapens the field or draws attention to an important need?
MALCHIODI: I think the popularity of these coloring books relays an important message about art and healing. Why did so many adults rush out to get those coloring books? To me, it says that a lot of people out there need to self-regulate. But those in the art therapy community emphasize that healing occurs in relationship, not only in the use of an inanimate object. A coloring book in itself isn’t going to challenge you to make the changes you need to enhance your quality of life, wellness, and health.
RH: Can you give me an example of helping clients build up coping mechanisms through combining arts and therapy?
MALCHIODI: A single father wanted me to work with his 10-year-old son after they were in a car accident together, with one of the boy’s friends in the backseat. A texting driver hit them. The father and the son weren’t hurt, but the friend was admitted to the hospital.
Afterward, the son kept drawing the accident in his notebooks, and kept repeating the story. He was distracted in school, and his grades fell. When I first saw him, he was excited to draw the accident to show me what happened. As I’ve often seen with school shootings and other traumatic events, it’s common among children to want to draw the event over and over. But if clients are showing you their anger, their upset, you can’t just say, “Let’s not do that anymore.” You need to help them reframe the story and help them figure out a way to put the incident in its correct place in time.
With this boy, we started to develop a ritual about when he could tell the story of the accident. We put all the drawings in an envelope, and the father, child, and I agreed that the drawings would go up on a shelf. Every time the boy wanted to tell the story, he had to get on a stepladder, and his father had to help get the drawings down so he could talk about the story, and then put them all back in the envelope when he was done.
We then did drawings about going to the hospital with his friend, seeing him admitted, visiting him, and his friend’s complete recovery. Soon the drawings started to make the accident look like just an incident in time. We drew other things about their friendship, too, like the time they went skiing together. Over time, he didn’t want to get that envelope down anymore, as he became refocused on the entirety of their relationship.
RH: So you’re doing all the different components of psychotherapy, from building up coping skills to reframing, to bits of exposure as well?
MALCHIODI: It is exposure therapy. If you’re drawing something you’ve experienced, you’re being reexposed to a lot of sensory material even in a drawing.
RH: Do therapists interested in incorporating art therapy into their existing practice need formal training?
MALCHIODI: Yes, and a big piece of the training is having them engage in art therapy themselves. But there’s a lot of emotion involved. Even the most benign things I ask people to explore for themselves in my seminars—like “What does that worry looks like? Show me where that worry is in the body, and what it feels like in the body.”—can cause some people to get up and leave. A big piece of what the art therapist offers is the knowledge of what it feels like to go through the process. With art therapy, you have to experience what it’s like to talk about what you’ve created and find out firsthand the healing effects of having other people witness it.
RH: Is there a time when art therapy wouldn’t be advised or wouldn’t be helpful?
MALCHIODI: Yes, which is why I’ve moved into the broader expressive arts therapy model. While I don’t think it’s inappropriate for anyone, some people just don’t resonate with putting something on paper. It may not be the best mode of self-expression to promote healing for certain people.
RH: So what’s new in the field?
MALCHIODI: I think we’re starting to realize where the visual arts fit in the continuum of expressive arts therapy, and we’re getting closer to understanding art therapy as a body-based approach. Through neuroscience, new findings about the mind–body connection, and all the research around trauma, we now have some explanation for why these expressive processes work. And it’s given us a deeper understanding of how we can harness imaginative powers and find ways—you might call them creative, I call them expressive—to reframe experiences.
Also, our client base is shifting. The biggest adopters right now are people in the military, who use these art-based approaches in helping vets heal from PTSD and traumatic brain injury. Ten years ago, we weren’t anywhere near that, but more and more active military personnel and veterans are asking for this kind of approach.
RH: In your work, do you find that these tough, traumatized men and women are skeptical of this approach at first?
MALCHIODI: In 2008, I was asked to develop resiliency programs based on Martin Seligman’s model of positive psychology with American military in reintegration programs. My first group were Navy SEALs who’d had multiple deployments, but because of their severe PTSD symptoms, most of them weren’t going back. Some were skeptical about art therapy, but they had a story to tell, and they were trying to transform the story and make meaning out of what had happened. A lot of that might start out in individual art therapy; then they’d move to a veteran’s support group, where they’d create more elaborate art. Some might go on to do something public, like poetry readings.
So they follow this continuum of meaning-making and allow people to witness what they went through, with the help of a professional to get them through the rough spots of dealing with their trauma reactions. A key element of art therapy is giving trauma survivors a means of expression that allows them to connect with and rejoin the community.
RH: So you’re guiding people to connect with others through their art.
MALCHIODI: Yes. Art has always existed for the purpose of transforming life’s most difficult experiences. People who’ve been through traumatic experiences must tell their stories and have those stories witnessed. Art therapy is a powerful tool for facilitating that.
Ryan Howes, PhD, ABPP, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. Contact: firstname.lastname@example.org.
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