By Eileen Misluk-Gervase, LPC, ATR-BC, LMHC, CEDCAT
Herron School of Art and Design, Indianapolis, IN
Art therapy has been available in clinical settings since the 1940s, bringing training in the arts and an interest in creativity, well-being, and mental illness (Junge, 2010). By the 1960s, the practice of art therapy was spreading across the US, thanks to artists, art educators and psychiatrists, who were interested in the diagnostic indicators and healing benefits of having patients create art.
The physical effects of eating disorders, and particularly the consequences of malnourishment, affect the brain’s ability to function properly. Such effects include disruption of neurotransmission, structural changes, and abnormal activity because of anorexic states. In addition, the brain is affected by conditions such as potential oxygen deprivation due to a low heart rate (Frank, 2011); nerve-related conditions, including seizures (Misra et al., 2013); shrinking of grey and white matter (Bang et al., 2016); adverse effects on the emotional centers of the brain; weakened reward pathway responses in the brain; and difficulty and disordered thinking, planning, and cognitive flexibility (Arnold, 2013; Kaye, 2007). Engaging in creative processes utilizes various brain networks and in turn activates these brain-related functions that can be compromised by an eating disorder.
Today, graduate art therapy programs are training master’s level mental health clinicians. Such programs integrate psychological theories with an understanding of creativity, art materials, and the art-making process and products within a clinical setting. With the field’s theoretical roots in Freudian and Jungian theory, art therapy has grown along with contemporary psychological theory. In the same way that mental health counselors practice cognitive behavioral therapy (CBT) or motivational interviewing, art therapists practice arts-based CBT and motivational interviewing, in which the theories of creativity and art-making are embedded in the assumptions of the identified theory.
Art Provided in Sessions vs. Art Therapy
Other mental health providers, such as counselors, social workers, and psychologists, use art materials within sessions to gain a greater understanding of the client. In this context, art serves as a bridge to conversation, a tool for relaxation, or a means for emotional release. In contrast, “Art therapy is an active therapeutic process that integrates the mind and body, allowing an individual to uncover, explore, and process emotional content through art making.” (Misuk-Gervase, 2020) This is achieved by pairing fear-arousing emotions with new experiences to support coping, regulating, and integrating (Hass-Cohen, 2008).
Art therapists create “holding spaces” for emotionally laden experiences while encouraging spontaneous engagement in the creative process through directive and non-directive approaches. Creativity requires methodological processes such as “problem-solving, organization, cognitive flexibility, abstract thinking, planning, willed action, and source and working memory” (Misluk-Gervase, 2020). Engaging in creative activities heightens a person’s “ability to engage in contradictory modes of thought, including cognitive, affective, deliberate, and spontaneous processing” (Ellamil et al., 2012).
Three Brain Networks
Creativity activates three brain networks: Executive Attention, Imagination, and Salience (Gotlieb et al., 2018). The Executive Attention Network activates during complex problem-solving tasks, and demands extreme concentration, and focus on working memory (Gotlieb et al., 2018; Kaufman, 2013). The Imagination Network constructs mental simulations from past experiences by using the same processes as remembering, future planning, and imagining alternative perspectives (Gotlieb et al., 2018). The Salience Network is activated in reward and punishment pathways and body distortions (Gotlieb et al., 2018). Additionally, researchers have noted the engagement of the brain’s dorsal and ventral stream during visual, sensory, and creative activities (Hass-Cohen and Loya, 2008; Lusebrink, 2004; Lusebrink & Hinz, 2016).
This is accomplished through the integration of vision, action, and detection of movement and location, and response to shapes, meaning, form, color, and brightness (Hass-Cohen and Loya, 2008). Hass-Cohen et al. (2014) stated that the centers that mediate emotional awareness are involved in subjective decision-making, such as choosing colors, shapes, and forms in meaningful image-making. The innate practices involved in art-making, from planning and decisions to meaning-making, pair with the diagnostic needs of individuals with eating disorders.
Materials and Processes Involved in Art-Making
In tandem with the field of psychology, art therapists utilize a variety of theoretical approaches to address the needs of clients and their presenting issues. In conjunction with these theories, art therapists take into consideration the properties of materials and the psychological and physiological processes involved in art-making.
A Creative Art Therapy Framework
The Expressive Therapies Continuum (ETC), a creative art therapies framework, provides a unified language and structure to discuss art-making within the therapeutic setting. The ETC is not a distinct theory; rather, it can be aligned with any theoretical perspective, and provides guidance on the effects of art-making and the creative processes involved in art therapy (Hinz, 2009; Lusebrink and Hinz, 2016).
The ETC organizes media and expression on three levels of complexity: Kinesthetic/Sensory, Perceptual/Affective, Cognitive/Symbolic, and a fourth level, Creative, which is conceptualized to cross all other levels. Art therapists may utilize the ETC to identify client needs, or to develop treatment plans, select materials, and formulate directives. The Kinesthetic/Sensory component processes somatosensory experiences and mediates internal and external sensations as they relate to art-making (Hinz, 2009; Lusebrink & Hinz, 2016). The Perceptual component emphasizes the formal elements of art-making (e.g., line, color, form, direction), nonverbal communication, and cognitive restructuring by exploring various perspectives (Hinz, 2009 ). “The Affective component supports identification, amplification, discrimination, and expression of emotions” (Misluk-Gervase, 2020). The Cognitive component requires planning and decision-making while integrating past and present imagery (Hinz, 2009). The Symbolic component supports the exploration of personal symbol formation and self-expression (Hinz, 2009). The Creative level is an integrating factor within the ETC as individuals work within and between the various components throughout the creative process (Hinz, 2009). In 1989, Wooley emphasized:
It should not surprise us that so many are finding unique value in experiential techniques. The fact that eating-disordered patients adopt physical and often complex metaphoric means of expressing their emotional pain suggests the difficulty we are likely to encounter in asking them to articulate the inarticulable. In moving to spatial, kinesthetic, and symbolic expression, we are, in a sense, agreeing to speak the patient’s language rather than our own (as cited in Makin, 2000).
While practicing art therapy with individuals with eating disorders for over a decade, I have witnessed the positive impact of this process on recovery. In art therapy, I have engaged clients in the creative process, along with verbal and nonverbal therapeutic approaches, creating an active therapeutic process that helps to build tolerance to the psychological and physiological needs associated with eating disorder recovery.
Cora: Challenging Eating Disorders Thoughts, Behaviors, and Beliefs
In her early 30s, “Cora” entered outpatient treatment with me after successfully completing residential treatment for anorexia nervosa and bipolar disorder. Her therapeutic goals included: continuing to challenge eating disorder thoughts, beliefs, and behaviors; increasing self-esteem and body awareness; and managing stressors related to her eating disorder and daily life. Cora explored the intersection of her restrictive patterns and self-harm through construction paper collage, using shapes and colors to explore the progression of her urges to restrict and subsequent cutting. These art materials supported cognitive processes such as planning, problem-solving, and symbolism while supporting emotional regulation. In describing her artwork, Cora was able to gain therapeutic distance from her self-harming behaviors and to identify thoughts and patterns previously left undiscussed. As a result, a more effective plan was created for her to reduce and eventually abstain from self-harming as a mode of coping.
This process supported further exploration of her dissonance with the various roles she played in the workplace and with her family. These roles consistently triggered her eating disorder symptoms. A layered painting process helped her explore the underlying beliefs embedded in these roles. Most influential were her diagnoses of anorexia and bipolar disorder, and her history with psychiatric treatment. Several sessions were devoted to the exploration of these concepts on a large canvas. Paint allowed for a fluid process that engages affect with a wide range of colors that supports symbolic exploration. The initial layer was a gradient of grays surrounded by hazy patches of yellow and purple as a representation of her bipolar disorder, with a thinly lined drawing of a floating stylized tree representing the self.
For several weeks, this process expanded to include a variety of other materials, including tissue paper. The imagery unfolded as she explored how these diagnoses influence her professional work, future, and intimate relationships. The layering process allowed Cora the ability to explore, take risks, cover and uncover through metaphor. It afforded her the ability to see the self through self-generated representations that mirror the complexity and layers of a person’s inner workings. The completed artwork was a backdrop of saturated blues, grays, and black. In the center, she affixed a large tree with a strong base and substantial trunk that was collaged from yellow, green, and blue tissue paper. Among the top branches, this tree bloomed with yellow, white, green, and blue poms. Nestled into its trunk and protected by the overhanging branch, Cora created a symbol of her daughter, a smaller tree, with a purple trunk and pink and white poms. This pairing served to reflect her role as a mother through the symbol of a strong and grounded tree. Cora and I worked together for over two years engaging in art-making, writing, and guided imagery to support emotional tolerance and regulation, increase insight, improve her self-esteem, and develop body awareness while enhancing her engagement in life-fulfilling activities.
Helping Art-Making and Creative Processes Meet Clinical Goals
Art therapists bring a unique skill set to the treatment team because of their depth of understanding about the use of art-making and creative processes to meet clinical goals. Additionally, the art products created in session serve to document clinical progress and provide insight into cognitive functioning and impairment. Art therapy requires a wide range of mental processes, from initial sensory integration to planning and problem-solving to symbolic representations (Hinz, 2009). It gives individuals with eating disorders the ability to create a visual map of their journey to recovery, to document experiences that are often void of words, and to visually construct an understanding of the eating disorder outside of the self. Art-making affords the ability to create visual representations of self, both the internal experience and the external representation of it (Luzzatto, 1995).
Makin (2000) described art therapy’s effectiveness as multi-layered because it offers opportunities for making associations and enabling association-making and self-soothing through the innate properties in art materials. In addition, patients gain insights into and possibilities for change that happen in the act of reviewing and discussing artwork. Art therapy in both individual and group settings requires that individuals actively participate in treatment and recovery. This is especially true early in treatment, where long periods of silence or a lack of commitment to therapy can be common. At this point, art therapy provides an opportunity for participation that circumvents these challenges. Engagement in art therapy allows individuals a safe space to take risks, relinquish control, and in turn gain mastery and autonomy.
Building a Visual Space
Exploring the dichotomy of rigid thinking (good/bad, right/wrong, healthy/unhealthy) through the arts offers a visual space to explore the continuum of messages and beliefs that drive patterns of behavior. This creates opportunities for reflection and projection through the art materials, which can be experienced as less threatening than verbal exploration. The challenges individuals experience in art therapy, art-making, and creative processes often mirror those they confront in everyday life (Makin, 2020), allowing communication around those challenges to be honest, authentic, and client-directed. The use of imaginative thought processes inherent in creativity can support individuals who struggle with exploring alternative perspectives. Van der Kolk (2014) noted that the effects of trauma have the potential to limit imaginative thinking, which can hinder the therapeutic process. As he writes: “Fear destroys curiosity and playfulness.” By integrating those qualities into treatment, therapists create a space that is failure-free, open to all, and that supports the uniqueness inherent in all people. According to Makin (2000), art therapy over time and as a whole (art-making, artwork, review and discussion) becomes ego-supporting, promoting a healthier sense of identity, which ultimately supports individuals and helps them reclaim their voice through visual language (van der Kolk, 2014).
American Art Therapy Association (https://arttherapy.org)
Art Therapist Locator (https://arttherapy.org/art-therapist-locator/
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