Elizabeth Beck

The latest Creative Therapy Session podcast featured a topic that I have always been interested in, but always felt hesitant to bring up during my schooling. I felt that the idea of conducting art therapy sessions online would have been a taboo topic in a program that emphasized the presence of the therapist with the client in order to foster a therapeutic relationship, not to mention the fact that I had no idea how one could go about making artwork online.

In this fourth episode of the podcast, Melissa Solorzano, ATR, interviews Kate Collie, PhD, ATR, RPsych, about the work she does in the emerging field of cyber counseling and the way she combines tele-therapy with art therapy. During the interview, Melissa and Kate discuss many of the questions described above and more.

Thank you Melissa for getting this interview! I believe that cyber therapy is a field that is not only emerging, but is here to stay and will only grow bigger, and for this reason its something that needs to be addressed and talked about extensively amongst the psychological community. Like it or not, there therapists like Kate who offer online group therapy services for people who live in remote areas, and there are also therapists who have set up shop in virtual communities like Second Life. Not only must we begin exploring the effect working virtually has on the therapeutic alliance, transference, picking up nuances during sessions, curative factors in therapy, socialization etc…, but we must also remember issues such as confidentiality and technological limitations (i.e., whether someone has a computer, speed of internet, malfunctioning software). Other questions to consider; is there a difference between being present in a therapy session as an avitar versus through a webcam where the therapist and client can see each other’s faces? What are the differences between text forms of communication (email, instant messaging) versus hearing someone’s voice through a microphone during an online therapeutic session? Are there populations that online sessions are more suited for than others? Is online therapy more effective than no therapy at all?

Its certain that a new frontier in therapy is already here and cannot be ignored. To quote Heidi Klum from Project Runway, “either you’re in or you’re out!”. I certainly don’t want to be left behind by technology, if in fact there are ways to work around all the issues discussed above and more.

A few months ago I watched the Oscar winning movie called Born Into Brothels and I’ve been meaning to write about it ever since. Its a documentary on a photographer from NYC, Zana Briski, who goes to Calcutta to photograph the red light district, when she discovers that the children of the prostitutes are interested in learning how to photograph pictures. She sets up a photography workshop for a number of these children, gives them cameras, and in turn these children photograph their everyday lives.

I wont get into much more detail so that I don’t spoil the movie for anyone who hasn’t seen it…but the line between being a photographer/teacher begins to blur for the NYC photographer, and the film began bringing up similar feelings for me as working within a therapeutic/social-work context. That is to say, the photographer seemed to learn from her experience that although we may want to save others from a life that we may view as tragic or that we would not want for ourselves, we must recognize this wish and our limitations where we can do no more than offer support and opportunity (to learn, to explore, to grow). I also have to give Zana credit for going above and beyond what many would have done or thought they were capable of doing for these children. At the very least, the children discovered a part of themselves that allowed them to be creative, explore themselves and their environment, as well as become empowered through the use of creative expression.

I recently organized an art show at Redwood Place (for staff and clients only), where the masks discussed in a previous post were featured. The art show took place at lunch time during a special barbq. The masks were hung all around the dinning room, and underneath each mask was a personal explanation or story, as well as the client’s first name to go along with their respective mask. In total, there were about 25 masks featured.

The clients seemed to enjoy walking into the dinning room, and trying to find their mask on the wall. I also observed that many clients needed encouragement to take the time to look at other people’s masks or read the blurbs to go along with the artwork. Some clients had difficulty remembering which mask were theirs, and needed a reminder to patiently look around the room to find their mask.

Several clients whose artwork was featured in the art show chose not to attend, but rather go to lunch at a local grocery store. Once they returned back to the facility, they seemed disappointed that they did not attend, stating that they had forgotten. This made me realize that although the art show was talked about and featured on the monthly calendar, extra reminders may be needed, such as by posting up special flyers around the facility advertising the art show further.

It was also interesting to see the reaction of the staff, who were curious about the masks and their stories. Many staff discussed feeling excited for the art show, where they would see the masks the clients’ artwork. During the exhibit staff members took the time to look carefully at each mask and ask clients questions. I felt that seeing the masks may have helped the staff see another side of the clients that they may have been unaware of previously…at least, that is my hope.

After the exhibit had taken place, I was surprised how many clients (even low functioning clients) asked when the next one would be and expressed interest in knowing what art project will be focused on next. Indeed…that is the question. Lately I’ve been thinking of slowly introducing paint and eventually mono-printing techniques to be done using paint, paper and cafeteria trays. But its summertime, and we have a beautiful garden in the back…maybe some drawing from life outdoors? We’ll see…

Darren Daz Cox asks:

Hey Liz, what collage techniques do you use in your work?

When I think about collage, I usually think about a magazine photo collage where you cut out words or pictures from magazines and glue them onto a separate page. In art therapy, often times collage is used as a way to approach clients who may be resistant to art making or clients who may need some extra structure (due to their developmental level or perhaps due to an anxiety provoking subject matter that is the focus of the collage).

The art therapist may choose to add even more structure to the collage making experience by having pre-cut collage pics and words available to the client. Sometimes these pictures can be divided up into separate categories in their respective folders or containers. Some categories or themes may include people, food, words, animals, nature, fashion items, etc… The downside to this is that the art therapist may be intentionally or unintentionally censoring images or words, or may be overlooking certain images or symbols because of countertransference issues, personal value issues, personal comfort level, etc… In other instances, the art therapist may want to encourage autonomy and self-expression by allowing the clients to search through magazines themselves for pictures or words that may stand out to them. The downside to this is that many times the clients get involved in reading articles or looking at the magazine rather than focus on art making.

The art therapist may want to provide a directive for the client, which can help structure the session and guide the client with a theme or suggestion of what to base the collage on. Other times the art therapist may choose to refrain from giving a directive, allowing the client to make whatever he/she desires. This decision is based upon, for example, what the therapeutic goals may be, as well as the client’s resistance to art making.

Along with magazines and paper, other useful materials for collage include scissors, decoupage or matte medium, paint brushes and glue sticks.

Once the collage is completed I often like to ask the clients I work with to title their work before we begin processing the piece.

I hope this answers your question. Let me know if I could provide you with any more info.

I introduced mask making during the art therapy groups I run. This is an ongoing project that will probably take several weeks to complete, depending on the attention span of the client, how quickly they are able to work, and how often they are present for art therapy (since groups are voluntary).

Materials

- Lunch trays
- Plastic molds that look like faces (1 for every potential group attendee)
- Tissue paper of a variety of colors
- Vaseline/Petroleum jelly
- White glue
- Water
- Small plastic containers to hold the glue
- Large paint brushes.

Introduction

Depending on the cognitive level of functioning of the group members you are working with, you may decide to have a conversation about masks and their potential meaning. You may choose to discuss topics like Jung’s concept of the persona, and how the way we present on the outside may be very different than how we feel on the inside.

In the case of the clients I work with, many of whom are lower functioning, I decided to take a more art as therapy approach, where I focus on aiding the clients work through any difficulties they may have with the art making process in order to facilitate a successful art-making experience.

I am currently toying with the idea of asking each client to describe what their masks remind them of, after their masks are finished, and then encourage them to make a short story (in some cases that could be one sentence) about their mask. Many clients are unable to read or write, so I would ask other staff members to attend this group to help record the stories of each client who asks for help with writing.

Procedure

Before beginning the group, mix a small amount of water with white glue, making decoupage. Place the decoupage into small containers. If you would like to promote peer interaction and sharing, you may choose to have clients share these containers. However, in my experience with this directive, many clients have never made a mask before, and seem to find it overwhelming to have to interact with their peers and learn something new at the same time. Therefore, in order to promote socialization, I like to end group by each client showing the piece they worked on during the session.

Because many of the clients I work with have difficulty establishing boundaries with other people, or recognizing when they are becoming intrusive onto other people’s boundaries, I have introduced the use of lunch-trays as a work space for each client during art therapy group. Before the group begins place a mask is upon a lunch tray, and position the tray in front of each client.

Cover the mask with the Vaseline/petroleum jelly. This will help the paper to easily be removed from the plastic form without any ripping.

Explain to the group that this directive will take several weeks to complete, and that they will be gluing many layers of tissue paper onto the mask. The reason for this is that paper is very delicate, and the more layers you put, the stronger the mask will be.

Demonstrate how to glue the tissue paper onto the mask by dipping your paint brush into the decoupage, and putting some glue directly onto the mask itself. Next, place a piece of tissue paper over the glue and add more decoupage ontop, smoothing the tissue down. Instruct the group to continue layering the tissue paper until the whole mask has been covered. Remind the group that they will need to cover the mask with several layers, which will take a few group sessions, and they will not be able to finnish in one day.

Results

All the clients who have attended the art therapy groups over the past few weeks (presently approximately 15 clients) have been able to successfully begin and/or complete making a mask. My observation is that the clients seem to calm as they tear and glue the tissue paper. There is often very little talking while creating is going on.

I have found that some clients may need a 1:1 explanation of the gluing process in addition to the group introduction. It may also be helpful to have other staff present, who can help clients with reduced dexterity in their hands to maneuver the paint brushes, tissue paper and the mask.

A common counter-transference reaction to this population is to feel like one must help the client complete a task perfectly, or to our standard. Sometimes this means we can take control from the client, and essential do the task for them. Therefore, it may be necessary to remind staff before/after group that the artwork being produced is indeed that of the client, and that we do not want to complete the project for them. As staff, we are trying to help the client complete the mask to their satisfaction, rather than our satisfaction. Furthermore, the goal is to help each client create a successful piece of artwork. If one sees there are spots that need more layers, or places that need more glue, one must be sure to point this out to the client, letting the client find his/her own solutions to the potential problem or ask for help in implementing their solutions.

Overall, since many of these clients have never made a mask before, they seem proud that they were able to follow instructions and make something more complex and unique than a pre-made arts and crafts project. However, I have found that some clients need encouragement to attend art therapy and complete their masks. For some it seems that the idea of trying something new, something they may fail at, is so overwhelming that they choose to avoid finishing their masks. Many people with developmental disabilities have the experience of not being able to complete a directive to the standard that was set for them. This may lead to feelings of shame and/or guilt. It seems that a schema has developed that describes the self as incapable. With these clients, this is a chance to learn and challenge their self-concept. I have found it helpful to reassure these clients that they are capable of completing this project, and that however the mask turns out, thats okay because art therapy is about self-expression not how pretty a picture we can make.

Working with the clientele I have been exposed to at Redwood Place, I have noticed that many of the clients struggle when it comes to sitting with negative emotions/situations. I doubt that this is something only reserved for the dually diagnosed DD and mental illness population, but rather this is something we all struggle with. Indeed certain aspects of western culture seem largely based on instant gratification.

In any case, the other day I was on the cusp of falling asleep, a time when the creative juices begin flowing, when I thought of the saying, “this too shall pass”. I didn’t pay much attention to it, but it stayed in my dreams…The next morning, as I traveled to work, I realized that this saying resonated with me in a way that applied to not only to my life, but also to my practice as an art therapist.

Working at a residential facility there are often interpersonal conflicts that come up, sometimes over and over again. During these times, I can easily spend half my day conducting conflict resolution, which may be repeated later again that day, week, month, etc… It occurred to me that this may partially be due to difficulties with sitting with the unpleasantness of a certain emotion or situation. Lack of tolerance to the negative aspects of life can cause social relationships to suffer. For example, one might become highly irritable, curt, or avoidant of others. This sometimes makes other clients feel targeted or left out of their friend’s life, which can perpetuate a cycle where client #2 has difficulty sitting with their negative emotions, and both clients become increasingly agitated, requiring some kind of crisis intervention and/or conflict resolution.

Another common scenario I have been exposed to are clients who are frustrated with waiting for their next placement, as they find that they have gotten everything they can out of the program. Sometimes clients wait years for a new placement, depending on their situation. These clients describe feeling like they are in jail, against their will. Indeed, wouldn’t every one of us feel somewhat trapped if we were waiting to move on with our lives for years? In any case, these feelings of frustration are sometimes acted upon in aggressive and violent ways, often against others.

Part of my job as a therapist, as I see it, is to help these clients express their emotions through artwork and through their words, so hopefully these clients will be able to tolerate their emotional states and situations without becoming aggressive. Another aspect of my job is to encourage an increase in frustration tolerance and hope by reminding each client they have choices regarding their behaviors (changing an external locus of control to an internal locus of control). Somehow, though, something seemed to be missing in my job description, in my philosophy of conducting therapy with this population…and that something came to me right before I feel asleep, “this too shall pass”.

The idea that everything in life; our emotions, our situations, our very existence is transient. Everything changes, although while we’re in the moment waiting for change to occur time can feel like its moving at a snail’s pace. For me, when I am unhappy with my current situation and there is nothing I can do to change it, in the near future or the distant future, the idea that everything comes to an end brings me both comfort and hope. I think that’s why I have decided to introduce this concept to the clients I work with.

I understand that this is an abstract concept, that it will take time for this idea to be experienced and understood, and that some may never identify with the notion. However, I believe that with some encouragement, especially after a crisis occurs, this notion can be a valuable tool in building one’s tolerance. For example, during a debriefing after a crisis, the client and therapist could discuss or make artwork regarding the emotions and situations involved, how they may have resolved themselves without becoming aggressive, and what coping skills could have been used to help make it through this tough time (i.e., listen to music, deep breathing, take a walk). If a client avoids aggressive or self-injurious behavior during a crisis, discussing how they were able to sit with negative emotions long enough for it to pass by in the moment. It could also be suggested that clients repeat to themselves “This won’t last forever” or “I’ll get through this alright” when they are upset, anxious or disappointed. In art therapy, posters can be made with self affirmations focusing on tolerating emotions.

I have been using many of the interventions described above since I began working with this population, without having analyzed my philosophical stance. I was following the lead of my colleagues, because they have many more years of experience than me.

I somehow feel grounded in the notion “this too shall pass”, and have found a confident direction to focus upon before, during and after a crisis situation. I suppose this means that I becoming more comfortable working with this population and sitting with my own difficult emotions that I experience when clients become anxious, upset, aggressive and/or self-injurious.

My sketchbooks are like diaries…they capture the situation, mood, mental state, ideas, blind spots, fears, humor, defenses and subjects of importance that I may have be experiencing at the moment I chose to draw. I also sometimes use my sketchbooks for planning more than upcoming art projects. I use them to write to do lists, reminders to myself, thoughts and random phrases. My sketchbooks help me organize my life, while at the same time they are holding environments for private concepts that I may not be ready to release to the public.

I don’t think it is a coincidence that while completing my master’s degree, Drexel University’s Art Therapy Faculty encouraged their students to use sketchbooks as ways to capture the dynamics of discovery, which were inevitable throughout our academic and experiential learning.

The experience of using sketch books as a way of containing and reviewing emotions, ideas, learning, and probably way more than can be described in words, has allowed me to introduce the concept of a sketchbook/diary to the clients I work with.

Book Making

Because many of the clients I work with have difficulties with dexterity in their hands, and because many of them refuse to use scissors for fear they might hurt themselves, introducing traditional book binding techniques using a needle and floss did not seem appropriate. Instead, I opted for a simpler approach, stapling the spine in order to create a book.

Materials

- Stapler and staples. I purposefully made sure that there were only 3 staplers in my group of 10, in order to promote client interaction and sharing.
- Colored paper, 12″ x 18″
- White paper, 12″ x 18″
- Materials for decoration: markers, oil pastels, foam shapes, glitter glue, etc…

Pre-structuring

Before group begins, make an example of a sketchbook to show the group. This can help to structure the group and allow them to visualize what the outcome of the group may be. Pre-making a book can also allow you to know the limits of your stapler- how many pages it can staple through. This can help avoid client frustration with the directive- that is, if one of the group’s goals is success orientation, which is common when working with people with developmental disabilities. However, if the goal of the art therapy group is to increase frustration tolerance, you may want to allow the clients to discover the limits of the stapler for themselves.

Execution

After introducing the example sketchbook, ask the group if anyone can explain what a sketchbook is, what it can be used for. In addition to their responses, explain times when one may want to use their sketch book, for example when they are upset or sad, when they are having a feeling that they are having difficulty putting into words, when something good happens, etc. Also explain that what they are making is theirs. Emphasize that the contents of a sketchbook can be kept private, or they can share their books with people that they trust, like their therapist, a family member, etc. Encourage the clients to keep their books in a safe place.

Ask each client what color they would like to have on the outside of their sketchbooks. Once each client has what will be their cover, ask them to fold the paper in half. Then hand out approx 6 pieces of white paper (this may vary depending on the capability of your stapler), and ask the clients to fold those papers as well. Demonstrate placing the white papers inside the colored paper, fold-to-fold. Then, demonstrate stapling- how to hold the paper while you staple, trying to staple as close to the fold as possible. Some clients may need help with stapling. I like to encourage some of the higher functioning clients to help clients who ask.

Once the books have been assembled, place other art media on the table so that the clients can decorate the covers of their sketchbooks and make it their own. The purpose of introducing other art media at this point is to help avoid some clients from feeling overwhelmed with the amount of stimuli in the group. The art therapist can further structure the group by limiting the types of art media available to the clients.

In terms of closure, I find it useful to have each client take turns sharing their sketchbooks with the group. This helps to promote socialization, group interaction, and is often self-esteem building since clients often recieve positive feedback for their products.

Results

Every group member was able to construct and decorate their books, some independently and some with help.

Some clients seemed to be taken aback by the concept that these books were for them, and they had the choice whether to share its contents with anyone. One client in particular repeated this concept to every staff member present within the art therapy group. This made me wonder how little privacy some clients with developmental disabilities are afforded in their lives. Some clients need help dressing, toileting, showering and cleaning their rooms. What then is for them and them alone?

Since the books did not contain very many pages, I suggested that once their sketchbooks were filled up, they could request to make another one. Several clients have taken me up on this offer, as they have been consistently writing and drawing in their sketchbooks.

As the first art therapist to be working within the facility, it is very gratifying to introduce new ways of self-expression to the clients. As with all techniques for self-expression, some things work for some people but not for others. For this reason, I try to encourage each client to remain open minded to new experiences, while remebering that rigidity is common amongst adults in general, people who suffer from mental illness, and people who have been diagnosed with a developmental disability.

I first learned how to make a stress ball, using a balloon and flour, when I was working with Jeanette Pailas ATR-BC at the Friends Hospital Eating Disorder Unit in Philadelphia, PA. The purpose of making the stress balls was so that the clients could use the final product itself during times of anxiety, but also the directive may represent a metaphor for eating: filling up a stomach, which is stretchy like a balloon.

I’m presently working with developmentally disabled individuals. They too have difficulties managing their anxiety. One client in particular tends to squeeze his had so hard in a fist, that he causes lesions to his skin with his nails. This inspired me to introduce stress ball making in my art therapy group. I prestructured the group so that there would be only a small number of steps, insuring the success of the clients (an important goal of artx with developmental disabilities).

Here is a break down of how I structured the group:

Materials

- Balloons
- Flour
- The top part of a water bottle (a make-shift funnel)
- Spoons
- Small cups
- Colored pencils

Prestructuring

- Stretch a balloon over the top of a water bottle. Prepare as many balloons and funnels as needed according to the size of your group.
- Prepare several small cups with flour. Each cup should have a plastic spoon in it, making it easy to transfer flour into the funnel. I decided to have a cup of flour per person, but having the clients share with each other can be an option to promote group interaction.

Execution

- Introduce the idea of a stress ball- what it is, what it can be used for. I find it important to remind the clients that balloons can pop…discussing squeezing the stress ball in the palm of their hands vs. digging your nails or twisting the balloons.
- Pass around a pre-made stress ball, so that the clients an see and feel an example of a balloon stress ball.
- Have a quick demonstration about how to make a stress ball. I began by holding up a pre-prepared balloon/funnel and spooning in some flour. I then demonstrated how to use the back of a colored pencil to pack down the flour. I let the group know that if they needed help holding the funnel or packing down the flour, they could ask (I usually have a recovery specialist in group with me. This can be very helpful if there are several clients needing assistance at once).
- Hand out materials.
- As the group began working, I encouraged them to share their techniques- what works to get the flour down and what doesn’t.
- We discussed what situations they themselves might find the stress ball handy.
- When a client felt that he/she had filled up the stress ball enough, I helped them tie off the balloon.

Results

I found that with encouragement the clients were able to successfully work through the frustration of stuffing the flour into the balloon (it takes some persistence). They also tended to be hesitant about getting dirty. Redwood Place unfortunately does not have a designated art room. We tend to use common areas, or a conference room. I also wonder what would happen if the group had the freedom to “get messy”. So far I haven’t introduced paint or clay in the short time I have been working there. In any case, I realized quickly that flour (as long as its not wet) offers easy clean up. You can sweep it off the floor and brush it off your clothes. I therefore demonstrated this fact to the group by pouring some flour on my pants, and brushing them off, like new.

After the group was over, several clients seemed proud of their work. I was surprised, however, that the next day the same clients were asking to make more stress balls. Their peers, who had not joined us for the previous art therapy group, had also seen the stress balls, and wanted to make their own.

Over the next 3 days the art therapy group consisted of making stress balls. Some clients wanted to make a new one because their last one broke. Others wanted two or three- one for their room, one for their pocket. Some wanted to make an extra one for family or friends. All in all, this seemed to be a successful directive that many clients enjoyed and found useful.

I’ve been at my new job for a little under 2 months. In that period of time I have begun introducing new ways of expressing oneself using structured media and directives. Here are some examples of the successes I’ve had over such a short period of time:

I decided to introduce collage in one of the artx groups. I pre-cut words and pictures (for added structure), keeping them in separate tupperware containers for easy pull-out and put away. Immediately the clients began searching through the tupperware, finding pictures and gluing them down onto colored paper. Some clients held up words and asked me to read the word to them, or explain its meaning. For one client in particular, the use of the pre-cut words seemed especially important to her. She appeared excited and began smiling as she completed her collage, periodically holding up her paper and saying “this all makes sense!”

It occurred to me that people with developmental disabilities often have deficits in their reading and writing abilities. Many of my clients describe thinking they are stupid and wonder how they appear to others. Perhaps having pre-cut words can help to lend a voice to these people, who may have difficulty finding words to say out loud what they think or how they feel.

Several clients have begun spontaneously drawing their feelings when they’re feeling anxious and/or upset. This is surprising to me because the clients I am speaking of rarely come to the artx groups. I had no idea of the developmental level in their artwork or that they even wanted to use artwork as a form of self expression/catharsis. In fact, many times when these clients are invited to attend artx group, they refuse.

Recently, one client went into the art supply cabinet after an incident with a peer and took out some collage words, pictures, paper and markers on her own, when the artx room was unoccupied. This client then came to my office with her drawing. She seemed to use it as a way to help both her and I understand how upset she was.

I think this vignette illustrates how important it is that all clients have access to art supplies at any given moment. This story also reminds me of the natural expressive and healing quality that art making has.

Working with developmental disabilities is a challenge…especially when the groups are not split up according to cognitive ability. I have some clients who are naming the scribble, while others are functioning on a schematic level in the same group. I find that art as therapy is a great approach with the lower functioning clients, however the higher functioning one’s seem to benefit from art psychotherapy as well.

In an effort to ballance the needs of the group, I’ve been trying to take a middle road approach (similar to Wadeson) when planning directives…but the fact remains that some of the clients do not have the ability to process abstract concepts due to their developmental level. Sometimes I wonder if my approach goes over their heads. At the same time, these clients don’t seem to notice any discrepancy between themselves and others while they are engaged in the process artwork making…in a similar way that a 4 year old doing artwork alongside an 8 year old does not seem to notice the differences in cognitive ability between himself and the 8 year old. They seem to take pleasure in the art making process and don’t seem self conscious of others in the group.

What I have found very tricky, however, is introducing a particular directive in a way that everyone can understand…so that the lower functioning people do not become agitated because the concepts are overly complex and so that the higher functioning people feel challenged and acknowledged. I guess that will come with time…