Adverse Childhood Experiences and Expressive Arts TherapyOn being alive and becoming whole (again)
“The word ‘therapy’ has its roots in the word therapeia, which is the Greek word for ‘healing’- and healing simply means ‘making whole’. Therapy=healing=moving towards wholeness”-Jeff Foster
EXPRESSIVE ARTS THERAPY –MAKES IT VISUALArt is a language of its own. That which is difficult, or impossible to discuss, can become apparent when visualised through an image, a sculpture, or any form, allowing it to speak on its own accord.
WHAT IS EXPRESSIVE ARTS THERAPY?
Expressive Arts Therapy focuses on the experience in the present moment. A variety of materials can be used, for example pencils, paint, wood, clay, fabrics, and digital paraphernalia. The choices for the material, technique and task are carefully made together with the client according to their needs. Working through images creates the possibility to discover personal qualities and difficulties making them tangible and specific. It offers a way to experience and express feelings and emotions. This creates an opportunity to learn new skills. The client and the therapist explore creative ways to understand and make sense of daily life experiences. From: Dutch institute for Expressive Arts Therapy.
“Art is to console those who are broken by life” Vincent van Gogh- A life in letters
“Expressive Arts Therapy speaks to a world of experiences that are free from words and conceptions, and connects with the bodily and sensory awareness.” (Smeijsters 2003, in response to Smitskamp 1997)
SURVIVING…THE FUNDAMENTAL WORK
Symptoms of early childhood trauma in expressive arts therapy.
Early childhood and chronic traumatization is classified as a sub-class of posttraumatic stress disorder (PTSD) according to the DSM-5. Adverse childhood events and early childhood and chronic traumatization interfere and hinder fundamental developmental tasks, such as developing a consistent sense of Self. When these tasks are placed under pressure during childhood, this can have life-long consequences. When clients with early childhood trauma are in expressive arts therapy, existential questions can arise as well as conflicting feelings in regard to belonging and being alive.
Destructive forces which have their origins in past violent experiences, clash with the vitality of actually being alive. In the expressive work this existential theme shows itself, for example, in difficulty taking up space and material, the difficulty of coming to (one’s own) form and the struggle of tolerating one’s own visual work. However, it is precisely the life force that is also present; the fact of living and the often-present intention to do so (Van Hemert & Kerkhof, 2012) that is addressed in the field of expressive art therapy. The expressive art therapy room, with all its belongings, can at best, together with the therapist, offer a Safe Holding Space, in which halted developmental tasks are given the freedom and space to unfold and continue to grow and blossom.
The formative and creating character of expressive art therapy is, in itself, already an antidote to the previously manifested violence and abuse, which was directed at destroying, repressing, putting down or being cornered. Experimenting, moving (outwards), claiming space, shaping, creating, playing, all these elements as part of universal basic needs, are being addressed as well as being put in motion by the expressive art therapist, within the safe confinement of the creating conditions that the expressive art therapy room offers in the present moment. Being offered something to have and hold, to give direction, intensity and form to, and having ownership to start, pause or stop an action, within the context of art therapy, allows clients to reclaim their own power.
Here I will discuss my experiences with clients with early childhood and chronic traumatization using several works from clients as well as a case presentation. All images are either my own work, or directly from clients, used with permission.
MATERIALS IN EXPRESSIVE ARTS THERAPY“
From a sense of disappearing, to a sense of being”The sensory feedback that accompanies expressive arts, i.e. the sensation of scribbling, of pencil on paper, the temperature and density of clay, the sliding of oil pastel crayon on paper, all confirm on a fundamental level that you as a person exist and are present in the here and now. Furthermore, sensorimotor work also offers an entrance or port-d‘entrée for working with early childhood, often, nonverbal traumatic memories.
The tangible, visible, and remaining character of the created works during art therapy acts as palpable proof of the presence of the client within that space, at that place and time (see figures 2 and 3). It transforms those inner experiences to something present, real and less fleeting, as well as more touchable/apprehendable, both physically and emotionally. Experiences rendered as an image, or sculpture, create a central thread, a process which can be reflected up on, and continued with. “I can see it, it is standing there, we can look at it together, it’s really true, it exists, I exist”. Where alienation of the Self often is part of the inheritance of the early childhood trauma, visual expression offers an opportunity to reclaim feelings, movements, experiences and thoughts. It is a first step towards integration, becoming whole.
Figures 2 and 3: Remnant traces of formative expression. Traces proving that you were here, visible
A THERAPEUTIC COMPANION
The visual works produced by the client, create an opportunity to reflect together with the therapist, on that which was created as well as the process that was involved. In this way a movement is created (adaptation and change), from inside to outside, and back inside again. A movement that, as long as the art therapeutic process takes, can keep going and form a seed/bud for a developmental movement which can reach far beyond the therapy room. This process, however, is not without its own struggle. Those who have endured suffering and were taught not to be, and to disregard all their intrinsic needs, require time and a sense of safety and trust, or perhaps hope and a sense of beckoning potential before they desire and dare to start with visual expression. That strange curious visual art, “Because what does it really say, and on top of that I am really bad at it…”. An exercise in co-regulation during a crisis is shown in figure 5 and 6.
As with every form of therapy, a safe therapeutic relationship must first be established, in which any growth-limiting cognitions can be managed, or rather in which those cognitions have a safe space, free of judgement. All parts of the client should experience a sense of being welcome, in that space, at that time together with the therapist. Without a doubt, conflicts will arise from time to time, but what a gain that a third party will constantly be present to absorb feelings of transference or for instance an increased or decreased arousal.
The expressive arts therapeutic triangle offers capacity to see which re-enactment is occurring in the here and now, while the therapeutic relationship, with any luck, can remain free of any (counter)transference-violence. An example is offered in the following case-report.
The client can hopefully tolerate the therapist as their companion, after all the threat is the material, the expressed art, created by the client, not the therapist. (Grabau, & Visser, 1987) The shared experience offers the client the opportunity to use the co-regulatory nerve-system of the therapist, client and therapist exist side-by-side with a shared perspective of something that appears to lie outside them.
Figure 5 and 6: Therapist and client R. together on one a single paper (50x65cm). tarting to move, getting in contact with your own acting power. The sensory feedback of scratching and rubbing on paper enhance the contact of the client with the here and
Figure 7. The therapeutic triangle
Today is the first time that Carla1 will be working with clay during expressive art therapy.
It is natural clay, fine fireclay. Carla likes the feel of the clay on her hands, she kneads and pushes the piece into her hands enthusiastically. There is play and fun, an exploratory inner child part is addressed in this first session.
As the session progresses, Carla gets the idea that the piece of clay in her hands must become ‘something’. A well-defined idea emerges, with requirements for function and aesthetics. The space to play and experiment is now all of a sudden significantly reduced, by these self-imposed requirements. Carla’s arousal increases visibly when she undertakes attempt after attempt to give shape to the emerged idea.
In fact, at this point Carla is already caught in a trap: no matter what she will produce, it will never be good enough. This is the image that Carla has internalised of herself with a history of early childhood trauma; that she is no good and that everything that comes out of her hands is worthless. Every time the sculpture is finished and Carla judges it not quite good enough, she destroys the piece and starts over. A re-enactment of not being permitted, or not being able to be a child in the past, is being repeated in the here and now, with tremendous energy and tempo. After attempt four the therapist is able to intervene and directs the client to allow the current attempt to exist, as an experiment, and to investigate what happens when one deviates from the beaten, destructive path. The therapist moves the piece a little further away from Carla but still within sight, and she offers Carla a new piece of clay to accommodate the increased arousal.
The destructive force is directed to the new piece of clay and space is opened to allow the (perceived) failure and all that it represents to remain. Carla weeps, not for the failure of the sculpture, but due being allowed to feel the grief of that which was lost. The therapist stays close, acknowledging the emotions released and encouraging Carla with a sense of trust (I can witness it and you can bear it) to give the emotions space. A moment arises in which the pain and sorrow are allowed to exist.
1 Carla is a fictitious name. The case describes part of a session in the beginning phase of the visual art therapeutic process. After these experiences nothing is ‘finished’ or ‘solved’, but a change has occurred in dealing with one’s own feelings of pain, sadness, failure and worthlessness. An impetus for further investigation and work.
MATERIALS IN EXPRESSIVE ART THERAPY (2)
As the previous example shows, the visual medium also offers a very welcome safety net, in the case of increased or decreased arousal. This space offers to work with physically involved methods that ventilate, regulate, or activate and can more than once act as a lifeline during the session. It offers the client, and perhaps even the therapist, a opportunity to co- and self-regulate and, in that way, return to a more comfortable level of arousal, which allows continuation with the contact in the here and now in all its forms, contact with the inner experience, contact with the visual work, contact with the therapist, and contact with the environment, see figures 8 and 9. In this way, clients can continue working through their emotions.
Figure 9. The involved body
Figure 8: Oil pastel and ink on paper, bilateral, both hands at once. Ventilate, regulate, integrate.
Besides the hard work when conflict arises, the driving force behind expressive arts therapy are the touching moments when a hurdle is overcome and the client can surrender to their own vitality and creative force and create without abandon. To freely and wholeheartedly experiment and create, shape and design. When one dares to take the space to see oneself reflected in the joint domain and when the developmental processes are given free rein, that is the power of expressive arts therapy.
A self-portrait created by client R is shown in figure 10, in this drawing an inner experience is expressed and created on paper.
Figure 10. Oil pastel on paper, by client R. Flooding. My head is filled. Both in movement as well as form, client R has successfully expressed that which she experiences on the inside. The creation process, as well as the final results are representa
…AND BECOMING WHOLE (AGAIN)RECOGNITION, ACCEPTANCE, AND INTEGRATION.
“I had to fall apart only to have found myself whole again.”
Figuur 11: Ink and pen on paper, Falling a part, containment, gathering and becoming whole (again). From disintegration to integration.
REINTEGRATION AFTER (RECOLLECTION OF) DESTRUCTIVE EXPERIENCES
After some experience has been gained in the fundamental work, space is created to jointly look at that which has emerged and to let it come together as a whole. From implicit to more explicit, from unconscious to conscious, from hidden to seen, from loose-fixed to a whole, its own unity and image-story.
In this stage of the process, we reflect together on what the client experiences with the image, the images, and with the creative process that was behind it. Which interpretation suits the client and how can, will and shall we continue to work on it? Which themes manifest themselves? How can we make room for the difficult, the ugly, the dark? Learning to tolerate all aspects of oneself and what one’s own nature produces.
Expressive work offers the possibility of creating a safe distance to the inner experience. By literally bringing it from inside to outside and then being able to look at it from a distance (together). The image can be removed, put away, destroyed or just cherished and safely protected. The client gains access to a new ability to act, a new expressive language, with which an experience of grip and self-governance can be achieved. Essential experiences and abilities to let that which was so terrifying in the beginning, come closer and exist.
Figure 12; Neocolor on paper. From inside to outside. From a sense of being overwhelmed, towards some distance and compassion. From resistance to embracing.
Moreover, something special happens when the client can give form to extremely painful and/or destructive forces. By creating from that which was essentially destruction, a transformation already takes place. By offering them a place in the shared external space, they often lose their destructive power and can develop into a creative/creating one. This takes some of the sting out of the inner conflict surrounding existence.
Figure 13: Various material on paper from client R. To bring out the unbearable. Ventilate. R. undertakes various brave efforts to externalize those destructive forces which she experiences on the inside. The high contrast of black and red, as well as the
TO FEEL IS TO HEAL By giving space to various internal tendencies using formative techniques, and subsequently enabling them to exist, space is created for recognition and acceptance to all that emanates from the client. The therapist is present here as a compassionate companion, acting as such and receiving all expressions of the client, bounding where necessary or putting them in a new perspective.
The fact that it is possible to work together in the expressive art therapy room is of great added value. The therapist is an observer, a witness, sometimes even a participant in what the client experiences, shapes and experiences. Witnessing the client’s process and being able to look together at the proofs of it, can have a deeply acknowledging and connecting effect.
The client experiences being permitted to be there and, and hopefully, experiences a moment of right to exist and connection.
The client is offered a Safe Holding Space in the here and now, in which the possibilities for exploring, experimenting, shaping and seeing oneself reflected are still included: in order to give stagnated developmental processes new space and to arrive at life experiences other than those of early childhood and chronic trauma.
“There is something more and different, also for you.”
Grabau, E., & Visser, H. (1987), Creatieve therapie: spelen met mogelijkheden. Van Loghum Slaterus, Deventer.Smeijsters, H. (2003), Handboek Creatieve therapie. Coutinho, BussumVan Hemert, A. M., & Kerkhof, A. J. F. M.. (2012), Multidisciplinair richtlijn diagnostiek en behandeling van suïcidaal gedrag. De Tijdstroom, Utrecht.
Trauma and Expressive Arts Therapy, Cathy Malchiodi. In Malchiodi, C. (2020), Trauma and Expressive Arts Therapy. Guilford Publications, New York City.
The images used in this ar ticle may not be copied or reproduced without the writ ten permission of the author. Kim Tukker, Registered Expressive Ar ts Therapist, based in the Netherlands. E-mail address: firstname.lastname@example.org