|
|
 |
|
Anorexia
Nervosa and Art Therapy: ANOREXIA NERVOSA Anorexia nervosa is a bewildering form of human suffering. It confounds most peoples' sensibilities and is a daunting challenge, even for the most experienced therapists. Hilde Bruch (1978), who has written extensively on the theory and practice of psychotherapy in anorexia nervosa, considers anorexia to be characterized by an underlying disturbance in the development of self, identity and autonomy. The process of therapy with anorexic individuals involves helping them 1. discover their creative and human potential and 2. give up the hateful, unlovable, empty and defective self image that underlies the illness. Bruch believes that
traditional psychoanalytic interpretative therapeutic approaches only
confirm the client's sense of inadequacy and interfere with the development
of self-awareness. Bruch devised a therapeutic approach aimed at centering,
cultivating, and nurturing the self. The role of the therapist is to
provide, through encouragement and support, an opportunity for growth
and healing of the self. ANOREXIA NERVOSA AND ART THERAPY Bruch (1973) suggested that art therapy could be used as a means of stimulating the individual's awareness of feelings. Mitchell (1980) also views artwork as a valuable tool to gain self-awareness. He contends that art work represents a less threatening and more controlled means of expression. Wolf, Willmuth & Watkins (1985) also agree that art therapy helps to increase an individual's awareness of unrecognized or unacknowledged feelings, becomes an outlet for expression, and offers an opportunity to increase self-control. Wolf (1985) found that the artwork serves as a good indicator of the issues and conflicts occupying the client. According to Wadeson (1980), the ideal qualities of an art therapist include honesty, empathy, consistency and respect. Wadeson emphasizes the importance of a non-judgmental, flexible style, a caring attitude, and a genuine concern and an ability to instill trust and confidence. Despite a reluctance to admit it, and anorexic adolescent desperately needs another person who relates to her honestly. Through a supportive therapeutic relationship, the adolescent is encouraged to express her feelings and explore her self. CASE STUDY
FAMILY HISTORY Rose's parents emigrated from Korea 25 years ago. They now own a store and both work long hours. According to the psychological report, it was Rose's maternal grandmother who strongly pushed Rose's parents to have a child. The grandmother agreed to be the primary caretaker when the child was born, and did care for Rose until she was 8 years old. At that time the grandmother had a stroke and was confined to a nursing home. Rose states she helped care for her grandmother, who had lost control of hands and couldn't eat or swallow. She died when Rose was 12, and Rose states that her anorexia started slightly before this. It appears that Rose is still struggling with unresolved grief. Ironically, it was the spiritual healer in Korea who said Rose's grandmother's ghost was causing her illness and that she needed to let go of her grandmother. Themes regarding grief, death, spirituality, and her similarity with her grandmother were often apparent in her spontaneous images. From our conversations, it was my impression that Rose still holds an idealized picture of her grandmother in her mind, and she seems to concentrate on their similarities and wanting to be like her, even to the point of being skeletal and near death. ANOREXIA NERVOSA AND SPIRITUALITY Similar to many anorexic individuals, spirituality and ascetism were prominent issues with Rose. Self-denial and fasting can be experienced as very spiritually invigorating. Rose spoke of this often, saying "I like feeling hollow, empty, like those religious people who starve … when I eat I feel like a pig, gluttonous … when I'm full, emotionally and physically, I feel gluttonous … I need to have balance - I received too much good attention so I had to suffer … I feel closer to my grandmother when I'm like this … " The feelings she experience and related to her starvation seem intricately linked to her Korean Buddhist culture and spirituality. It is important understand the core beliefs of Korean Buddhism in order to understand Rose's inner world, and how it relates to the development and maintenance of her anorexia. Korean Buddhists believe that humans, natural forces and objects all possess spirits. It is the Buddhist belief that in order to be free, one most realize that a fixed self is an illusion. Korean Buddhism teaches that all phenomena are impermanent and interdependent, the world is continually in flux, coming into existence and passing away, conditioned from one moment to the next by interrelated phenomena. There is an emphasis on suffering and non-existence of a self. It focuses on suffering because only by addressing a problem can a solution be found, the more individuals cling to a belief in a self, the more pain and alienation they feel. All of Buddha's teachings are a mean of experiencing a liberation from a self-centered existence in which suffering is inevitable. The foundation of Buddhism is meditation, one learns simply to be in the present moment rather than dwelling on the past or fantasizing of the future and it is considered the main means for attaining enlightenment. Rose's Korean culture and Buddhist spirituality are very important components of her life, and therefore her illness, which may be a contributing, perpetuating factor to the maintenance of her anorexia. She told me during one of our individual sessions, as we looked at her drawing of the pond with a lotus (which she stated reminded her of her grandmother, and relates to enlightenment in Buddhism), that she went to Korea to see a spiritual healer.
ART THERAPY AND ANOREXIA NERVOSA As part of her treatment program, Rose was required to attend group art therapy sessions. The first day we met, Rose eagerly participated in group art therapy and when I offered to meet with her individually, she agreed that she would appreciate the opportunity to review and discuss her art journal. A therapeutic alliance was needed to nurture Rose's motivation for recovery. It appeared that Rose had difficulty establishing rapport with many staff members on the unit, which may have been due to her fears of being misunderstood. It was my impression on the unit that frequently her acts of assertiveness or requests for 1:1 discussions were experienced by many staff as symptoms of her disorder, and resulted in her being labeled as "manipulative" or "needy." It also appeared that Rose was aware of these labels unconsciously, since she often talked about feeling "blamed and unjustly portrayed as bad and untrustworthy" and that she was afraid to "talk about my feelings, because then I'll get special attention that other kids don't get and I don't deserve it…" During the first few art therapy sessions, Rose began the therapeutic process similar to the way she related to food - extremely selective and controlled. Control and selectivity can be seen in her art by it's rigidity, concreteness, and careful rendering of detail with pencil. As our therapeutic relationship developed, she felt safe enough to explore looser materials, experimenting with losing control and then regaining it in an empathic, nurturing, nonjudgmental environment. ART THERAPY AND SYMBOLIC IMAGERY The art work over her 4 week hospitalization was prolific, and the imagery that developed became increasingly intricate and complex. Over time, as our therapeutic relationship developed and as her art making became more intense, I found that we were able to discuss a variety of issues through the use of a visual dialogue, using Rose's artwork, in particular her art journal, as a means for her self-exploration. During our sessions, I supported Rose as the ultimate authority concerning the meaning and interpretation of her artwork. Her artwork stands on its own as a evocative testimony to her inner life. However, when accompanied by her own words to describe the imagery, it becomes a poignant illustration of her inner turmoil. Art expression is a language, but not a common one since it is unique and not immediately understood. Wadeson (1980) suggests that once this language of the individual's symbolic imagery is understood, there can be immediate communication for client to therapist through the image. Rose first introduced herself to me through her art and as our therapeutic relationship developed, I came to understand her language of imagery through her specific symbols. When we sat to review her daily journal entries, she did not have to repeat lengthy explanations of the symbols repeated throughout the pages, since the meaning was understood. In a person-centered therapeutic environment, it is the client, not the therapist, who puts meaning to images and symbols from the unconscious. I found it very important to learn what meaning the symbols held for Rose, rather than make any assumptions. All symbols and associations are idiosyncratic, influenced by her history, culture, personal circumstances and her stage in therapy, and not necessarily universal. Unless Rose shared the meaning that each symbol carried for her, I could only speculate about the possibilities. Rose was verbally articulate and could talk about her problems intellectually and superficially. She was able to verbalize that her need to be perfect and in control was a problem. She would often say, ""I'm always over-analyzing things, reading into things, going over and over in my mind things that happen, I know I'm distorting everything in my mind, I know that's my problem." However, she was totally out of touch with her emotions. She would often say, "I feel empty…I just don't know what I feel…I don't know how to be angry…" It appeared that her emotional needs were starved along with her body. She seemed to hide her fears and low self-esteem behind her words. However, through her images and symbols, I became acquainted with her inner world behind the obvious symptoms. Her art journal was the entrance to this world and became the meeting place where our therapeutic relationship developed. ART THERAPY AND STEREOTYPED ART Symbols that teenagers draw repeatedly in the same way are referred to as stereotyped art. According to Kramer (1971), stereotyped art usually serves as a defense. Moriya (1995) suggests that rather than blocking the therapeutic process, stereotyped symbols may facilitate the process, by creating safety and security, similar to that of a transitional object. According to Kramer (1971), children may create stereotyped art to repeat a previous success. Stereotyped art can also provide some kind of structure or organization. During art therapy sessions, clients may choose to cling to familiar, safe symbols they are sure they can draw well, not as a means of stopping further exploration, but as a source of courage. In the case example, Rose tended to use more symbols when she was feeling very depressed, anxious or chaotic, in a way they may have been "safe, familiar companions" like transitional objects. In particular, she would often draw the same rose image repeatedly. It is possible that she was once given positive feedback from her parents or grandmother for this drawing, so she continues to draw it repeatedly as a symbol of herself. Also, she continually uses symbols for the Korean Buddhist culture, such as the swatsika, lotus, and yin-yang. These are all symbols that are repeatedly found throughout the artwork in books and decorations in Korean Buddhist temples, buildings and homes. So, through her own drawings, Rose may be trying to repeat these forms as a way to seek approval or conform to the culture she values. Bruce Moon (1990) suggested that the therapist's role is to be attentive to the image, to explore emerging symbols, to acknowledge feelings that may be evoked by the image. I followed this approach in my work with Rose, by attentively listening to her meaning behind the images and retelling the meaning, so that she felt understood and supported. In this case example, Rose represented anger with "fire"; sadness with "tear drops"; confusion with "spirals"; peace with the "swatisika" or "lotus"; change with "lightening" and herself with a "rose", which were all repeated, stereotyped symbols that were drawn frequently in her private journal as well as her group art therapy pictures. Each one of these stereotyped symbols that Rose created appeared to have more than one level of meaning at any given time. Depending on the situation, they appeared to be a defense, a manifestation of resistance, or most importantly, a facilitation of the therapeutic process. Although Rose shared the apparent meaning of these symbols during group therapy, it was during our individual sessions that she would discuss the more intense, personal thoughts and feelings behind these symbols. In a safe, non-judgmental, trusting, empathic therapeutic environment, Rose was able to share her inner turmoil through the safe symbols in her journal. ART THERAPY AND SELF EMPOWERMENT In addition to the art becoming a means of communication for Rose, it became a self-empowerment tool by providing a means of actively participating in decision-making and facilitating self-exploration. Art provided her with the opportunity to begin to express her emotions and verbalize her insights. By working together in discussing her drawings, Rose become aware of and gained a better understanding of her confusion, fear, anger and guilt. Rose needed encouragement to develop and trust in her ability to genuinely and appropriately express her feelings fully, even if they seemed overwhelming or frightening. Anxiety, guilt, shame and anger were emotions which seem quite overwhelming and frightening to Rose, and her symbols for those emotions were always rendered in a quite controlled and contained manner. Rose attempted to regard herself as beyond ordinary human neediness. As she drew, she talked to me about her intense fear of pursuing her own needs or experiencing pleasure. As she described her drawings, she would often say, " I'm evil and guilty … I don't deserve attention … I'm causing so many problems … people have it worse than me … I feel gluttonous, like a pig, taking in too much … I don't want to need anything … the only blame I cast is on myself for wanting happiness I can't have, I believe I don't deserve … " ART THERAPY AND SELF-EXPRESSION Bruch (1973) noted that many anorexic clients have difficulty in recognizing and expressing internal feeling states. From this perspective, art as an expressive medium may have certain distinct advantages in treatment since it has a concrete, kinesthetic, and tangible quality that words lack. A picture does not disappear in the air like words do. A feeling or thought symbolically represented on paper can be literally seen, touched and acknowledged as words cannot. In addition, the picture may express what the client lacks adequate words to describe. It seemed to me that Rose was able to use the art in her journal to help her in formulating and clarifying their feelings, attitudes and conceptions before exposing them in the potentially dangerous medium of words. Also, art could be used in a way to contain intense, painful emotions, with less fear of losing control over them than would be the case in verbal interactions. Through art therapy, I entered Rose's world and learned what the important issues were for her. I experienced her point of view, her thought patterns, her structuring of experience, her symbolization. In relating to her, I tried to meet her on her ground. I was as receptive as I could be and communicated to her my sense of what she was sharing with me, without imposing my opinions or judgments. It was apparent to me that art was a way for Rose to communicate her distress and express her fears of accepting help. Once given permission to protect and care for herself within this safe, nurturing, empathic environment, Rose was able to acknowledge feeling threatened, needy, special, yet undeserving. The first drawings she shared with me from her journal poignantly reflected the concerns and issues she was struggling with on a daily basis. Rose was able to
use her daily art journal in order to ability to take time to reflect,
to see changes and review progress, to help her more accurately identify
and express feelings and to expand her ability to communicate with others.
A journal encourages reflection, and when utilized on an ongoing basis
it allows for continuous self-expression. For Rose, her journal became
a place where she could identify and chart her feelings through here
use of images. Rose's art journal was a private, safe place for her
to express her thoughts and feelings. As our therapeutic relationship
developed, she felt increasingly more safe and understood by me, and
therefore she was able to share these personal, private images and the
related thoughts during our individual sessions. As her hospitalization neared an end, I continued to support Rose's self investigation and understanding her artwork. The art directives I chose emphasized her free choice of drawing and her expression of feelings. After exploring looser media such as paint and pastels for several session, she returned to materials such as ink and pencil that she used in the beginning stage of art therapy which provided safety for her to assist in closure. Her image of the store, which integrated all of the symbols she used throughout therapy, was titled "My Journey to Recovery" was created at the end of her hospital stay. As she prepared to leave the inpatient unit, she was able to reflect on her experience and the resulting image clearly poignantly portrays her conflicting, opposing feelings of pleasure and pain; love and hate; good and evil; isolation and togetherness; and wanting to recover and wanting to hold on to illness. To further assist her in closure of our therapeutic relationship, the final day of her hospitalization we were able to review her artwork together and discuss her changes during hospitalization. Rose's images indicated a progression, a subtle change in form and content, over the course of therapy. It appeared that the use of certain symbols reflected the state of her inner world at that particular time. As Rose and I reviewed her work, she commented on her consistent use of color and symbol to represent her feelings during her hospital stay. As I reflected her insights, Rose was able to see, through her artwork, a sense of herself that remained consistent over time, yet could also grow and change. With the support of a therapeutic relationship, she was able to picture herself as capable to move out in the world and experience a wider range of feelings. CONCLUSION Anorexia Nervosa is a disturbing disease which affects the mind, body and soul. It appears that a single approach directed at helping someone overcome this disorder is ineffective. The complexity found in attempting to understand the development and maintenance of anorexia nervosa reinforces the need for an integrative and multidimensional approach that accounts for the many aspects of the disorder itself. Art therapy offers striking advantages as a treatment modality since it helps the client to form a strong therapeutic alliance and aids clients in establishing a sense of trust in their own feelings, intuitions, and abilities. Art therapy and anorexia nervosa seem closely related since they are both about expressing feelings without words, yet one is self-empowering and the other is self destructive. As I worked with Rose, I witnessed her own destructive and creative ways that she expressed herself without words. It was my hope, that by listening to her and attempting to understand her inner world, that I could support her creative choice to express her feelings through art. SYMBOLS IN ROSE'S ART "her own verbal
descriptions" Swatsika:
"peace and harmony" Fire: "my
anger…I'm afraid to express my anger…" Drops: "blood
filled tears…tear filled blood….full of sadness…tears
of sadness, joy, confusion, frustration…I felt so alone… " Flowers: Lightening: "bolt
of change…anxiety" Tree: "it
has all it's basic needs, but it's still alone…" Tornado:
"confusion…" Spiral: "caught
in a downward spiral…this illness is a vicious cycle…no way
out…helpless" Bird: "flying
free…peaceful…" Wave: "waves
of depression and anxiety…overwhelmed…hopeless…" Water: "overwhelmed
sometimes…peaceful sometimes" Yin-yang:
"my connection to Buddhism….striving for balance…" Ankh: "represents
my spirituality…" Three (3):
" there are a lot of 3's in my work….right now I'm thinking
of three problem which are my dad's birthday because I can't go home
to celebrate, the anniversary of my grandmother's death, I can't go
back to school…"
|
"Rose"
is a 15 year old Korean American female with a 3 year history of anorexia
nervosa. 
As
our therapeutic relationship became stronger, Rose was able to express
her thoughts and feelings regarding her religion, her treatment, and
at times, her family. The Korean culture is also an important dimension
to take into account, as it relates to the development and maintenance
of her eating disorder. During our sessions, Rose often talked about
fighting against the "western medical model" and feeling misunderstood
about her culture since she said, "they don't understand why I
would want to see a Buddhist monk…they think I'm doing something
stupid or wrong…" She talked about the importance of her family,
"I want to go home for my father's birthday, it's important that
our family be together to celebrate … I can only imagine how hard
it was for my mom to see me that way, close to death, it must have hurt
her so much … I feel horrible for the pain I've caused my family
…" The Korean culture places a great importance on family
and hierarchy, with females often seen as burden. The emphasis in the
family is respect, academics, piety, and respect. Koreans tend to express
emotions only with peers or family, and the educated are more controlled
and selective, express negative feelings only to immediate family. It
is the traditional role is mother to provide support/nutrients and father
discipline. 
