Treating Trauma with Art Therapy: Basic Principles & Directives
In looking over my posts, I don't see one directly outlining my way of treating trauma. After years of treating trauma with a diverse group of clients in a myriad of settings, I have developed my way of approaching it based on the wisdom and research of many who have come before me. I can't take credit for developing any of the individual theories or approaches personally, but I will summarize them, adding in art therapy interventions when they are used. Those interventions I developed myself are marked with an asterisk.
I will start with summarizing how trauma affects people and follow up with the essentials of how I treat trauma and its symptoms. The art examples are from past clients, mostly youth: releases were signed for the publishing of these pieces and all indicators of identity have been removed.
Effects of Trauma
- Throws off a person's ability to accurately read the safety of any given situation. They can misread a safe situation as dangerous or perceive a dangerous situation as safe.
- Dysregulates a person's stress response, often leading to hyperarousal (racing heart, fast breathing, anxiety, anger, "flight" or "fight" modes) or hypoarousal (lethargy, slowed physiological and cognitive responses, crying, depression, "freeze" mode), or a dramatic vacillation between the two. Often a person can no longer regulate their own nervous system, having problems returning to baseline when stressed.
- Negatively impacts a person's ability to form or maintain interpersonal relationships. Often a person's ability to trust others is compromised, as is a person's ability to accurately read others' emotional cues and respond appropriately.
- Causes attention issues via hypervigilance (constantly scanning for danger) or dissociation ("blanking out" when triggered). When a person's attention is largely taken up by scanning for danger, they cannot focus on tasks or people. In children this can be misread as ADHD.
-Can cause a negative self-perception or identity disturbance: a person blames themselves or sees themselves as damaged or not worthy of positive treatment.
-Via the effects listed above, a person can develop anxiety disorders, mood disorders, substance abuse disorders as co-occuring with PTSD or in the place of. In complex trauma the above disorders can also include eating disorders, personality disorders (e.g. Borderline PD), behavioral problems, and behavioral disorders (Oppositional Defiant Disorder, Conduct Disorder, etc.).
Treatment of Trauma
Stabilization:
- Establish safety as much as possible. It is very difficult if not impossible to treat trauma when a client continues to live in unsafe, let alone traumatizing, circumstances. When I worked in agencies that provided broader clinical services I was often directly involved in this task. Now as an outpatient provider I coordinate with other agencies to insure safety.
- Assess breadth and intensity of symptoms: intrusion symptoms, avoidance symptoms, cognition and mood issues, arousal and reactivity issues, significant functioning impairment, and presence or absence of dissociative features.
- Psycho-education is crucial for adults, parents and children to normalize what they are experiencing, or what they may experience as treatment continues and as more time passes.
- Support clients in learning, practicing and mastering self-regulation skills. I usually begin each session with a self-regulation exercise, and I sometimes end with one as well if the session brought up triggers. This also includes learning and practicing self-monitoring, so the client knows when self-regulation is needed. Directive: *Body Mapping. Start session with a body awareness meditation, guiding client to check in on sensations (painful, pleasant, neutral) starting on the top of the head and moving to the bottom of the feet. Then provide a simple outline drawing of a body and some colored pencils and ask client to depict the sensations they felt/feel in various parts of their body with color, patterns, and images. Discuss the finished map: this is a time when a lot of gentle observation and validation are key.
-Support clients in identifying and connecting with external resources such as family members, friends, religious communities, neighbors, cultural groups, support groups, etc. Natural supports are always more effective and sustainable over time than clinically-oriented supports. Directive: Circles of Support. Ask client to create a map of the supports they have in their life at this time, with their name or a drawing of themselves in the center. Explain that it's important to have a friend or an ally at the main places they go in their world: home, neighborhood, work, school, in their general community. Help client identify who they have already, and help client brainstorm supports they would like to add to their world. This may include getting to know a friendly face in the neighborhood or at work, attending a temple/church/mosque, reconnecting with a family member, etc. Add these ideas to the map in a different color pencil/pen.
- Introduce concept of relative safety. Help clients shift from a globalized sense of danger to a more specific one, identifying nuances in levels of safety. For example, school may not feel entirely safe to a child but it is safer than an abusive home or a war zone. Help a client conceptualize these nuances and clarify that a place that isn't entirely safe is not therefore entirely dangerous. This includes identifying places and people that have been and still are safe. Directive: *Safety Graph. In the style of bar graphing, help client create a simple, colorful graph of the various places where they spend time. On the y axis (vertical) help client create a relatable gradation of safety levels: see example below. On the x axis, ask client to add place(s) where trauma occurred and places where client now goes on a regular basis.
Processing Trauma:
- Once stabilization is established with above interventions, the processing of the trauma phase begins. This is not necessary for everyone who has experienced trauma and is in fact contraindicated for people who have just experienced a trauma days before or who show no signs of PTSD. Those with established PTSD or complex trauma, however, are being negatively impacted by shattered and disorganized memories of what happened and thus are helped by creating order and meaning out of their disorganized memories of the event(s).
- This phase includes regular practicing of self-regulation skills and monitoring the client to determine whether pace of treatment needs to be slowed down or shifted in some way.
-I support the client in telling their trauma story through a narrative approach and often use art to enhance the process and bring in another way for the client to own the story. I also find the art tends to naturally include resources that may have been overlooked. The art is not often a literal picture of the traumatic event(s): it may include a component of the trauma as well as other elements of the person's life or home at that time. The art may also include elements in the client's current life that are either negative or positive, real or fantastical. Let the client guide this process with you in terms of approach to the trauma story, both in its verbal expression as well as in the art. Assume the telling may take several sessions or more, depending on the number and intensity of traumatic events. Directive: *Collage of Life and Trauma. Ask client to sort through collage materials (I have a large collection of pre-cut images from a wide variety of magazines to save on time and distraction) and find images that remind client of the trauma and their life during time of trauma. Supply a surface for client to glue images to or a container for client to keep images in. If client choses a container, encourage client to make the container their own through paint, collage, etc. Use finished piece as a starting point for a new or continued conversation about trauma, incorporating aspects of client's life at the time that weren't mentioned before. Note potential resources/help/saving graces that are present in art: help client incorporate these into trauma narrative.
I will start with summarizing how trauma affects people and follow up with the essentials of how I treat trauma and its symptoms. The art examples are from past clients, mostly youth: releases were signed for the publishing of these pieces and all indicators of identity have been removed.
Effects of Trauma
- Throws off a person's ability to accurately read the safety of any given situation. They can misread a safe situation as dangerous or perceive a dangerous situation as safe.
- Dysregulates a person's stress response, often leading to hyperarousal (racing heart, fast breathing, anxiety, anger, "flight" or "fight" modes) or hypoarousal (lethargy, slowed physiological and cognitive responses, crying, depression, "freeze" mode), or a dramatic vacillation between the two. Often a person can no longer regulate their own nervous system, having problems returning to baseline when stressed.
- Negatively impacts a person's ability to form or maintain interpersonal relationships. Often a person's ability to trust others is compromised, as is a person's ability to accurately read others' emotional cues and respond appropriately.
- Causes attention issues via hypervigilance (constantly scanning for danger) or dissociation ("blanking out" when triggered). When a person's attention is largely taken up by scanning for danger, they cannot focus on tasks or people. In children this can be misread as ADHD.
-Can cause a negative self-perception or identity disturbance: a person blames themselves or sees themselves as damaged or not worthy of positive treatment.
-Via the effects listed above, a person can develop anxiety disorders, mood disorders, substance abuse disorders as co-occuring with PTSD or in the place of. In complex trauma the above disorders can also include eating disorders, personality disorders (e.g. Borderline PD), behavioral problems, and behavioral disorders (Oppositional Defiant Disorder, Conduct Disorder, etc.).
Treatment of Trauma
Stabilization:
- Establish safety as much as possible. It is very difficult if not impossible to treat trauma when a client continues to live in unsafe, let alone traumatizing, circumstances. When I worked in agencies that provided broader clinical services I was often directly involved in this task. Now as an outpatient provider I coordinate with other agencies to insure safety.
- Assess breadth and intensity of symptoms: intrusion symptoms, avoidance symptoms, cognition and mood issues, arousal and reactivity issues, significant functioning impairment, and presence or absence of dissociative features.
- Psycho-education is crucial for adults, parents and children to normalize what they are experiencing, or what they may experience as treatment continues and as more time passes.
- Support clients in learning, practicing and mastering self-regulation skills. I usually begin each session with a self-regulation exercise, and I sometimes end with one as well if the session brought up triggers. This also includes learning and practicing self-monitoring, so the client knows when self-regulation is needed. Directive: *Body Mapping. Start session with a body awareness meditation, guiding client to check in on sensations (painful, pleasant, neutral) starting on the top of the head and moving to the bottom of the feet. Then provide a simple outline drawing of a body and some colored pencils and ask client to depict the sensations they felt/feel in various parts of their body with color, patterns, and images. Discuss the finished map: this is a time when a lot of gentle observation and validation are key.
-Support clients in identifying and connecting with external resources such as family members, friends, religious communities, neighbors, cultural groups, support groups, etc. Natural supports are always more effective and sustainable over time than clinically-oriented supports. Directive: Circles of Support. Ask client to create a map of the supports they have in their life at this time, with their name or a drawing of themselves in the center. Explain that it's important to have a friend or an ally at the main places they go in their world: home, neighborhood, work, school, in their general community. Help client identify who they have already, and help client brainstorm supports they would like to add to their world. This may include getting to know a friendly face in the neighborhood or at work, attending a temple/church/mosque, reconnecting with a family member, etc. Add these ideas to the map in a different color pencil/pen.
- Introduce concept of relative safety. Help clients shift from a globalized sense of danger to a more specific one, identifying nuances in levels of safety. For example, school may not feel entirely safe to a child but it is safer than an abusive home or a war zone. Help a client conceptualize these nuances and clarify that a place that isn't entirely safe is not therefore entirely dangerous. This includes identifying places and people that have been and still are safe. Directive: *Safety Graph. In the style of bar graphing, help client create a simple, colorful graph of the various places where they spend time. On the y axis (vertical) help client create a relatable gradation of safety levels: see example below. On the x axis, ask client to add place(s) where trauma occurred and places where client now goes on a regular basis.
Processing Trauma:
- Once stabilization is established with above interventions, the processing of the trauma phase begins. This is not necessary for everyone who has experienced trauma and is in fact contraindicated for people who have just experienced a trauma days before or who show no signs of PTSD. Those with established PTSD or complex trauma, however, are being negatively impacted by shattered and disorganized memories of what happened and thus are helped by creating order and meaning out of their disorganized memories of the event(s).
- This phase includes regular practicing of self-regulation skills and monitoring the client to determine whether pace of treatment needs to be slowed down or shifted in some way.
-I support the client in telling their trauma story through a narrative approach and often use art to enhance the process and bring in another way for the client to own the story. I also find the art tends to naturally include resources that may have been overlooked. The art is not often a literal picture of the traumatic event(s): it may include a component of the trauma as well as other elements of the person's life or home at that time. The art may also include elements in the client's current life that are either negative or positive, real or fantastical. Let the client guide this process with you in terms of approach to the trauma story, both in its verbal expression as well as in the art. Assume the telling may take several sessions or more, depending on the number and intensity of traumatic events. Directive: *Collage of Life and Trauma. Ask client to sort through collage materials (I have a large collection of pre-cut images from a wide variety of magazines to save on time and distraction) and find images that remind client of the trauma and their life during time of trauma. Supply a surface for client to glue images to or a container for client to keep images in. If client choses a container, encourage client to make the container their own through paint, collage, etc. Use finished piece as a starting point for a new or continued conversation about trauma, incorporating aspects of client's life at the time that weren't mentioned before. Note potential resources/help/saving graces that are present in art: help client incorporate these into trauma narrative.
- After the initial phase of getting the story out, I then work with the client to organize the story. Of course this can naturally start during the initial processing of the trauma narrative, but may need fine tuning during this phase. A major component of the organization is time: the sense of time and sequence of events before, during, and after a traumatic event is often shattered and strewn all over a person's life rather than contained to the time frame when the trauma occurred. For a person with complex trauma, this naturally takes longer as the traumatic events may in fact have occurred throughout their life: some of this, especially early childhood trauma, may include some guesswork. I encourage the client to follow their instincts as to the general timeframe of a trauma. If they have no idea, I use developmental indicators evident in the telling of the story (e.g. family members present and their perceived age) or in the client's manner (e.g. tone of voice, language usage, body posture) to pinpoint the general time of the trauma. Either way, developing a sequential order to events is key to putting the trauma "in its place," giving it a place to live in a person's life history. When you have a series of art pieces from the telling stage, this is helpful in organizing events as you have a very tactile and visual way to sort through what happened. If there is no art or gaps in the art, writing things out can be very helpful here. There of course may still be gaps and things we will never know involved in the trauma: reminding the client of this is helpful. Directive: Trauma Timeline. Ask client to create a timeline of traumatic event(s) on paper or board, with lines and words, images, collage, etc. If they want help with this, support them in whatever ways they prefer: sitting beside them as they write, reminding them of the different memories they've uncovered, cuing them to stop and use self-regulation skills if indicated, mixing colors for them, etc. Depending on extent of traumatic history, this may take 1-2 sessions to complete. Encourage client to leave timeline in office while in progress unless they appear very able to self-regulate and want to work on it at home.
- Finding meaning for the client in regards to what they have been through is a crucial element in healing from trauma. It is like, having isolated the infection to the area of the original wound, you clean the wound, end the infection, and allow the body to heal over the gash with new tissue. The new tissue is the meaning, how this experience has changed the client or their world in ways that, if not positive, are helpful. This meaning can take a myriad of forms. I find it often includes understanding the bigger picture, the context in which the trauma occurred and their place in it. For survivors of war crimes, this often includes some historical knowledge as to the roots of a conflict. For survivors of complex trauma and/or intergenerational trauma, it is understanding the family history that led to the client's trauma occurring. If there are family members to ask, it can be helpful for the client to get information from them. If not, we can make some educated guesses based on the therapist's knowledge of human behavior and how trauma gets passed on in combination with "random" images and ideas that pop up in the art and in the client's current life (through dreams, uncanny experiences, relationship patterns: see The Story Lives for ideas).
Finding meaning also includes finding ways that the experience changed the client for the better. This is a delicate topic and cannot be introduced prematurely: a person who has been through trauma needs plenty of time to feel anger and grief over what they have been through. We therapists don't want to bypass that important process by painting a happy veneer over it. I usually wait for the client to arrive at this understanding on their own. When I do bring it up, I imply that their healing from the trauma has changed them for the better, not necessarily the trauma itself. Healing from trauma can mature and deepen a person. It can uncover reserves of courage and strength hitherto unknown by the client. Also, through understanding via the bigger picture how trauma gains momentum and tends to pass on through families and victims of violence to others, it can be very meaningful to know that by courageously healing their own trauma, they will not pass it on to others.
Meaning-making may also (but doesn't need to) include future goals of helping make the world a better place. Perhaps because of what they have been through they will advocate for political action to save others from going through the same. Perhaps they want to move towards mentoring others who have been hurt. Again, this altruistic urge is not necessary in the meaning-making phase, but it may be present. If it is, support the client in considering realistic and appropriate goals.
Directive: *Life After Healing. Ask client to create an art piece about their experience of life after braving and completing the healing process. This is very open-ended, as they are beyond needing the safe containment of a more structured directive. This is entirely in their hands now, as is their life. Spend time with the art piece after completion, reflecting on their process of healing and the client's courage and strength. It takes guts to heal from trauma, massive courage. Honor this with the client.
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