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What the Art Therapy is Doing at the Walker Unit

Art Therapy is an emerging practice in mental health settings, particularly for children and families who experience trauma induced symptoms (Kozlowska & Hanney, 1999; Nielsen et al., 2019). Many of the young people and their family members experience verbal communication difficulties. Where previous standard interventions have been ineffective, they often enter the unit anxious and fatigued. The art therapist in this unit provides structured individual, family and group-based art therapy treatment by working non-verbally with art materials as part of care. The non-verbal approach of art therapy has been effective in engaging this difficult to treat group of young people (Nielsen, 2018; Nielsen et al., 2019, 2021).

While most psychological therapy interventions inform the framework for art therapy, in this setting there has been an opportunity to further develop a “responsive art psychotherapy” practice (Havsteen-Franklin, 2014; Nielsen, 2018). The art therapist has been able to contain emotionally charged projected experiences, by their capacity to provide an interpretive visual response in session. This has been particularly helpful when the young person or their family member is in the early phases of treatment and are unable to reflect upon, or make any links between their thoughts, feelings and behaviours.

Working on the young person’s willingness to engage is a common first line goal in treatment. By their engagement with the art therapy in the group programme, the young people have an opportunity to express their distress safely, using art materials to develop an understanding of containing difficult emotions for themselves. During the group programme, it has been important for the art therapist to facilitate their safety in this experience by participating in the art making process alongside the young people. Depending on the capacities of the young people, after the artmaking, a discussion may occur. They are invited to look and think about the artworks made in the group process. For those unable to reflect, individual art therapy may be recommended. This is especially helpful if themes of trauma are emerging in the artworks. Supporting them with their capacity to communicate difficult internal experiences safely is the focus of the art therapy. Then by looking at what has been represented in the artworks, over time they are able to sit with and think more about what has been externalised in the object of the artworks made.

As many of the young people and their families experience verbal communication difficulties, art therapy can safely assist the young person and/or family member to non-verbally communicate their feelings at a pace that is comfortable for them and support their thinking (or more accurately incapacity to think), grounding them in the present and feelings of safety. As the young person and/or family member engages in their artmaking, by making a response artwork an experienced senior art therapist can non-verbally support the unintegrated fragments of their emotionally overwhelmed experience. The sensory movements involved in artmaking seem to enable access to dissociated experiences safely (Chong, 2015). The implicit non-verbal communications made in the artworks can be a useful contribution in treatment, as trauma content can be revealed in images long before the cognition and explicit narrative is available (Bucci, 2007a; Nielsen, 2018).

Working with dissociation safely in the art therapy has been a main component of in-session practice at the Walker Unit. Recent trauma research supports capacity to access this material safely through non-verbal visual communication (Coulter, 2015; Hoshino & Cameron, 2008; Nielsen, 2018). The main goal of the art therapy in this setting is to stabilise emotional dysregulation and increase tolerance for distress. In some cases, the family members may present as distressed as the young person. As a right brain to right brain non-verbal activity, artmaking alongside the family member and the young person has had the potential to evoke the curative factor of a shared dysregulated to regulated experience (Nielsen et al., 2021; Schore, 2011). This has given these young people and their families hope for agency and change, despite the losses in their capacities to verbally communicate their feelings. The images in Fig. 11.1 demonstrate how an art therapist might make a non-verbal response (right) in the containment of the young person’s distress (represented in the images on the left).

Fig. 11.1
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Young person and therapist images

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How the Art Therapy is Implemented at the Walker Unit

All art therapy, individual, group and family sessions are structured and planned with the multi-disciplinary team. When the art therapy is introduced to the young person and/or family member, there is a common anxiety for those unfamiliar to the materials to think that art skills are required. Often an art therapist will begin by explaining this is not the case and that the main requirement is to ‘have a go.’ This can get under the wire of the reluctance to engage and appeal to their capacity to play, experiment or explore new ideas. To make a mark on the paper is the only requirement. Boundaries within the art room are explained, for example, not talking about other people’s work in the art room and that there is a locked art therapy cupboard provided for storage and safety of the artworks made. This is an important intervention to ensure the safety and containment of the shared internal experiences made explicit by the artworks.

Three assessment sessions are often introduced when there is a referral and after the third session, a summary is shared including images, to reflect on the young person or family member’s availability to engage and think about their work. After producing at least three artworks, an art therapy consent form is signed by the young person and/or family member for the permission to photograph or share images and include them in MDT meetings, art therapy reports, educational in-services and/or research publications. Some of the principles and procedures within art therapy practice are shared. This can encourage collaboration from the young person or family member regarding their ongoing engagement, responsibilities and capacity to think about what is happening for themselves.

Images can be utilised as documents to their experience. They are able to demonstrate capacity for change or cognition to function and can offer information beyond text by measuring “intonation, gesture, tempo.” (Sagan, 2019). Symbols can be another measure of a patient’s developing capacity to communicate, by non-verbally, bringing what was implicit into explicit conscious form (Bucci, 2007a, 2007b). Examples of the non-verbal shift from implicit, dissociative content to the more explicit symbolic content are presented in Fig. 11.2.

Fig. 11.2
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Shift from dissociative to symbolic content

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When words are in the work the cognition is more likely to function alongside the difficult feeling (Fig. 11.3).

Fig. 11.3
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Words in artwork

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The sequence in Fig. 11.4 demonstrates the layers and detail of how an embodied image can be made and is an example of what cannot be thought about or put into words by the young person or family member.

Fig. 11.4
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Embodied image

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Where diagrammatic content is applied to the embodied feeling, consciousness and thought forms are made available to the young person or family member. Symbolic examples in Fig. 11.5 demonstrate line and form emerging in the imagery and demonstrate a capacity for integration of thoughts and feelings.

Fig. 11.5
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Integration of feelings

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When the young person is feeling distressed with thoughts of suicide or self-harm and makes images such as Fig. 11.5, it is more possible for them to safely integrate their feelings, strengthening their ‘emotional muscle’ and building their confidence and competencies to survive the thoughts for a safer outcome.

When the young person is experiencing psychosis, it is almost impossible for them to integrate their thoughts and feelings, their internal experience may remain fragmented and detached. Art as therapy can provide an option for the young people to self sooth or distract themselves, as in Fig. 11.6.

Fig. 11.6
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Art for soothing and distraction

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The images in Fig. 11.7 reflect a young person who was floridly psychotic, after some time in silence they had said, “I have all these thoughts I don’t know where they come from and they make me say things I don’t want to say.” The image has, “I am a train” scratched into it. Such images can assist with reality checking.

Fig. 11.7
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Psychotic images

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Figure 11.8 outlines a generalised process for the art therapy treatment at the Walker Unit

Fig. 11.8
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The process of art therapy

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The Art Therapy Space

The art therapy room is located opposite the seclusion room which is rare for an art room as they are usually located away from the main ward. The art therapy room has remained low stimulus and the walls neutral for the young person or family member to feel safe to enter. The palette of materials are limited and in ‘good enough’ condition. It is important for the young person to understand the art therapist is not there to entertain them. Neither is it a performance driven activity, as it might be in the school setting. Figure 11.9 identifies the materials used and how the table is set.

Fig. 11.9
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Art materials

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Outcomes

A data base of images as well as the young people’s feedback has been gathered to demonstrate effectiveness (Nielsen et al., 2019). Eighty per cent of the young people at the Walker Unit have reported that art therapy has helped them to express themselves safely and begin to think about how their thoughts and feelings relate to their behaviours. Previously this had been difficult for them to do. Families have also contributed to feedback and reported they have found art therapy to be helpful (Nielsen et al., 2021). The young people and sometimes family members also contribute to their art therapy reports by choosing their images and finding the words to communicate their experiences. This has been particularly important as a handover document for the young person to communicate their needs, as the verbal therapies remain standard practice in the community.

Conclusion and Recommendations

Verbal interventions may be too challenging for young people or family members who feel unsafe with their thoughts and feelings. Supporting them with their capacity to communicate difficult internal experiences safely has been the focus of the art therapy at the Walker Unit with the main goal, to stabilise emotional dysregulation and increase tolerance for distress. Responsive art making (Havsteen-Franklin & Altamirano, 2015; Nielsen, 2018; Nielsen et al., 2019, 2021) is an emerging clinical practice within art therapy. This practice is used in this setting with the young people and their families and challenges common beliefs that the purpose of images is to solicit a narrative. There is a lack of awareness of the capacity for non-verbal visual art therapy experiences in mental health services. A permanent 32 hour a week position has made it possible for the art therapist in this setting to provide a consistent approach for the young people and their families, while maintaining flexibility with the team. This is very rare for art therapy practitioners and more positions need to be made available to support mental health services in the future. The permanency of the role has also supported research opportunities, an important consideration for the development of art therapy positions to be maintained in the future.