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Expressive and Creative Arts Methods for Trauma Survivors

  • Edited by Lois Carey
  • Paperback 224 pages
  • £17.99
  • ISBN 1 84310 386 9

Reviewed by the Editor of ‘Play for Life’ August 2006

Lois Carey lives in New York, where she has been a practicing therapist since 1978. She is Adjunct Professor of Play Therapy at Hofstra University and President of the New York branch of APT. Her work will be familiar to PTI/PTUK Members through her book ‘Sandplay Therapy with Children and Families’

The purpose of this collection of contributions is to demonstrate how play, art, music therapies, sandplay, storytelling and psychodrama (a contentious subject for play therapists – see ‘Play for Life’ Summer 2006) can be used to aid the recovery of trauma victims. The publication is well timed because of recent natural disasters and terrorist atrocities but also deals with the trauma of children resulting from abuse.

The success of this type of book, in my view, depends upon the quality and relevance of the individual contributions for Play Therapists and also how they fit together.

The book gets high marks for the range of modalities and methods described as well as for the illustration of many different theoretical approaches thus fitting PTI/PTUK’s integrative holistic model.

The scene is set in a foreword by Judith Rubin which makes a general case for the use of arts and creative therapies for helping trauma survivors by reference to case studies. There is a link to the first chapter making the point that through neuroscience we can better understand why the arts are so therapeutic and provides an overall strategy: firstly access the nonverbal right hemisphere (through images, sounds and movements), then enable it to communicate with the left hemisphere to gain cognitive and affective (emotional) mastery.

‘Neuroscience and Trauma Treatment’, written by David Crenshaw, starts with an excellent summary of the latest research covering the biological effects of psychological trauma: the disruption of homeostasis causing acute and chronic effects on many organs and biological systems; the way children appraise and process information; the effect upon perception of threats. The development of the infant’s right hemisphere has deep connections to the limbic and autonomic nervous systems and plays a dominant role in the human stress response. A secure attachment with the primary caregiver facilitates the development of a child’s coping capacities. However early relational trauma can lead to enduring right-hemisphere malfunctioning. Most alarming is the effect on the right brain’s stress coping systems. The research of Schore, van der Kolk, Perry, Pate, Pollard and Teicher is referenced for further study in this area.

Crenshaw also provides a summary of the issues, emerging from neurobiological research that need to be addressed in trauma treatment:

  1. Safety
  2. Stabilising impulsive aggression against self and others
  3. Affect regulation
  4. Promoting mastery experiences
  5. Compensating for specific developmental deficits
  6. Judiciously processing both the traumatic memories and trauma related expectations
  7. Developing in the child an awareness of who they are and what has happened to them – repair of the sense of self
  8. Learning to observe and respond to the present instead of recreating the traumatic past – desomatizing memory
  9. Teaching self-soothing to cope with hyperarousal physiological systems
  10. Finding meaning, developing perspective and a positive orientation to the future

Although the use of talk is considered essential for clients who were too young to understand what happened, whom no one listened to or believed or who need help in making sense of what happened, words alone can’t integrate the disorganised sensations and actions that have become stuck. Neuroimaging scans have shown that when people remember a traumatic event, the left frontal cortex shuts down – in particular Broca’s area, the centre of speech and language. In contrast areas of the right hemisphere associated with emotional states and autonomic arousal, especially the amygdala, which is the centre for detecting threat light up.

The remainder of this chapter suggest ways in which the therapist can carry out the tasks of trauma therapy.

The second chapter written by Nancy Boyd Webb covers ‘Crisis Intervention Play Therapy to Help Traumatised Children’. She points out the similarities and distinctions between trauma and crisis, briefly refers to a tripartite assessment model that she has developed and suggests deficiencies in the DSM (Diagnostic and Statistical Manual possibly because of children’s limited verbal abilities and/or their unwillingness to revisit or reveal their frightening memories. A summary is provided of the symptoms of post traumatic stress disorder (PTSD) grouped as: re-experiencing, avoidance, arousal.

Webb’s description of crisis intervention play therapy, which is a short term approach, incorporates elements of cognitive-behavioural and psychodynamic play therapies. The therapist attempts to repair a child’s faulty perceptions and clarify any incorrect attributions related to the cause of a crisis or traumatic event.

Webb is in favour of sensitively encouraging, but not forcing, the child to reconstruct the traumatic experience, either literally or symbolically in play therapy, which although initially frightening, eventually provides cathartic relief to the child. ‘Whereas the memory remains threatening to the child, the crisis therapist finds ways to point out that this event occurred in the past and that the child survived and is safer and stronger now. The ultimate goal of crisis intervention play therapy is for the child to gain some feeling of mastery over traumatic experience through the realisation that it will no longer continue to impact on his/her life. Two detailed clinical examples are given. The author’s guidelines are:

  1. Establish a supportive therapeutic relationship with the child
  2. Teach the child some relaxation methods to help keep anxiety in check
  3. Provide toys that will assist the child in recreating the traumatic event
  4. Once the child feels safe in the therapeutic relationship encourage a gradual re-enactment of the traumatic event with toys
  5. Move at the child’s pace – do not attempt too much in one session
  6. Emphasise the child’s strength as a survivor
  7. Repeat that the traumatic experience was in the past
  8. Point out that the child is safe in the present

The third chapter ‘Working Toward Aesthetic Distance’ covers the use of drama therapy for victims of trauma. This is of less interest because it is addressed at therapists working with adult clients. However the use of masks and the technique of concretization, as described could be used with children.

A model for working with groups using an expressive arts model for PTSD children is given by Susan Hansen. It is a structured, directive approach using expressive arts to encourage clients to talk based on the belief that children who have experienced abuse followed by the development of PTSD symptoms require the support of other peers to help to manage the ‘after-effects’. A useful framework of a typical programme of 12 weeks, with goals and activities for each week together with a structure for each group is given.

Chapter 5 Peter: A Study of Cumulative Trauma – From ‘Robot’ to ‘Regular Guy’ starts with short but excellent summary of the history and development of psychoanalytic concepts and therapy with children. This features the work of Charcot, Breuer, Freud, Hug-HeLBUth, Anna Freud, Melanie Klein, Madeline Rambert, and Lussier linking it with Erik Erikson, Winnicott, the later attachment researchers: Bowlby, Cassidy, Shaver, Main and neurobiology Schore, Siegel, Solomon and Sroufe. There is a brief section on the use of expressive arts in therapy followed by a thirteen page case study (over three years) of a nine year old boy adopted from a Russian orphanage who had suffered extreme neglect which impaired emerging brain development. This mainly illustrates the use of art, stories and talking therapy.

The next chapter, written by P Gussie Klorer, also covers art therapy but used with traumatised families rather than individual clients. It makes the distinction between treating a single traumatic event and one where trauma has been prolonged over many years. A concise history of family art therapy provides plenty of references for further study: Kwiartkowska – credited as the originator, Landgarten – art as a family assessment tool, Riley and Malchiodi’s – paradoxical techniques, Arrington – a systematic approach, Linesch – application of a family systems approach, Sobel strategic family therapy, Roijen’s – model for transcultural art therapy, Hoshino’s adaptation of the addressing model, Belnick – crisis intervention model and Wadeson’s multi-family art therapy approach. Then there are there are references for family art therapy based upon a particular population: drug and alcohol problems (Springer), sexual abuse issues (Cross), single parent families (Brook), within a deaf system (Horowitz-Darby), integration within the child protection system (Manicom and Brononska) and with political refugees (Kellog and Volker).

The goals of family art therapy in trauma work are given and then explored including a case example:

Goal Strategy
Help the family to explore individual reactions to the trauma Draw what happened
Explore the role that each person plays Recognise shift of roles – restore equilibrium
Help each family member to communicate needs Reframe the event as a catalyst for change
Help the family to find support, either from one another or outside the family system Locate and involve other resources such as extended family members

This is followed by a section that deals with the treatment of families with prolonged trauma by instancing neurobiological effects associated with the two main reactions – a dissociative or hyperarousal response. These can include raised heart beat rate and smaller intracranial volumes in the brain. Research also indicates that traumatic memories may be stored in the right cerebral hemisphere, which would make the use of speech to access memory of trauma more difficult. Rather than having ‘the clients will begin to talk about the trauma’ as a goal, ‘the clients will begin to express feelings about the trauma’ can be a more effective objective in trauma work, since it bypasses the need for verbalisation. Two more cases make the point. An excellent chapter.

Chapter 7 covers vocal psychotherapy for adults traumatised as children. It will not be of great interest to the majority of our members because of its directive and analytic orientation and the need for the therapist to possess some musical skills.

Two chapters are devoted to sandplay. The first by Lois Carey herself describes therapy with a traumatised boy. Most of our members will already be familiar with Lois’s writings on sandplay. The most significant difference is the incorporation of a post-scene discussion as the culminating point of each session. The child is encouraged to tell a story about what has been constructed but all discussions are kept within the metaphor of the tray. In the extensive case study sandplay is ‘the catalyst that enabled an almost mute child to express the inexpressible in ways that words could not have done.’

The second of the two chapters links sandplay with a body centred approach. Dennis McCarthy briefly covers concepts such as ‘container’, ‘filter’, ‘energy’, ‘discharge’, ‘pulsation’ and cathartic play derived from the work of Wilhelm Reich, Alexander Lowen, Carl Jung and Erik Erikson. Pulsation with its cycle of expansion and contraction of play may be a very useful idea for explaining a child’s behaviour in therapy to third parties. The first case example concerning a five year old boy deals with medical trauma and is a good example of the application of a body centred approach. The second case is about physical and emotional abuse that caused a bowed neck and a taut mouth making her speech inarticulate illustrates how abused children are able to translate their traumatic experiences into a private language of their own (Ferenczi) – sandplay is an ideal format. A third case where emotional neglect in an orphanage leads to problems after the first few years in adoption, shows the process of contraction into symbolic negativity followed by expansion into positive aggression during sandplay therapy. Another very interesting chapter.

The first chapter contributed by Diane Frey, ‘ Puppetry Interventions for Traumatized Clients’ is sound, straightforward and includes a useful list of criteria for selecting puppets for treating traumatised clients, but contains little that will be new for most of our readers.

However her second chapter ‘Video Play Therapy’ is innovative and in the reviewer’s opinion essential reading for any practitioner. To quote: ‘ Video play therapy is the process in which clients and therapists discuss and play out themes and characters in films, which relate to the core issues of their therapy. In video play therapy a bond develops between the viewer and the film. In the very best films, viewers often experience a dissociative state in which everyday existence is suspended. Films have a greater influence on individuals than any other art form’. Video Play therapy applies the principle of indirection, just as in therapeutic storytelling. Clients will accept information through videos that they will not always accept directly.

Video therapy is an extension of bibliotherapy (selecting appropriate stories to read or be read by the children to meet a therapeutic objective). Films offer a wide range of interpretations determined by the clients’ needs. The therapist offers guidance and connections that help the client to understand the underlying dynamics and might only suggest watching a particular segment. The child (or the therapist deciding to work directively) may re-enact parts of the video using dressing-up, puppets or sandtray or drawing. Children may also make their own video.

The chapter cautions about not using video play therapy with clients who have difficulty in distinguishing reality from fantasy and those who have very recently experienced trauma. Criteria for selecting videos for therapeutic use together with a short list of titles and applications. The ‘Lion King’ is particularly recommended. The four main stages of client process is given as a framework.

The chapters end with Joyce Mills’ s ‘Bowl of Light’, a story and exercise using clay that most Members will be familiar with from their training.

Since a number of the chapters feature art therapy it is a pity that none of the illustrations are in colour. It is also a shortcoming that all contributors are American – play therapists throughout the world work with trauma. Despite these minor drawbacks Lois Carey is to be congratulated upon presenting a large variety of approaches. The book does a very good job of promoting the use of expressive arts therapy to complement talking therapies and achieve results that talking therapy cannot.

The lists of references for further study will be especially useful for students seeking a basis for their specialised essays and dissertations.

Recommended as a buy. A candidate for PTI’s ‘Book of the Year Award’.