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For the purpose of this case study all names and identifying information has been changed to protect and maintain client confidentiality. Consent has been given to present this case study and to use images of the client’s artwork.
Hannah is a 14-year-old female who was referred to KidsAid by her mother. Hannah was sexually abused by her step brother for many years. The perpetrator lived in the family home as part of the family unit and the abuse had been carried out unseen by the significant others in her life.
Initially, Hannah’s mother found out accidentally from a message Hannah had left on her phone. When confronted by her mother, Hannah denied the abuse and was subsequently made to apologise to the perpetrator. This had a significant negative effect on the level of trust in the mother/daughter relationship.
Later, Hannah confided in her mother that she had indeed been assaulted. Hannah felt, at this time, that she could no longer bear it alone. From the point of acceptance, the perpetrator was removed from the family home. Hannah began self-harming on a regular basis and was diagnosed with PTSD. More recently there had also been a more serious attempt at taking her own life. Hannah was assessed by CAMH who suggested that she would benefit from Art Therapy, however there was waiting list which was up to a year long. Hannah was referred to KidsAid as we were able to offer therapy with immediate effect.
Their relationship seemed to be complex and their attachments to each other were disorganised; at times avoidant and at other intense. Outcome measures were completed by bother Hannah and her mother on the Strengths and Difficulties questionnaire. The results indicated that Hannah was in the abnormal range for emotional symptoms.
Hannah’s Mother said her wish was for Hannah to be in a safe environment where she could accept and address the complex issues she was facing and to help her to manage her behaviours. Hannah stated her aim was to be happy.
Hannah came for her first therapy session at KidsAid House. She was very shy and used minimal words to communicate. The space was offered to her as a safe environment where she could use art materials to aid her non-verbal expression and develop communication. Hannah lacked confidence with her use of art materials and looked to me to direct the content of session. To ease some of pressure I suggested that we could make an image together. We took it in turns to choose materials and tentatively she began to add marks to the paper. Art Therapy Literature supports the important role of parallel making in strengthening and building non-verbal communications in therapy.
We made conversation as we worked on the image and slowly our two images became one on the page. I considered her lack of trust in others and how potentially frightening entering into a new relationship would be for her. In the session, I was asking her to trust me before she had had any opportunity to test this trust and offer it without reservation.
Toward the end of the session Hannah poured glitter over parts of her image where there was no glue to help fix the glitter in place. This temporary surface made me consider how hesitant she felt. The glitter seemed symbolic of the temporary nature of her ability to trust. She seemed to be showing that she did not feel safe enough to have something more permanent at this stage.
As the sessions progressed Hannah grew more confident and began to move more freely around the space using materials more independently. She began to develop trust in our relationship by testing what was safe and not safe to bring to our sessions through the fragility of her art work and my ability to hold these and keep them safe. Trust was a central concern in our therapy and a subject which we discussed in great detail.
Hannah’s early images had a directional flow that appeared as a theme. Her artwork had an area of containment in one corner that seemed grow and spread across the page.
Hannah soon began to make verbal links between the image and feelings of light being held or trapped by the darkness. She progressed quickly onto being able to reflect and articulate the feelings contained within the image. Expression through art allows the client to communicate traumatic memories though the use of the sensory aspects of art making.
Emerging research indicates that art expression may help to stimulate verbalisation of traumatic experiences by using areas of the brain that are not typically associated with language (Cathy Malchiodi, 2013, Arts and Health).
There were a few planned breaks in our sessions due to holidays and this appeared to support the growth of her trust in our relationship by knowing that I would return after the break. On her return, I observed that she was making better eye contact and exercising more control over the content of her sessions. With the trust now more firmly established she began to talk openly and honestly about some of her earlier experiences. It was important that the sessions proceeded at her pace, as it was possible that any drive to discuss the trauma may have led to a re-traumatisation or a superficial regurgitation of the events without deep processing.
Steadily, Hannah began to speak about the abuse and was able to make direct links between this and some of the suicidal thoughts she had been feeling. Hannah said that she felt guilt about the wider implications of being honest and how this had affected her family. She felt that others held her responsible for the abuse she experienced. She began to ask open questions such as, “why did it happen to me?” and “why was I chosen?”. At this time, I felt that Hannah was bringing a lot of emotional weight to the sessions and was using her art to consider the ambiguity of her feelings. Hannah said that she felt that her relationship with her mother was good, but she still questioned why her mother had not noticed. She began to explore her emotions through her image making. She thought about the images and the space being a container for ‘bad feelings’.
An important part of the therapy was revisiting some of the traumatic experiences so that they could be contained into the sessions and her art making. Hannah spoke about the positive effects of being able to “leave” some of these memories with me so that she did not have to carry them with her. She spoke about some aspects of her life such as socialising with friends that felt too challenging for her to do at the present time. We spent time thinking about managing her expectations of what being happy meant and that possibility of good and bad feelings co-existing.
Around the central point in therapy Hannah began to notice changes in herself. I also observed a change in Hannah’s presentation at this time. Her eye contact had improved as well as her ability to maintain conversations and direct the flow of the exchanges between us. Hannah’s artwork also began to change and develop. She began to demonstrate symbolic images of growth and regeneration. She became more expressive and spontaneous with her use of materials and undirected she began to place meaning within some of her pieces. This helped us explore ideas around hope and aspirations for the future. Hannah began to share that she felt more confident and that she was beginning to feel more able to carry out tasks independently.
An important part of the therapy was supporting Hannah to realise her potential outside of her traumatic experiences. We were able to think together about the abuse being only one aspect of her life rather than it being something that defined her. Hannah was able to contemplate this complex thought through creating art and reflecting on all the different aspects of herself which combined made her. We were able to think and hold in mind the emerging parts of Hannah which we have been able to discover together during her therapy. Art making supported Hannah to develop a sense of identity and personal boundaries, which she was able to translate outside the sessions. For Hannah, the process of change was about being able to learn about self and explore the meaning of safe and trusting relationships.
“Art Therapy has acted as a supportive medium for Hannah as she has been able to use the art materials to express an internal dialogue which she had previously struggled to put into words”
‑ Katelina Fusco, Art Therapist
Hannah used art materials to communicate feelings of uncertainty and through the countertransference I was able to develop a better understanding of how she was feeling about herself. As our therapy session drew closer to an end we made plans well in advance for the ending. In our last few sessions Hannah reflected on her journey so far and the changes which she had made in her life. She recognised that she was no longer self-harming, she was sleeping well and she was feeling able to do tasks independently outside of home. In our final session together, Hannah and I reviewed her artwork. She picked out key pieces which held significant meaning for her and shared how helpful she had found art making to be and how it had supported her ability to process feelings. She chose to take her artwork with her, which for me showed that she was now able to take the contents with her and continue to make use of the skills she had learned in processing her feelings.
At the end of Therapy Hannah and her mother complete another Strengths and Difficulties questionnaire and her score showed that she was now well within the normal range for emotional symptoms.
Art Therapy has acted as a supportive medium for Hannah as she has been able to use the art materials to express an internal dialogue which she had previously struggled to put into words and had led to self-depravation and harm. Art making has supported Hannah to have an outlet where she has been able to contain some of her worrying feelings without having to cause harm to herself.
Hannah must be commended for the courage she has shown in her ability to revisit some upsetting memories in the sessions. Hannah’s desire to overcome her negative thoughts, which she felt were stopping her from being able to grow and flourish, have been pivotal in helping her consider her feelings.
These are extremely important learning opportunities for Hannah and I have seen great improvements in her ability to make secure relationships and the confidence to share unknown and ambiguous feelings about change. Hannah has shown strength and courage by returning to the room each week and facing some of the upsetting things she has brought.
Hannah is an intelligent and articulate young woman who has made positive progress in her Art therapy.