Practicum Paper

Art Therapy and Metaphor Running Head: CRISIS STABILIZATION

Art Therapy and Metaphor in Short Term Crisis Stabilization for Adults and Adolescents. Julie Kotler The Graduate Program in Art Therapy George Washington University, Alexandria, VA May, 2010

THIS WORK HAS BEEN COMPLETED IN ACCORDANCE WITH THE GW CODE OF ACADEMIC INTEGRITY.

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Harold and Purple Crayon by Crockett Johnson One evening, after thinking it over for some time, Harold decided to go for a walk in the moonlight. There wasn’t any moon, and Harold needed a moon for a walk in the moonlight. And he needed something to walk on. He made a long straight path so wouldn’t get lost. And he set off on his walk, taking his big purple crayon with him. But he didn’t seem to be getting anywhere on the long straight path. So he left the path for a short cut across a field. And the moon went with him. The short cut led right to where Harold thought a forest ought to be. He didn’t want to get lost in the woods. So he made a very small forest, with just one tree in it. It turned out to be an apple tree. The apples would be very tasty, Harold thought, when they got red. So he put a frightening dragon under the tree to guard the apples. It was a terribly frightening dragon. It even frightened Harold. He backed away. His hand holding the purple crayon shook. Suddenly he realized what was happening. But by then Harold was over his head in an ocean. He came up thinking fast. And in no time he was climbing aboard a trim little boat. He quickly set sail. And the moon sailed along with him. After he sailed long enough, Harold made land without much trouble. He stepped ashore on the beach wondering where he was. The sandy beach reminded Harold of picnics. And the thought of picnics made him hungry. So he laid out a nice simple picnic lunch. There was nothing but pie. But there were all nine kinds of pie that Harold liked best. When Harold finished his picnic there was quite a lot left. He hated to see so much delicious pie go to waste. So Harold left a very hungry moose and a deserving porcupine to finish it up. And, off he went, looking for a hill to climb, to see where he was. Harold knew that the higher up he went the farther he could see. So he decided to make the hill into a mountain. If he went high enough, he thought, he could see the window of his bedroom. He was getting tired and he felt he ought to be getting to bed. He hoped he could see his bedroom window from the top of the mountain. But as he looked down over the other side he slipped- And there wasn’t any other side of the mountain. He was falling, in thin air. But, luckily, he kept his wits and his purple crayon. He made a balloon and he grabbed on to it. And he made a basket under the balloon big enough to stand in. He had a fine view from the balloon but he couldn’t see his window. He couldn’t even see a house. So he made a house, with windows. And he landed the balloon on the grass in the front yard. None of the windows was his window. He tried to think where his window ought to be. He made some more windows. He made a big building full of windows. He made lots of buildings full of windows. He made a whole city full of windows. But none of the windows was his window. He couldn’t think where it might be. He decided to ask a policeman. The policeman pointed the way Harold was going anyway. But Harold thanked him. And he walked along with the moon, wishing he was in his room and in bed. Then, suddenly, Harold remembered. He remembered where his bedroom window was, when there was a moon. It was always right around the moon. And then Harold made his bed. He got in it and drew up the covers. The purple crayon dropped on the floor. And Harold dropped off to sleep.

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Introduction Crisis stabilization provides a safe and medically stable environment for the psychiatric patient struggling with their illness. In a limited amount of time, the therapy provided must address patient needs and enhance the stability of the patient. Traditional art therapy assessments are difficult to utilize in this environment as almost all therapy is conducted in a group setting. Difficulty in understanding the patient is furthered by the limited time in the setting, insurance companies denying coverage, and patient defenses being so well rehearsed. Art therapy within this setting may be used to help the patient try to use art as therapy or art as conveying the non-verbal message, one that is traumatic or overwhelming. Art therapy in crisis stabilization is the beginning of a long journey. The writer will explore a therapeutic directive that was developed to begin the journey through recovery and expose patients to art therapy, most of them for the first time. Exploring the use of the metaphor from a children’s book to begin the session, the writer will explore the purple crayon drawing from co-occurring adults in art therapy sessions. Next, the writer will examine purple crayon drawings that were created by adolescents as a way of introducing art therapy and problem solving. In this part of the paper, subsequent art will also be examined. The writer proposes that the use of this technique enabled a quick therapeutic relationship to be formed. Through the metaphor, work with the adolescents lowered defenses and allowed the writer to become a trusted presence and facilitator. The metaphor presented in the children’s storybook, Harold and the Purple Crayon by Crockett Johnson, is one that highlights the recovery from trauma, patient empowerment, and the true journey of a person lost. Lost in the woods, far from home,

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not knowing which way to go, Harold depends on the purple crayon in his hand to draw his next step and the path he will take. With a sense of humor, even during times of fear, Harold keeps his wits about him, and progresses through the journey looking always towards home and comfort. Harold is a metaphor for us all, searching, trying to move forward, to grow and change, find comfort and safety in a world of unknown crisis. Harold is all of us. And yet, Harold has his purple crayon. Harold has the power to change his destiny by simply drawing it different. This story blends meaningful art, and the metaphor of survival, resiliency and hope. Developing self-esteem and potential for adults and adolescents make changes in their lives, grow as individuals, and practice selfreliance is one way to use the purple crayon directive. Can the metaphor found in the children’s book, Harold and the Purple Crayon (1955) be used as a therapeutic directive with adult and adolescent patients who are struggling with mental illness and adults with mental illness and addiction issues? This story was used as the beginning of the art therapy group working with both populations. In the co-occurring adult and diverse adolescent population, the high rate of recidivism indicates that much more needs to be done to help patients seek the solutions within themselves. Preparing patients for the work that lies ahead in their recovery, this therapeutic directive begins the long and arduous process of recovery. Finding hope, personal responsibility, and empowerment as themes in the artwork, the art therapy intern hoped to begin illuminating the process of recovery and strengths within the patient. This paper examines whether the story metaphor can facilitate co-occurring adults and adolescents with mental illness to develop a plan for recovery, work through barriers, and empower themselves to seek solutions for recovery.

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“I can’t draw.” “What am I supposed to draw?” “I couldn’t draw a straight line with a ruler (Reynolds, 2004).” As art therapists, how many times do we hear the moaning of a group or single individual when a directive is presented? Patients often claim they are not good artists, or art is not their thing, yet with the use this directive, resistance can be address. The focus of this art directive was to make art therapy accessible to a wide range of cognitive abilities. This article will discuss the reading of children’s literature used as a way to lower anxiety and allow the client to focus on making art. The writer’s desire to experiment with adult clients to develop a greater understanding recovery based upon strengths and positive psychology. Patients are hospitalized at some of the darkest times in their lives. They already sense their weaknesses. The writer’s art therapy directive was developed to address strengths and enhance the patient’s vision of their future. The metaphor can provide a simple structure to approach a complex problem. Patients can use the literature as stepping-stones for ideas of what to draw, allowing themselves to get lost in the words of the story and evoking an unconscious connection to the art. Art therapists can use the literature to navigate issues with resistance to art making, investigate the thought process of the patient, and help to create a dialogue with the patient that enhances the relationship between the art making and therapeutic benefits for the patient. Patients of all cognitive abilities can benefit from the simple metaphor presented in a story; the rhythm of the story is being read, or the simplicity of the literatures’ illustrations. This paper will address the method in which the art was created, analyze the patient art, and give a description of the group process that occurred with this particular

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directive. An idea is drawn is an idea that can become a reality. During the group processing of their purple crayon drawings, patients were able to ask the artist how they were going to achieve those goals, to elaborate on the path to which they were going to follow to recovery. Frequently, patient’s drawings brought forth their strengths, whether they were family supports, a sponsor, their pets, children, a home, or their realities, of needing a job, a supportive physician or therapist, or some structure to their day. Making the drawing made these concepts clear. In addition, subsequent artwork will be examined to illuminate the clinical picture of the patient. Literature Review Drawing a Change Malchiodi (2003) notes that drawing an image is one of the first ways that cognitive restructuring can occur for a patient. “Art therapy is based on the use of imagery in treatment, cognitive-behavioral therapy is about language” (Malchiodi, 2003, p. 74). Mixing the two of these concepts can enhance recovery for some patients, it is what Malchiodi states, “seeing one’s negative thought in black and white is a very powerful experience and can bring home the personal tyranny of such cognition” (Malchiodi, 2003, p.75). Restructuring the way clients feels or thinks or behaves by drawing it incorporates cognition and art in a simple way. Patients and therapist work together to process the artwork and highlight the positive strengths or identify the negative self –thoughts. Simply getting the patients to express themselves through a purple crayon drawing can bring clarity to the issues the patient is facing. “By asking the patient to make the image presenting the problem, the therapist can guide the patient through an analysis of image and the problem” (Malchiodi, 2003, p.75). Malchiodi

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(2003) suggests the exploration of the patient’s problem be determined by the following questions. Asking “what the problem is, what does the image tell the viewer about the problem, what thoughts came up during the making of the image, and what thoughts are you having now” (Malchiodi, 2003, p. 75) are all applicable to the purple crayon directive. Riley (1999) looks at adolescents with a unique perspective calling this population a “development skewed by circumstances” (p.20). In the hospital, the adolescents triggers, whether they be family or friends, are gone enabling the writer to see a different side of the adolescent, as side without defenses. In groups of adolescents, the process of creating art is further enhanced by embracing the concepts that Yalom (1993) has practiced with regard to the importance of group therapy. The melding of appropriate group therapy concepts with the way that adolescents are developmentally make group art therapy a safe place for adolescents to be themselves. They may disclose more, find trusting relationships, and ask for help with situations that seem too difficult to handle on their own. Adolescents may not trust assessments given by art therapists. Having been disappointed by adults previously and as part of their developmental stage, the purple crayon directive may be used to begin a conversation or open the door to the issues surrounding the patient’s hospitalization. Given in a small group may lower anxiety and encourage participation in the group. As part of the writer’s internship, in many cases, art therapy was the only therapy that generated a positive patient response. Artists and non-artists can participate in this directive and have satisfying results. The simplicity of the drawings in Harold and the Purple Crayon enable the participant to

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see that a circle can be a balloon, a wavy line can be water, and a rectangle can be a house or building. Malchiodi presentation of cognitive behavioral therapy combined with art therapy indicates, “the overall goal is to develop positive self-statements and internal images that reduce negativity and enhance successful performance” (Malchiodi, 2003, p.75). While Malchiodi explains that “expressing negative thoughts can be helpful” (Malchiodi, 2003, p.75) for many patients recognizing the negative thoughts, feelings and actions that have already happened can be overwhelming, however, drawing these feelings can lower anxiety. With the purple crayon technique, cognitive reframing can occur, enabling adults and children to process traumatic thoughts and events. Malchiodi states that the combination of activities, cognitive behavioral therapy and drawing done together may, in fact, “reduce the sequelae of posttraumatic stress” (Malchiodi, 2003, p. 72). Strengths Based Recovery Katherine van Wormer and Diane Rae Davis (2003) present a different view of recovery, specifically from addictions. Their strengths based program in focused upon where the patient is right now. Recognizing that the patient has already noted their lack of some skill to refrain from the addiction, van Wormer and Davis state that their theory “comes from a practical understanding that a focus on capabilities rather than defects fosters hope (where there is despair), options (where there is a perceived dead end), and increased self-efficacy (where there is a feeling of helplessness)” (van Wormer & Davis, 2003, p.5). Furthermore, a strengths based program can give hope. “No matter how dismal the circumstances, people have possibilities, resiliencies, and capacities for change and even transformation. They look for and try to nurture the gleam that is often

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hidden by misery, protective strategies, and the failure to achieve goals set by others” van Wormer & Davis, 2003, p.67). The embodiment of the program is choice. Enabling patients to make choices in the recovery process and encouraging them to take personal responsibility in their own recovery can be very successful. Focusing on the positive aspects of the clients life, the development of strategies that support the recovery of the patient allow the patient not just personal responsibility but also with a purple crayon drawing a strategy to gaining and maintaining success.

Strengths based programs such

as the one presented by van Wormer and Davis focus on the good the patient has in their lives, not the pathology. Even “relapse is no longer regarded as a personal failure but rather as an integral part of the change process” (van Wormer & Davis, 2003, p.69). The concept of solution-focused therapy is an exciting one. For many patients, once they participate in this kind of therapy, insight is inevitable. Solution-focus is “based on the assumption that the future can be created and negotiated, regardless of the problem. The future is not a slave of the past events in a person’s life; therefore, in spite of past traumatic events, a person can negotiate and implement many useful steps that are likely to lead him/her to a more satisfying life” (van Wormer & Davis, 2003, p.84). The purple crayon directive is a simple way to illuminate the strengths of the patient, encourage a journey forward and identify the steps needed to incorporate recovery into their life. Reading Harold and the Purple Crayon (Crockett, 1955) support the idea of a miracle question elucidated by van Wormer and Davis (2003). This is a question that through persistent questioning by the art therapist, the patients can literally draw themselves in recovery, illustrating the necessary steps to be taken to get to the path of recovery. “This question leads the client directly into imaging, describing, creating, and

Art Therapy and Metaphor 10 embellishing on a day in the future without the burden of the particular problem that led or required the patient to seek help” (van Wormer & Davis, 2003, p.84). The art expression that emerges can be motivational, provide momentum for change and be the tangible representation of where the patient is going in the future. Drawing the answer to the miracle question can be the catalyst for change. Working with the Metaphor Focusing on the strengths of the patient is a model that encourages the art therapist also. Looking at the patient from the core of their strengths relieves the therapist of the necessity of focusing on the diagnosis and pathology. Rather the therapist can engage the patient in the model of guiding the patient through active exploration and art making that enhances the patient’s recovery. “Fostering tolerance and respect for clients’ values, capabilities, circumstances, and culture is particularly relevant to groups who often receive discriminatory treatment” (van Wormer & Davis, 2003, p.86). van Wormer and Davis (2003) suggest that this method helps therapists by lowering burnout and frustration levels. The therapists are the guides but the patient is the person holding the purple crayon. The patients are ultimately in charge of their own destiny and choices. McNiff (1998, p.99) additionally advocates for art in psychiatric hospitals, as “human differences are incessantly variable whereas the search for more positive and universal outcomes of artistic activity suggests that mentally ill people can use creative expression to transform and overcome the limitations of their conditions.” This concept is encouraging for strength-based work with patients. Understanding the process in which art is created may be a mechanism for change for the co-occurring patient. With the purple crayon directive, a metaphor is created empowering the patient

Art Therapy and Metaphor 11 and enabling the development of personal responsibility towards recovery. “Metaphors are constructs that are part and parcel in the work of art therapists. They allow therapists to learn to enter into clients’ constructions of their stories as depicted into their art” (Alter-Muri & Klein, 2007, p.83). Harold and the Purple Crayon (Crockett, 1955) present a rich metaphor that empowers, can evoke feelings of hopefulness and transcends age and cultural stereotypes. Harold and the Purple Crayon (Crockett, 1955) provides a story that is without color barrier or cultural assumption appealing to all people who are without a plan, lost, or seeking a new path. The application of the purple crayon directive is appropriate to diverse populations and culture, not limited by gender, race or religion. Martin (2000) states that using good fiction is “a way to develop precision of language for doing therapy.” Using children’s literature with adolescents and adults as part of the process to focus the client, present information simply, and to demystify the art making for the self-proclaimed “non-artists” in the group is an efficient way to start the session. Short stories are brief and rich in content and have a theme that is easy to decipher. Due to their simplicity, performance anxiety was lower. The stories can be metaphors for the recovery process in addictions and depression. Drawing a way to solve the problem the patient is faced with empowers. Based on the drawings that were created, patients were able to communicate their needs in recovery and visualize the path they would follow. With the purple crayon directive, a metaphor is created empowering the patient and enabling the development of personal responsibility towards recovery. “Metaphors are constructs that are part and parcel in the work of art therapists. They allow therapists to learn to enter into clients’ constructions of their stories as depicted into their art”

Art Therapy and Metaphor 12 (Alter-Muri & Klein, 2007, p.83). Harold and the Purple Crayon (Crockett, 1955) presents a rich metaphor that empowers, can evoke feelings of hopefulness and transcends age and cultural stereotypes. Klorer (2000) writes about “staying in the metaphor” while working with children as many of the feelings that they have cannot be verbally expressed (p.17). For children who have been exposed to trauma the feelings they have can be overwhelming. Because the writer’s internship was in crisis stabilization, the work is just beginning; it is as Klorer (2000) describes, “setting the stage” for deeper work with the expressive therapies (p.22). Adolescents often don’t have the ability to describe their personal stories; the metaphor may be a place that is safe. Staying in the metaphor may give the adolescent a launching pad that enhances safety and security. Perhaps initiating and enhancing the therapeutic relationship in this short-term environment where adults have been viewed as untrusting and suspicious, even when the child enters the therapeutic relationship tentatively. The art therapist has the welcome task of providing structure and unconditional positive regard, with the hope that modeling this relationship in the hospital will allow the adolescent to look for this type of relationship in other parts of their lives. Furthermore, as Klorer (p.27) indicates, “Children know what they need.” The difficulty is accessing the support and removing the triggers for the behaviors that have made life impossible to live thus far. Martin (2000) further supports the use of the metaphor in the therapeutic environment. “Metaphors can be powerful because they often express complex experiential meaning quickly and in a way that other words cannot, it is typically embedded within experiential networks of memories, incidents, images and feelings

Art Therapy and Metaphor 13 constituting an associated meaning context” (Martin, 2000, p.46). The therapist can bring the patient’s experience to the forefront, open eyes, and be able to enhance the feeling of empathy with a metaphor that is accurate in summing up an experience. Martin (2000) claims that therapy happens in small increments, the use of literature is a practice that can be used as a first step. With Harold and his purple crayon, the metaphor of being lost, found, hungry, tired, lonely, and courageous are embodied in a single short story. Reading this story as part of the group process for an art directive can be a way to begin the recovery process. The metaphor can capture a feeling and make the patient feel understood and heard. Use of the purple crayon drawings could eventually encompass assessment of a patient’s coping skills and identification of strengths, as much as a future plan for the patient. As with bridge drawing, a technique developed by Hays and Lyons (1981) where the researchers have established the bridge as a form created to get somewhere else. The bridge is used as a symbol. Bridges drawn by patients can be a “projective technique for assessment and therapeutic aid” (Hays & Lyons, 1981, p.207). Hays and Lyons research the use of the bridge drawings in the therapeutic environment. Based upon the idea that bridges are a symbol of overcoming obstacles and that bridge drawings are artistic metaphors to “bridge the verbal communication gap with the non-verbal qualities inherent in artistic expression” (Hays & Lyons, 1981, p. 207). Hays and Lyons further explain that an art therapy technique is a “concrete implementation of theory introduced by the art therapist, at the appropriate time to facilitate creative and therapeutic change” (Hays & Lyons, 1981, p. 212). Developing communication between the therapist, patient and group is another result of purple crayon drawing and the presentation of the story to

Art Therapy and Metaphor 14 the patient. Maintaining the strength model and incorporating symbols into the therapeutic environment follows the theoretical basis that Carl Jung developed. Jung viewed the human being in a positive manner. In his theories, he believed that the therapeutic goal for the client was individuation, this being necessary for self-growth. In his prolific writings over the course of his career, Jung saw spirituality as a cornerstone for much of his work with dreams, symbols, and art. Jungian theory emphasizes the image that is produced by a client as its own entity. Client art is related to the artist as an expression of the active imagination and Jung believed that the art could stand alone, on its own as representation of the client’s ego, persona, self, or shadow (Rubin, 2001). Further enhancing Jung’s use of art in therapy is the need to be “consciously integrated, made intelligible, and morally assimilated” (Rubin, 2001, p.84). Constructing a theory, as Jung does, that embraces art making and encourages verbal communication of what the art means, enables the field of art therapy to flourish. The creation of this directive is made understandable by Jungian theory, with focus on the picture as it stands in itself and the ideas surrounding the development of self through art making. Philosophically speaking, ideas surrounding balance of archetypes and dreams are evident is Jung’s theories and are pertinent is examining ideas about addictions. Jungian theories provide information on symbolism, dreams, and pathology, while also embracing art and creativity. Feen-Calligan (1995) studied the use of art therapy in recovery from addiction and as a way to develop spirituality. “The process was meditative, uplifting, inspiring, and creative, I had the opportunity to daydream, to fantasize, to concentrate, and to work through various details of my life!” (Feen-Calligan, 1995, p. 47) With an

Art Therapy and Metaphor 15 endorsement that powerful, one can see how art therapy can be embraced by addicts as a source of comfort during the journey of recovery, not only enabling the patient to grow, but also to develop and heal new aspects of themselves. Feen-Calligan furthers the connection to Jungian theory by connecting spiritual and creative endeavors such as “making art or music, writing, walking, fishing, or camping” (Feen-Calligan, 1995, p.47). Jung believed that an addiction was a lack of spirituality, and that drinking or selfmedicating was a need to feel special or unique. Therefore, part of the recovery process according to Jung would include work in discovering personal spirituality, creativity, relaxation, and acknowledgement of higher power. As Feen-Calligan (1995) points out, “the Latin for addict, addictus, means to devote, surrender, deliver over, or give oneself up habitually” (Feen-Calligan, 1995,p.49). Naturally, the connection to alcohol or substance abuse is surrender, but as Feen-Calligan surmises, “doing art might feel good and create the same spiritual and emotional high” (Feen-Calligan, 1995, p.49). Hoffman and Calvert (2007) state, “creativity became integral for mental health” (p.252). Multi-dimensional care for the patients in the psychiatric facility further enhances the concepts of “art and creativity holding a special place in the human psyche” (Hoffman and Calvert, 2007, p. 252). Daily activities at my inpatient psychiatric hospital are planned to support recovery through the development of spirituality awareness, self- expression, and art therapy. Support for the individual patient and their immediate needs are met through direct contact with mental health workers, addiction counselors, art and music therapists, and doctors. Attention to the detail of the patient, their stories, and needs are part of the journey to recovery from the stronghold of their addiction. The presence of a strength model is felt throughout the hospital philosophy by

Art Therapy and Metaphor 16 treating the whole patient, creatively, with compassion and acknowledgement of a journey. The purple crayon directive integrates intervention and group process while focusing on a process oriented treatment plan provides a path that is recovery. Art Therapy in the Hospital Working with adults and adolescents in a psychiatric hospital, the challenge lies in many of the practices that take place. The time for art therapy is only one hour per week for some of the hospital units. Meaningful process has to happen quickly and is often interrupted by the social worker, doctor, or psychiatrist. However, in each of the art therapy sessions that were conducted in the 450 hours during my first practicum, it should be noted that each was a success, whether the group process was a positive experience or the patient noted personal insight as they may have had their first experience with art.

Most of the patients that I was in contact with felt powerless over

both their mental illness and their addiction. Groups dedicated to coping skills, anger management, open studio (to develop leisure skills), spirituality, and personal recovery plan development in addition to art therapy were scheduled to maximize the experience during the patient’s average stay of 4-7 days. The purple crayon directive enabled the art therapist to be authentic and genuine, be creative without being overwhelming, visualize recovery, develop a picture of what coping skills were needed after leaving the hospital, strengthen the self esteem, ask for help from the group through the art, and finally, picture hope (Malchiodi, 2003, p.268-278). As Malchiodi (2003) writes, “art therapy has been adapted to the specific needs of addiction treatment over that last two decades” (Malchiodi, 2003, p.282). Art therapy can be an integral part of the recovery process for a patient struggling with both mental

Art Therapy and Metaphor 17 illness and addiction. “Feelings of worthlessness, powerlessness, and personal failure often experienced by the addicted person” are what make addictions specialist refer to addictions as a shame-based illness.

The rivalry between control, self esteem

development and helplessness are evident in the addiction process. Creativity can provide relief from the shame, as “addicts feel powerless to break their conditioned response and the recovery process, like the creative process, offers individual with addictions choices that the addiction does not” (Malchiodi, 2003, p.283). The success of the purple crayon directive in the art therapy group rests in “establishing safety with the group, developing an understanding of the addictive illnesses, breaking through denial, surrendering to the process of recovery, and understanding the origins of shame” (Malchiodi, 2003, p.284-292). With these goals as part of the art therapy group, patients were able to participate in the purple crayon directive successfully. Minimal resistance was displayed and the group process that occurred was insightful as the journey to recovery began. Group Art Therapy- The Milieu The therapeutic attitude that was the also the philosophy for my unit at the hospital is encompassed by what Moon (2002) calls milieu therapy. This concept requires the staff to work as a team. The patient is a person, not the disease. Everyone in the milieu is treated with respect and consideration. The focus of this approach is that all the people that are on the unit are important to the recovery of the patient. The groups are mandatory and there is therapeutic value to each group. Art therapy had a purpose, rather than making a picture, or even telling a story, the end result would be most successful if the patient expressed personal insight. Three parts of milieu therapy relate

Art Therapy and Metaphor 18 directly to my practicum experience are the effect of the environment to hinder or enhance therapeutic goals, that all people that are in the milieu have an effect on the treatment, and the creation of a “flexible studio environment” (Moon, 2002, p. 77-80). Within the walls of the psychiatric hospital, all of these goals were addressed and attempted to achieve them daily was the standard. Group therapy was the standard in the hospital. With that being the only model in the hospital setting, there was no privacy for the patients. The patients ate together, slept in double rooms, and sat in a recreational room together. As Moon (2003) states, “everyone helps to create the spirit of the studio” (Moon, 2002, p. 78). This could hinder, thwart, impede or it could be collaborative in the studio. The purple crayon directive, as a first introduction to each other, enabled the patients to be on a level playing ground. Those with art backgrounds and self proclaimed non-artists worked together to create their new story. The art created with purple crayons showed significance in the patient’s self-knowledge. I based the “relational aesthetic” many of the concepts that Moon (2002) illustrates. The “art work was relevant to concerns of the individual, people are changed in some way by making the art, the art process was accessible to a diverse group of people, and the artist has moved, affected, challenged, comforted or provoked to action themselves or others in the group” (Moon, 2002, p. 141). Furthermore, the art created deepened relationships, enhances group discussion, and created a feeling of selfdiscovery. Changing Behavior The purple crayon directive is solution-focused. Acting as a map for recovery, the drawing that is expressed by the patient allows the patient to create a narrative. Not

Art Therapy and Metaphor 19 only does the problem become visible, the creation of the solution or steps to the solution becomes evident, often becoming clear for the first time. Mixing the verbal expression with the drawing the patients becomes their own story, while also creating a separation from the problem (Malchiodi, 2003, p.88). The patient can be themselves, not their problems, and many times they see – If they always do, what they always did, they will always get, what they always got. This drawing directive gives the patient the chance to externalize the problem and see it with new perspective. Developing understanding is a very large part of creating solutions for the problem a patient brings to therapy. “Art expression adds another dimension to these approaches by providing creative ways to externalize, reframe, and re-story the problem” (Malchiodi, 2003, p.90), thereby creatively giving patients a way to change what they have always done that was troubling and create a new way to mange their lives. Use of the purple crayon technique can be a simple exploration with children and adolescents who are at any developmental stage. While this directive is not an assessment, drawings can be identified as expressions of trauma or developmental delay with regards to schema the child draws upon. The use of Kramer’s third hand can be instituted with children and this technique (Malchiodi, 2003, p.98). In this case, the third hand would be the art therapist and would further augment the metaphor and the successful result that can be achieved by the child in therapy. With the adolescent population, the purple crayon directive is effective for many reasons. By enabling adolescents the opportunity to participate in the reading of the story and the following directive they can “control communication, feel respected, have an opportunity to feel omnipotent and externalize the problem” (Malchiodi, 2003, p.227).

Art Therapy and Metaphor 20 Adolescents have freedom to draw what they want, share what they want, be as expressive as they choose, and create an opportunity to view a problem in a new way with fresh perspective. This particular group in therapy can become the experts of their own destiny, an important piece to success in art therapy. Empowering teens is most important and while simply drawing on the paper can see the cumulative effect of the purple crayon directive, further opportunities to open discussion exist. As for the art therapist, she is granted a chance to “move into the teen’s world as much as possible, finding this metaphor… that has been individualized to meet the developmental need” (Malchiodi, 2003, p.226). First Practicum Experience The writer’s first practicum experience occurred in a suburban psychiatric hospital unit of 16 beds. Both men and women were on the co-occurring unit. Cooccurring in this setting indicated that the patient was both dealing with substance addiction and mental illness. Anxiolytic addiction, alcohol dependence, cocaine, heroin, cannabis, majianana, and prescription drugs were part of my experience at this short stay unit. The average stay of the patient on the unit is 4-7 days and during that time the patient is encouraged to participate in as many of the groups that are provided as possible. Typically a patient arrives through the emergency room of a local hospital to our unit with the precipitating factor of suicidal ideation or recent drug overdose. The first twelve hours of their stay on the unit the patient is excused from group if they need to sleep or are experiencing symptoms of withdrawal. The building in which my unit is housed is a former hospital that was bought by a larger hospital approximately 10 years ago. Renovations are ongoing and the state of the

Art Therapy and Metaphor 21 hospital is quite dreary. The annual art therapy budget is $300.00 per year. The writer petitioned the hospital early in my practicum so that as part of the admission process, patients signed a release to photograph artwork that remained in their chart. Early in the writer’s practicum she worked consecutive days in a row, as with the type of hospitalization the patients had, it was unclear as to where they would be the next day. Quick therapeutic alliances needed to be formed, as the patient would be moving on when insurance deemed necessary. The art therapy offered at this hospital occurred 1 day per week for 1 hour. Group participation is mandatory on the unit, unless the patient was with the doctor; the patient was likely to attend. The art therapy was a mix of directive and non-directive methods. The art therapy offered in a group placed an emphasis on the processing of the art experience post activity. When a non-directive experience was provided, the focus of the group was solely on the making of the art and the creation of a piece of work that the patient could be proud of, more art as therapy. The patients that participated in the art therapy groups were of all types of cultural backgrounds, diagnosis, age and gender. They are 18-70 years old. They are homosexual, heterosexual, and bisexual, some patients are professionals working for the government, computer programmers, homemakers, mechanics, nurses, lawyers, authors, artists, students, and information technology specialist. The writer’s patient population has legal history pending and has served time in prison. They are HIV positive, Hepatitis B and C positive, syphilis, heart disease, anorexia, schizophrenia, bipolar with manic features, manic depressive, major depressive episode, psychotic, agoraphobic, sad, lonely, hungry, homeless, jobless and most are without family supports. They

Art Therapy and Metaphor 22 sometimes had no place to go and sometimes have very little desire to be anything except a patient. The bed provided and the three meals a day were a welcome change for many of the patients on the unit. Many of the patients are dealing not just with the challenge of the addictions, but they are faced with the long road to recovery, and then must deal with the challenge of chronic mental illness. The writer’s patients are more to me than their diagnosis, their addiction, or what they do when they are outside the hospital. The writer’s responsibilities each day began with organizing the notes for the day and completing the assessments of the new admissions. On any given day, there could be up to 10 new admissions depending upon the current census of the unit. There could have 1 or 2 beds blocked due to a patient’s active psychosis. Potentially there could be patients on suicide observation or unit restricted which would make the patient ineligible for groups off the unit. Part of the writer’s responsibility to know which patients could not come to group and plan for that fact, perhaps switching gears and plans in order to make accommodations for the patients who must remain on the unit. Due to the frequent fluctuations in census and the limited average stay of the patient, termination in the classic sense was not practiced. Planning for termination began when discharge planning was introduced to the patient, perhaps 10-24 hours before the patient left the hospital. Team meetings consisted of two psychiatrists, the nurse manager, two social workers, the substance abuse counselor, the discharge planner, a charge nurse and the art therapist. Each morning at team, the charge nurse would report on the new admissions, the events of the past 12 hours, and any discharge that was going to happen that day. Often it would be the case that a discharge would not be reported in the morning, yet the patient would be gone in the afternoon. The way discharge was handled; it was the

Art Therapy and Metaphor 23 writer’s experience that termination, while an important part of the therapeutic process, was not handled in an appropriate way. Fortunately, with all the art that the writer photographed, over 176 pieces of work were collected into a termination piece of work that was presented at team meeting. The ideas behind termination were questioned often in the time the writer spent at the hospital. Was termination more for the patient or more for the therapist? Termination was conducted for the writer in completing the movie of patient art work and presenting it to team. Each day that the writer was on the unit, it was her responsibility to write the notes for the groups that occurred that day. She also planned for the groups. Groups were not limited to art therapy. The experience provided enhanced the writer’s skills in counseling greatly. Coping skills, anger management, open studio, expressive therapy, spirituality, and stress management were weekly experiences for the patients. Each morning day began with paper work, assessments and notes, then team meeting, and exercise. In order to get to know the patients better, most days at my practicum, the writer went to chemical dependency group. Because patients were at the hospital for such a short time, the writer felt that she could better understand and develop a therapeutic relationship. Issues came out at those groups that helped me plan for the 11:00am group with more ease. Planning for a group where the writer had an understanding of the level of cognitive functioning and the issues that were coming up in the group dynamics made for a smoother transition to the next group. Up to four hours per day were spent in direct client hours, with three to fours working on daily progress notes and functional assessments. Each morning after the progress notes were prepared we had a team meeting with

Art Therapy and Metaphor 24 a 12-hour report on each patient. The report considered the patient, their response to therapy, and any reaction to new medication. Compliance with the prescribed medications and how the patient was doing in the milieu were also important aspects of the patient’s progress. Part of the experience that each patient has on the unit includes staff intervention with a mental health worker. The mental health worker acts like the “eyes and ears” of the milieu, focusing on the relationship that the patients develops with others and gaining understanding of the patient’s response to treatment. The team meetings were a place where the art therapist’s voice was of value. Contributions made by both my supervisor and myself were carefully considered and were considered to be important. Art therapy was of value. As an expressive therapy, art therapy already had a place in the therapeutic offerings of the hospital, the writer’s role was solid as part of the therapeutic team. Feeling comfortable participating in the group meetings, adding my observations regularly when asked. During my time at the hospital, there was a change in physicians, yet the quality of care continued due to the strength of the team and nurse manager. Formal supervision meetings occurred one time per week, Wednesday at noon for one hour. However, supervision was happening informally at all times. Fortunately the writer’s supervisor was a willing and competent teacher, as much as she was a part of the group dynamics. Gratefully, the writer utilized her willingness to process each group after we finished. We worked on notes together, discussed observed behavior, and talked about patient diagnosis. We examined artwork together looking for similarities and differences among patient populations. The art that we made together in-group was examined and discussed between us to help the writer gain more understanding of the

Art Therapy and Metaphor 25 individual patient. The writer’s supervision was one of gentle guidance, she allowed the writer to lead the groups early in her practicum, from the fifth week. Fortunately having had experience as an art educator, the writer had experienced teaching art skills, the counseling part, was not as easy. The writer is grateful for the leadership and respect that the supervisor gave me during my experience. Faith and trust allowed the writer to grow as an art therapist and as a person. Nearing the end of the writer’s first practicum, the supervisor and the writer planned for termination with her unit. The writer developed an awareness of the skills that she wanted to develop in her second experience. Needing to work with another population, she began to interview and explore the options that were available. It was critical to find an experience that enabled her to create balance and self care in her life, spend time with my family and have diverse experiences with different kinds of patients. Exploring the options with the local school system and other agencies, it became clear that working with a new population was going to be a challenge. Most services that she encountered service children after the academic school day, making the balance between home and work nearly impossible. After much research, the writer went to her supervisor with the ideas to create an art therapy program with the adolescents in my hospital. Would staying at the same hospital system give the writer enough diverse experience? It was important to be very clear in the goals for the second year. The writer believed that the creation of an art therapy program for a different population would allow her to grow in numerous ways, especially in that she would be able to further develop my skills, keep the same art

Art Therapy and Metaphor 26 therapy supervisor, and have a different direct supervisor for the new program. This was a chance to build a program from the ground up. Word of my switching to another unit began to leak out. There was sadness expressed by the nurse manager on my current co-occurring unit and excitement from the adolescent unit as the writer had filled in for an ailing recreational therapist for about a month early in the first part of my practicum experience. She felt some concern about how she was going to deal with the personality of the nurse manager on the adolescent unit, it was going to be a demanding position, who would I answer to, and would that person be not just be a supervisor but also a person that would help me develop appropriate boundaries in my responsibilities. The writer acquiesced to work that she was either not scheduled to do, or not supposed to do, so it was important to begin this practicum with a clear set of objectives and a schedule that would be clearly laid out for the staff on that unit. Clinical Work During the 465 hours at the writer’s first practicum site, the writer conducted the purple crayon directive 8 times, with varying groups of people with many different diagnoses. The group always began the same. First, the writer would introduce myself as the art therapy intern. Then, the litany of self -deprecation begins. “Art therapy, I am not good at art.” “I can’t draw at all.” Resistance all around the group, and it was contagious. Explaining that for this directive, you didn’t need many skills, if you could make a circle, line, square and rectangle. Then the writer would explain that this art directive began with a story. Next, she would read the story Harold and the Purple Crayon (1955) by Crockett Johnson. While reading the story, the writer would

Art Therapy and Metaphor 27 frequently gaze up to see if the patients were engaged in the story, enabling her to gauge responses. Not once during any of the sessions did the writer stop early due to resistance to reading the story. All of the groups were engaged in the adventures of Harold and the magic of his purple crayon. Upon finishing the story, the writer would ask the question, “Why do you think that I read this story?” Inevitably, the group came up with thoughtful and insightful answers that addressed the metaphor of self-created solutions to their problems. The answers seemed to lie within the paper they created themselves. After the discussion, the writer gave each person a big purple crayon and white paper. They were asked to draw their own road to recovery. What are the people, places, and ideas that they needed to have in place and in their picture to illustrate their own recovery? Each patient was to draw the map to and through recovery. The “opportunity to behave in an alternative way and practice new skills attempted, experience information into a visual form” (Rubin, 2001, p.215). The following case studies are based upon one meeting in an art therapy session and the processing of the art made during that one session. The information provided is a snapshot of a patient in crisis stabilization. In most cases the patient had been discharged before follow-up art therapy session could be held, as art therapy is only one time per week on the co-occurring unit. The purple crayon directive was not used every art therapy session that the writer facilitated, however, more clinical experience was gained using this technique because of the comfort level of the writer. The patients most often wanted to collage, spending most of their time reading the magazines, using the art making as therapy.

Art Therapy and Metaphor 28 Case Study “Michelle”

Figure 1 Figure 1 is the drawing of a 41 year-old separated woman with 2 children. Michelle lived in a recovery house for 6 months; she had been recently dismissed from the house when she had stolen sleeping pills from another house member. She tried to commit suicide and was rushed to a local hospital, then arrived on our unit in withdrawal, disheveled and disoriented. This was her third visit to our psychiatric facility is less than 3 years. Her 1 year-old baby was born testing positive for opiates. Her husband had recently given her an ultimatum- “Get clean or get out, for good.” This hospitalization was Michelle’s last chance with her family. Michelles’s drawing illustrates the challenges of remaining clean. As shown, Michelle is at the bottom of a large hill. Blocking her path on the hill are the obstacles that she has to face. She must become abstinent, embrace NA and AA, get support, go to an IOP (intensive outpatient hospital), and seek counseling. At the top of the hill, her family and the sun shining brightly. Unfortunately, as the hill rises, with the obstacles and challenges that lie ahead, the tombstones become a part of the landscape. Finally, across the hill, written at a diagonal is the word “DETERMINATION” cutting across the

Art Therapy and Metaphor 29 mountain of difficult to achieve goals. The family at the top is so small in relation to the problems that Michelle will face in her recovery goals. However, she has made a map, creating a visual reminder of the plan she has made for herself. Michelle draws herself with very little investment. No hands, no feet, but planted firmly in the right direction- heading up to meet the challenges that lie ahead. Her goals are clearly delineated by the drawing. She knows that this is her last chance, her only chance to change and get her family back together. Her self esteem is at an all time low, but she is clear about what her plan is to put her family back together. Case Study “John”

Figure 2 Figure 2 is an illustration by John a 37 year-old man who has been overtaken by his addiction for many years. He also draws himself in the lower left hand corner of the page. He has been plagued by voices for 17 years. He surrounds himself in the picture with liquor, drugs and prescription drugs. The prescribed medications are there with the other drugs to show his confusion in figuring it all out, what to take, how to best care for him. He is unsure of what he should take and how alcohol and illegal substances interfere with illness. His path is heading up towards the house at the top of the paper.

Art Therapy and Metaphor 30 An arched shaped of trees surrounds the top of the house indicating that the house is a pleasant place to be. Furthermore, written at the top, is “drug and alcohol free environment, p.s. no substances.” John wants to get to the top, and his picture acts as a reinforcement of the desire to be in recovery. Noticing in the picture that a horizontal line is drawn across the path, creating an obstacle or challenge for John, when questioned about the line in the path, he said he would “just jump it.” Drawing himself less stick figure-like, John seems to portray himself more fully, with more investment, and consideration. Feet heading in the drug free direction and moving up towards the peaceful house. Case Study “Nick”

Figure 3 Wheelchair bound and homeless Nick illustrates in figure 3 his desire to get back to home. He is absent from this picture; no path is indicated in how to achieve his goal of getting a home. However, during the session, the development of the house creation absorbed much of Nick’s time, perhaps leaving him with little time to put him in the drawing. The perseverative quality of the bricks indicating that Nick may not be able to

Art Therapy and Metaphor 31 focus on anything, except where he will live. Understandably he seems to have little selfesteem or coping skills to deal with his homelessness, and yet, he boldly draws what he wants to attain. Nick wants a home. Case Study “Katie”

Figure 4

College student and psychology major 20 year-old Katie illustrates the road of hope. Newly diagnosed as a bipolar, and a recovering alcoholic, her happy family is on one side of the road and her friends on the other. The far right corner her house and diagonally placed on the opposite side of the road is school. She speaks to the group passionately about getting back to school, seeing the sun, and beach in the horizon. Her drawing is an actual road map, a way to get back to school, the friends, and the normalcy she is craving. Drawing her supports, family friends, school, and the newly prescribed medication, Katie is hoping that this her chance to change and move on with her life. Case Study “Andrew”

Art Therapy and Metaphor 32

Figure 5 Faintly drawn, with little pressure on the crayon, Andrew draws his recovery plan (Figure 5), without investment and very little hope. His schema for houses and buildings indicates very low cognitive functioning. As a 42 year-old man, who worked as cook prior to his hospitalization, Andrew’s drawing shows little promise for change. He has drawn himself under the words “CAN’T FIND THE SHOPPING CENTER.” The shopping center is where he wants to stay away from, as there is the lure of drugs and the triggers of seeing others use that he can’t stay away from. His drawing of himself has a large head of hair, unlike the way he looks in reality. The path he has made is faint, without desire, and unsure of what is to happen next. The reality of losing his job has made the future uncertain. Case Study “Ben”

Art Therapy and Metaphor 33

Figure 6

Ninety A’s are in the path of Ben’s drawing (figure 6). Ninety alcoholics anonymous meetings in ninety days are the way that Ben is going to be successful in recovery. Ben draws himself going from his house to the meetings, and then returning to living with his significant other, going to more meetings, gaining more friendships, and going towards the sun. The light is the ultimate goal. Reaching the destination will require B. to meet his goals, and at the end he draws himself happy. Following the path of meetings for Ben will require hard work and determination. Ben sat for the whole session drawing and counting the A’s to make sure he had the right number. His investment is in himself; he wants the recovery, and the life that comes with being sober. Case Study “Louise”

Art Therapy and Metaphor 34

Figure 7 The church and spirituality are the focus of Louise’s drawing (Figure 7). For Louise to be sober, she is calling on a higher power. In her discussion, 27 year-old, recently diagnosed bipolar, Louise states that the salvation she has is the church and her meetings. Her drawing shows people passing out, alcoholic’s anonymous literature, and a separate path. She is drawn on the opposite side of the Y-shaped path, finding the common ground with the people on the other side is part of Louise’s goal and picture map of recovery. Jesus sits above the church, smiling down on Louise. The sun is on the opposite side, bright, big and shining down on Louise. Counting on spirituality is what is grounding Louise and keeping her hopeful in her recovery.

Case Study “Carol”

Art Therapy and Metaphor 35

Figure 8 Resistance to the idea, and unable to gain understanding of the metaphor in the story of Harold, figure 8 depicts a denial so deep that Carol would only draw where she wanted to go immediately. She wanted her bed. Actively oppositional to all groups, Carol would not address the future or her desire for the next step in her recovery. She didn’t believe that she had a problem. Her schema for drawing hands is very curious and slightly concerning, perhaps indicating cognitive functioning problems. Also curious is the dot where her belly would be, upon checking the chart, may be a response to a recent miscarriage. The catalyst for her major depressive episode may have been the recent loss and the exhibition of anger part of her grieving process and post-traumatic experience.

Case Study “Dan”

Art Therapy and Metaphor 36

Figure 9 The day a the beach, all the family together, the wind blowing the umbrella, big sun shining and a boat on the water enjoying the tranquility and peacefulness of the beach, and yet, in the middle of the picture is a shark fin. Sand castles and smiles for everyone, but why does Dan have the shark there? In the group discussion, Dan explains, that he doesn’t know why he put the shark there. It is especially concerning for him as he states that the little girl in the pictures is petrified of the water. She hardly enjoys the beach because of her fear of the sharks. The fin is so pronounced and a part of the picture, perhaps it is representative of the unknown that the financial and job stressors have put on Dan’s marriage. Dan refers to himself as a mean drunk; perhaps, the shark is symbolic of his “shadow” (Finlay, 2000, p. 6). In major financial demise, and his wife recently admitted to a psychiatric hospital across town, Dan portrays his hopes for a new day. Case Study “Ellen”

Art Therapy and Metaphor 37

Figure 10 Mother and daughter, no hands, legs or feet, holding hands under the sun. Ellen discussing her drawing illuminates the process of her drawing with more understanding than what we see here in figure 10. A minimal tree, impoverished people drawn, without body parts, perhaps a sign of resistance. The bright shining sun that takes up the sky, the picture illustrates a hope for a new beginning without a much support to make that beginning happen. No family or home to live in, on new medication and without a job, it appears that this drawing is an anxious response to a question that for Ellen has no immediate answers. Literally, without a leg to stand on, unclear about what the future holds, and without means, Ellen’s illustration is a desperate look at what appears to be a an empty existence. Case Study “Fred”

Art Therapy and Metaphor 38

Figure 11 Lightly drawn, with little pressure applied to the crayon, Fred’s drawing is a look at some ways of escape. The car and boat in the picture are what Fred says gives him freedom, not from his addiction but from the world. They are what allow him to move forward. Insightfully discussed in the group, with a new diagnosis of schizoaffective disorder, F. feels trapped with his disease. Fred’s purple crayon drawing enables him to illustrate what he sees as a way to change move on and being part of his recovery. The freedoms to travel independently, leave the locked facility, and move into a different phase of his life. Case Study “Greg”

Figure 12

Art Therapy and Metaphor 39 Figure 12 has Greg moving up the building of recovery, passing through and holding on to “love, peace, freedom, self-control, respect, god, understanding, wisdom, and knowledge” to get “the top.” Plagued by drugs and addiction Greg is unable to stop using. Each of the windows holds the face of a support person, the people that will love him through the challenge of recovery. Greg’s sad faced person at the bottom and the happy faced Greg at the top of the recovery building. The person at the top of the recovery building is not only smiling, but he is also bigger, taking it up more room, filling the space of the drawing, illustrating that he would be, as a recovering person, here to be part of a world without drugs. Second Placement The writer’s second placement was an art therapy intern in adolescent unit of a locked psychiatric hospital near a major metropolitan city. The hospital was surrounded by woods, set up on a hill with architectural design from the early 1960s. The unit was strictly crisis stabilization for males and females ages 12-17 years old. The writer stayed at the same hospital as the first placement with the same art therapy supervisor. However, the writer’s direct supervisor was now a recreational therapist who had worked at the hospital for 28 years. The facility was run down, yet during the internship many changes occurred to the physical building. The writer was able to consult on murals for patient rooms and utilize a grant to make the rooms appear more current and pleasing to the patients. The hospital has four units; three adult units and one adolescent unit. During the interview process for this internship, it was critical for the writer to have more experience with art therapy in a group setting. Previous exposure in art therapy during the writer’s first placement was limited to once per week. With the new

Art Therapy and Metaphor 40 internship, the writer had the chance to create her own schedule. Working 4 days a week, 8-9 hour days, the writer had unlimited possibilities. A schedule was created with art therapy everyday, directive in the morning, and open studio in the afternoon. There was time to participate in and conduct hospital admission assessments, art therapy assessments, group process notes, and attend team and family meetings. Patients in the adolescent unit represented many diagnostic groups. Many of the patients arrived from the emergency room with suicidal and homicidal ideation. Few were substance abusers, many had parent child relational issues, and most had mood disorders. The average length of stay was 7-10 days, however, many of the patients stay longer due to child protective services need for intervention. Discharge for a minor is different than with an adult, many parents would not take their child back home and often the patient had to go to respite care to wait for state or county intervention. Clinical records for patients on the unit were available to the writer after completing computer training in Sunrise. The writer was able to access information both on the computer and in a paper chart. Art therapy notes were part of the paper chart as the hospital continues to upgrade its system to include rehabilitation services in the near future. The art therapy intern’s role in the unit included planning for and leading all the art therapy and open studio groups. This included developing new and utilizing art therapy directives that served the patient population in a person centered way that also served the group. The writer arrived at her placement between 6:00am and 7:00am each day, prepared the group notes, and conducting functional assessments for each new admission. Each new admission was interviewed and the paper work was then completed and signed off by the therapeutic recreation supervisor. Group progress notes were

Art Therapy and Metaphor 41 completed at the end of art therapy and open studio groups. Each day the writer participated in team meeting. Team meetings included the charge nurse, two social workers, a discharge planner, the psychiatrist, and the art therapy intern. The art therapy intern brought art to team meetings regularly, often called upon by the psychiatrist to show a particular patient’s work. The art therapy intern had the opportunity to interact with the team about the patient’s stability and possible discharge. The team meetings were lengthy, lasting anywhere from 1-2 hours, giving a 12 hour report on the patient’s activity in the milieu, the therapeutic response, and their mood. During team meeting the art therapy intern would be invited to participate in any family meetings that were occurring during the day. Family meetings were absolutely necessary as part of the discharge planning. A patient could not be allowed to leave the hospital without a meeting, if the meeting went poorly, as many did, other meetings would be scheduled. It appeared that the only way to leave the hospital was to have a calm and pleasant meeting. Often the meetings went poorly, however, with increased time spent in the hospital, the patient’s defenses seemed lower, and the patient became more acquiescent. Promises were made for better behavior, rules to be adhered to, and hopes of medication compliance were shared. Staff in the team meeting shared that this behavior was part of the adolescent condition, they were not to be trusted or believed, nor were their parents. The writer believed differently based on the non-verbal communication that she shared with the patients. Some patients were that way; most were people just asking for love, structure, and acceptance from their parents. Daily family meetings with individual patients were a source of great learning for

Art Therapy and Metaphor 42 the writer. While only observing, participating in these meetings enabled the writer to see some of the origin of behavior, understand the history, and hear another side of story. With the chance to attend family meetings, there was also the opportunity to process the meetings afterwards with a clinical social worker. In addition to supervision with the social worker, the writer was then able to have supervision with her art therapy supervisor. This proved to be a rewarding experience allowing the most learning and providing a rich understanding of human behavior. Case Study “David” History David is a 14-year-old African American boy in the 8th grade that received art therapy 4 times per week for 4 weeks while he waited on the adolescent unit for placement at a residential placement center. David is approximately 5’2” and 107 pounds. David has been dressing as a female since October 2008. He is flamboyant and provocative. He can be seen singing, dancing, swaying his hips, wearing a bra, and wearing long hair extensions that are dyed purple. David will go up to staff and peers hugging and kissing them. David reports that males and females have sexually assaulted him, reporting that his father gave his a prostitute for his 13th birthday. It is unclear if this was given as a gift or was trying to “cure” him of homosexuality. Investigations by the local city police were dropped for lack of evidence. David reports that he was afraid of being hurt and that is why he had sex with the prostitute. He also reports contracting Chlamydia from the sexual encounter. While staying at his father’s home, David reports being penetrated by his father’s friend and having the friend masturbate in front of him. Another friend of his fathers would make David engage in oral sex and an older male

Art Therapy and Metaphor 43 cousin attempted to sodomize him. The cousin threatened to hurt him if he did not comply. In 2003, David was placed in foster care for about a month but was removed because his foster mother alleged that he sexually abused a 3-year-old female cousin. David reportedly touched and fondled other students in a bathroom when he was in elementary school. David displays oppositional and significantly impulsive behaviors, has a history of difficulty with authority figures and very poor boundaries. David puts himself at risk by going into neighborhoods known for criminal and drug activity. David refuses to go to school and runs the streets during the day. David’s parents were married until he was 3 years old. They then separated and David lived with his mother. Visits with David’s father have been physically, sexually, and verbally abusive. Diagnosis David reports that school is not safe for him now as his peers tease him about being gay and his female style of dressing. His current diagnoses are Bipolar Disorder NOS, Attention Deficit Disorder, Oppositional Defiant Disorder and Sexual Abuse (focus of attention on the victim). David has an extensive legal history, stealing women’s clothes from the local mall. Substance abuse history includes smoking marijuana and drinking vodka daily. David has been on Ritalin and thought that it was working, however, lately mother thinks that the medication has stopped working. It is not clear if David is being compliant with the medication. David was admitted to the crisis stabilization unit at the writer’s internship as he reported having suicidal ideations without a plan. Treatment Goals

Art Therapy and Metaphor 44 David’s treatment goals were developed by the writer and her supervisor and addressed concerns relating to his recent behaviors. Theses goals included increasing his ability to demonstrate appropriate social skills, contracting for safety of self and others, improving boundaries with peers, and stabilizing mood through compliance with medication. Other goals include impulse control and improved frustration tolerance. Art therapy goals included increasing self- esteem and appropriate self -expression. Throughout our sessions each of these goals were verbally addressed and supported by the group. Discharge was not dependent on these goals; however, careful consideration was made in the next placement as staff was concerned for David’s physical safety. Therapeutic Relationship David continued his flamboyant behavior at all times of the day in the milieu. He often asked for an as needed medication such as benedryl if he felt his behavior was getting out of hand. David seemed to appreciate individual attention from the writer, commenting on her clothing or hairstyle first, even before saying “hi”. Initially friendly, David would become distraught and angry if he made a request that was denied. David would start fights with peers, threaten staff and then run up and give the peer or staff member a hug. His labile mood was difficult for the staff to deal with, as was the way his crossed dressed. David and the writer formed an easy relationship, one that met him where he was at the particular moment. Being present for the family meetings enabled him to trust the writer more with his feelings. In opposition to the unit staff, the writer felt it important to be accepting of David, including the dressing up and his behavior. He often would not do the directive art therapy but would come to the open studio instead. The following artwork was created in open studio, on 18” by 24” paper. The writer

Art Therapy and Metaphor 45 believes that work David created may have helped him to feel safe while he waited for his unknown placement. While the art that was created was superficial, David began a journey into his own personal self-expression. The writer recommends continued exposure to art therapy as David moves to residential placement. The work that David started was just the beginning of the process of recovery and healing. Art Interventions Session 1

Figure 13 Engaging David was a difficult task. In all the therapy, group is the norm. This was an issue for David, fitting in with his peers was almost impossible due to the issues with his sexuality. The cross dressing was distracting for the staff, often making them uncomfortable. In figure 13, David took the opportunity to write about how special he felt. He wrote, “My hair and body are fabulous, I am special beyond what special is and can be,” “One of G-d’s children” is how he describes the drawing. In each paragraph he talks about his special qualities and the unique ways he expresses himself. During this particular session, David and a peer had a verbal argument that led to a physical

Art Therapy and Metaphor 46 altercation. He was removed from the group and sent back to the unit. Points were than deducted from his total and he was placed on room restriction, isolating him from his peers and staff. Observations Prior to the fight with another group member, David was invested in his process. Taking a few minutes to get started, David requested different supplies than what was on the table, asking for markers instead of colored pencils, big paper instead of small. In response to the directive, David was appropriate, still acting flamboyantly, but setting to the task without hesitation. He did, however, continue to represent himself as a female, drawing hearts as flowers, and creating floating images on the paper. The cross at the top right corner of the page could be a reference to the faith that David discusses daily. Each passage references faith and the special qualities that David believes he possesses. The passages seem to be written as wishes and dreams. The goal of group therapy for David was to connect to his peers in an appropriate way, build social skills, and begin to rebuild trusting adult relationships. Many of David’s relationships with peers and staff in the milieu had been filled with contention. In session 1, the writer noticed calmness, different than what was typically David on the unit. As he worked, there was a focus and attention paid to the details of his work. Thoughtfulness in his expressions of self-confidence, wishes for what he hoped would be, and the flamboyant behavior was less of an irritation to the peers in the group. Perhaps the art that David made acted as a bridge to his peers, both male and female, encouraging the group to support him, enabling him to “fit in” with the group. The session allowed David to express his narcissistic views safely.

Art Therapy and Metaphor 47 Session 2

Figure 14 In session 2, a directive suggested by the writer’s supervisor was presented to the group. The directive is “I am, I fear, I want.” Using images from magazines or drawings done by the patient answers the questions. Dividing the paper into 3 sections, in a 45 minute session, David completed figure 14. Observations With the presentation of the magazines, glue and scissors, David eagerly began the process of collecting images to represent himself. Not clearly understanding the task, David answers the question, “I am…..Peace.” “I fear…Harmony.” “I want….Love.” Ignoring the fear column of the paper, perhaps because the fears were too great or seemed insurmountable, David chattered away casually asking his peers for scissors or another magazine that might meet his needs better. Superficially responding to the directive, David remains guarded, only sharing with the group that his thinks Beyonce has “got it going on.” When asked about the dessert in the “I fear” column, David responds that of course, he fears dessert, “it might make me fat.”

Art Therapy and Metaphor 48 The writer noticed a different response to the art therapy than what had been previously seen in the other therapeutic groups. In recreation therapy, during a game, David was eager, but often spoke out of turn, side-talked with his peers and was generally very irritating to the (recreation) group leader. In art therapy with the writer, there was a noticeably softer side of David emerging. After the fight in session 1, there was compliance with the unit rules. Being aware of transference, one began to wonder who the writer represented in David’s world. In crisis stabilization, was the writer ever going to know? Being comfortable with not knowing might have to be enough. Session 3

Figure 15 In session 3, David was resistant to the new directive. He would not do what the group was doing, instead, he asked for a big piece of paper and stood up to retrieve the magazines off the cart. While the writer gave the directive to the group, David thumbed through magazines tearing out pages that he wanted to use for his own art. Observations The writer chose to let David do something different in the group. Not knowing

Art Therapy and Metaphor 49 whether or not this was right, it seemed that keeping the safety in the group to be the most important. After the fight between David and a peer, the writer was more cautious about the space, and the directives that were presented. David did not want to do what the group did. He asked for supplies to work on a collage. Without hesitation, the writer gave him the supplies. We were to have a family meeting after this group and during team meeting the message was clear- “Don’t upset him today.” Keeping the space safe was most important. Meeting David where he was seemed the goal. In his collage, David keeps himself organized and calm, carefully cutting out the images that he relates to his idealized image of him as a female. The power that David wedges in the group is one that the writer and her supervisor discuss during supervision. Due to the nature of crisis stabilization, it is more often the goal to keep the milieu calm. The goal of the therapeutic groups is beginning to trust. After years of physical and sexual abuse, this is David’s first chance to be with safe adults in 5 years. Acceptance of the place where David started in the art therapy group is where the writer had to begin with David, despite the feelings that she had about his lack of participation in the group. The writer was grateful for any participation from David. The writer was extremely conscious of how she was responding to David. She questioned treating him like a female. What was the right way to address him? He often came to groups in purple braids, a bra filled with tissue, short skirts, and high heels. Was his gender confusion pathological? Or was the confusion due to the abuse, did he feel safer being a female? Would being female keep him safe from the male and female abuse that he suffered while living on the streets? Session 4

Art Therapy and Metaphor 50

Figure 16 In session 4, the group began by addressing the temperature of the group. We set to work creating our feelings using abstract images. David again protested. He got up to the magazine cart. Finding safety in the images of the magazine, in figure 16, he creates a piece that shows what he desires to have when “he grows up.” During supervision, it was clear the writer didn’t want to push. What was her hesitancy in calling David in on his defenses? Fear? Would there be ramifications to lowering his defenses that would set his treatment back to the beginning of his admission? Through self-understanding made the writer aware of her fear of bringing up feelings in David that she might not have “answers” to, feelings of not knowing how to handle a situation. The writer’s desire to contain David’s feelings, by making him feel safe, but also by heeding the warnings of the team not to upset David, made the writer keenly aware of her role in the group. While leading the group, the writer understood her role to be somewhat of a babysitter, “keeping the kids safe”, but how could she step out of that, and push past the heavy wall of defenses with the lack of team support? Could the writer be comfortable with just getting by in the group? The goal of the team did not support David’s goals. Questioning the team it became clear that their discomfort with

Art Therapy and Metaphor 51 David’s cross-dressing made him an undesirable patient to support. As a student, the writer felt even more helpless in the situation, but more eager to provide support and understanding and develop trust with David. Session 5

Figure 17 In session 5, his family meeting visibly upset David. After the meeting the writer gently encouraged David to join in the art therapy group. He was extremely reluctant. He had been crying after seeing his mother. In the meeting that the writer attended with the mother and the social worker, David was told that he would be attending a residential treatment center in another part of the state. He screamed and cried that he wanted to go home. The pamphlets for the residential treatment center were provided to David. He screamed at his mother, his shoulders shook as he cried, and the pain filled the room. While David did not want to attend the group and he did not participate in the group formally, he did use the collage to calm himself. This was a tremendous change for David, a he had been previously using medication as needed to regulate his moods and anxious feelings. For the first time, David rejoined the group, on his own terms, talking with his peers about leaving. David used the art making to quiet his mind from

Art Therapy and Metaphor 52 the rapid cycling of negative thoughts. He was able to re-focus and perhaps begin to see that he might have a future different from the one he would have had on the streets. Session 6

Figure 18 In session 6, the final art therapy session before discharge, David claims he “wants love.” In the session, with his peers and the writer he seems to desire acceptance. For the first time in a month, David uses the markers, talks with his peers, and maintain the female persona he has been holding onto. He seems open to talking with rather than talking at the staff and peers in the group. While this appears to be a small change, it is gratifying to watch slivers of a changing David present themselves. With the departure from collage, David seems to want to take control of his life. Seeming to empower himself with the marker in his own hand, David can begin to write his own story, embrace the choices that he can make independently, and begin to deal with the trauma that has surrounded his life since the age of 3. Case Study “Michael” History Michael is a fifteen-year-old Caucasian boy of Russian descent. He is currently a

Art Therapy and Metaphor 53 9th grade student and resides with his adopted parents. He is being raised as a Catholic. Michael was adopted from a Russian orphanage when he was 3 years old. The family has one biological child who is 21 years old. At the age of 5 years old Michael was evaluated initially, showing he demonstrated borderline ADHD Syndrome. In addition, at that evaluation Michael showed some signs of Post-Institutional Behaviors/Post Traumatic Stress that resulted in oppositional-defiant behaviors, especially impulsivity. Michael is currently taking Strattera and Concerta for several years with some positive results. Recently he has added 5mg of Abilify to help address mood changes. Michael has some low grade processing problems but does not have an Individualized Education Plan in place due to the fact that he has been in private schools for his entire school career. Current Symptoms Michael has been referred to the hospital for increasingly violent behavior and oppositional behaviors with his parents. He has been skipping school and most recently failed to attend his confirmation at church, a situation was identified by the adoptive parents as the catalyst for the argument prior to admission. He was admitted to the adolescent unit due to increased oppositional behaviors. Michael still shows many of ADHD features, but is a bright and capable adolescent who is not showing any signs of a learning disability. By the parents report his is not working up to full potential as he is failing most of his tests even thought he has excellent academic and language abilities. He has very poor planning and organization, and limited motivation and performance. Michael’s parents are concerned as he continually engaged in oppositional-defiant behaviors. He has been suspended for cutting classes in the past and is now involved with

Art Therapy and Metaphor 54 juvenile domestic relations courts due to two assaults within the home. Court intake was completed and Michael is on court contract, but it is very clear that at the beginning of his admission, he had very limited insight, guilt and remorse. Michael also admitted to smoking marijuana on a regular basis, which may have contributed to his labile mood. Michael presents himself in a well-groomed manner. He identifies with skateboard culture, wearing his blond hair longer than his chin and his bangs covering one eye when he speaks. He reports having many friends, being the captain of the junior varsity football team, and having a girlfriend. Diagnosis Michael’s parents have been overwhelmed regarding his grossly inappropriate behaviors has increased over two years. Recent aggressive behaviors resulted in court involvement. Michael’s overall affect was blunt and indifferent. The current diagnosis is Major Depressive Disorder, Identity Disorder of Adolescence, Marijuana Use, and Developing Conduct Disorder. The writer believes that the more recent emergence of issues stems from an undiagnosed attachment disorder resulting from the first three years of life being spent in an orphanage. Therapeutic Relationship Michael and the writer had art therapy sessions for two weeks, five sessions total in a group setting for approximately 45-50 minutes per session. The writer also attended the family meeting that a social worker conducted during his stay on the unit. Michael was extremely likeable and pleasant during art therapy, seeming to enjoy the time, asking for more art materials and wondering during the day when it was time for art therapy. The writer quickly formed a therapeutic relationship with Michael. He was eager to

Art Therapy and Metaphor 55 participate, knowing that he would be released sooner if he followed “the program.” During the sessions, Michael disclosed that he missed his parents, but that he was happy to be in a safe place. He also indicated that there was “total chaos and confusion” within the home and could acknowledge that his moods were somewhat responsible. Michael shared that he feels that he is not able to communicate at any level with anybody and that he has “no family life.” He contributed that he feels like “giving up” at this stage of his life. Michael seemed to feel safe in the milieu with the support of his peers during the therapeutic interventions that were provided. He was well liked by the staff and peers showing no signs of aggression, depression, suicidal ideation, or conduct disorder. Treatment Goals The treatment goals were developed by the team and supported by the art therapy intern during sessions. Theses goals included increasing his ability to demonstrate appropriate coping skills, contracting for safety of self, improving the parent/child relationship, and stabilizing mood through compliance with medication. Additional goals include impulse control, identity development, substance abuse education, forming trusting adult relationships, increasing self-esteem and appropriate self -expression. Throughout our sessions each of these goals were verbally addressed and supported by the group. Discharge was not dependent on these goals; however, the parents made careful consideration. There was to be another placement out of the home. Previously the parents told the social worker they would not bring Michael back to their home, as they were afraid of him. Recommendations for a “wilderness program” were made to the parents by a private neuropsychologist. The treatment team was not in agreement, feeling that this program would add to Michael’s lack of attachment and abandonment.

Art Therapy and Metaphor 56 However, Michael was discharged to the airport and boarded a plane to a program hoping to “break down” Michael’s Conduct Disorder profile and deal with his depression and identity issues. The writer noticed that transference was taking place in our group therapy sessions. Wondering about the lack of attachment, Michael’s transference and the writer’s countertransference, the writer wondered about her desire to protect and nurture. Though remaining professional for the art therapy sessions, the writer had a strong desire to shake the parents during the family session. The writer could not be a savior for Michael; however, she could demonstrate healthy adult relationships and develop appropriate attachment behaviors. Art Interventions Session 1

Figure 19 Figure 19 was created using the therapeutic purple crayon directive on Michael’s first day in the hospital. Using the metaphor, the writer hoped to assess Michael’s feelings about himself and his insight into his behavior. Prior to this session Michael had been in the emergency room in restraints waiting for a bed on the unit. He had not

Art Therapy and Metaphor 57 slept the night before but insisted on being in the group even though he would have been excused. Beginning with the house Michael roughly drew the outline of the house, adding the door and windows next. Then his drew a stick figure in the lower left hand side. To the right of the house is another door. Michael drew a dome over the house. The writer wonders if the dome was added as a protective bubble or perhaps as an invitation to the writer to probe further. He then scribbled faintly over the house and the rest of the picture. Finally, he wrote the words “no one else home.” While in group he stated that “no one understands him” and that he will “run away” to defend himself. Observations Throughout the session Michael appeared to be enthusiastic and interested in the task, needing no re-direction to stay on task. The most significant part of this session was Michael’s admission that he felt so alone, distant from his family, seemingly isolated and unattached. The impoverished figure and careless effort in making the art seemed to highlight the discrepancy between Michael’s physical presence in the room and his investment in making the drawing. This may be explained by his exhaustion from the events the previous evening. The inconsistent line quality and haphazard placement of lines may indicate a lack of investment in the drawing. Figure 19 may represent the defenses Michael has developed in the crisis. The drawing seems to represent an opening to new thoughts about Michael’s future. While the words he spoke may not support that concept, the drawings are a window into potential. Session 2

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Figure 20 During session 2, figure 20 was created in the group art therapy session. The writer provided the opportunity to make a self-representative collage. Using papers of different textures and colors, and magazine images. The directive was to develop a collage that tells the group something about you. Observations Michael set to the task enthusiastically. He got up from his seat quickly to gather magazines that seemed to be of interest. Then walking to the other end of the room, he chose papers that seemed to please him. Asking for scissors and a glue stick Michael then focused on the task. By this session, Michael had begun to form easy friendships with his peers and with the staff. Seeming eager to please the staff and attain all his behavior points, he participated in the group verbally, raising his hand to share and even offering to help clean up the tables after the session. Michael chose a car picture and a female figure indicating that he like both. While full investment in the art making was evident, the art highlights traditional adolescent images and identifications. Little personal insight was developed by this task, as Michael seemed to remain guarded and cautious with sharing his feelings.

Art Therapy and Metaphor 59 Session 3

Figure 21 Figure 21 was created in session 3. Acknowledging requests to paint, the writer distributed watercolors and paper for the group. The directive was to “paint how you are feeling right now.” Observations The paper split in half, one side warm and the other cool and dark seem to illustrate Michael’s feelings about his family. This painting was done after a dramatic family session where Michael’s parents told him that he would not be returning home. During the group, Michael acknowledged that he might have made his family turn against him forever. His feelings about his adoption seem to be rising to the surface during this session. The family session revealed that Michael’s mother was also adopted, Michael’s father was recently unemployed, and that Michael would not be returning to the school he had attended last year. The session was volatile and the anger between father and son was tangible. As an adolescent, Michael was testing limits with the religion his family practices and the rules of school. The colors and definitive split in the paper may represent his ideas about himself as a “good/bad” boy. The painting may also indicate

Art Therapy and Metaphor 60 his split feelings about leaving his family to attend the wilderness program they have chosen. In the group he said, “I am happy to have a fresh start, but it sucks to leave my friends without saying goodbye.” Session 4

Figure 22 In session 4, Michael drew figure 22 as he approached his discharge date. He was eager to begin the new placement and what he considered to be an “adventure in the west.” Figure 22 represents self-identified strengths of spirituality, respect, and problem solving ability. Observations Michael’s low self esteem seemed to be affecting his mood while inpatient. He indicated that he was feeling sad because his family was sending him away. “They just don’t want to deal with me,” he said during the group art therapy. Having the opportunity to examine his strengths, even in this rough form, allowed glimmers of more positive feelings to shine through. In the group, Michael presented himself as these strengths, indicating that it made him feel better to be identified this was rather than as the kid with a drug problem, the skater boy, or the kid who failed 9th grade. With the

Art Therapy and Metaphor 61 focus off the negative aspects of his life, he said he began to “feel more hopeful about the future.” Session 5

Figure 23 Figure 23 represents Michael’s last art therapy session before his discharge to the wilderness program. The directive in this group was to think of a song title that represented who you are or who you wanted to be. The goal was to only use the title, not the lyrics of the song. Then each member of the group developed their own cover art for the album of their life. Observations Michael set to work quickly on this directive. He knew that discharge was going to happen that day, perhaps even being pulled from the group early to get on the airplane to the wilderness program. His choice of song, “Old Man” seems to be a future wish. The mountains may represent his desire to have something solid and steady in his life. The dark clouds may indicate past troubles. Michael told the group, “Lightening strikes coming from the clouds showing that I have the energy to get through the program out west. I am going to make it.” He added the drawing of money during the group

Art Therapy and Metaphor 62 discussion, piggybacking on his peers ideas that he would need money to survive and get through the tough times. Michael did leave at the end of that art therapy group. With his cover art in hand, he thanked the writer for her help, said goodbye to his peers and walked out the door. The writer had to confront her feelings about his leaving without proper termination. Who was termination for, the patient or the therapist? Michael seemed satisfied with the way he left the hospital. It is the writer who is feeling that the work we did together is unfinished. The biggest lesson may be in being satisfied with not knowing what happens with the patient, but knowing that as a clinician that you have been present, authentic, and given the gift of yourself to another human being. Conclusion Art therapy in crisis stabilization is a unique experience. The art therapy intern, if not scheduled regularly does not get to form therapeutic relationships with the patients, often feeling more like someone who fills the hours of the day rather than a therapeutic presence. Triggers, escalation, and crisis are the building blocks to hospitalization. Once in the hospital, the triggers removed, whether the illegal substance are gone or the parents that make the parent/child relationship so volatile removed, the real person begins to emerge. With both placements, the writer had the opportunity to work many hours per week and see the patients metamorphosis from sickly and angry to more well and pleasant. In team meetings, often the writer was met with irritation from other professionals on the team. Noting the patient’s positive response to art therapy, the writer saw a different patient; one with defenses lowered, a dimension that was not what the staff noticed as “manipulating” but as a person reaching out for help. Each patient, with

Art Therapy and Metaphor 63 the own unique story, can only be met where they are right now. The writer’s ability to address each patient in an authentic way, in the here and now, allowed the writer to see some very good work happen. Termination is a word that is not used with crisis stabilization patients. Often the patient does not know when they are leaving or where they are going until the moment they are picked up. Unfortunately, insurance companies determine discharge, not by the team. Relationships and therapeutic work must begin from the moment the patient enters the hospital. Many times the patient doest not get to say goodbye to the staff or peers. Sometimes the patient leaves while the group is in another activity. This leaves the milieu feeling disconnected and empty. Without preparation for leaving, the staff policy is not to tell the patient about impeding discharge until a ½ hour before the transportation arrives. The writer believes that this policy is in effect due to experiences with patient regression. In the end, the writer believes that being present everyday is not necessary, yet being present every moment that the writer was there was critical. Being in each and every moment was part the writer’s commitment to the patients. Using the purple crayon directive was a way to therapeutically open the door with patients. It was a shared experience, unlike any they had recently, and yet with the reading of the story, may have taken the patient back to a time when life was less complicated. The use of this therapeutic directive was a warm up for the arduous work that is recovery. The writer believes that staying in the metaphor was safe for the patients and for her as she developed a therapeutic relationship. One size fits all therapy seems to be the operating concept in crisis stabilization,

Art Therapy and Metaphor 64 however, with the introduction of art therapy to the adolescent unit, the writer saw major changes occur in patient care. Use of restraint and seclusion was lower during the intern’s placement. The adolescents responded to art therapy, even asking for it during times it was not on the schedule. Art therapy was more person-centered therapy than any other therapy on the unit. The writer was grateful for the chance to meet the patients where they were, rather than where the team thought they should be, applying the lessons the writer had learned in class. The response to this technique was gratifying. The programs that went into place during the second placement were well received by the staff and patients, raising morale by keeping patients engaged, having patients disclose more information than before, and making the unit a more aesthetically pleasing place. The placements the writer interned in were both excellent because of the great amount of support provided. With each placement, the writer’s ideas were embraced and she had a safe launching pad for cultivating them. The writer was able to write a hospital based grant for $3000.00 for art supplies. After receiving the grant, she purchased and utilized the materials in her second placement. The writer was asked to participate in the new design of patient rooms. Finally, she became an integral part of the team, educating the staff about art therapy on a unit where only therapeutic recreation had been provided. The environment was one of personal safety that enables the writer to develop professionally and deepen her therapeutic skills. With the introduction of the purple crayon therapeutic directive, the writer could access patients quickly, getting to know them and begin a therapeutic relationship. With supportive supervision, the learning from this experience was more apparent. Art therapy in academics and art therapy in the work place are dramatically

Art Therapy and Metaphor 65 different. There was little time provided for art therapy or open studio sessions; some days 45 minutes and others 1 hour. While theories and techniques are useful, working in high acuity settings, the writer feels that the only way to find your own authentic voice is to venture out on your own. Succeed sometimes, fail other times, and be present for all those experiences. This experience is about a learning journey that never ends. The academic courses cannot prepare the art therapy intern for the pain they will be exposed to, whether it is the pain of trauma, separation, disease, or abuse. However, with repeated exposure to the human condition, the coping skills and resiliency that emerge provide hope that in spite of skewed development or bad luck, survival can occur. Undifferentiated schizophrenia, suicidal ideation with a plan, schizoaffective disorder, bipolar, alcohol dependence, chronic dysthimia, cocaine abuse, THC dependence, bipolar mixed with severe psychosis, major depressive disorder, auditory hallucinations, internally distracted, agitated, flat affect, mood depressed, posturing, bipolar disorder with hypo-manic features, certified, tearful, negative attitude, no support, bizarre behavior, isolative, irritable, anxious, in denial, and homeless- These are the words that are used to describe the patients the writer worked with at the inpatient psychiatric hospital. Art therapy was the key to seeing patients not as pathology, but as people with strengths and solutions. Empowering and illuminating the process, patients may be able to identify their own strengths and use those strengths to help themselves.

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